How Monkeypox Spreads: What to Know About Transmission and How to Protect Yourself

Digitally-colorized electron microscopic (EM) image depicting a monkeypox virion (virus particle), obtained from a clinical sample associated with a 2003 prairie dog outbreak, published June 6, 2022. The image depicts a thin section image from a human skin sample. On the left are mature, oval-shaped virus particles, and on the right are the crescents and spherical particles of immature virions. Courtesy CDC/Goldsmith at al. (Photo via Smith Collection/Gado/Getty Images)

Digitally-colorized electron microscopic (EM) image depicting a monkeypox virion (virus particle), obtained from a clinical sample associated with a 2003 prairie dog outbreak, published June 6, 2022. The image depicts a thin section image from a human skin sample. On the left are mature, oval-shaped virus particles, and on the right are the crescents and spherical particles of immature virions. Courtesy CDC/Goldsmith at al. (Photo via Smith Collection/Gado/Getty Images)

Photo: Smith Collection/Gado/Getty Images

As the monkeypox outbreak intensifies with each passing day here in the United States and globally, researchers are learning more about how the virus spreads and infects people.

But as was the case during the earliest days of the COVID-19 pandemic, misinformation and confusion about the virus’ transmission is also spreading, particularly on social media—and in some cases that misinformation is spreading even faster than the monkeypox virus itself.

In order to get the virus under control and allow individuals to protect themselves, or get treatment if needed, it's important to accurately understand how monkeypox transmission really takes place.

Here's what you need to know about how the virus spreads, your risk of getting it, and how to stay safe while avoiding misinformation.

These Pictures of Monkeypox on Skin May Help You Identify Rashes or Lesions

Monkeypox's Primary Mode of Transmission

Monkeypox can be transmitted in a number of ways, although by far the most common is from direct intimate contact, said Hana El Sahly, MD, professor of molecular virology and microbiology at Baylor College of Medicine.

“The two most important ways of transmission of monkeypox are through skin contact or through mucosal surfaces, especially the respiratory ones,” Dr. El Sahly told Health. These mucosal surfaces include the mouth, rectum, and genitalia.

"The sexual contact is potentially allowing for one or both of these modes of transmission to take place," she added.

The reason for this, added David Wohl, MD, professor of medicine in the division of infectious diseases at the University of North Carolina, Chapel Hill, has to do with just how infectious the actual monkeypox sores are.

"While there could be sophisticated studies that use PCR techniques to find monkeypox virus in somebody's saliva or their semen, or on their elbow, it really is the weeping lesions that pose the most risk," Dr. Wohl told Health.

And though monkeypox can be spread through any kind of intimate contact, right now, the virus seems to be primarily passing between men who have sex with men. The CDC reported that 99% of confirmed monkeypox cases in the U.S. are in men, and 94% are in men who recently engaged in close intimate contact with a man.

This certainly doesn’t make monkeypox a disease that can only be passed around in queer communities, however. And, the CDC has made clear that monkeypox is not considered a sexually transmitted disease (STD) at this time. It’s certainly easy for monkeypox virus to pass from person-to-person when that direct skin or mucous membrane contact is happening during sex, but any close contact with a lesion could put a person at risk.

"This found a niche in sexual networks, and that's where it's been able to travel, just like a boat or a raft along the river," Dr. Wohl explained. "But once that river starts to branch out to other tributaries, we start to see other types of folks that will—we're starting to see this now—get infected."

Monkeypox in Children: What Parents Need To Know About the Risks

Other Possible Modes of Transmission

Because monkeypox doesn't necessarily need to be passed via sex, the population at large may be concerned about whether they need to restrict close contact with people in public, or even with public objects, surfaces or foods.

The good news is that even though this sort of casual transmission can happen, it's highly unlikely that a person would catch the virus this way.

Infections From Surfaces, Objects

Many Twitter users may have seen stories online alleging that monkeypox on surfaces can infect people at any given time. One such story was from an individual who said they contracted monkeypox from scooter handlebars, which later turned out to be false. Additional tweets about catching monkeypox from toilet seats have been circulating on the site.

The question of transmission via surfaces can be a bit complicated, since it’s true that monkeypox can linger on surfaces for longer periods of time, putting people at risk. In one study, the CDC says the monkeypox virus was found in a person’s home 15 days after they left it unoccupied.

But even though monkeypox can linger on surfaces and objects if a person with lesions comes into contact with them, it's unlikely that this 'fomite transmission' as it's called, will actually take place.

"A person can find E. coli in their sponges at home," Dr. Wohl added. "But it doesn't necessarily mean that we're going to get food poisoning from it. Monkeypox transmission from surfaces is likely similar."

“In most cases, the inoculum, the amount of germ there is not enough to make us sick even if it’s present,” Dr. Wohl said. “So while somebody who has monkeypox might touch something, the chances that thing is infectious to somebody else depends upon the conditions.”

In addition to the large amount of virus that would need to be present on a surface to cause transmission, a person would also have to touch their eyes, nose, or mouth after touching this contaminated surface in order to get sick with monkeypox. With the number of cases so far, Dr. Wohl said, the fact that only a few have been linked to fomite transmission likely means that the odds of catching it this way are very rare.

"Concern about transmission via fomite is low for the general public at the current stage of the outbreak," Dr. El Sahly added. "However in households with a case of monkeypox, or in healthcare facilities administering care to monkeypox patients, attention should be given to transmission via fomites."

Close Contact in Public Spaces

Even though getting monkeypox from touching a contaminated surface is fairly unlikely, there are other concerns about how a person might catch monkeypox without sexual contact. Crowded train cars, festival or concert crowds, or bars and nightclubs are all places where people may be having close contact.

This is another mode of transmission that, though possible, is probably unlikely, Dr. Wohl said.

"Festivals, bars, and concerts where attendees are fully clothed and unlikely to share skin-to-skin contact are safe. However, there are activities that occasionally take place at these and other locations (like kissing) that might spread monkeypox," Dr. El Sahly added.

Another question circulating online is whether, like COVID, monkeypox could be spread in the air through coughing, sneezing, or breathing. The hashtags #MPXisAirborne and #MonkeypoxIsAirborne are being shared on Twitter. But catching monkeypox this way is yet again possible, but unlikely.

"It's not like COVID-19, the SARSCOV2 virus, which can float on air really far. The monkeypox virus is bigger, it can be found in droplets. So that would mean that somebody maybe who has a mouth lesion and who's coughing or sneezing, maybe they could propel this out and people can get it," Dr. Wohl said. "I'm not as worried about respiratory transmission."

People who have monkeypox and those they may be coming into contact with—like family members or healthcare workers—are encouraged to wear masks, the CDC says.

It would make sense for additional prevention measures, such as mask wearing, to be adopted more widely, Dr. El Sahly added. Such a step would lower a person's risk of catching the virus in public places or in healthcare facilities.

In general though, casual contact does not seem to be a major player driving the outbreak right now.

"Monkeypox doesn't seem to be that particularly hyper, super infectious. It doesn't seem to be something that people are catching by sitting on toilet seats or trying on clothes, or being on subways together," Dr. Wohl said. "That just doesn't seem to be a good way that this virus can transmit from one person to another. This virus likes to be transmitted, if you will, by direct contact, and that's what I would be worried about."

Although, it's worth noting that just because these modes of transmission are more uncommon, it doesn't mean there's no risk of catching monkeypox this way.

An early release research letter a team of Stanford researchers found that a man in California contracted monkeypox after having no recent sexual contact with anyone. Researchers said the case could highlight the possibility of virus transmission at crowded outdoor events or through contaminated sheets or surfaces.

"The virus is capable of transmitting in other ways, which makes most persons at risk of acquiring and transmitting the virus," Dr. El Sahly said. "It may seem like it is too much to go through and absorb, having went through COVID-19, but we all need to be armed with knowledge and be cautious."

What Steps Can You Take to Slow the Spread of the Outbreak?

Being knowledgeable about monkeypox and how it spreads is a good first step toward getting the outbreak under control.

It's easy to fall victim to online confusion and fear, Dr. Wohl said—part of our instinct as humans is to be afraid of and want to avoid pathogens so that we stay safe. But, because we know a good deal about monkeypox and how it spreads, people should be able to make a relatively informed call about how much they may or may not be at risk of catching monkeypox at this stage of the outbreak.

Dr. Wohl added that even though men in gay and bisexual communities have been the biggest targets for testing and vaccination efforts, really anyone who has sex with men could be at risk of getting monkeypox—in particular, transgender women and sex workers have largely been left out of the conversation, he adds.

"The chance of any one person who has sex with a man getting infected is really, really low. But if you're in a place where there has been more transmission with monkeypox, if you're in sexual networks where the virus has found itself and concentrated, your risk is higher," he said.

To protect against transmission, it’s best to have an open conversation with your partner and, before engaging in close contact, make sure that they’re not feeling sick or experiencing any rashes.

Monkeypox seems disgusting or terrifying to a lot of people, Dr. Wohl said, which he thinks is in part due to the virus' name. But doing what we can to avoid stigma, get tested and vaccinated, and be extra cautious if need be are all steps in the right direction.

"We're going to have to be a little bit more cautious right now, but most of us don't have to do anything different than what we're doing now—good hand hygiene. I think COVID-19 mitigation strategies have helped us for flu. I think they've helped us obviously for COVID-19 and they can help us here too," Dr. Wohl said.

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