As monkeypox goes sexual: a public health perspective

Abstract

Monkeypox, a smallpox-like self-limiting disease with symptoms lasting 2–4 weeks, is a zoonotic disease in humans caused by an orthopoxvirus and was initially diagnosed in 1970 in the Democratic Republic of the Congo (DRC1).1, 2 The disease has ever since not only spread to other regions of Africa (primarily West and Central), but increasingly also to regions outside Africa in recent years. Recently, reports from cases in Europe have aroused attention.3, 4, . Since its first diagnosis in 1970, the number of cases has increased by a minimum of 10-fold and the median age at presentation has evolved from young children (4 years old5) in the 1970s to young adults (21 years old) in 2010–2019.5 Such changing epidemiology of human monkeypox may be related to the cessation of smallpox vaccination, which provided some cross-protection against monkeypox, leading to increased human-to-human transmission. Thirty years after the eradication of smallpox, the incidence of human monkeypox has dramatically increased in the DRC from 0.72 per 10 000 in the 1980s to 14.42 per 10 000 in 2006–07 suggesting a 20-fold increase in human monkeypox incidence.6 Vaccinated persons had a 5.2-fold lower risk of monkeypox than unvaccinated persons (0.78 vs. 4.05 per 10 000). Since long-lasting cross-protective immunity from previous smallpox vaccination has been reported based on the US monkeypox outbreak in 2003,7 JYNNEOS™ currently licensed in the United States to prevent smallpox is also licensed specifically to prevent monkeypox.8 CDC, in conjunction with the Advisory Committee on Immunization Practices (ACIP), is currently evaluating JYNNEOS™ for the protection of people at risk of occupational exposure to orthopoxviruses in a pre-event setting. Individuals who have had contact with known monkeypox patients, health-care workers, very close personal contacts and those in particular who might be at high risk for severe disease such as immunocompromised individuals must be therefore prioritized for vaccination. This vaccine based on a special modified virus Ankara (MVA) has been tested and found safe also in patients with atopic disorders such as allergic rhinoconjunctivitis or atopic eczema.8 Since 2003, import- and travel-related spread to regions outside of Africa has occasionally resulted in outbreaks.9 In 2003, the first monkeypox outbreak outside of Africa was 70 cases in United States and was linked to contact with infected pet prairie dogs that were housed with Gambian pouched rats and dormice imported from Ghana. Monkeypox was also reported in travellers from Nigeria to Israel in September 2018, to the United Kingdom in September 2018, December 2019, May 2021 and May 2022, to Singapore in May 2019 and to the United States of America in July and November 202110. As of 21 May 2022, 92 laboratory-confirmed cases, and 28 suspected cases of monkeypox with investigations ongoing, have been reported to WHO from 12 Member States that are not endemic for monkeypox virus, across three WHO regions.11 As of 24 May 2022, 5 cases of monkeypox have been reported in Germany.12 The current outbreak has been triggered through sexual transmission at raves held in Spain and Belgium with most of those infected being men who have sex with men (MSM).13 This marks a significant departure from the disease's typical pattern of spread in Central and Western Africa as well as earlier import- and travel-related spread to regions outside of Africa. Such appearance of outbreaks beyond Africa and changing epidemiology of the disease highlights the global relevance of the disease. Therefore, increased surveillance and detection of monkeypox cases are essential for understanding the evolving epidemiology of this resurging disease. On 19 May, researchers in Portugal uploaded the first draft genome of the monkeypox virus that was detected there and preliminary genetic data indicate that the strain is related to a viral strain predominantly found in West Africa known to cause milder disease and a lower death rate (≈1%).14 Although most of the cases in the current outbreak have presented with mild disease symptoms, and for the broader population, the likelihood of spread is very low, the virus can cause severe disease in certain population groups—such as young children, pregnant women and immunosuppressed persons.15 Further investigations are therefore warranted to accurately estimate the level of morbidity and mortality in this outbreak. Transmission of the disease can occur through contact with an infected animal or human, or with human bodily material containing the virus.16 Transmission between humans mostly occurs through large respiratory droplets and hence requiring prolonged face-to-face or household contacts. Transmission may also occur through bodily fluids, lesion material or indirect contact with lesion material. Symptoms of the disease include fever, headache, muscle aches, backache, swollen lymph nodes, chills and exhaustion. A rash typically develops often beginning on the face, and subsequently spreading to other parts of the body including the genitals. Noteworthy is the predominance of lesions in the genital area among MSM in the current outbreak.16 A Monkeypox rash goes through different stages, mimicking chickenpox or syphilis, before finally forming a scab and falling off, at which stage the individual is no longer infectious. The difference in appearance from chickenpox or syphilis is the uniform evolution of the lesions. The incubation period is typically 6–16 days but can extend up to 21. Although no licensed treatments are available, two oral drugs—brincidofovir and tecovirimat—approved for treatment of smallpox have demonstrated efficacy against monkeypox in animals. A recent retrospective observational study of clinical features and management of human monkeypox in the UK demonstrate that of the 7 cases between August 2018 and September 2021, 3 treated with 200 mg brincidofovir once a week orally developed elevated liver enzymes resulting in cessation of therapy.17 One patient treated with 200 mg tecovirimat twice daily for 2 weeks orally, experienced no adverse effects and had a shorter duration of viral shedding and illness (10 days hospitalization) compared with the other six patients. Within the specific context of the nature of the 2022 monkeypox outbreak, public health institutions and community organizations involved in raising awareness among general population must especially focus on MSM and individuals who have multiple sexual partners both MSM and otherwise.18 Individuals presenting with symptoms indicative of monkeypox or infected with the monkeypox virus must quarantine or isolate themselves for 14 to 21 days and must be additionally advised to abstain from sexual activities or any activities involving close contact until the disease is either excluded or the infection is resolved. Ideally, high-risk contacts, such as roommates, sexual partners and those who have been in close contact with an infected person, must also quarantine themselves for 14 days and monitor themselves for developing symptoms. Prompt isolation, testing and notification of suspected cases are warranted to contain spread of the disease. For positive cases, contact tracing both backwards and forwards must be initiated and any exposed mammalian pets should be quarantined. Subject to availability of smallpox vaccines in respective countries, health-care workers should consider vaccination of high-risk close contacts (ring vaccination) after a risk–benefit assessment. Although monkeypox still remains a relatively rare infection, its changing epidemiology during the current outbreak mandate increased surveillance, monitoring of morbidity and mortality and public health strategies targeting MSMs and individuals with multiple partners. The increase in Monkeypox infections in Europe in the last years could have two main reasons. First, the increase in non-variola vaccinated and or a mutation of the virus. Both could have led to an increased infection rate from person to person. Finally, as clinical presentation of monkeypox involves several dermatological manifestations such as rashes and lesions that progress through several stages (from enanthem to scab) before falling off, dermatologists and venerologists are most ideally suited to diagnose and treat the disease. We thank the team of the WIR centre. We also thank the Ministry of Labor, Health and Social Affairs of the state of North Rhine-Westphalia, the Deutsche AIDS-Stiftung, the diocese of Esssen, the city of Bochum, ViiV Healthcare GmbH and Katholisches Klinikum Bochum for their support in setting up the WIR centre. Open Access funding enabled and organized by Projekt DEAL. The authors declare no conflict of interest. None. Data sharing not applicable - no new data generated, or the article describes entirely theoretical research

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