This blog explores the origin of monkeypox, the recent outbreak of the virus, its prevalence in Scotland, and its impact on the gay, bisexual, and other men who have sex with men (GBMSM) community. The blog also outlines the symptoms and modes of transmission of monkeypox, and available treatments including vaccination.
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Where did monkeypox originate?
Monkeypox is a viral infection which was first identified in the Democratic Republic of the Congo in 1970. It is a zoonotic virus, which means that it is transferred from animals to humans and back. Unlike COVID-19, monkeypox is not a new virus affecting humans; it has been endemic in parts of central and West Africa for decades. However, little international attention was paid to the treatment of, and vaccination against, monkeypox until the recent outbreak in Europe and North America.
When did the outbreak start, and how many cases are there in Scotland?
The current UK monkeypox outbreak was identified in May 2022, with the first case reported in London on 7 May 2022. The first identified case in Scotland was reported on 23 May 2022. Between then and 26 August 2022, there have been 79 laboratory-confirmed cases of monkeypox in Scotland, according to Public Health Scotland’s weekly report on the prevalence of the virus. However, this number may be an underestimate, as monkeypox is thought to have been circulating undetected outside countries where it is endemic for some time, possibly misdiagnosed as other infections.
Alongside the UK’s other public health agencies, Public Health Scotland has agreed a Four Nations approach to controlling the outbreak of monkeypox, focused on minimising the spread of the virus and its impact on the NHS. Monkeypox is a notifiable disease under the Public Health (Scotland) Act 2008, which means that every case is notified and individually followed up by a local Health Protection Team for contact tracing and isolation advice.
Although cases are increasing, monkeypox is still considered to be a rare illness, and the likelihood of catching monkeypox in Scotland is currently low.
How is monkeypox transmitted, and what are the symptoms?
Monkeypox is not easily spread between people. However, it can be transmitted through close personal contact with someone who is infected with the virus, such as:
- touching the blisters, scabs, or skin of an infected person, including sexual contact
- contact with clothes, towels, bedding, and other personal items used by someone with a monkeypox rash, blisters, or scabs
- respiratory droplets from a person infected with the virus, such as coughs and sneezes
Monkeypox can cause a variety of signs and symptoms, including:
- muscle aches and back pain
- low energy
- swollen lymph nodes.
These symptoms are usually followed or accompanied by a rash which lasts for two to three weeks. The rash can appear on the face, eyes, mouth, throat, palms of the hands, soles of the feet, groin, and genital and anal regions. The lesions are flat to begin with, then fill with liquid before drying and falling off. The number of lesions can range from one to several thousand. Symptoms usually start five to 21 days after a person becomes infected, and most people get better without treatment two to three weeks.
Why is monkeypox affecting the gay, bisexual, and other men who have sex with men (GBMSM) community?
Anyone can catch and spread monkeypox; however, most of the cases in the UK so far have been identified in gay, bisexual, and other men who have sex with men (GBMSM). Monkeypox is not a sexually transmitted infection; however, it can be passed on during the close contact that occurs during sex and other intimate contact, and is thought to be predominantly spreading through sexual networks in the GBMSM community.
Because the virus has so far mostly affected GBMSM, there are some concerns that the monkeypox outbreak could lead to further stigma being directed towards the gay, bisexual, and other men who have sex with men (GBMSM) community, and misdirection of public health communication regarding the virus. Cases may also be missed in the wider population if monkeypox is mistakenly seen as an illness that only affects GBMSM people.
How is monkeypox diagnosed?
A definitive diagnosis of monkeypox requires assessment by a health professional, and PCR test on a viral swab to rule out other similar diseases, such as chickenpox. People in Scotland who are concerned that they may have monkeypox, or have been in close contact with someone infected with the virus, are advised to contact their GP or local sexual health clinic.
Do people with monkeypox and their close contacts need to self-isolate?
People who are diagnosed with monkeypox in Scotland are advised to self-isolate at home until they meet the de-isolation criteria set out by the UK Government. The close contacts of people with monkeypox are advised to self-isolate for 21 days following their last contact with the infected person. Financial compensation is available to those self-isolating in Scotland under the Public Health Scotland (2008) Act.
How is monkeypox treated, and who is most at risk?
For most people, the symptoms of monkeypox will be relatively mild, and will improve on their own within a few weeks. Paracetamol may help to relieve some of the symptoms. An antiseptic mouthwash or local anaesthetic cream may be prescribed by a GP to help with painful mouth blisters, and antihistamines may be prescribed to help with itching. Antiviral medicines have proven beneficial in treating monkeypox patients with severe symptoms; however, these medications make little difference for people with mild monkeypox symptoms.
A minority of people may need hospital treatment, usually after becoming dehydrated from fever or vomiting and require intravenous fluids. Less commonly, some people may develop sepsis and will be given antibiotics in hospital.
Newborn babies, young children, and those with immune deficiencies may be at higher risk of more serious complications of monkeypox. There is very limited evidence on the impact of monkeypox during pregnancy, but when pregnant, the World Health Organisation advises avoiding close contact with people with the virus.
What is the monkeypox vaccine, and who is eligible?
Monkeypox is caused by a virus similar to smallpox, and smallpox vaccines have been found to be effective against monkeypox. The vaccine used in Scotland is Imvanex, and contains a virus that’s been modified so that it cannot multiply in the human body. Although the vaccine is not yet licensed for the prevention of monkeypox, it has been previously used against monkeypox in the UK. There are currently limited supplies of the vaccine, so it is being offered to people at the highest risk of contracting monkeypox, and will be offered more widely as more supplies become available. The vaccine can be given either before or after exposure to monkeypox.
The groups considered at the highest risk of monkeypox are:
- Gay, bisexual, and other men who have sex with men, including those who have multiple partners, take part in group sex, attend sex on premises venues, or have had a bacterial sexually transmitted infection such as chlamydia or gonorrhoea in the past year.
- Healthcare workers in high-risk settings, who may provide care to a person with monkeypox.
- Some people who work in settings with a higher risk of contact with people with monkeypox, such as sex on premises venues.
The vaccine will also be offered to people who have had high-risk contact with someone with monkeypox. The vaccine is most effective when administered within four days of exposure to monkeypox, but it can be given up to 14 days later.
Healthcare workers at higher risk of contracting monkeypox can access the vaccine through their employer. Members of other highest-risk groups are advised to contact their local sexual health clinic to obtain the vaccine. However, concerns have been raised regarding the lack of resources available to support sexual health services in assessing and vaccinating against monkeypox, and the impact on other vital services offered by the clinics.
Although monkeypox cases are increasing in Scotland and across the UK, case numbers remain low, and most people with monkeypox experience only mild symptoms. However, as the outbreak continues, more information may become available, and SPICe will continue to provide updates on the evolving situation.
Sarah Swift, Researcher, Health and Social Care