Monkeypox virus (MPXV), a double-stranded DNA virus, is part of the same family of viruses as the variola virus, the virus that causes smallpox.

Monkeypox was first reported as a zoonotic infection transmitted from animals to humans in 1958. The first human-to-human transmission outbreak was reported in 1996 in the Democratic Republic of Congo through respiratory droplets and direct contact with infected individuals.

As international travel became more common, viruses that were once fairly confined to certain locations more easily spread around the world. In July of 2021, a case of Monkeypox was found in a U.S. resident who had traveled from Nigeria to the United States. However, unlike the current outbreak, this case did not result in any known community transmission.

Despite the limit on international travel due to SARS-CoV-2 (COVID-19), we are experiencing a global outbreak of Monkeypox. As of August 7, 2022, there are 28,781 confirmed cases in nearly 82 countries, most of which are seeing their first Monkeypox cases.

What’s troubling about the current cases is that Monkeypox appears to spread through simple close contact with an infectious rash, lesions, scab, or bodily fluids. It can also be transmitted through respiratory secretions during prolonged face-to-face contact or during intimate physical contact, including cuddling, kissing, or sex. It is not yet known if it is spread through semen or vaginal fluids, but there is growing evidence that that route is likely.

Further complicating matters is that Monkeypox symptoms usually start within three weeks after exposure to the virus. A rash typically begins on the face and spreads to many areas of the body, including the mouth, chest, hands, feet, and genitals. The rash evolves sequentially from macules to papules to vesicles to pustules (sores) that crust and fall off.

Infected individuals are only thought to be contagious from when they have symptoms to when all sores, including scabs, have healed and a fresh layer of skin has formed. This can take several weeks. Researchers are still trying to understand if the virus can spread from someone with no symptoms or very few bumps on their skin.

Recently, the global medical diagnostics company Flow Health has developed a novel PCR assay to detect Monkeypox from saliva specimens. The advance allows testing of individuals prior to the development of lesions. We’ve seen individuals test for Monkeypox who actually have COVID-19. Alarmingly, there have been cases of individuals with both illnesses.  

At Flow Health, we have observed that nearly every positive case has reported a viral prodrome period of flu-like symptoms. One of the major challenges this fall will be to delineate between COVID-19, influenza, and Monkeypox, as they are initially present with the same symptoms, namely fatigue, fever, chills, muscle aches and backache, as well as respiratory problems.  Swollen lymph nodes can also be a telltale sign, after which a rash typically appears.

The current stigma is that Monkeypox is an STI/STD within the gay community. While intercourse is clearly an early vector for transmission, Monkeypox is not an STI/STD, though Monkeypox is especially risky in close contact situations (skin to skin, droplet, and fluid exposure). While public health has mostly limited Monkeypox testing to high-risk individuals, there are widespread reports of Monkeypox spreading to the population in general through non-sexual activities.

The World Health Organization has recently reported that in endemic countries, the Central African clade (clade 1) fatality rates are as high as 10%, and the Western African clade (clade 2) fatality rates are 3-6%. Researchers found the current strain, clade 3, diverges from clade 2 by 50 single nucleotide polymorphisms (SNPs), and several mutations have made the virus more transmissible. Monkeypox outbreaks from clade 3 are much less fatal than clade 1 and 2, with a 1% case-fatality rate.

Complications of Monkeypox can include secondary infections, bronchopneumonia, sepsis, encephalitis, and cornea infection with ensuing loss of vision. Further, the post-acute sequelae of clade 3 are yet to be researched.

As we’ve learned from the early days of COVID-19, cases often get misdiagnosed, leading to exponential transmission. The US has tripled its Monkeypox cases in just 15 days after the Centers for Disease Control and Prevention (CDC) recorded 1,424 additional cases on Monday, the highest daily count since May.

We believe it’s a public health and vital medical standard of care to screen everyone, men, women, and children presenting with flu-like symptoms for Monkeypox. Our goal is to administer early treatment to break the chain of transmission and prevent another worldwide pandemic.

We respectfully call on the CDC and FDA to get behind alternative specimen types such as saliva to make testing during the prodrome period accessible and viable for every American.