Monkeypox: What Should Massage Therapists Be Watching For?

By Ruth Werner

We’re not done with COVID, not by a long shot (public behavior notwithstanding), and now we have warning signals of another contagious viral infection that is behaving in ways we haven’t seen before—monkeypox.

Before you panic, let’s remember that information is the best defense—so here is some background on monkeypox you can use to take appropriate action and to be a source of reliable information to your clients and others.

What Is It?

Monkeypox is a viral infection. It is a member of the Orthopoxvirus family, along with smallpox and cowpox.

The name “monkeypox” is a bit misleading. It was first identified in monkeys in 1958, and in humans in 1970, but it occurs most often and is spread to humans most easily by a variety of rodents. Animals that can carry this virus include prairie dogs, squirrels, and groundhogs, but it has also been seen in other mammals. It may affect certain varieties of domestic rabbits, mice, and rats. We don’t know whether other common household pets like gerbils, guinea pigs, and hamsters can spread monkeypox.

Monkeypox is similar enough to smallpox that anyone vaccinated against smallpox has protection from monkeypox, which is good news for some of us. The worldwide campaign to vaccinate against smallpox was so effective, however, that the virus was essentially eradicated in the wild, and routine vaccination in the US was suspended in 1972. That means people under 50 years old probably have not been vaccinated for smallpox, so they lack protection from monkeypox.

Who Gets It?

Until recently, monkeypox outbreaks were geographically limited to Central Africa (one subtype or “clade” of the virus that is highly virulent), and to West Africa (a different, less virulent clade). In Central Africa especially it can be a serious health threat, with infections severe enough to cause death in 3–10 percent of diagnosed cases. Ironically, some effective vaccines against this virus have been developed, but they are not made available to African populations who need them most.

The US saw one limited outbreak of monkeypox in 2003, when pet store prairie dogs caught the virus from rodents imported from Ghana. During that outbreak, 71 cases were identified in the US, all from exposure to infected prairie dogs. Human-to-human infection was not suspected in any cases—which is not true of the current form.

Outbreaks in Africa recently resurged, partly because fewer people have been vaccinated against smallpox. About 19,000 suspected cases and some 200 deaths have occurred on the continent since 2009. So far in 2022, it has caused at least 70 deaths in Africa; due to underfunded surveillance, this is probably an undercount. 

Outside of endemic African countries, over 10,000 cases of monkeypox have been reported this year. These have occurred in Europe, Asia, South America, North America, and Australia—all places where monkeypox is not typically seen. The US has seen 866 confirmed cases so far, and that number is rising quickly. No deaths from this infection have been reported outside of Africa at this point.

Transmission, Signs, and Symptoms

Two things make the current monkeypox outbreak different from what we have seen in the past: many cases have appeared simultaneously in nonendemic countries; and we are seeing human-to-human transmission. In the affected countries of Africa, the infection has also changed: in rural areas it seems to be mostly spread through contact with infected animals, but it is becoming more common in cities, where human-to-human contact is the main transmission route.

Human-to-human spread occurs through direct, often intimate or sexual, contact with a symptomatic person, or prolonged indirect contact with their bedding, clothing, or other intimate items. Researchers believe it may also be spread through respiratory droplets, as well as by way of contact with infected skin lesions. It is communicable from the onset of symptoms through when the skin lesions are fully healed.

The recent versions of monkeypox show some variety in presentation. In the most typical form, infections typically incubate for 1–2 weeks after exposure. Then patients may develop fever, malaise, and inflamed lymph nodes; this is the prodrome stage. This is followed by a painful rash with blisters that then fill with pus, and eventually become itchy as they scab over and heal over a course of 2–4 weeks. The rash may be all over the body, or local to the site where the infection was contracted. However, some people don’t experience the prodrome stage with fever and inflamed lymph nodes: their first symptoms are the characteristic blisters.

The less virulent form of monkeypox is a self-limiting infection: it runs its course and then resolves without life-threatening complications. However, concern is mounting that this virus may mutate with worldwide spreading, and it may become more dangerous and more capable of causing serious health consequences like pneumonia, sepsis, encephalitis, and more.


As a viral infection, monkeypox can’t be treated with antibiotics. No antiviral medications have been officially approved for it, but some have been provisionally used in the absence of other options. But getting through monkeypox is usually just a matter of time: from exposure to prodrome fever and swollen lymph nodes, through the rash and healing of the lesions.

So far, this infection has been rare, mild, and self-limiting. Infected people are counseled to isolate, and others in their circle may qualify for vaccination to help limit community spreading.

Implications for Massage Therapy

What does all this mean for our practice? We know a few things about monkeypox that can help us feel confident about our clinical decisions, at least until information changes.

The main issue to keep in mind is that while the practice of massage therapy involves touch and close contact, this infection does not appear to be communicable in asymptomatic people. If our clients have fever, malaise, and swollen lymph nodes, they need to delay their massage—that is true in all cases, not just for monkeypox. If our clients have undiagnosed blisters, pustules, or scabs that started as blisters, they should investigate this with their primary health-care provider before receiving massage. Again, this is true for all circumstances, not just monkeypox.

In short, if we follow basic precautions about working with people who don’t have signs of communicable diseases, clients with communicable monkeypox will most likely not find their way to our table. How long after an infection should we wait to offer massage? The Centers for Diseases Control and Prevention (CDC) says after the rash has fully healed (that is, the blisters have scabbed, and the scabs have fallen off), the person is no longer contagious. That may take several weeks, but it is at least a clear guideline.

I hope this overview of monkeypox has helped you feel more confident and capable of dealing with this possibility in your practice. Once again, information is our best defense, and now you have some resources you can use to keep yourself and your clients safe.

author bio

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (available at now in its seventh edition, which is used in massage schools worldwide.


  1. Centers for Disease Control and Prevention. “Monkeypox: Signs and Symptoms.” Updated June 24, 2022.
  2. Centers for Disease Control and Prevention. “Monkeypox: Clinical Recognition.” Updated June 24, 2022.
  3. Centers for Disease Control and Prevention. “Monkeypox in Animals.” Updated June 24, 2022.
  4. Children’s Hospital of Philadelphia. “A Look at Each Vaccine: Smallpox Vaccine.” (2014). Accessed July 12, 2022.
  5. Kozlov, M. “Monkeypox in Africa: The Science the World Ignored.” Nature 607, no. 7917 (2022): 17–18:
  6. Magazine, S. and S. Bajaj. “What You Need to Know About the History of Monkeypox.” n.d. Smithsonian Magazine. Accessed July 12, 2022.
  7. World Health Organization. n.d. “Multi-Country Monkeypox Outbreak: Situation Update.” June 4, 2022.
  8. Yasinski, E. “Frequently Asked Questions About the Monkeypox Outbreak,” Medshadow Foundation (2022). Accessed July 12, 2022.

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