Monkeypox - Frequently Asked Questions (FAQ)

Update 1 September 2022

This information is oriented towards the general public and serves in no way as a replacement for medical advice. This outbreak differs from previous outbreaks. Therefore, these recommendations will be updated as more information becomes available. We always try to stay on top of new developments. However, information changes rapidly, despite our efforts to keep this page up to date. If you discover an error, please let us know. We will review the content and correct it as soon as possible.

Where does monkeypox occur?

Until recently, monkeypox was a disease found mainly in forested areas in Central and West Africa, namely in the Democratic Republic of Congo and Nigeria. Since May 2022, there has been a major outbreak outside the African continent. Countries in Europe and North America have been particularly affected, including Belgium.  

How many cases are there in Belgium?

As of early August 2022, there are more than 20,000 confirmed cases in the world, including seven hundred in Belgium.

See the current epidemiological situation:

What are the symptoms?

Often, 5 to 21 days after infection, a flu-like syndrome (fever, muscle aches, headaches, general discomfort) develops, followed by skin lesions. These skin lesions can be (red) spots, pimples, blisters or suppurative bumps, which finally heal after scabs have formed. These skin lesions can occur anywhere on the body and are sometimes painful. They are often found at the site of infection, especially around the anus, on the penis or in the mouth. These skin lesions can also occur without fever or flu-like syndrome.

We also see less classic presentations, such as people who have little or no skin lesions or who only have local symptoms, such as an inflammation of the throat, the anus or the urethra.

How is monkeypox diagnosed?

The doctor bases his or her diagnosis on the visible symptoms. For confirmation, a sample will be used, such as a swab of the skin lesions, a swab of the throat or the anus, or a saliva sample. The presence of the virus is then established via a PCR test (of the swab).

The samples must be taken in protective circumstances. To avoid contamination, it must be done in a separate room by a care worker wearing protective clothing.

I have monkeypox. What should I do?

To prevent further contamination, you should self-isolate at home until all lesions have completely dried up. This means:

  • Stay at home. Leaving the house is only allowed for essential reasons, such as medical appointments and urgent errands if no one else can take care of it. Do you need to leave the house anyway? Then wear a surgical mouth mask and cover the skin lesions (e.g. by wearing long sleeves and trousers).
  • Stay in your own room. Wear a surgical mask if you do leave the room or have contact with housemates.
  • Do not share household items such as clothing, bedding, towels and eating utensils with other members of the household.
  • Avoid physical contact, especially sexual contact, until the skin lesions have healed (scabs have fallen off). Condoms alone may not give full protection against monkeypox.
  • Avoid contact with animals (especially rodents such as mice, rats, hamsters, guinea pigs).
  • Notify the people with whom you have had close contact in the last three weeks. So they can monitor themselves for fever and skin symptoms, and report if any symptoms appear.

Can I be cured of monkeypox?

Fortunately, the disease usually heals spontaneously after a few weeks, without any residual lesions. Sometimes a scar remains. A small minority of patients need to be hospitalised, usually for pain control. Serious complications, such as severe inflammation or infection of the skin lesions, occur rarely. Fortunately, the fatality rate of the disease is very low.  As of early August 2022, only 4 deaths have been reported: 1 in Brazil, 1 in India and 2 in Spain (out of more than 20,000 confirmed cases).

Can monkeypox be treated?

No specific treatment is currently available. Targeted antiviral drugs are currently only used for scientific research. In case of complaints, the symptoms are treated with analgesics, antipyretics, anti-itch medicines, etc. Serious cases with a complicated form of monkeypox can be treated with the antiviral drug tecovirimat (currently only during hospitalisation). These are usually patients with some form of immune abnormality, such as leukaemia, or patients taking medication that acts on the immune system. A number of treatments are available in Belgium.

How can I avoid contracting monkeypox?

  • Avoid contact with people who have the disease (or who are suspected of having the disease based on their symptoms) until they are allowed out of isolation.
  • Limit your sexual contacts and discuss monkeypox with your partner. Anonymous sexual contacts are a risk and make it difficult to notify exposed partners in time.

There is currently no approved medication to protect you from exposure.

Vaccination is currently used as a tool to reduce the further spread of monkeypox. It is offered both immediately after a risk exposure (such as after sex with a patient who tested positive for monkeypox) and before a risk exposure in certain target groups with multiple sexual contacts (such as sex workers).

Due to limited data on individual protection, the vaccine cannot be seen as the ultimate solution against monkeypox. After vaccination, one can still be susceptible to monkeypox: a vaccine does not protect.

General measures remain necessary:

- modification of risk behaviour,

- isolation and

- avoiding sexual and skin-to-skin contact with sick people.

How do you contract monkeypox?

You can get monkeypox through:

  • Direct contact with skin lesions that contain a lot of virus. For example, through prolonged skin-to-skin contact or sexual contact.
  • Contact with body fluids or mucous membranes of an infected person. In infected patients, we often find high concentrations of virus in the saliva and anal, but also sometimes in the semen.
  • Spread by saliva droplets is possible, but probably less efficient.
  • In theory, transmission via contaminated surfaces or linen (such as bedding or towels) is also possible.

In the current outbreak in Europe, for the time being, mainly men who have sex with men (MSM) are infected. Sexual contact appears to pose the greatest risk of infection, more so than skin-to-skin contact. Kissing also seems to be a risk exposure. Persons who have several sexual partners should be particularly vigilant.

What should I do if I had close contact with an infected person?

If you came into contact with someone infected with monkeypox, you should take a number of measures depending on the risk. This also applies if you have been vaccinated. After all, there is insufficient certainty about the degree of protection after vaccination.

In case of a high or very high-risk contact (sexual contact, intense skin-to-skin contact or another kind of contact: see above)

  • Be on the lookout for possible symptoms for 21 days. Call a centre that tests for monkeypox as soon as symptoms start showing.
  • Avoid sexual contacts and other kind of close contact.
  • Avoid contact with children, pregnant women and immunocompromised persons.
  • Avoid contact with mammals.

In case of very high-risk contact (sexual, intense skin-to-skin contact)

  • Wear a surgical mouth mask for all contacts with other people.
  • In case of contact with young children (e. g. in nurseries), pregnant women or people with immune disorders, stay in quarantine for 21 days.

What should I do in case of close contact with an infected person?

If you came into contact with someone infected with monkeypox, you should take a number of measures depending on the risk. This also applies if you have been vaccinated. After all, there is insufficient certainty about the degree of protection after vaccination.

In case of a high or very high risk contact (sexual, intense skin-to-skin contact or other contacts: see above)

  • Monitor possible symptoms in yourself for 21 days. If you have symptoms, call a centre that tests for monkeypox.
  • Avoid sexual contacts and close contacts.
  • Avoid contact with children, pregnant women and immunocompromised persons.
  • Avoid contact with mammals.

In case of very high risk contact (sexual, intense skin-to-skin contact)

  • Wear a surgical mouth mask for all contacts with other people.
  • If you come into contact with young children (e.g. in nurseries), pregnant women or persons with immune disorders, stay in quarantine for 21 days.

I suspect I might have monkeypox. What should I do?

Contact the outpatient clinic of ITM by calling 03 247 66 66 (on weekdays from 9am to 5pm) if:

  • you've developed unexplained skin lesions with vesicles or skin lesions around the anus and you either:
    • are a man who had intimate contact with one or more men within the last few weeks;
    • have been in West or Central Africa.
  • you've had close contact with someone infected with monkeypox in the last few weeks and you either:
    • developed a fever;
    • developed skin lesions;
    • have complaints of inflammation of the throat, anus or urethra.

If you live outside of Antwerp, you can contact the emergency department of a hospital with a local infectious disease specialist (travel clinics/yellow fever vaccination centres).

Always contact the health care providers before visiting the clinic. This allows the healthcare workers to prepare themselves and make sure they are able to follow the strict protective measures. If in doubt, you can always contact your doctor by phone, but always mention before your consultation that you suspect to be infected with the monkeypox virus.

Does a vaccine exist?

There is no vaccine specifically against monkeypox. Because the monkeypox virus is closely related to smallpox, the smallpox vaccine is thought to offer good protection against monkeypox. However, data on the exact level of efficacy is still limited. The vaccine does not replace general precautions, so after vaccination, stay vigilant and limit your sexual contacts.

In Belgium, there are two available vaccines: Imvanex® and Jynneos®, approved respectively by the EMA (European Medicines Agency) and the FDA (Food and Drug Administration, USA) for the indication of monkeypox. In Belgium, mainly Jynneos® is used at the moment. You have to sign a form before receiving the vaccine, as the Jynneos® is only officially approved in the United States.

Other vaccines, such as those against chicken pox (varicella) or zona, do not protect against monkeypox.

Who is currently eligible for vaccination?

Vaccination is used both before a risk contact (as a preventive measure) and after a risk contact. You can consult the conditions of both ways of vaccination down below.

The vaccination campaign is aimed to impact the further spread of monkeypox as best as possible with a limited number of vaccines. This implies that for the time being, not everyone who wants to be vaccinated can do so.

ITM tries to deploy the current stock of vaccines as quickly and efficiently as possible. The vaccination strategy may change depending on the available number of vaccines, the evolution of the outbreak and the knowledge about the disease. Keep in mind that the government may also reallocate vaccines to other locations.

From November 2022 onwards, there should be many more vaccines (about 30,000) available in Belgium, so we will be able to vaccinate the target groups (MSM with multiple sexual partners among others) on a much wider base, or even provide them with a second dose.

VACCINATION BEFORE A RISK CONTACT: PREVENTIVE VACCINATION

In early August, a limited group of patients was able to receive a preventive vaccination: they received one dose of the vaccine subcutaneously and will get a second dose several months later (phase 1). From September onwards, a larger number of people is eligible for vaccination: they will receive one small intradermal dose (1/5) of the vaccine and a second small intradermal dose (1/5) after 28 days (phase 2). This has been accomplished thanks to the donation of vaccines by other countries and the switch to the intradermal micro-dose vaccination technique. With the latter technique, a smaller quantity of vaccine (1/5 of the dose) is sufficient for vaccination, which means that a larger group of people can now be vaccinated with the same quantity of vaccine.

This evolution (the increase of the stock and administration through intradermal means) allowed the government to further expand the indications for vaccination. From September onwards, additional risk groups can also benefit from vaccination if there are no contraindications (see the question "Who is currently not eligible for vaccination?").

New indications for intradermal 2-dose vaccination:

  • Men who have sex with men (MSM) and have had one STI in the last 12 months.
  • Women who take PrEP.
  • Male and transgender sex workers.
  • People with severe immune disorders and a higher risk of infection. Immune disorders include uncontrolled HIV infection, medication-induced immunosuppression (after transplantation, for example), malignant blood diseases, congenital immune disorders, etc.
  • Laboratory staff treating the virus samples.

VACCINATION AFTER A RISK CONTACT: POST-EXPOSURE VACCINATION

The following people may receive a vaccine within 4 days after the risk exposure to monkeypox:

  • People having had a very high-risk contact.
  • People having had a high-risk contact and an increased risk of serious infection.

In rare cases, we might consider vaccination between 4 and 14 days after risk exposure, notably when the individual is at risk of severely being affected, as assessed by the doctor at the vaccination centre.

Through vaccination after risk exposure, we aim to prevent acmonkeypox infection and/or severe symptoms. However, the data on the efficacy of this approach is still limited. Receiving a vaccine after exposure is no guarantee that you will not develop the disease. For this reason, it remains important to be vigilant for symptoms and to follow the measures for very high-risk contacts (see above).

If you are eligible for vaccination after a high or very high-risk contact, you should contact your HIV reference centre urgently. In Antwerp, you can contact ITM by calling 03 247 66 66.

Who is currently not eligible for vaccination?

Not eligible for vaccination are:

  • people under 18 years (unless in exceptional cases),
  • people with symptoms of monkeypox, other serious illnesses or acute infections with fever,
  • people who got vaccinated against smallpox as children (unless they are immunocompromised)
  • people who recently contracted monkeypox,
  • people who are allergic to the vaccine or any of the ingredients.

When will the second dose of the vaccine be administered?

Boosters may be administered after 28 days. At the start of the vaccination campaign, the Superior Health Council decided to postpone the second dose for up to 8 months after the first dose. This is still valid for people who already received a vaccine via the subcutaneous injection method (until the end of August 2022) and people who received their vaccination in France through the subcutaneous method.

As of September, we will be switching entirely to intradermal vaccination. Patients who receive their vaccine as an intradermal injection will be invited to receive a second dose after 28 days.

People with severe immunosuppression and risk contacts will always receive 2 subcutaneous injections with a 28 day interval (exceptional situation).

What are the possible side effects of vaccination?

Current vaccines show a more favourable side effect profile than previous generations of smallpox vaccines because it does not contain a replicating virus.
The most common side effects are:

  • Reactions around the place of injection: pain, redness, swelling, hardening and itching. When injected intradermally into the forearm, itching and rash are common side effects. With the 2nd intradermal injection, this is much more frequent than with the first dose, and occurs in almost everyone.
  • Headache, muscle pain, nausea, fatigue.

Can the monkeypox vaccine be administered in combination with other vaccines?

No specific research on the interaction with other vaccines has been conducted yet. The current smallpox vaccine contains a live, but non-replicating virus and thus falls in the classification between the groups of ‘live-attenuated vaccines’ and ‘inactivated vaccines’. As there is no extensive experience with this intermediate group as of yet, the recommendations for live-attenuated vaccines are maintained.

For safety reasons, an interval of at least 4 weeks should be maintained with:

  • live-attenuated vaccines, such as the measles vaccine or the yellow fever vaccine.
  • mRNA COVID-19 vaccines in males up to 40 years of age. This is because men in this age group have a higher risk of developing myocarditis after being injected with the mRNA COVID-19 vaccine. It is unknown whether this new generation of vaccines has an increased risk of (peri)myocarditis.

Where can I get a vaccine?

People who think they may be eligible for vaccination should contact the HIV reference centre in their region, or the centre where they are being followed up:

  • Antwerp: Institute for Tropical Medicine, 03 247 66 66
  • Brussels: CHU Sint Pieter, 02 535 31 77
  • Brussels: VUB, 02 477 60 61
  • Brussels: UCL, 02 764 21 22
  • Brussels: ULB, 02 555 72 00
  • Hainaut: CHU Charleroi, 071 92 22 58, 071 92 23 07
  • Limburg: Jessa Hospital, 011 33 81 11, 011 33 76 50
  • Liège: CHU Liège, 04 270 31 90
  • Namur: Mont-Godinne CHU: 081 42 28 61 (weekdays); 081 42 31 01 (weekends)
  • East Flanders: UZ Gent, 09 332 21 11, 09 332 23 50
  • West-Flanders:
    Bruges: AZ Sint Jan, 050 45 23 12
    Ostend, 050 45 23 20

How can I get vaccinated at ITM?

PREVENTIVE VACCINATION (IF YOU WERE NOT YET AT RISK)

As of September, ITM proactively invites people (known as ITM patients) for intradermal vaccination (MSM that were diagnosed with 1 STI in the ITM lab).

If you don’t receive an invitation, but nevertheless think that you are eligible for vaccination (e. g. because the STI was diagnosed by another centre or your GP), you can make an appointment through a referral letter. Ask your GP to fill in the referral letter down below. He or she will evaluate the indications for vaccination through the form. Once you have a referral letter, you can make an appointment via the following link. Bring your signed referral letter with you to your appointment. If you don't, the doctor won't be able to administer the vaccine.

A referral letter doesn't necessarily guarantee a vaccination. A possible reason might be that your referring GP overlooked something during your evaluation (a wrong indication or failure to notice a contraindication). Another reason could be that the government has allocated vaccines to another location and therefore ordered them to be transferred.

POST-EXPOSURE VACCINATION (IF YOU WERE ALREADY AT RISK)

If you are eligible for vaccination after a high or very high-risk contact, please contact ITM by calling 03 247 66 66

Is the vaccine free?

The government offers the vaccine free of charge. If your file has been properly prepared by your HIV specialist, ITM will only charge for a nursing consultation. If, during your visit, there is an exceptional need for medical advice, this will be charged according to the applicable RIZIV nomenclature.

Am I protected if I have been vaccinated against smallpox?

There is no vaccine specifically for monkeypox. As the monkeypox virus is closely related to the smallpox virus, the smallpox vaccine probably also offers good protection against monkeypox. Routine vaccination against smallpox was discontinued in Belgium in the 1970s. It is possible that vaccination in childhood still offers some protection against monkeypox. However, the protection provided by the vaccine diminishes with age. So, it is possible to get infected anyway. Preventive measures remain applicable.

We suspect that the monkeypox infection only takes place once in a lifetime and that it results in a basic immunity for a certain period of time. However, we are not sure at this moment and the hypothesis that there can be no reinfections needs to be proven by further research.

Little is also known about the degree of protection of the current generation of vaccines against monkeypox. Although we expect that the use of vaccines will help prevent the spread of monkeypox, the magnitude of this effect remains uncertain. So there is no guarantee that you will not be infected again.

After a monkeypox infection or after vaccination (either preventively or after exposure), the general preventive measures continue to apply.

Am I protected if I have had monkeypox?

Our understanding of how long immunity lasts after a monkeypox infection is currently limited. Even if you have had monkeypox in the past, you should do everything you can to avoid being exposed again. After a monkeypox infection, the general preventive measures continue to apply.

Which sexual acts are considered safe after vaccination?

Although it is somewhat clear how the virus is spread, there is certainly a need for further research. We expect that during an active monkeypox infection, high concentrations of the virus will be present on all mucous membranes (mouth, anus, urethra) and on the skin for several weeks. All contacts with these mucous membranes (anal, oral, vaginal) and skin can cause transmission. We find that most people get monkeypox through sexual contact. We recommend not being sexually active (insertive oral, anal, vaginal) for at least 21 days or until the skin lesions have healed. Kissing, tongue kissing as well as intense nude cuddling can be considered as risk contacts.

A monogamous sexual relationship or self-gratification do not pose a risk.

Where can I find more information about monkeypox?