A large study found that monkeypox is significantly driven by sex among men

The main cause of the global outbreak of monkeypox is due to sex between men, according to the first peer-reviewed paper analyzing a large group of cases of the virus.

The outbreak, which epidemiologists believe initially began in mid-spring gatherings of gay and bisexual men in Europe, has alarmed these experts ever since by ballooning to nearly 16,000 cases worldwide.

Now infectious disease specialists are developing an increasingly accurate understanding of the dominant channels of monkeypox transmission, as well as the patterns of the typical disease course.

Brown University epidemiologist Jennifer Nuzzo said in the new study published Thursday in the New England Journal of Medicine. “The clinical presentation of this infection suggests that sexual transmission, rather than just close physical contact, may aid the spread of the virus in this population.”

“This large, multi-country study provides the most complete set of clinical and demographic data on monkeypox cases that occur outside endemic areas,” said Nuzzo, who was not involved in the study.

No one died of monkeypox infection outside of Africa during this outbreak. For many people, the disease is relatively mild and resolves on its own within a few weeks without the need for medical intervention. However, the new paper notes that monkeypox can cause pain so severe that a large proportion of people infected with the virus require hospitalization to manage the pain.

Dr. Jason Zucker, an infectious disease specialist in Columbia University’s Department of Medicine, said: “We’ve seen patients with severe rectal pain that gets worse every time they go to the bathroom, genital pain every time they urinate and sore throat every time they swallow. “. .

In the United States, confirmed cases of monkeypox have increased dramatically in recent weeks, reaching 2,593 as of Thursday. As fears escalate among infectious disease experts about the virus become endemic In the United States and around the world, the Biden administration has come under fire from activists and the public health community that its health agencies have failed to act quickly enough to stop the outbreak.

The recent sharp rise in monkeypox diagnoses in the United States could be driven in part by an increase in testing, especially after the Centers for Disease Control and Prevention introduced five commercial testing companies in the past two weeks.

Public health experts also hypothesize that major LGBTI gatherings in June may have facilitated transmission of the virus. 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 likely to see the final effects of sexual encounters in late June and early July.

For the new study, a consortium of dozens of researchers 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 were among men, including a transgender man, of whom 98% identified as gay or bisexual. This stark demographic finding is in line with data on outbreaks from around the world, such as a recent report by Britain’s Health Security Agency that found that of the 699 cases of monkeypox for which information was available, 97% were gay, bisexual or other men. who have sex with men. New York City, the epicenter of the US earthquake, had only one woman infected with the virus out of 639 confirmed cases as of July 19.

Accordingly, the European Center for Disease Prevention and Control described the risk of developing monkeypox for the general public, particularly those who do not have sex with multiple partners, as “very low”. in last meetingDr. Ajam Rao, medical officer of the Centers for Disease Control and Prevention’s Division of Pathogenesis and Pathology, used the same words to describe the risks to the general public.

In the new global study, the men had a median age of 38 and their ages ranged from 18 to 68. Three-quarters of them are white, and 41% are HIV positive.

Although some public health officials, including those at the Centers for Disease Control and Prevention, warn the public about the risks of transmitting monkeypox in the home, only three of the 528 cases, or 0.6%, are believed to have been acquired. them through these means. Only four, or 0.8%, were considered to have been transmitted through close non-sexual contact.

The study authors reported that 95% of cases were likely transmitted through close sexual contact. Moreover, their paper provides strong new evidence that anal sex itself, although not necessarily ejaculation, is a major source of transmission.

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

“The finding that 95% of cases may have been transmitted during sex provides reassurance that this outbreak is primarily caused by very close contact and may explain why it has been, until now, largely confined to the dense social networks of men who have sex with men,” he said. Dr. J. K. Pharma, MD, an infectious disease expert at Weill Cornell Medicine.

People wait in line to receive the monkeypox vaccine. (Kena Betancur / AFP via Getty Images)

Similar to what has been generally seen in monkeypox cases in 11 African countries where the virus has become endemic since it was first detected in humans in 1970, people who have contracted monkeypox during an outbreak often have their initial development of lesions in the anal or genital area.

Nearly three-quarters of the men in the new study had lesions in those areas.

“Respiratory aerosols or nebulizers do not appear to have been an important mechanism of transmission, because if so, you would likely have seen more cases among heterosexual women,” said Dr. Celine Gunder, Principal Fellow and General Editor of Public Health at Kaiser Health News. “We haven’t done that now.” “We also haven’t seen any evidence that monkeypox is transmitted through hugs, for example. So it seems to require very close and intimate contact to be transmitted.”

The World Health Organization recently reported that monkeypox outbreaks “continue to affect primarily men who have sex with men who report recent sex with new partners or multiple partners”. The CDC has recommended the Jynneos vaccine for men who have reported more than four sexual partners in the past 14 days.

The new paper supports these descriptions of the outbreak. This includes his finding that of nearly three-quarters of men who provided a sexual history, the average number of sexual partners they reported over the past three months was five, with a quarter of men reporting 15 or more.

During the previous month, 1 in 5 men reported that they had used drugs during sex, and a third of them had sex at the site of the sex site. Of those tested, 29 percent had a sexually transmitted infection or STI.

Public health experts have warned that monkeypox symptoms are often confused with an STD.

The new paper addressed the still-open question of whether monkeypox might be transmitted through semen. Of the 32 men whose semen was analyzed, 29 samples contained viral DNA. Previous research has come to a similar conclusion.

The scientists note that these results do not confirm that semen transmits the virus. They say more research is needed.

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

Condom use among gay and bisexual men has steadily declined since HIV became a treatable infection in 1996. The advent of HIV prevention pills over the past decade has combined with scientific evidence that treating HIV Prevents cross-infection to accelerate this decline. In a CDC survey published in 2017, nearly three-quarters of gay and bisexual respondents reported having sex without using a condom within the past 12 months.

Based on the new paper, Gunder said, “If you want to avoid getting monkeypox, and based on what we know about how monkeypox is transmitted, condoms would be very effective in preventing the bulk or majority of vision transmission now and would be particularly effective in preventing those pests.” most painful.”

Monkeypox often causes initial flu-like symptoms before the rash appears, followed by the appearance of skin lesions. In the new research group, those most common initial symptoms included fever, fatigue, muscle aches and headaches. 13 percent of the men were hospitalized, the most common being severe pain, especially anal pain.

Even taking into account these hospitalized cases, the health outcomes of the men in the study were “reassuring,” the study authors said, noting that the majority of cases did not include any serious health complications.

HIV infection was not associated with any differences in health outcomes for monkeypox. Since almost all men with HIV had successful treatment for this virus, they usually had healthy immune systems.

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

Referring to the many pictures published by the newspaper about how the virus appears in different locations of the body, as well as in the mouth and throat, she said: “We hope that doctors in primary care and emergency departments do not see many cases. He will also be able to recognize many presentations and will not miss you.” Diagnosis”.

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