Most cases of monkeypox in the current outbreak are linked to sexual activity, but research published Wednesday by the U.S. Centers for Disease Control and Prevention (CDC) offers new insights into other ways it can be caused. could be spreading.

A man first noticed his injury and subsequently developed a rash about two weeks after attending a “large and crowded outdoor event where he had close contact with other people, including dancing, for a few hours,” according to with researchers at Stanford University School of Medicine.

He tested positive for smallpox after seeking care at an emergency department about a week later.

The patient’s “primary risk factor” was close, nonsexual contact with numerous unfamiliar people at a crowded outdoor event,” the researchers wrote, and the case “highlights the potential for spread at such gatherings, which may have implications for epidemic control.

The event he attended in the UK was not a rave and was not attended specifically or primarily by people who identify as gay or bisexual, according to the researchers.

While many contestants wore tank tops and shorts, he wore pants and a short-sleeved top. He didn’t notice anyone with skin lesions or who looked sick, and he participated in a few other similar events over the next four days.

According to CDC guidelines, “the disease can spread to anyone” through close contact, which is usually skin-to-skin, as well as intimate contact that includes sex, hugs, massages, and kisses.

The patient – ​​a man in his 20s who recently returned to the US after traveling to the UK – reported no sexual contact and had no evidence of genital injury.

Saliva samples and nasal swabs tested positive for the virus, although the patient did not report any related signs of illness such as fever, chills, or cough.

A previous analysis of monkeypox cases by the CDC found that early warning signs of the disease are less common in the current outbreak compared to “typical” smallpox.

In about 2 out of 5 cases, the condition began with a rash—but no reported prodromal symptoms, such as chills, headache, or malaise.

These findings indicate that transmission may be “associated with clinical symptoms” and things like hotel bedding and high-contact areas in public settings could be modes of transmission.

However, despite no reported sexual contact, a patient’s rectal swab tested positive for the virus, which indicates “potential for sustained sexual transmission.”