Monkeypox has been in the news recently, and we wanted to take a moment to synthesize what is important to employers. In general, monkeypox is a rare infection not usually found in the United States. It originated in Central and West Africa and was first detected in the late 1950s from a colony of sick monkeys. Rarely infections have been reported in several other countries, typically from returning travelers from Africa. Can monkeypox be a threat to your workplace population health? Here is what employers need to know about monkeypox.
UPDATE: August 4, 2022
The World Health Organization reports nearly 20,000 cases worldwide and has now declared Monkeypox a Global Health Emergency. The U.S. has now seen nearly 6,000 confirmed cases. Cases are primarily being transmitted through direct physical contact with another person who is symptomatic. Analysis shows 98% of cases are through this mechanism. There are some reports of infections being transmitted through soiled laundry from infected persons. There are two vaccines that are effective against Monkeypox. Fortunately the majority of cases do not need to be hospitalized and there have been no deaths from Monkey Pox in the U.S. Employers should stay informed about this outbreak and consider preparing infection control policy that addresses general infectious diseases in the workplace (and if personal illnesses are brought into the workplace) with addendums to address specific illnesses.
What is Monkeypox?
Monkeypox is a zoonotic disease (a disease caused by viruses passed between animals and people). It causes similar symptoms to those seen in the previous cases of smallpox but is clinically less severe. After eradicating smallpox in 1980, monkeypox has emerged as another severe orthopoxvirus for public health, and it is now the focus of global attention. Monkeypox mainly occurs in central and western Africa, often near tropical rainforests, but has been increasingly appearing in cities. Animal hosts include various animals, including rodents and non-human primate species.
A multi-country outbreak of monkeypox has occurred in several regions of the globe, the full extent and effect of which remain unclear.
In the United States, the largest outbreak (approximately 70 infections) of monkeypox due to the infected prairie dogs exposed to imported animals from Africa occurred in 2003. Since then, only a sporadic infection of monkeypox has been documented in the U.S. In July 2021, a patient was diagnosed with monkeypox in Dallas, Texas. This patient developed symptoms during his return trip from Nigeria. In May 2022, a case was identified in Massachusetts. This patient had recently traveled to Canada by private transportation and had not traveled to Africa. Further details are pending about this case.
Natural Host of Monkeypox Virus
Various animals have been identified as susceptible to the monkeypox virus. This includes rope squirrel, tree squirrel, Gambian pouched rat, dormice, non-human primates, and other species. The monkeypox virus has not been identified as an animal disease yet; however, further studies are needed to determine this.
The monkeypox virus is an enveloping double-stranded DNA viral infection that belongs to the OrthoPoxvirus genus of the Poxviridae family Two distinct genetic clades of monkeypox exist: the Congo Basin clade and the West African clade. Historically, the Congo Basin clade has been associated with more severe diseases than the Central African clade. So far, the geographical division between the two groups has been in Cameroon, the one country where both viruses have been found.
Zoonotic transmission can occur through direct contact with the infected animals’ blood or bodily fluids or through contact with their skin or mucous membranes. Evidence of monkeypox virus infection was found in many animals, including rope squirrels, tree squirrels, Gambian poached rats, dormice, different species of monkeys, and others. However, the natural host of the monkeypox virus has not yet been found, but rodents are the most likely the source. Eating inadequately cooked meats and other animal products from infected animals can pose a health risk.
People who live in or near forests may have indirect or low-level exposure to the infected animals.
Human-to-human transmission is often by close contact with respiratory secretions, skin lesions of an infectious person, or through nasal droplets. The infection is usually caused through prolonged exposure, which puts healthcare workers, household members, and other close contacts of the patients at greater risk. Human-to-human transmission can also occur through large respiratory droplets, and prolonged face-to-face contact may be required (within a six-foot radius for ≥3 hours without personal protection equipment). Transmission can also occur through close contact with infected skin lesions. In May 2022, an outbreak in non-endemic countries appears to be associated with sexual activity, although the exact transmission mechanism is not yet known.
However, the longest recorded chain of transmission in a given community has increased from six to nine subsequent person-to-person infections. This may be a reflection of declining immunity in all communities because of the cessation of smallpox vaccination programs. Transmission can also occur through breastfeeding or by skin-to-skin contact. It is unclear whether specific sexual transmission routes can transmit the monkeypox virus. More studies are needed to understand human-to-human transmissions.
How Common is Monkeypox?
Monkeypox is less common and milder than smallpox. The unusually high number of people infected with this virus outside of Africa with no known travel links to the region means the virus is now circulating in the community.
What Are The Symptoms?
Predominant symptoms include fever, rash, lymph node swelling, muscle aches, and chills. Most infections have mild symptoms and recover without medical intervention. For seriously ill patients, medical attention is necessary until the patient recovers from the infection. The fatality rate is approximately 10 percent for the Central African strain, and deaths generally occur in the second week of illness. In contrast, there were no deaths in the United States due to the less virulent strain.
Initial symptoms include:
- Fever (high temperature), headaches, swollen glands, back pain, and aching muscles
- When the fever breaks, a rash may develop, usually starting on the face and then moving to other skin parts.
- A rash usually starts as an itchy red spot, but it may change into a blistery sore, then a scabby sore, and finally a scab. Lesions can cause scars.
- The infection usually clears itself up within 14 to 21 days.
Monkeypox in The Workplace:
For several reasons, monkeypox will most likely NOT be a concern for an outbreak or epidemic for employers in the U.S. Firstly, infected persons are contagious only when symptomatic (in contrast to COVID-19). Secondly, no documented cases of human-to-human transmission during the largest outbreak of 2003, where 70 patients did not have any secondary infections. Infections are typically acquired through contact with an infected animal’s bodily fluids or a bite. Monkeys and humans occasionally are the source of infection. The primary reservoir/source of infection remains unknown but is likely to be certain rodents.
At this moment, the monkeypox virus doesn’t seem to be a concerning factor in the workplace. Even though the disease is “not another COVID,” experts highly recommend employers take caution and advise self-isolation for infected and exposed employees.
Dr. Cherry is the Chief Medical Officer for Axiom Medical. He is an energetic physician executive with a passionate focus on health, human performance, and prevention. He is dual board certified in Occupational/Environmental Medicine and Preventive Medicine/Public Health. He is a distinguished fellow within the American College of Occupational & Environmental Medicine.