Monkeypox is predominantly driven by sex between men, a large study finds

The global monkeypox outbreak is primarily caused by sex between men, according to the first major peer-reviewed paper analyzing a large number of cases of the virus.

The outbreak, which epidemiologists believe originally began in mid-spring at gatherings of gay and bisexual men in Europe, has since alarmed such experts by escalating nearly 16,000 cases worldwide.

Now, infectious disease specialists are developing an increasingly refined understanding of the predominant channels of monkeypox transmission and typical disease progression patterns.

“These data clearly indicate that infections have so far occurred almost exclusively in men who have sex with men,” said Jennifer Nuzzo, an epidemiologist at Brown University, about the new study published Thursday in the New England Journal of Medicine. “And the clinical presentation of these infections suggests that sexual transmission, and not just close physical contact, may help spread the virus among this population.”

“This large, cross-national study provides the most complete clinical and demographic data on monkeypox cases occurring outside of endemic areas,” said Nuzzo, who was not involved in the study.

No one has died from monkeypox infection outside of Africa during this outbreak. And for many people, the disease is relatively mild and goes away on its own in a few weeks without the need for medical intervention. However, the new paper reports that monkeypox can cause pain so severe that a significant proportion of people with the virus require hospitalization for pain management.

“We have seen patients with severe rectal pain that worsens every time they go to the bathroom, genital pain with every urination, and sore throat with every swallow,” said Dr. Jason Zucker, an infectious disease specialist in the Columbia University Department of Medicine.

In the United States, confirmed cases of monkeypox have increased dramatically in recent weeks 2,593 from Thursday. With afraid to rise among infectious disease experts that the virus will become endemic The Biden administration has been heavily criticized in the US and around the world activists and the public health community that their health authorities have not acted quickly enough to contain the outbreak.

The recent sharp rise in monkeypox diagnoses in the US could be due in part to increased testing, particularly after the Centers for Disease Control and Prevention onboarded five commercial testing companies in the past two weeks.

Public health experts are also theorizing that large LGBTQ pride gatherings in June may have facilitated transmission of the virus. And given the infection’s incubation period — the new paper puts it at seven days, with a range of three to 20 days — the nation is now potentially seeing the resulting downstream effects of sexual encounters in late June and early July.

For the new study, a multi-researcher consortium pooled data on 528 cases of monkeypox diagnosed between April 27 and June 24 at 43 sites in 16 countries. These cases included 84 people (16%) in the Americas and 444 (84%) in Europe, Israel and Australia.

All cases involved men, including one transgender man, of whom 98% identified as gay or bisexual. This strong demographic finding is consistent with data on the outbreak from around the world, such as: last report by the British Health Security Agency, which found that of the 699 monkeypox cases for which information was available, 97% were in gay, bisexual or other men who have sex with men. In New York City, the US epicenter, only one woman out of 639 cases was diagnosed with the virus Confirmed by July 19th.

Accordingly, the European Center for Disease Prevention and Control characterized rated the risk of monkeypox for the general public, particularly those who do not have sex with multiple partners, as “very low”. in one last meetingused dr Agam Rao, a medical officer in the CDC’s Division of Pathogens and Serious Consequences Pathology, used the same words to characterize the risk to the community.

In the new global study, the men had an average age of 38 and ranged in age from 18 to 68. Three quarters are white and 41% have HIV.

Although some public health officials, including those from the CDC, have warned the public about the risk of household transmission of monkeypox, only three of the 528 cases, or 0.6%, were believed to have been acquired this way. And only four, or 0.8%, were thought to have been transmitted through nonsexual close contact.

The study authors reported that 95% of cases were likely transmitted through close sexual contact. Additionally, her article offers strong new evidence that anal sex itself, while not necessarily ejaculation, is a major source of transmission.

“The strong likelihood of sexual transmission was supported by the findings of primary genital, anal and oral mucosal lesions, which may represent the site of inoculation,” the study authors wrote.

“The finding that 95% of cases may have been transmitted during sex confirms that this outbreak is mainly caused by very close contact and may explain why it has so far been largely confined to dense social networks of men who have sex with men . said Dr. Jay K. Varma, infectious disease specialist at Weill Cornell Medicine.

People line up to get the monkeypox vaccine
People wait in line at a vaccination center on the Bushwick Education campus in New York on Sunday to receive the monkeypox vaccine.Kena Betancur/AFP via Getty Images

Atypical of what has been generally observed with monkeypox cases in the 11 African countries where the virus has become endemic since it was first detected in humans in 1970, people who contract monkeypox during this outbreak often have their initial development of lesions in the anorectal or genital area.

Almost three quarters of the men in the new study had lesions in these areas.

“It doesn’t seem like respiratory droplets or sprays were a major transmission mechanism because if that were the case, you probably should have seen more cases in cis women. And we haven’t yet,” said Dr. Celine Gounder, Senior Fellow and Public Health Editor at Kaiser Health News. “We also haven’t seen any evidence that monkeypox is transmitted through hugs, for example. So it really seems to require quite close, intimate contact to be transmitted.”

The World Health Organization recently reported that the monkeypox outbreak “continues to primarily affect men who have sex with men who have recently reported having sex with new or multiple partners.” The CDC has recommended the Jynneos vaccine for men who have reported more than four male sexual partners within the past 14 days.

The new paper supports these characterizations of the outbreak. It also includes noting that of the nearly three-quarters of the men who provided a sexual history, the median number of sexual partners they reported in the past three months was five, with a quarter of the men being 15 or more reported.

In the previous month, one in five of the men reported using drugs during sex, and one-third had sex at a sex-on-site venue. Of those who were tested, 29 percent had a sexually transmitted infection, or STI.

Public health experts have warned that monkeypox symptoms are often confused with sexually transmitted diseases.

The new paper addressed the outstanding question of whether monkeypox could be transmitted through seeds. Of 32 male semen analyzed, 29 samples contained viral DNA. previous research came to a similar conclusion.

Scientists note that these results do not confirm that semen transmits the virus. More research is needed, they say.

Some health authorities, including in the UK, have advised men who have recovered from monkeypox to wear a condom during sex for eight weeks as a precaution in case the virus remains in semen.

Condom use among gay and bisexual men has declined steadily since HIV became a treatable infection in 1996. The advent of the HIV prevention pill over the past decade, along with scientific evidence that treating HIV has prevented transmission hastened this decline. in one CDC survey released in 2017nearly three quarters of gay and bisexual respondents reported having had sex without a condom in the past 12 months.

Based on the new paper, Gounder said: “If you want to avoid monkeypox, and based on what we know about monkeypox transmission, condoms will be very effective in preventing much or much of the transmission that we have right now.” see and will be particularly effective in preventing these most painful lesions.”

Monkeypox often triggers initial flu-like symptoms before developing a rash, followed by the development of skin lesions. In the new study cohort, the most common initial symptoms were fever, fatigue, muscle pain and headache. Thirteen percent of men were hospitalized, most commonly for severe pain, particularly anorectal pain.

Even accounting for those hospitalizations, the study authors said the health outcomes of the men in the study were “reassuring,” noting that the majority of cases did not present with any serious health complications.

HIV infection was not associated with differences in monkeypox health. Because almost all HIV-positive men have been successfully treated for this virus, they usually had healthy immune systems.

dr Chloe Orkin, an infectious disease expert at Queen Mary University of London and the study’s lead author, joined her colleagues in calling for greater awareness of monkeypox manifestations among healthcare providers in hopes of improving case detection.

Noting the many images the newspaper has released showing how the virus can manifest itself in different parts of the body, as well as the mouth and throat, she said: “We hope doctors in primary care and emergency rooms don’t see many cases will also be able to recognize the many presentations and not miss the diagnosis.”

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