Monkeypox, a viral zoonotic infection that has spread to several non-endemic countries this year, has afflicted more than 31,000 people around the world, including nine cases in India.

While the origin of the virus is still a mystery, social stigma around the disease is widespread. "Studies are underway in affected countries to best determine how people are being exposed to monkeypox... It is essential that no one stigmatise anyone who is affected by this event because anyone can get monkeypox and because stigma can undermine control efforts," said the World Health Organization.

To offer scientific information and bust popular misconceptions around the disease, FactChecker spoke to three experts — Dr Ishwar Gilada, infectious diseases expert and a consultant for HIV/STDs, Dr Umang Agrawal, Infectious Diseases Consultant, PD Hinduja Hospital & Medical Research Centre, and Dr Jacob John, virologist and former professor at Christian Medical College, Vellore.

The first step in addressing the virus is through public education and facts, to amp up research in antivirals for monkeypox and increase skilled virology laboratories in every Indian state, said Dr John.

Myth #1: Monkeypox is an airborne virus

Fact: Unlike COVID-19, monkeypox is not highly contagious as it is not an airborne disease, said Dr Gilada. Monkeypox is primarily transmitted by close skin-to-skin contact. Close contact has to include face-to-face contact, intimate physical contact, such as kissing, cuddling, or sex.

"The human-to-human transmission usually results from skin-to-skin contact which is inevitable in sexual encounters," Dr John told FactChecker. "Semen is rich in viruses in infected males and its deposition into rectum or mouth is highly infectious. The respiratory fluids also contain viruses and close face-to face contact can also be infectious."

There's high risk of transmission from infected secretions during sexual contact. When asked if monkeypox can be clubbed with other sexually transmitted infections (STIs), such as herpes, gonorrhea and HIV, Dr Agrawal said, "STIs generally include infections transmitted through bodily fluids such as through semen or vaginal secretions only. However, monkeypox is predominantly transmitted when the patient comes in contact with infected discharge from lesions of monkeypox. So, technically it does not fit into the definition of STIs."

Myth #2: Monkeypox affects only the LGBTQI+ community

Fact: Monkeypox is mainly transmitted through any close contact, including sex. Hence it can affect anyone regardless of gender and sexual orientation, the doctors said. While the outbreak is currently spreading among sexually active queer (mainly gay and bisexual) men as well as some transgender people, at least five children in the United States and one pregnant woman are also among the infected.

Moreover, complications associated with monkeypox were more frequent in children and people who are immunocompromised with an increased risk of bacterial superinfection, sepsis, keratitis, respiratory complications due to pharyngeal abscess and pneumonia, or encephalitis, according to an article in The Lancet.

When asked about why the virus is predominantly found in queer men, Dr Agrawal, said, "It is still difficult to really say as to why monkeypox is overwhelmingly seen in queer men but this is being researched. It just happens that the infection was introduced in a certain community and it is likely to spread faster in communities because of frequent close contact."

Dr Gilada, who is currently treating two monkeypox patients, said there is a lot of phobia and misinformation around this disease. "Patients and their families have been hounded and asked unnecessary questions by health officials who have no prior experience in dealing with HIV or similar diseases. This increases fear among people belonging to the LGBTQ community as well as those outside the community. Due to the lack of awareness and stigma attached to the disease most are reluctant to even visit or be examined by doctors," said Dr Gilada.

The National AIDS Control Organisation which is under the Union Health Ministry has more than 20,000 Integrated Counselling and Testing Centres mainly located in government hospitals. An ICTC is a place where a person is counselled and tested for HIV, of their own free will or as advised by a medical practitioner. Dr Gilada suggested that NACO should open a new wing to exclusively deal with patients with monkeypox as they are better equipped.

"NACO's Integrated Counselling and Testing Centres are in partnership with most high-risk communities such as the transgender community, people with multiple sexual partners, sex workers. Let NACO deal with it. These doctors have dealt with HIV cases before and can deal with the patients in a sensitive manner," said Dr Gilada.

Myth #3: Rashes are the only symptoms of Monkeypox

Fact: While rashes are one of the main symptoms of the disease, there are a total of four main symptoms to look out for: fever, rashes located in or near the genital area, anus, hands, or feet, swollen lymph nodes and difficulty in swallowing said Dr Gilada. Other symptoms include myalgia (pain in muscles), exhaustion, headache and respiratory symptoms such as nasal congestion and cough.

According to the Centers for Disease Control and Prevention (CDC), initially, the rash can look like pimples or blisters and may be painful or itchy. Later, a dent may appear on the rash. Monkeypox symptoms usually start within three weeks of exposure to the virus, said Dr Agrawal. Usually, the first phase is when someone is infected but does not feel sick for a couple of days.

During the second phase, the person may show flu-like symptoms and can be contagious now. In the third phase, lesions appear on the skin, genital area, inside the mouth, etc. It is confirmed that a person is contagious during this stage. However, for some people the rash appears before the flu-like symptoms, explained Dr Agrawal.

"Monkeypox can be spread from the time symptoms start until the rash has healed, all scabs have fallen off, and a fresh layer of skin has formed. The illness typically lasts 2-4 weeks," says the CDC.

Myth #4: Monkeypox is always symptomatic

Fact: Asymptomatic cases are generally those with mild symptoms. "In this case, mildly symptomatic and asymptomatic cases are usually clubbed together," said Dr Gilada.

Immunity of the host, virulence of the parasite and the environment are three most important things in this infection. "Some people remain asymptomatic mainly because their immunity is good, virulence of the organism is low and they might be vaccinated with the smallpox vaccine," explained Dr Gilada.

Myth #5: Monkeypox cannot be treated

Fact: While there is no targeted treatment for monkeypox, it can be treated with antiviral medications such as tecovirimat (TPOXX), which may be recommended for people with severely weakened immune systems. However, Dr Agrawal said most patients are likely to recover on their own.

However, according to Dr John, two smallpox vaccines may help in dealing with monkeypox. "Jynneos and ACAM2000 vaccines have been approved by the Food and Drug Administration in the US for prevention and immunisation against monkeypox," said Dr John.

It is vital for those who experience these symptoms to contact a doctor or local health department for further guidance. The doctors said it is important to avoid close contact, including sexual intercourse until the infected person recovers and is examined by a healthcare professional.