Suspected monkeypox cases rise in California; officials expect more to come

The number of confirmed and suspected monkeypox cases in California climbed to eight on Wednesday as officials in L.A. County and San Francisco said they were prepared to see more cases.

Officials said it was crucial that people become aware of the symptoms and healthcare providers be on alert for new cases, as the telltale rash — which has been seen in some recent cases first in the genital area — can sometimes appear similar to more common sexually transmitted infections. Health officials say they're hoping to contain the monkeypox outbreak but say it's possible there is already community spread of the virus.

“While most cases resolve on their own, monkeypox can be serious in rare cases and we want to prevent further spread in the community," said Dr. Susan Philip, the health officer in San Francisco, which reported its first suspected monkeypox case Friday.

"We need to be prepared for seeing more cases," Los Angeles County Public Health Director Barbara Ferrer said, although she added there's no indication at this time that there's going to be a massive outbreak of monkeypox locally.

L.A. County reported its first suspected monkeypox case last week and a second case on Wednesday. Both cases occurred in people who recently traveled; the patients were under isolation.

Sacramento County has reported five confirmed and suspected monkeypox cases, according to the California Department of Public Health.

As of Wednesday afternoon, there were 40 confirmed and suspected cases of monkeypox nationally, with the most number of cases in New York (nine); California (eight); Florida (four); Colorado and Illinois (three each); and Utah and the District of Columbia (two each).

The specific monkeypox variant that has been found in the majority of cases in the U.S. has been linked to the variant that has appeared in Europe, Capt. Jennifer McQuiston, deputy director of the U.S. Centers for Disease Control and Prevention's Division of High Consequence Pathogens and Pathology, said at a news briefing Friday.

Nationally, most of the monkeypox cases known to the CDC involve people who have recently traveled or have had close contact with someone who was infected. But at least one of the recent cases in the U.S. involves someone who doesn't know how they were exposed to the virus, McQuiston said.

"This could be happening in other parts of the United States — there could be community-level transmission that is happening. And that's why we want to really increase our surveillance efforts," McQuiston said. "We want to really encourage physicians that, if they see a rash and they're concerned it might be monkeypox, to go ahead and test for that."

Health officials have noted that early data show that a high number of the current monkeypox cases are among men who have sex with men; however, anyone can be infected with the virus, including healthcare workers and family taking care of those who are ill. One recent case has occurred in a woman, McQuiston said.

Monkeypox was first discovered in 1958 in colonies of monkeys kept for scientific research. Most human cases of monkeypox have historically been identified in the Democratic Republic of Congo, where a human infection was first identified in 1970. The monkeypox virus is naturally found in certain wildlife in that country; the CDC says rodents and nonhuman primates, such as monkeys, may harbor the virus and infect people.

For global travelers, the CDC has issued a Level 2 monkeypox travel alert, warning about cases related to the current outbreak on every continent except for Antarctica.

In the current outbreak, 1,200 confirmed and suspected monkeypox cases have been reported from 29 countries, with the most cases being reported in Europe and North America. Of them, Britain has reported more than 300; Spain and Portugal, about 200 each; and Germany and Canada, more than 100 each.

The CDC urged world travelers to avoid close contact with sick people, including those with skin and genital lesions; avoid contact with dead or live wild animals such as small mammals and nonhuman primates, such as monkeys and apes; avoid eating meat that comes from wild game or using products that come from wild animals from Africa, such as creams, powders and lotions; avoid contact with contaminated material used by sick people such as clothing; and wear a mask, which can provide further protection against many diseases, including monkeypox.

Health officials emphasized that the threat to the general population was low, given that monkeypox is not nearly as contagious as other infectious diseases, such as COVID-19. Between humans, monkeypox can be transmitted through close, sustained, skin-to-skin contact with someone who has an active rash and skin sores. The virus can be spread during sexual and intimate contact and through shared bedding and clothing. It’s also possible it can be spread through kissing and breathing at very close range.

Monkeypox can also be spread from animals to humans through a bite or scratch from an infected animal, handling wild game or using products made from infected animals.

Spreading through the air is not thought to be a major avenue for monkeypox transmission, given that past disease investigations have shown that monkeypox-infected people who are likely contagious on an airplane flight have not spread the virus to other passengers.

Health officials and experts have sought to strike a balance in their warnings, noting that people generally recover from the disease while also underscoring the urgency to contain the outbreak and identify cases, and warning that the skin lesions can be quite painful in some cases.

“It can be really painful, and some patients have reported needing prescription pain medicine to manage that pain. The sores can also cause long-term scarring on the skin,” McQuiston said.

Traditionally, monkeypox is believed to begin with a fever and feeling of being unwell, followed by a rash. But in some of the recent cases, the rash has appeared first. Other symptoms can include headache, muscle aches, backache, chills, exhaustion and swollen lymph nodes. Rare complications include lesions that appear in the eye, which can endanger vision.

The monkeypox rash results in well-rounded skin lesions, and as they progress, they turn into papules, which are raised areas of the skin that can appear like a pencil eraser, McQuiston said. They can then fill with a clear fluid, which turns into pus.

The rash can appear similar to syphilis and herpes, which are far more common than monkeypox. McQuiston said it can be confusing to initially distinguish monkeypox from other illnesses, and that’s why healthcare providers should be on the alert for potential cases and request a test if they think it could be monkeypox. In some recent cases in Europe, people have been simultaneously infected with monkeypox and a sexually transmitted infection.

“They should test for monkeypox even if they think they might have a positive test for another, more common” sexually transmitted infection, McQuiston said.

No deaths have been reported in the current monkeypox outbreak worldwide, McQuiston said. Patients whose cases have been reviewed by the CDC as of Friday are either recovering or have already recovered, “and those who still have a rash are being advised to stay home and stay away from other people until they’re fully recovered.”

Full recovery happens “when all of the sores have scabbed over, the scabs fall off, and new healthy skin has emerged,” McQuiston said. A person is no longer contagious once all the scabs have fallen off.

Recent monkeypox cases in the U.S. known to CDC officials have been among adults, McQuiston said, and most reported international travel in the 21 days before their symptoms began. It generally takes seven to 14 days for a person to develop symptoms after being exposed to monkeypox, but it can take up to 21 days.

McQuiston said authorities are working hard to contain the outbreak.

“Our containment strategy is focused on identifying cases, identifying their contacts and making sure they get vaccine offered to them and that cases are being isolated to prevent onward spread,” McQuiston said.

The recent outbreak is concerning because monkeypox cases are not usually found in the U.S., officials have said.

The only previous U.S. outbreak of monkeypox occurred in 2003, leading to 71 confirmed or suspected cases — mostly in Wisconsin, Indiana and Illinois. Those who were infected had come in contact with pet prairie dogs obtained from an animal distributor in suburban Chicago that had been housed near Gambian giant rats and dormice that came from Ghana.

Though monkeypox can be fatal in countries where healthcare resources are poor, the 2003 U.S. outbreak did not lead to any deaths.

This story originally appeared in Los Angeles Times.