By: Bryan Herb

One of my Zoom Vacations travelers, Dr. John O’Grady is board certified in both internal disease medicine and infectious disease medicine, and has been recognized as a Top New Jersey Doctor every year for more than a decade. Since he has traveled with us in numerous Zoom Vacations tours all over the world, we know him very well, and seized the opportunity to get more information on Monkeypox and how it may impact the world of traveler. Dr. O’Grady graciously accepted my request for an interview. I hope you find this interview as helpful as I did.

Bryan: How is Monkeypox different from Chickenpox or shingles?
John: Varicella (the virus which causes chickenpox as well as shingles) is similar to Monkeypox in that it also causes a vesicular (blister-like) rash and, in several outbreaks, it has been difficult to distinguish between the two viral infections. However, one feature which distinguishes between the two is LYMPHADENOPATHY (generalized swelling of lymph nodes) which is more distinctive of Monkeypox. Diagnostic testing, such as a swab sample from an active lesion, would clearly differentiate between the two and confirm the diagnosis.

Bryan: While traveling on planes, cruise ships, etc., is there any aspect that could make me susceptible to Monkeypox?
John: Human-to-human transmission of Monkeypox occurs through the following routes:

• Close contact with infectious skin lesions; spread is thought to occur primarily through direct contact with infectious sores, scabs or body fluids. As such, Monkeypox can spread during activities that include close, personal contact with an infected individual.

• Mucous membrane micro-abrasions are a potential portal of entry (ie. deep kissing).

• Indirect contact with infectious fluid on contaminated linens.

• Large respiratory droplets exposure… especially with prolonged face-to-face contact (within a six-foot radius for > 3 hours in the absence of PPE (mask)

• Activities resulting in re-suspension of dried material from infected lesions (ie. shaking contaminated linens) may also present a risk.

Bryan: Should I be concerned if traveling to an area with a large Monkeypox outbreak?
John: If there are documented outbreaks in your geographic community there is obviously more risk of exposure to Monkeypox and more attention to mask-wearing and social distancing would be appropriate if possible). Not too dissimilar to the COVID issue precautions; although Monkeypox is MUCH LESS infectious via aerosolization.

Bryan: Can you tell us the ways someone can contract Monkeypox, besides close intimate contact?
John: Sure:

• Transmission can also occur through contact with materials or fomites that have become contaminated with infected material, such as clothing, linens or sex toys contaminated with infectious material from body fluids or sores.

• Monkeypox virus is also thought to spread through respiratory secretions, although prolonged face-to-face contact may be required for transmission to occur via this route. This can occur with prolonged face-to-face interaction such as kissing or cuddling for a prolonged period of time.

• Activities resulting in re-suspension of dried material from lesions (eg. shaking contaminated linens) may also present a risk and should be avoided.

• The Monkeypox virus can be spread via a bite from an infected individual or infected animal (the classic example is a prairie dog which was responsible for a small outbreak in the mid-west US in 2003).

• Finally, the Monkeypox virus can also be transmitted vertically (pregnant woman to fetus) and cause congenital infection.

Bryan: How can you best safeguard yourself from Monkeypox?
John: Some good rules of thumb are:

• Avoid close contact with anyone who might be suspected of having it (ie. has unexplained fevers, malaise, swollen lymph nodes and new/unexplained skin lesions

• Any individual diagnosed with Monkeypox should self-isolate until their rash has healed.

• If a partner has Monkeypox, avoid sex until their rash is completely healed, this includes anal, oral or vaginal sex. Continue to use a condom for 8-12 weeks after symptoms resolution.

Bryan: I have heard that Monkeypox is much harder to spread than COVID-19. Is this true?
John: Monkeypox is NOT as contagious as the virus that causes COVID-19. You are unlikely to contract Monkeypox by being near someone unless you have direct contact with their skin or are face-to-face for a prolonged period of time.

Bryan: Why is the world having a stronger response to COVID-19 than to monkeypox
John: On July 23, 2022, the WHO declared this Monkeypox outbreak a public health emergency of international concern. For most individuals, Monkeypox is a self-limited disease with the symptoms lasting from two to four weeks. Although some patients may develop severe disease, as of mid-July 2022, thousands of confirmed cases of Monkeypox in dozens of countries have been reported; yet no deaths (from Monkeypox) have yet been reported in non-endemic countries. Cases continue to emerge and this may change. However, unlike the SARS COVID-19 outbreak where tens to hundreds of thousands were dying within the first month of the outbreak, the outbreak of Monkeypox does not appear to require as drastic a response as was required with COVID-19.

Bryan: In addition to bumps on the skin, travelers can get fever, headache, muscle aches, fatigue and swollen lymph nodes. Can you tell us more?
John: Monkeypox has traditionally caused systemic illness that includes fevers, chills and myalgias with a characteristic vesicular rash (similar to herpes simplex, chickenpox and smallpox). However, during the Monkeypox outbreak starting in May 2022, the prodrome typically lasts up to five days and is characterized by fever, intense headache, swollen lymph nodes, myalgia (muscle aches) and severe fatigue. Some patients have presented with genital, rectal and/or oral lesions without the initial prodrome

Several complications of Monkeypox have been reported; these include secondary infections, bronchopneumonia, sepsis, encephalitis and infection of the cornea with ensuing loss of vision.

Bryan: Is Monkeypox contagious and still able to be passed skin-to-skin even if the person displays no symptoms?
John: The potential for transmission from an individual with asymptomatic infection is uncertain. In a recent, yet-to-be-published study, at the beginning of the 2022 outbreak in Europe, stored anogenital and oropharyngeal specimens from 224 men who had been tested for gonorrhea and chlamydia were PCR tested for Monkeypox; three men had anorectal specimens positive for Monkeypox DNA despite absence of symptoms or known/reported exposure to a person with Monkeypox. Although the finding raises the concern that people with mild disease could contribute to ongoing transmission, none of the contacts of the three men developed clinical Monkeypox, and follow-up Monkeypox testing performed 21 to 37 days after the initial positive sample was negative

In short, it is unknown but doubtful that a person without skin lesions or symptoms is highly contagious.

Bryan: Is there a reason that the bumps often start on the face?
John: The rash tends to be more concentrated on the face but often develops on the palms of the hands and soles of the feet. Other sites may include oral mucous membranes, conjunctivae, anus and genitalia. In the present outbreak, some patients have presented with proctitis (pain in the rectum) or with lesions located on the genital or perianal area alone. The lesions go through several stages:

• The rash typically begins as 2 to 5 mm diameter macules (spots)

• The lesions subsequently evolve to papules (bumps), vesicles (small blisters) and then pustules. They are well-circumscribed, deep-seated and often develop umbilication (a central depression on the top of the lesion).

• The lesions eventually crust over, and these crusts dry up and then fall off. This usually occurs 7 to 14 days after the rash begins

• The lesions typically begin to develop simultaneously and evolve together on any given part of the body. However, during the global outbreak of Monkeypox beginning in May 2022, not all lesions were in the same stage of development.

• The rash associated with Monkeypox is often described as painful, but in the healing phase (when crusts develop) it can become itchy. Persistent scratching of the lesions can cause secondary skin infections.

Bryan Herb is co-owner of Zoom Vacations®,
a US company that creates stylish international private events and gay group vacations to the world’s hottest destinations. Learn more about them at www.zoomvacations.com or call 773.772.9666.