San Francisco has seen its first probable case of monkeypox, part of a global outbreak that now involves nearly 800 people, mostly gay and bisexual men, the Department of Public Health announced Friday evening, June 3.
The health department said the person had recently traveled to a location experiencing an outbreak, but gave no further details about the case. The individual is in isolation and has reported no close contacts in San Francisco during the period when they could have spread the virus.
"The risk to the general population from this virus is believed to be low as the known cause of spread is prolonged contact and bodily fluids," the health department said in a statement. "Having close physical contact, including sex, with multiple people can put a person at higher risk for monkeypox."
In a media briefing earlier the same day, the federal Centers for Disease Control and Prevention said 20 monkeypox cases had been reported in 11 states — a number that rose to 25 by that afternoon (click here for the latest CDC numbers). All but one are men, and most have a recent history of international travel. In California, three confirmed or suspected cases have been identified in Sacramento and one in Los Angeles, in addition to the new San Francisco case.
CDC officer Captain Jennifer McQuiston told reporters that it is not clear how long monkeypox has been circulating in the U.S., and there "could be community-level transmission" that has not yet been identified.
The first case in the ongoing outbreak was reported May 7 in the United Kingdom. As of June 4, the World Health Organization has identified 780 confirmed cases in 27 countries where the virus is not endemic, with high numbers in several European countries and Canada. Previously, monkeypox was mostly seen in West and Central Africa.
So far, all but a handful of these cases have been men, most of whom identify as gay, bisexual, or other men who have sex with men. Many cases have been linked to a Pride event in the Canary Islands, a fetish festival in Belgium, and saunas in Spain and Montreal. While anyone can contract monkeypox through close personal contact, health officials are urging the gay community, in particular, to be alert ahead of this month's Pride events.
Close personal contact
The monkeypox virus is transmitted through close personal contact, including skin-to-skin contact, kissing, contact with clothes or bedding, and respiratory droplets at close range. But it is not thought to spread through the air at longer distances like the virus that causes COVID-19.
It is unclear whether monkeypox is directly transmitted through semen, but — like herpes and syphilis — it can spread through contact with sores during sex. (As a precaution, the U.K. Health Security Agency advises people with monkeypox to use condoms for eight weeks after infection.)
"Close contact is not only sexual contact," said Dr. Boghuma Titanji, an infectious disease specialist at Emory University. "If you are at a crowded concert, bar, or club, body to body with other people, that's close contact too. All forms of sexual contact are close contact. Infectious pathogens flourish with the right timing and opportunity. That's how outbreaks occur."
Monkeypox, which is related to smallpox but less severe, causes flu-like symptoms, swollen lymph nodes, and a rash that can occur on the face, in the mouth, or anywhere on the body; the lesions, which can be painful, typically progress from flat to raised to pus-filled. The virus has an incubation period of up to three weeks before symptom onset, and the illness typically lasts two to four weeks. Transmission is most likely when people are symptomatic, and they can remain infectious until the sores are completely healed and the scabs fall off.
However, the new cases do not always follow the classic monkeypox pattern, experts say. Some people have only one or a few lesions, often on the genitals or in the anal area, which may resemble more common sexually transmitted diseases. Some individuals do not experience associated symptoms such as fever, fatigue, or swollen lymph nodes.
People with monkeypox usually recover without treatment. The new cases have so far been mild, with no deaths reported. Certain antiviral medications used to treat smallpox can also be used for monkeypox, and smallpox vaccination prevents monkeypox as well. A recently approved smallpox and monkeypox vaccine, called Jynneos, is now being administered to high-risk contacts of known cases. Because monkeypox has a long incubation period, vaccination within four days after exposure can prevent illness, according to the CDC.
Health officials do not recommend vaccination for the general population, or for all men who have sex with men, at this time. Nonetheless, the federal government is ramping up Jynneos supplies. An older smallpox vaccine, called ACAM2000, is held in the national strategic stockpile in case of bioterrorism, but it can cause side effects and is not safe for some groups, including people living with HIV.
Alert but wary
While monkeypox is not a "gay disease," the current outbreak appears to be driven largely by transmission within sexual networks of gay and bi men, including at events and venues where men have sex or other close contact with multiple partners.
Fortunately, gay men and their providers have experience identifying and managing the spread of sexually transmitted diseases. Advocates say it's crucial that the CDC, local health departments, and LGBTQ and AIDS organizations raise awareness and marshal resources in the most affected communities.
"Everyone needs to step up their game. This is an all-hands-on-deck moment," said longtime HIV activist Gregg Gonsalves, an associate professor at Yale School of Public Health. "Public health departments are overstretched with COVID and our own organizations know our community best. We have the chance to contain this outbreak in our community, but we have to act swiftly, decisively, and put all our resources to this task."
Yet health officials and advocates are wary about emphasizing the gay angle for fear that LGBTQ people could again be subject to the kind of blame and stigma seen during the HIV epidemic — and that such stigma could deter people from seeking care. They also worry that focusing on transmission among gay men could lead other groups to think they're not at risk.
The San Francisco health department is monitoring updates and guidance from the CDC and the California Department of Public Health, the city agency said in a statement. Systems are in place to receive reports of suspected cases and to identify and reach out to individuals who have been in contact with them. The California DPH has procured the Jynneos vaccine for preventive use in people identified as close contacts.
"San Francisco is prepared for this case and others, should more occur. We want to emphasize that this is not a disease that spreads easily through the air like COVID-19, however, we do want people who might have been exposed to watch out for symptoms and to see a medical provider immediately if they develop symptoms for an evaluation," said city health officer Dr. Susan Philip. "While most cases resolve on their own, monkeypox can be serious in rare cases and we want to prevent further spread in the community."
Health officials are urging people to seek care for any unusual rash, no matter how mild, and asking clinicians to adopt a high level of suspicion that monkeypox might be a cause. The DPH advises people with a rash or other symptoms to avoid close contact — including sex — until a medical evaluation has been completed, inform sex partners of symptoms and cooperate with contact tracing. People experiencing symptoms should contact their regular provider, City Clinic at 356 Seventh Street or the San Francisco AIDS Foundation's Magnet sexual health center in the Castro.
For those planning for Pride and other upcoming events, CDC epidemiologist Dr. John Brooks told reporters during a May 23 briefing that the agency is not recommending that events be canceled. However, he encouraged people to "hold themselves back from participating if they're feeling ill and to seek evaluation if after an event they start feeling ill."
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