The monkeypox outbreak continues to accelerate worldwide; by some counts, the U.S. now harbors the most significant number of currently known cases. Pathways for the initial spread beyond endemic areas for this current worldwide outbreak are thus far unclear but may be at least in part related to international infected passenger travel. Now, with elevating case counts, there remains an increased risk of infected persons spreading disease during travel-related activities.

Many right now tend to ignore or downplay their own risk of contracting this disease, as a majority of current reported cases are still related to intimate male-to-male contact.

However, cases are now being reported among children, non-sexual household contacts, and male and female transportation workers.

Yes, there are other pathways for the transmission of monkeypox. This disease is most commonly spread when someone is in very close contact (often skin-to-skin) with an infected person, not just intimate contact. But transmission can also occur from contacting virus-contaminated objects or surfaces or via contaminated dust particles.

In Africa, where monkeypox is endemic, most cases are now reported to arise from household transmission (not sexual contact), and only around 60% of these cases involve men. In addition, as monkeypox is a “zoonotic” virus, it can be transmitted by animals and thus spread by contact with infected animals such as rats, squirrels, prairie dogs, or monkeys. (The term “monkeypox” is thought by some to be a misnomer as the most common vector animals are rodents).

Most previous U.S.-occurring monkeypox case reports have been related to the spread caused by infected animals imported to the U.S. or by persons infected while abroad in endemic areas and then returning to the U.S.

This current outbreak has been profoundly more aggressive and widespread for reasons that are not totally clear to the experts!

Monkeypox is not currently known to be “airborne,” thus, the infection must occur by direct or extremely close contact with an infected person or by contact with contaminated surfaces or materials. The virus can enter the body through broken skin, the respiratory tract, or through the eyes, nose, or mouth, including inhalation of very close-proximity contaminated respiratory droplets or via transport by contaminated dust particles.

Survival times for virus particles on contact fomites such as door handles, counters, and tabletops are reported as highly variable based on multiple factors. But, exposure to the sun, simple disinfectants and unfavorable conditions such as hard, non-porous surfaces will significantly limit virus survival times.

Pox survival times are significantly increased on absorbable and porous materials such as clothing, linens, and bedding. The CDC notes that pox viruses can potentially survive in these materials for up to 15 days but can possibly, under favorable circumstances, survive for months or longer. Though there are currently few published estimates on the potential level of risk for transmission via contact with contaminated clothing, bedding, or surfaces, various experts note these as “possible” vectors. There have been reports throughout history of pox viruses being transmitted via contaminated blankets, clothing, and similar materials.

The true risk from contact or inhalation of aerosolized, contaminated dust particles remains unclear but is listed as possible. Dust particle-associated risk is greatest for those who directly agitate and aerosolize these particles.

All risks, however, increase if there are growing numbers of infected persons circulating in the population (the current situation).

This means that monkeypox-infected individuals with active disease can, via secretions and/or draining vesicles, potentially contaminate surfaces and materials in the seats, rooms, and areas in which they are traveling or residing.

The CDC, the EPA, and other agencies offer guidelines on cleaning and disinfecting potentially monkeypox-contaminated items. Using simple soap, hot water or common disinfectants will suffice for most materials, depending on the material or surface. Guidelines include avoidance of dry dusting of potentially contaminated spaces/surfaces (wet dusting recommended) and avoiding shaking or other perturbations of contaminated clothing, linens and bedding materials during removal and transport to avoid shedding infectious particles.

Final thoughts

With the rapid increase in the spread of this disease, increasing numbers of infected individuals may be transiting in commercial transportation and residing in hotels or other similar facilities. Such conditions may place transportation and hospitality workers, especially those who are responsible for servicing and cleaning hotel rooms, airplanes, taxis and other conveyances, at increased risk.

Two recommendations for hospitality and transportation workers:

1. Personnel who provide cleaning services should continue to use the precautions enacted during the current COVID pandemic — including personal protection while cleaning and follow CDC, EPA, and other applicable guidelines — now with the additional precautions for potential monkeypox contamination when servicing public conveyances, hotel rooms, and other guest facilities. Special care should be used with linens, bedding and other more porous, absorbent surfaces and when dusting.

2. Policy decision-makers should consider this group as having a potential increased risk for contracting monkeypox disease and, thus, should be granted rapid access to monkeypox vaccines.

Harry Severance is an emergency physician.

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