By Ruth Werner
Two years ago, directly on the heels of the crisis phase of the biggest and most deadly pandemic of our lifetime, another contagious disease shoved its way into the headlines—do you remember? We called it monkeypox at the time, but since then it has been renamed to mpox. In 2022, mpox was seen in places and in numbers it had never been seen before, and its mode of human-to-human transmission—touching the rash or blisters—made it of special interest to massage therapists.
Here we are again: mpox is in the news, and it’s time for an update, because this one is very different from the 2022 version.
A Refresher
First, a refresher course on mpox: This is a viral infection. It is a member of the Orthopoxvirus family, along with smallpox and cowpox. Some animals, especially some rodents, can be viral reservoirs. Close contact with these animals may then spread the infection to humans, who can spread it to each other, mainly through touch.
If you are old enough to have been vaccinated for smallpox, you have some protection from mpox. But if you were born after 1972, you probably haven’t had the smallpox vaccine, which means you could contract mpox.
Mpox occurs in two main viral types, called clades, and each clade has two subtypes: clade I, Ia, and Ib; and clade II, IIa, and IIb. Beginning the summer of 2024, there was concern surrounding a sudden rise in the incidence of clade Ib infections in Africa, mainly coming from the Democratic Republic of the Congo (DRC). This clade is substantially more virulent than the other types, and it has been especially dangerous for young children.
2024 Mpox Outbreak
In August of this year, the World Health Organization declared the 2024 outbreak of clade Ib a global mpox emergency. This version of mpox has a higher case fatality rate than the other variants.
So far, only two cases of clade Ib mpox have been diagnosed outside of endemic areas: one in Thailand, and one in Sweden. Both of those patients had recently traveled to Africa. At this point, it is still highly isolated to endemic areas in and around the DRC.
In the meantime, the 2022 clade IIb mpox outbreak is still active, including in the US. In the last two years, we have seen over 32,000 cases of clade IIb mpox, and 58 deaths in this country. About 60 people are still diagnosed every week. The good news is that all the US diagnoses so far have been the clade IIb type, which is less virulent than clade Ib.
Transmission of Clade Ib
The 2024 clade Ib infection seems to spread more easily than the 2022 clade IIb version. Direct contact between an infected and uninfected person is the typical form of transmission. This can happen between a caregiver and a child, prenatally between a pregnant person and their baby, and during sexual activity, especially between men who have sex with men and their other sexual partners of any sex. Transmission can also happen through fomites: the virus contaminates objects like towels or bedding, then new hosts pick up the infection from those surfaces.
At this point, clade Ib is spread strictly through direct and indirect contact. Extensive testing shows that the risk of airborne transmission is unlikely. Nonetheless, because the virus can be found in saliva and mucus, infected people are counseled to wear masks when they are around others, and their caregivers are recommended to use appropriate personal protection equipment, especially gloves, glasses, and masks, while they are caring for patients with mpox.
How threatening is the possibility of a widespread outbreak of clade Ib mpox in the US? The Centers for Disease Control and Prevention have run model simulations and have concluded that our risk for substantial illness and fatalities is low. However, that doesn’t mean we can ignore this health threat.
Mpox of any kind is contagious when any visible signs are present—these typically take the shape of rashes, blisters, or scabs. Lesions can occur anywhere, but are often seen near mucous membranes, in the nose and throat, groin, genitals, anus, and on the soles and the palms. Other signs and symptoms include fever, headache, muscle and back ache, low energy, and swollen lymph nodes. Testing is underway to see if mpox is communicable before symptoms emerge, but we don’t have any solid information on that yet.
Vaccine?
A safe and effective vaccine that offers protection from all varieties of both mpox clades is available in the US and elsewhere. The first shipment of doses arrived in DRC on September 5, 2024, and more are scheduled to follow.
This is the same vaccine that was instituted in 2022. It requires two doses for full efficacy, but that provides more than 99 percent protection from contracting the virus. Mpox vaccines are especially recommended for health-care workers who have patients with mpox, people in the same household with patients, sex workers and their clients, and people with multiple sexual partners, especially if they include men who have sex with men.
For Massage Therapists
I will conclude this with the same guidance I suggested two years ago:
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 easily 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 mpox. 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 mpox.
If mpox is especially common where you work, you might consider adding the following question to your intake form: >Do you have any blisters or pimples in a new pattern?
Because it is possible that respiratory droplets may carry some virus, it is important to continue to observe excellent hygienic practice in massage settings.
Finally, if you work in a location where mpox is highly prevalent, you may consider using gloves during massage, until numbers subside and mpox is no longer considered a significant risk.
In short, if we follow basic precautions about working with people who don’t have signs of communicable diseases, clients with communicable mpox will most likely not find their way to our table.
How long after an infection should we wait to offer massage? Experts agree that 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 mpox 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 continuing education provider. She wrote A Massage Therapist’s Guide to Pathology(available at now in its seventh edition, which is used in massage schools worldwide. Werner is available at ruthwerner.com.
Related Content
Read:
“Monkeypox: What Should Massage Therapists Be Watching For?” by Ruth Werner (2022)
Learn:
“Hygiene: Critical Updates for Massage Therapists” with instructor Ruth Werner
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