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Medical Experts Address Fears, Realities of Monkeypox

As a national health emergency is declared, Duke researchers discuss testing, community responses and who is at risk

Medical Experts Address Fears, Realities of Monkeypox

DURHAM, N.C. -- While children can contract the monkeypox virus, it is not likely to spread rapidly once schools reopen this fall, a Duke pediatrician cautioned Friday. 

Because the virus spreads through prolonged, close, skin-to-skin contact, youngsters are unlikely to get it in school and daycare settings as long as parents, teachers and other providers take precautions, said Dr. Ibukun Kalu, an assistant professor of pediatrics at Duke.

Kalu joined two Duke Health colleagues Friday to discuss the monkeypox virus outbreak – which President Biden declared a national health emergency this week. In a virtual briefing with journalists, the three experts fielded questions on testing, public health messaging, how communities should deal with the virus, stigmas associated with monkeypox, and other issues. (Replay the briefing on YouTube.)

Here are excerpts:


Dr. Cameron Wolfe, infectious disease specialist

“This is a virus that is most closely related to smallpox but presents quite differently.”

“It starts as a flat red rash that moves into, classically, a blister. As it evolves that blister actually becomes more of a firm postule – often quite painful. ... Eventually over two to three weeks, typically those blisters will dry and dead skin peel off and new skin form underneath. Once those blisters have sealed and rehealed, that’s when we think people are no longer infectious.”

“It’s unique because it’s spread predominantly through close, intimate skin-to-skin contact. If we compare this against COVID, which was overwhelmingly a respiratory infection, this is orders of magnitude less infectious. This is not the kind of infection … where lots of people in a similar enclosed space can get infection. It requires really quite intimate contact.”

“We’ve seen that intimate contact mainly so far occur actually through sexual networks and partner networks, friendship networks dominated so far by men, particularly men who have male sexual partners.”

“There’s nothing about how the virus moves that cares about your gender, who you love, who you hang out with. There’s no reason this needs to stay in those populations. … But so far at least it’s very dominated in male populations.”



Dr. Ibukun Kalu, pediatrician

“Although we’ve seen more infections in a specific social network, it is possible and it is expected and we have started to see infections in children. Most often there is, in some way, shape or form there is household contact. It’s important to emphasize it’s prolonged exposure, prolonged contact. We’re not expecting that childcare settings and schools will see rampant monkeypox infections run through the kids. But it is possible for children to get infected.”

“The key presenting symptom has been a rash, and children get a lot of rashes. There are other vaccine-preventable infections that can cause fever and rashes, and this is a great time to insure your child is up to date with all routine vaccines. For example, chicken pox, measles, and other things we’d have to test for if we see a child with fever and a rash.”



Vincent Guilamo-Ramos, dean of the Duke University School of Nursing

“We should be thinking about it from a public health lens. One of the main ways we can mitigate this is … by fact-based messages. Highlight key prevention strategies. Be honest.”

“Stigma plays an important role in how we message. We need to make sure we’re not blaming and we’re actually reaching out to communities to seek partnerships, thinking about ways we can work together from a public health model to really try to prevent this and to mitigate.”

“Over the past couple of years, there has been some erosion to some of the ways in which our communities have experienced some of the public institutions that are responsible for our public health messaging. We’ve got to turn that around. We’ve got to get people to understand that the messages we’re providing are in fact based on science. We stick to the facts. We’re not blaming. We’re simply looking for ways to work together to stop monkeypox.”



Dr. Cameron Wolfe

“The testing is really important here. Not only does it help the individual know that they’re positive or not, it also helps us set up contact tracing. Tracing is something we did at the beginning of COVID. It’s really important here. People may not know they’ve been exposed, and we actually have interventions with vaccines for people who have been exposed.”

“This is a close contact, skin-to-skin related condition so actually remaining at home during that home is really crucial.”

“Most people manage okay at home. But the key is, if you think the symptoms are consistent, please seek out to get a test, please isolate yourself while you’re wait for the results.”



Dr. Ibukun Kalu

“If a child has a known exposure and a new rash, there’s a high chance that it’s monkeypox. If a child doesn’t have a known exposure ... and has a rash without any fever, lymph node swelling or really any other symptom, it may be worth talking to your provider, but it’s highly unlikely you have monkeypox.”

“How the rash looks might differ. Children might get hand-foot-and-mouth-disease. People are used to seeing that. We’ve seen monkeypox cases that look like that, or look like some other infection. So in those cases I’d encourage you to talk to your provider. Take a picture of the rash. Watch for progression. If a rash starts and looks the same all day, looks the same the next day, does not get worse, does not start to scab, it’s also highly unlikely to be monkeypox.”



Dr. Ibukun Kalu

“It would typically mean prolonged contact, skin-to-skin contact. That may occur in daycare, it’s just not as common. It typically means there’s a household exposure, or there’s a person in the household that has been diagnosed with monkeypox and took care of the child and had prolonged skin-to-skin contact. The period that is considered ‘prolonged’ may vary.”



Vincent Guilamo-Ramos

“People who are sexually active, particularly men who have sex with men, we’ve got to talk to our partners. We’ve got to ask whether or not we’re feeling sick. Do we have fever? Do we have any muscle aches? Do we have any lymph nodes, sore throat? I think it’s very important right now to have open communication prior to engaging in sex.”

“If you have an unexplained rash, if you have any rash emerging that looks unfamiliar to you -- even if you think you know what it is .. it’s a great time to get tested.”

“There are going to be many people who … will really need a harm reduction approach to how they prevent and mitigate monkeypox. People will and do have sex and we need to think about strategies for how we can reduce risk and not dichotomize it, not make it all or nothing.”

“We need specific guidance for families and households, particularly if someone in the household has monkeypox. How can they prevent forward transmission within the home?”



Vincent Guilamo-Ramos

“We have had unprecedented times over the past couple of years. Our public health infrastructure has really taken a beating. In my view there’s many ways that we have gotten things right. I certainly think the recent declaration that monkeypox as a national emergency does provide opportunities for innovation, for rapid escalation of our response, for data agreements and partnerships that are now more possible.”

“It is also true there is more that we can do. We need to think about things from a health equity lens and insure we’re reaching the right people, that we’re moving at the pace that we need to, that our messages are targeted, and that we have vaccine. That we have actual testing and treatments that can reach the people who most need it.” 



Dr. Ibukun Kalu

“We’ve all learned a lot more about preventing infections in our spaces. This doesn’t have to be an individual effort. We need federal, state and local efforts to target communities at the greatest risk.”

“I also would just challenge all of us to remember that washing hands, cleaning our environment, separating our things, isolation and quarantine are not new terms. We can use the knowledge we’ve gained throughout the pandemic to help in preventing monkeypox in our spaces.”



Dr. Cameron Wolfe

“For folks who had that in the past, it does likely confer some memory and some protection, but we don’t exactly know how much.”

“So whilst it gives you some protection, I’m certain, how far away you were from that vaccine is relevant, and if you think you’ve had someone who had a meaningful exposure, you should go ahead and get one of the new vaccines.”

“Yes, there’s some remaining protection, but it’s hard to quantify how much.”

“That new vaccine is not a living vaccine. It’s a non-replicating virus so it’s actual safer in a much larger group of patients. It’s approved in anyone over the age 18, it’s OK in pregnancy, it’s OK in people who are immune-suppressed – which the old one is not – so the breadth of people who can safely take it is much greater. It was approved prior to COVID, even, so this is not a new vaccine. It’s gone through the standard FDA and CDC approval steps.”



Vincent Guilamo-Ramos

“I’m not sure the issue is really with the name. From my point of view, what stands out is  that really when you talk about the observed cases in the United States … most of the cases have been in men who have sex with men. There is a chance there could be a kind of framing of this as a gay disease. With that comes the potential for stigma. I think what we need to do is think about this as being a public health emergency that has the potential of spreading beyond one community.”



Dr. Cameron Wolfe

“I’ve seen scenarios where individuals who present as heterosexuals don’t get tested because they’re not deemed to be at risk. That’s nuts. That just has to change.”

“I’ve seen scenarios where individuals have not got the right yet about isolation and why it’s important if you’re positive or nervous you’re positive, you separate yourself in a way that keeps other safe.”

“We learned lessons in COVID. In those first six months in particular when we didn’t know everything up front. Initial thoughts needed to be checked and reassessed and modified, and that’s OK. I think we’ll go through the same thing here. We are learning about the application of the medicine. We are learning about the way this transmits. It’s very clear so far it is close skin-to-skin contact, usually in an intimate situation. But not exclusively. So let’s not bias ourselves into sort of assuming this is a disease that only affects one spectrum of our community because there’s nothing biologically that (proves) that is the case.”



Dr. Ibukun Kalu

“I have received a number of questions about children returning to school .. and children who have already been in school. To be clear, children can get infected and it’s still important that a new rash, or a new rash plus fever, is assessed properly. And that adults in those settings – which I probably would assume they have the highest risk of spreading to the kids – if they’re infected. So adults, seek out care if they have a new rash or new fever or have an exposure prior to working in a childcare setting.”

“If we emphasize those actions … I doubt schools will be the main site for spread.”

Faculty Participants

Vincent Guilamo-Ramos, Ph.D.
Vincent Guilamo-Ramos is a professor of nursing, a nurse practitioner and dean of the Duke University School of Nursing. He studies the prevention of HIV/AIDS, sexually transmitted infections, and improving the lives of youth receiving HIV prevention care.

Ibukun Kalu, M.D.
Dr. Ibukun Kalu is an assistant professor of pediatrics in the Division of Pediatric Infectious Diseases at the Duke School of Medicine and a medical director of pediatric infection prevention at Duke University Medical Center.

Cameron Wolfe, M.D.
Dr. Cameron Wolfe is an infectious disease specialist at Duke Health and an associate professor at the Duke University School of Medicine. His areas of study include infectious diseases and biological and emergency preparedness for hospital systems.

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