Monkeypox global emergency: Sexual activity believed to be causing epidemic

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Cases of monkeypox continue to rise worldwide as the epidemic progresses steadily. On Saturday, following the meeting of the Committee of Emergency Situations, the WHO designated the latest public health emergency of international concern. However, scientific principles, evidence and other relevant information are currently insufficient and leave many unknowns. Recently, an international collaboration of researchers identified new clinical symptoms in humans infected with monkeypox, the largest study to date. Their findings will improve future diagnostics, help slow the spread of infection, and help the international community prioritize the limited global supply of monkeypox vaccines and drugs for communities most at risk, including men who have sex with other men.

According to the CDC (Centers for Disease Control and Prevention), as of July 20, more than 16,800 cases of monkeypox had been reported in 74 countries, and only 6 of them were endemic for this disease. The epicenter of this epidemic remains Europe, a high-risk region according to the WHO.

In addition, following a meeting of the Committee of Emergency Situations on 22 July, the Director-General of WHO decided that the global monkeypox epidemic constituted a public health emergency of international concern, issuing a number of recommendations depending on the situation in the country, but insisting on screening and adequate protective measures, despite the apparent lack of reliable scientific information. Indeed, in Africa, monkeypox is mainly spread among humans by infected wild animals such as rodents in limited outbreaks that do not cross borders. But in Europe, North America, and elsewhere, monkeypox is spreading among people not associated with animals or recent travel to Africa.

Recently, an international team of researchers conducted a multi-country study that provides the most comprehensive set of clinical and demographic data to date on monkeypox cases occurring outside of endemic areas. A study by scientists at Queen Mary University of London has revealed new clinical symptoms of the infection. They will facilitate future diagnosis and help slow the spread of the disease in the at-risk community outside the endemic area identified in the study, namely among men who have sex with men. The work was published in The New England Journal of Medicine.

New patient profiles and advanced diagnosis

This case study was conducted in response to an emerging global health threat. It collects data on 528 confirmed infections in 43 locations between April 27 and June 24, 2022. It should be noted that in many people the disease is relatively mild and resolves on its own within a few weeks without the need for any medical intervention. Common systemic symptoms preceding the characteristic rash include fever, lethargy, myalgia (muscle pain), and headache; lymphadenopathy (enlarged lymph nodes) is also common.

However, many of the infected people examined during the study had symptoms not recognizable by modern medical definitions of monkeypox. These symptoms include sores on the genitals and sores in the mouth or anus. In 95% of those infected, the infection was transmitted sexually. Moreover, WHO experts suspect that epidemics in Europe and North America were spread sexually during two spring raves in Belgium and Spain.

Moreover, the clinical symptoms are similar to those of sexually transmitted infections (STIs) and can easily lead to misdiagnosis. In some people, anal and oral symptoms have led to hospitalization for acute pain and difficulty swallowing.

Chloe Orkin, professor of HIV medicine at Queen Mary University of London, said in a statement: “We have shown that current international case definitions need to be expanded to add symptoms that are not currently included, such as mouth ulcers, on the posterior mucosa.” passage and simple ulcers. These specific symptoms can be severe and lead to hospitalization, so getting a diagnosis is important. Expanding the case definition will help clinicians more easily recognize the infection and thus prevent its transmission from humans.”

The current spread of the virus is disproportionately affecting gay and bisexual men, with 98% of those infected belonging to this group, the authors of the study said. This conclusion is consistent with data on the epidemic worldwide, as a recent report from the UK Health Security Agency shows: of 699 infections, 97% were gay, bisexual or other men who have sex with men.

The WHO director agrees with this conclusion in a press release: “While I am declaring a public health emergency of international concern, it is currently an epidemic that is concentrated among men who have sex with men. with multiple sexual partners. This means that this is an epidemic that can be stopped with the right strategies in the right groups. Therefore, it is critical that all countries work closely with the communities of men who have sex with men to develop and deliver effective information and services, and to take action to protect the health, human rights and dignity of the communities concerned.”

Public stigma and the global epidemic

The health situation with monkeypox is even more worrisome as there is a global shortage of vaccines and treatments for the infection. The results of this study, including identifying those most at risk of infection, will contribute to the global response to the virus. Public health interventions targeting a high-risk group can help detect and slow the spread of the virus. Illness recognition, contact tracing and advice to people to self-isolate will be key elements of the public health response.

But the WHO director warns: “Stigma and discrimination can be as dangerous as any virus. In addition to our advice to countries, I also call on civil society organizations, including those with experience working with people living with HIV, to work with us to combat stigma and discrimination.”

What’s more, while sexual intercourse is the most likely route of transmission in most of these cases, the researchers note that the virus can be transmitted through any close physical contact through large respiratory droplets and possibly clothing, other surfaces, or skin wounds. . Indeed, the scientists note that their findings do not support the transmission of the virus through semen, which requires more research. Not to mention, on Saturday, US authorities reported for the first time in the country two children infected with the monkeypox virus. Although the causes are not yet known, it is likely that the infection occurred through skin breaks on the arms or hands during contact with a carrier of the virus.

That is why, in its statement, UNAIDS is calling on the media, governments and communities to respond in a rights-based, evidence-based response to avoid stigmatization. Not to mention the fact that the authors themselves acknowledge the presence of bias. They are related to studied cases only from people who came for a consultation, which means that asymptomatic patients or patients with milder symptoms are not included. Moreover, the latter are not necessarily men who have sex with other men.

Matthew Kavanagh, Acting Deputy Director of UNAIDS, says: “Stigma and blame undermine trust and the ability to respond effectively during outbreaks like this, hindering case-finding efforts and encouraging ineffective punitive measures. […] We confirm that this disease can affect anyone.”

The authors conclude that viruses know no boundaries, so it is imperative that the world act in concert and quickly to close knowledge gaps and contain the outbreak. As is often the case in clinical medicine, diseases can present in many different ways, and monkeypox is no different. This epidemic shows that viruses will continue to threaten humanity and that international coordination and solidarity are essential for public health. Viruses can only be defeated on a global scale.

New England Journal of Medicine.

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