The Persistence of Monkeypox

Greetings from an undisclosed location in my apartment. Welcome to Viral Transmissions.

Today, August 5th, is the 60th anniversary of the death of Marilyn Monroe.

Today I’m going to talk about practical implications of the environmental persistence of monkeypox virus, because a lot of the feedback on the last issue was people who wanted to know how to protect themselves from virus in the environment. We’ll discuss gym mats and shared laundry facilities, but I also link to some resources that are fairly comprehensive.

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Now, let’s talk viruses.

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Monkeypox questions

There was really vibrant discussion of monkeypox transmission in the comments section on the last issue. A couple of questions stood out to me, and I want to give you the feedback that I have based on strictly my opinion on both issues. Please keep in mind through this that your local or national health authority has almost certainly provided guidance on monkeypox; I can provide color on such guidance and help you understand why it is the way that it is, but I cannot supersede that guidance in anything other than an opinion. I am nobody’s CDC, and my thoughts should be used only with acknowledgement of the potential risks involved. You really should do independent evaluation.

Now, let’s dive in.

Yoga mat pox

It was asked whether a group of aerialists who share mats should be concerned about transmission through the mats that are being shared in the course of their exercise.

I’ll start by saying that this is in several ways similar to my own concerns about things like using shared gym equipment or trying on clothes at a store. However, one thing that is different in this circumstance vs others is the community involved. When I go to the gym, I am concerned about equipment use by strangers who I do not know. Likewise when I am trying on a pair of pants at a department store. I don’t know the provenance of everything that I encounter and put to my skin in these settings.

In the setting of a fitness group and community, on the other hand, you have a method of protective barrier establishment that you might not have in the settings I’ve described: you can talk to the people and make sure everyone is watching out for signs of monkeypox. People should learn what a monkeypox lesion looks like, and if they notice anything like it on themselves, obviously don’t go to a group workout—but also see a doctor.

The CDC maintains some guidance for recognizing monkeypox, and it includes a gallery of photos of lesions. Found here: https://www.cdc.gov/poxvirus/monkeypox/symptoms.html

And here is one photo from that gallery:

Image is of a small skin lesion, looking almost like a pus-filled pimple. It might be easy to mistake for a pimple, even—which may be one reason we continue to see spread of monkeypox. Please note though that generally speaking, there will be several of these in the rash, which would be unusual for pimples, and there are other differentiating characteristics that are described on the CDC site.

Likewise, in such a group setting it is possible to establish norms that reset the histories of the mats—by this I mean, make everyone wipe down the mats they bring, habitually, before use in the sight of others using something like Clorox wipes.

Incidentally, I wipe down my gym equipment before and after use. Before, for my safety. After, for the sake of the person after me.

Another key difference with mats vs gym equipment is the length of time in which you have close contact with it. When I use a bench at the gym, yes I’m generally clothed but there are parts of me that are not covered and they can touch the equipment for a long period of time. I tend to put down a fresh towel to isolate from those parts of the equipment.

With mats, on the other hand, we don’t generally roll exposed parts of our bodies around on a mat for many minutes. I’m not saying it is impossible for monkeypox virus (MPXV) to transfer from a mat to a person through transient contact, but keep in mind that the contagiousness here is not the same as for the SARS-CoV-2 virus that we are more familiar with. Frequent, prolonged exposing contact is what you want to be mindful to avoid. Transient contact may pose some remote risk, but I do not think this risk is currently at a level where it needs to be behavior-modifying.

Laundry day and monkeypox

I was asked to comment on what procedures would be best used in environments where there is shared use of laundry facilities. In the course of that discussion, a few sources that have guidance on this were cited:

• US CDC — https://cdc.gov/poxvirus/monkeypox/specific-settings/home-disinfection.html (see section on Laundry)

• Nigerian CDC — https://ncdc.gov.ng/themes/common/docs/protocols/96_1577798337.pdf (See Section 5.2.2, and the overall chapter beginning on p 19)

• Canadian National Collaborating Centre for Environmental Health — https://ncceh.ca/content/blog/monkeypox-personal-service-establishments (See bullet beginning, “Because orthopoxviruses…”

• NYCDOHMH¹ — https://www1.nyc.gov/assets/doh/downloads/pdf/monkeypox/laundry-guidance.pdf

I will note that basically all of the advice here is the same: if you have monkeypox, you should isolate your soiled linens and laundry from that of others, and when you do clean it, it should be at temperatures over 60 degrees Celsius with detergent. Drying should also be done on the hottest possible setting.

Let’s go back over something, though: this is all guidance for if you have monkeypox.

The questions I am being asked are not from people who have monkeypox. They are from people who do not want their laundry machine to turn them into people who have monkeypox. For that, I think we can be a little less restrictive.

The agencies above are concerned with turning a contaminated garment into a sterilized garment. Unless you wear the clothes of someone who is recovering from monkeypox, or otherwise interact directly with such clothes, this is not what you’re chiefly concerned about.

Instead, you are concerned about secondhand transfer for infectious MPXV particles from such clothes, to your laundry machines, to your clothes. In this I believe we have a transmission risk that is much easier to manage than the situations described above.

Let’s establish a few facts first:

• The clothing of people who have monkeypox definitely becomes contaminated; this is a legitimate concern

• MPXV can be destroyed by:

  • UV radiation

  • Detergents

  • High temperatures, particularly hot water, which is an agent that causes osmotic damage and also acts as a very weak detergent

  • Common disinfectants

• MPXV can be liberated from adhesion to surfaces by:

  • Mechanical manipulation

  • Washes with strong solvents such as water

  • Soaps and detergents

It does not take everything on this list to clear a laundry machine of MPXV contamination. During the cycle where an infected person’s clothing is being washed, a large volume of water and detergent conditions are present. This begins the decontamination of their clothing, but it also begins the decontamination of the machine. By the time the clothes are removed, gallons of water have rinsed the machine multiple times and highly concentrated detergents have been washed through. Since many people use too much detergent anyway, there’s probably quite a lot of residual detergent in the machine during the rinse cycle that continues to discourage MPXV from surviving within the machine.

When an uninfected person’s laundry then encounters that same machine, if there is any functional MPXV left inside it it is not in very high quantities. It is then subjected again to heat, detergent, and water—maybe not always heat. But certainly detergent and water. So that small possible residual contamination is soaped and washed again, further damaging and diminishing it. I would be very surprised if after two separate detergent treatments and a succession of water washes and dilution events, there is any MPXV whatsoever remaining in the laundry machine.

You may not be as comfortable, however. If that is the case, you can decontaminate your laundry machine of choice before you load your laundry into it. This may add some cost, but I’m speaking specifically to the people who are most worried here, and I think that to this group it may be worth it. Just do a HOT laundry run with detergent and an empty machine. In fact this is recommended for regular maintenance of your washing machine anyway, so you’re kind of doing the landlord or laundromat a favor here. If you have a good building, maybe you can request that they do this themselves once a day during this public health emergency, but the best way to be sure of decontamination is to make sure you perform the procedure while you personally have custody of the machine, and then do your laundry right afterwards. Again I want to emphasize that I do not think this is necessary and am not doing it myself, but I also don’t think anyone who wants to do this is wrong—they just have more fear or less of a risk tolerance than I do, and that’s OK. If it helps you feel better in your life and more comfortable, then great.

In the course of researching for this, I ran across a piece entitled “Master Question List for Monkeypox” from the US Department of Homeland Security that runs through a lot of important and well-referenced facts about MPXV. One thing that I think is really worth paying attention to is the “decontamination” section, especially because it is not written for a monkeypox-infected audience. It is written for people who are trying to destroy the virus in the environment. That piece is found here: https://www.dhs.gov/sites/default/files/2022-07/22_0712_st_monkeypox_mql.pdf

One thing that struck me from this is the following fact:

EPA lists emerging viral pathogens into Tiers (1-3), denoting increasing difficulty of inactivation. MPXV is Tier 1, meaning that it is among the easiest to destroy (chemically), with inactivation of virus upon destruction of its envelope.

The envelope of MPXV is a fatty layer that is readily destroyed by detergents. I really do think that after you’ve washed your clothes with a good laundry detergent, there isn’t going to be any residual MPXV from some hypothetical prior user left on your clothes. But if you still feel concerned, I think that my suggestion above reduces the risk to infinitesimal.

I hope this answers your questions! Next week I’m going to turn back to COVID-19 to do a situation report, but will continue to update on monkeypox as well—so keep your interests coming in the comments and I’ll set my agenda based on what you want to see discussed.

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I’ve been reading a book by Patrick Radden Keefe called Empire of Pain, which is a multigenerational biography of the Sackler family, the dynastic pharmaceutical tycoons who brought America OxyContin. Radden Keefe has an incredible talent for pacing in a nonfiction setting, and his ability to present facts in a way that is damning without writing judgmentally is, frankly, remarkable.

Something that has struck me is the degree to which one individual covered in only the first third of the book, and who had nothing whatsoever to do with OxyContin, ended up shaping the pharmaceutical industry as we know it today. One Dr. Arthur Sackler appears to have shaped everything that you can do right—and wrong—in pharmaceutical marketing, while also being a leading force in the push to treat psychiatric illnesses with pills instead of lobotomies…and also being the first person to use ultrasound diagnostically. He was also a frankly addicted art collector, unabashed philanderer with pretense of philanthropy, and a secretive and corrupt person whose defenses of his ethical breaches read laughably thin in retrospect.

The book is a fantastic expose of the history of a complicated edge of the pharmaceutical industry, and well worth a read. One thing I will especially say for it is this: today, we have a lot of rules we have to follow in pharma, and there is rarely a rule put in place if someone hasn’t demonstrated that the rule is needed.

As I’ve said throughout, I want to hear from you, too, with your questions about monkeypox, or COVID-19, or just updates about your lives. This newsletter is a community, so reach out!

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I have a commitment to accuracy, but I’m still human and I get things wrong. Sometimes, very wrong. If you catch an error, let me know—you can email me directly or leave a comment.

Thanks for reading today. It’s great to be writing to you again. Have a wonderful weekend!

Always,

JS

1. For those who aren’t locals, that’s New York City Department of Health and Mental Hygiene.