Over the last few weeks there have been reports of an atypical outbreak of monkeypox in the European Region and other parts of the world where the disease is not usually found. We spoke to Dr Richard Pebody who leads the High-threat Pathogen team at WHO/Europe to find out more about the virus, why the outbreak is concerning and what people should do to protect themselves and others from infection.

1. What is monkeypox and how is it spread?

Monkeypox is a rare viral infection, usually found in forested areas of Central and West Africa. The disease originates in animals, but in the last 50 years or so has also been reported in humans.  

Monkeypox does not normally spread easily between people as it requires very close physical contact to allow the virus to enter the body. This could be through broken skin; the eyes, nose or mouth; and as a result of coming into contact with the lesions, bodily fluids or respiratory droplets of infected people. It can also be contracted through prolonged contact with the contaminated possessions of infected people, such as clothing, bedding and towels. 

The disease it causes is usually self-limiting, with most of those infected recovering within a few weeks without the need for treatment. However, the disease can be more severe, especially in young children, pregnant women and individuals who are immunocompromised.

2. What are the symptoms and how long do they last?

Someone who has contracted monkeypox usually starts to show symptoms between around 6–13 days after contact with an infected, symptomatic person, or their belongings, but it can take up to 21 days.  

The most common symptom is an evolving rash that develops from vesicles into blisters. During the recent outbreak in the European Region, most of the cases have been picked up in sexual health clinics, with patients presenting with lesions on their genitals and anus. 

The rash may be accompanied by a fever, muscle aches, chills, exhaustion, headaches, a sore throat, or swollen, painful lymph nodes (raised glands, particularly in the groin and potentially in the neck, under the chin and in the armpits).  

The symptoms in the current outbreak have been mostly mild, however lesions can be very itchy or painful and can become infected. Symptoms usually resolve by themselves after about 14–21 days.

It is important that people are informed about monkeypox, can spot the signs and symptoms, and report any unusual rash to their doctor or health-care provider. 

3. How can monkeypox be treated?

The disease is usually self-limiting, meaning symptoms usually go away without the need for treatment within 2–3 weeks. Some people may require antibiotics and analgesia to treat secondary infections and local pain. 

While a new vaccine has been approved for the prevention of monkeypox, and the smallpox vaccine has also been demonstrated to provide protection, these vaccines are not widely available in the European Region.  

4. Is it unusual to see cases of monkeypox outside Central and West African countries?

Sporadic cases have occurred over the past few years in the European Region, usually as a result of travellers visiting Western and Central African countries and returning with an infection. These imported cases have not usually led to infections in other people, although some limited spread to household and health worker contacts has previously occurred.  

5. What is concerning about this latest outbreak in the European Region?

The current outbreak in the Region is concerning because it is not typical of those that have previously occurred for a number of reasons:

• firstly, because an increasing number of countries in the Region have reported cases of monkeypox – all but 1 case had no travel links to areas where monkeypox is endemic;
• secondly, the cases have mainly, but not exclusively, been identified among men who have sex with men (MSM) seeking care in primary and sexual health clinics;
• thirdly, because of the geographically dispersed nature of the cases across the Region and beyond, it is possible that the virus has been spreading undetected in communities for some time;
• fourthly, the most reported clinical presentation is of localized rash, particularly around the genitals and anus, with associated regional lymphadenopathy (swelling of lymph nodes). 

Even so, the fact that the virus is not easily spread from person to person means that the risk to the general population is still considered to be relatively low. 

6. What do we know about the virus in circulation in the European Region?

There are 2 known types of monkeypox virus, the West African type and the Congo Basin (Central African) type.  

So far, all the cases recently reported in the Region have been of the West African type, which is known to cause a milder, usually self-limiting disease and only very rarely causes severe disease or death.

Further investigations are underway to determine the likely source and extent of infection, and limit further onward spread. 

7. Who is at most risk from catching monkeypox?

While the most recent outbreak appears to have disproportionately impacted MSM, it is important to stress that monkeypox can affect anyone who comes into close prolonged contact with an infected individual or their infected belongings. It would therefore be wrong to stigmatize anyone for the outbreak. People at potentially heightened risk of infection include health-care workers, commercial sex workers, and household members and other close contacts of active cases, such as sexual partners. Other groups at the highest risk of severe disease from monkeypox include: pregnant women, young children, and individuals who are immunocompromised. These groups need to be especially protected to prevent infection. 

8. Does this atypical outbreak mean the virus has evolved?

Monkeypox is normally a stable virus, meaning it is does not tend to rapidly mutate. Sequencing of the virus from recent patients is currently underway to assess its genetic makeup, which will allow for proper assessment and contribute to our understanding of the level of transmission in the European Region, and when the original introduction may have occurred.  

9.   Could this be a new pandemic like COVID-19?

No. Monkeypox requires close personal contact with an infected person or their belongings so is not as easily spread. This would include direct contact with body fluids or sores on the body of someone who has monkeypox, or with direct contact with materials that have touched body fluids or sores, such as clothing or bed-linen. Although respiratory transmission is possible, we know this likely occurs through large droplets that don’t linger in the air or travel far, and so may occur  when people have close, face-to-face contact.

10. Could the monkeypox outbreak lead to the cancelling of festivals and imposition of travel restrictions over the summer?

We are not recommending cancellation of events or travel restrictions. As we enter the summer season of festivals, large gatherings and parties, it is what people do at these events that matters. As mentioned, monkeypox needs close physical contact between people so is not readily transmitted. We encourage safe sexual behaviour and good hygiene, like regular handwashing, to help limit transmission of the virus. Summer festivals can be good opportunities to reach out to specific population groups with public health messaging.  

11. What should people do if they suspect they might have monkeypox?

It is important that people report symptoms and take precautions to stop possible transmission to others, particularly those at high risk of developing severe disease. 

• If you have an unusual lesion or rash, consult your doctor or health-care provider straight away.
• Try not to touch the lesions or rash as this could spread the disease.
• Wash any bedding or belongings of an infected person that you may have come into contact with.
• Wash your hands regularly.
• Avoid close physical contact, including sexual contact with others.
• Anyone that has suspected, probable or confirmed monkeypox symptoms should isolate as much as possible until the symptoms have resolved.
• In particular, keep isolated from pregnant women, young children and immunocompromised people to protect them from infection. 

You are extremely unlikely to have monkeypox if you have not been in close contact (such as touching their skin or sharing bedding) with someone who has monkeypox or has monkeypox symptoms; or if you have not recently travelled to West or Central Africa. 

12. How can we prevent further transmission and put an end to the outbreak?

Rather than vaccination, the primary measures to control the outbreak are contact tracing and isolation. It is very important that people confirmed with monkeypox disclose their contacts so these can be alerted to monitor their symptoms. 

We also need to help prevent people from getting the virus in the first place, so would recommend:

• avoiding skin-to-skin or face-to-face contact with anyone who has symptoms;
• practicing safe sex;
• cleaning your hands regularly, especially before and after having contact with a symptomatic person and their belongings. 

13. What is WHO doing to better understand and control the outbreak?

WHO is working with concerned countries, facilitating information sharing and supporting surveillance, testing, infection prevention, clinical management, risk communication and community engagement. 

WHO is also working with vaccine manufacturers to assess the potential for scaling up monkeypox and smallpox vaccines should there be the requirement to vaccinate those at most risk of catching the disease, or who could potentially suffer from more severe disease outcomes.