In the foggy current round of monkeypox virus transmission, a clearer one has finally emerged. The latest issue of Euro Surveillance, the leading European medical journal, published a special research on monkeypox. A total of four articles reported on the epidemiological investigation and diagnosis and treatment process of monkeypox cases diagnosed in Italy, Portugal, the United Kingdom and Australia in May. Most of the patients in the report were young men who had previously had sex with men, and some were HIV-positive. In addition, researchers detected monkeypox virus in the semen of three Italian monkeypox patients for the first time.
As of June 5, local time, according to statistics from the US Centers for Disease Control and Prevention, the number of confirmed monkeypox cases in the world has reached 911, with 76 suspected cases, and 36 countries have reported confirmed and suspected cases. Among them, a total of 225 cases have been confirmed in the UK and 186 in Spain. On June 3, the World Health Organization rated the risk of monkeypox as "moderate."
Prior to this, although most of the confirmed cases were men who had sex between men, there were also analyses that mass sex acts in the two carnival parties in Europe in May were the main reason for the spread of this round of monkeypox, but no Accurate evidence that the virus is transmitted sexually (semen or vaginal secretions). Regarding the human-to-human transmission route of monkeypox virus, the basic expressions of WHO and national health agencies are, "transmit from human to human through diseased body fluids, respiratory droplets and pollutants"; "accompanied by Prolonged close contact for sex, not sex itself."
"Considering the global susceptibility to smallpox vaccination in the mid-to-late 20th century, the spread of monkeypox to non-endemic areas is a recognized risk," the researchers said in European Monitor. The underlying assumptions of epidemiology in Europe have changed, which has profound implications for surveillance and control."
Italian patient semen sample positive for monkeypox virus
In this issue of European Surveillance, the Italian team reports epidemiological investigations and diagnostic information on four Italian monkeypox patients. Four patients were all adult men in their 30s who had sex with men and had a history of travel abroad in the first two weeks of May, 3 patients attended a one-time minority gathering in Spain, 1 patient Engaged in sex work while traveling. During the trip, they had condomless sex with different male partners.
At the same time, 4 patients had a history of sexually transmitted disease infection. Two of the patients were HIV-infected and received antiretroviral therapy; the other two received antiretroviral pre-exposure prophylaxis. One patient claimed to have been vaccinated against smallpox 30 years ago.
There are several issues that remain to be seen in the study of the four monkeypox cases, the researchers said. "First, it has been suggested that in the current outbreak, monkeypox virus is transmitted from person to person, but this route of transmission has been reported to be inefficient in previous outbreaks caused by the virus, the West African clade."
"Secondly, the clinical presentation of the 4 patients appeared to be different from the information in the available literature, the skin lesions of the patients were asynchronous, ranging from single or clustered spots to umbilical papules with progressive central ulceration, and finally to crusting. The lesions were numerous on the genitals and perianal area."
"Finally, monkeypox-infected individuals were predominantly male. In areas where monkeypox was prevalent, most cases were observed in males, possibly related to their hunting behavior, whereas in the current outbreak, the majority were MSM ( men who have sex with men), are those who have multiple sexual partners or who have sex without a condom.”
The researchers highlighted in the report, "The semen from 3 monkeypox patients at the time of suspected symptom onset (5-7 days) was found to be positive for monkeypox virus DNA, with a Ct (virus threshold cycle number) range of 27 to 30. Viral DNA detected in 3 semen samples ruled out contamination of biological samples. While these findings cannot be considered definitive evidence that semen is contagious, they suggest shedding of the virus whose transmission efficiency cannot be determined by Excluded. In addition, the Ct value in the patient's semen is also within the range of the Ct value detected in the nasopharyngeal swab."
However, the researchers say it needs to be considered that many other viruses that cause viremia can also be found in semen, but not as direct evidence of sexual transmission. This is because, for the virus, the blood-testis barrier is imperfect, especially in the presence of systemic or local inflammation, so in the case of viremia, the virus can sow seeds in the male reproductive tract. The virus may not replicate in the reproductive tract, but it persists.
Therefore, the researchers said, "The sexual behavior of this series and the lesions initially primarily in the anal and genital regions suggest that close contact during sexual intercourse is important for virus transmission. Further studies are needed to assess the role of monkeypox virus in different Presence, persistence and infectivity in bodily fluids."
Portugal reports 14 simultaneous HIV-positive cases of monkeypox patients
The Portuguese research team conducted an epidemiological survey of 96 confirmed cases of monkeypox in Portugal as of May 27. The researchers obtained the demographic characteristics, clinical manifestations and exposure of all 96 cases through face-to-face and telephone interviews. In total, in-depth information on 27 confirmed cases was collected.
Epidemiological studies show that the first cases of Portuguese monkeypox developed symptoms as early as April 29. This suggests that monkeypox virus has been circulating undetected in Europe since at least early April and may have been imported into Portugal. The outbreak curves also show different routes of exposure to the virus, including being in specific settings (such as saunas used for sexual contact), going abroad during the incubation period (Spain, UK, and Brazil), and exposure to non-Portuguese nationals. Most of the cases were not part of an established chain of transmission - only 1 had contact with another confirmed case, and few cases reported contact with someone with similar symptoms or a history of travel abroad.
In addition, the age of the cases ranged from 22 to 51 years (median 33 years). All cases were male. Almost all cases identified themselves as men who have sex with men (MSM), while one reported having sex only with women. In the 21 days prior to the onset of symptoms, most cases reported having sex with multiple partners, and 3 had contact with animals (2 with cats and 1 with pigs).
"The clinical presentation of monkeypox in this outbreak is atypical, with lesions starting in the genital area rather than the face, and contact tracing has been difficult because a large proportion of cases had sex with multiple or anonymous sexual partners," the researchers said.
Portuguese researchers emphasized that although monkeypox is a zoonotic disease, studies have shown that the genetic adaptation of monkeypox virus to human hosts is increasing, and the possibility of human-to-human transmission is increasing. Therefore, it is necessary for the relevant health agencies to carry out further preventive measures, "early risk communication and targeted preventive measures for sexual minorities living in Portugal, and careful consideration to ensure a non-stigmatizing approach. In addition, most importantly, The goal is to raise the awareness of medical staff and identify suspected cases."
"Although monkeypox virus is classified as moderately circulating, further genetic characterization of monkeypox virus isolates from Portugal and other European countries is required to elucidate the origin and disease dynamics of this outbreak," the researchers said. ."
Community spread of monkeypox in UK, divided into three separate incidents
The monkeypox outbreak in the UK has been divided into three distinct events, according to the British researchers. The first was the first confirmed case on May 7, an isolated case imported from Nigeria, a country endemic for monkeypox. Of the 116 close contacts identified, including healthcare workers, none developed monkeypox infection at the end of the 21-day follow-up period.
This was followed by a separate family cluster discovered on May 12. The first case in the cluster developed symptoms on April 17. He had no travel experience in monkeypox endemic countries and could not determine the source of infection. As of May 25, none of the 98 close contacts (including health care workers) linked to the household cluster had developed monkeypox infection.
Finally, four new confirmed cases of monkeypox infection were reported in England on 16 May. The patients were adult males (age ≥18 years). These new cases have no known links to previous cases and have not traveled to countries at risk for monkeypox. Two of them were sexual partners.
As of 25 May 2022, there have been 86 laboratory confirmed cases of monkeypox virus infection in the UK. The report describes available data on confirmed cases in the UK as of 25 May 2022.
Of these, 82 confirmed cases were associated with Event 3, and were not associated with either the first travel-related case (Event 1) nor the family clustered case (Event 2). Of the cases associated with Event 3, gender information was provided in 79 cases - all male. Of these, 66 (83%) were homosexual, or bisexual, or other men who had sex with men (GBMSM). Sexual orientation/behavior was unknown in 16 cases. The median age of the patients was 38 years. In the 21 days prior to the onset of symptoms, 18 reported travel to multiple countries outside Africa. Sexual health history has been identified as being associated with group sex, private sex parties, and use of dating apps.
There were also significant differences in the close contacts of the patients in these three separate events. Contacts of cases related to events 1 and 2 were primarily passengers who were on the same flight as the travel-related case or health care workers who had been in contact with the patient before the patient was identified as a suspected monkeypox case. By contrast, many of the contacts in Event 3 are in the community. The median number of community, household, or sexual contacts reported for each confirmed case in Event 3 was 4, with a maximum of 25. In Incident 3, a total of 356 community contacts were identified, including 83 households (23%), 78 sexual contacts (22%), 89 friends/shared spaces (25%), 82 workplaces (23%) %) and 24 community health care (7%).
“In some cases, it is difficult to determine the true number of sexual contacts due to circumstances such as group sex. Of the 78 sexual contacts reported in incident 3, only 28% reported names or contact details. Some cases Refusing to share personal details of their sexual encounters, or reporting multiple anonymous sexual encounters. This undoubtedly challenges public health action and calculations," the researchers said.
"This is the first time the UK has reported sustained transmission of monkeypox, and MSM is disproportionately represented in new cases based on case reporting in most countries, suggesting that the virus spreads person-to-person through close contact, including sexual networks. spread between.
The researchers concluded, "Our goal should still be to eliminate monkeypox virus, but success in public health requires a concerted international effort: this includes identifying cases and their contacts. Involving the community in case detection and prevention In addition, public health risk assessment and communication will be critical due to challenges in tracing close contacts in sexual networks. If we are not able to achieve epidemic control rapidly globally, then it is imperative to expand capacity for routine testing and Consider alternative vaccination methods, including pre-exposure vaccination and expanded vaccination for those at higher risk of infection."
As of June 5, local time, according to statistics from the US Centers for Disease Control and Prevention, the number of confirmed monkeypox cases in the world has reached 911, with 76 suspected cases, and 36 countries have reported confirmed and suspected cases. Among them, a total of 225 cases have been confirmed in the UK and 186 in Spain. On June 3, the World Health Organization rated the risk of monkeypox as "moderate."
Prior to this, although most of the confirmed cases were men who had sex between men, there were also analyses that mass sex acts in the two carnival parties in Europe in May were the main reason for the spread of this round of monkeypox, but no Accurate evidence that the virus is transmitted sexually (semen or vaginal secretions). Regarding the human-to-human transmission route of monkeypox virus, the basic expressions of WHO and national health agencies are, "transmit from human to human through diseased body fluids, respiratory droplets and pollutants"; "accompanied by Prolonged close contact for sex, not sex itself."
"Considering the global susceptibility to smallpox vaccination in the mid-to-late 20th century, the spread of monkeypox to non-endemic areas is a recognized risk," the researchers said in European Monitor. The underlying assumptions of epidemiology in Europe have changed, which has profound implications for surveillance and control."
Italian patient semen sample positive for monkeypox virus
In this issue of European Surveillance, the Italian team reports epidemiological investigations and diagnostic information on four Italian monkeypox patients. Four patients were all adult men in their 30s who had sex with men and had a history of travel abroad in the first two weeks of May, 3 patients attended a one-time minority gathering in Spain, 1 patient Engaged in sex work while traveling. During the trip, they had condomless sex with different male partners.
At the same time, 4 patients had a history of sexually transmitted disease infection. Two of the patients were HIV-infected and received antiretroviral therapy; the other two received antiretroviral pre-exposure prophylaxis. One patient claimed to have been vaccinated against smallpox 30 years ago.
There are several issues that remain to be seen in the study of the four monkeypox cases, the researchers said. "First, it has been suggested that in the current outbreak, monkeypox virus is transmitted from person to person, but this route of transmission has been reported to be inefficient in previous outbreaks caused by the virus, the West African clade."
"Secondly, the clinical presentation of the 4 patients appeared to be different from the information in the available literature, the skin lesions of the patients were asynchronous, ranging from single or clustered spots to umbilical papules with progressive central ulceration, and finally to crusting. The lesions were numerous on the genitals and perianal area."
"Finally, monkeypox-infected individuals were predominantly male. In areas where monkeypox was prevalent, most cases were observed in males, possibly related to their hunting behavior, whereas in the current outbreak, the majority were MSM ( men who have sex with men), are those who have multiple sexual partners or who have sex without a condom.”
The researchers highlighted in the report, "The semen from 3 monkeypox patients at the time of suspected symptom onset (5-7 days) was found to be positive for monkeypox virus DNA, with a Ct (virus threshold cycle number) range of 27 to 30. Viral DNA detected in 3 semen samples ruled out contamination of biological samples. While these findings cannot be considered definitive evidence that semen is contagious, they suggest shedding of the virus whose transmission efficiency cannot be determined by Excluded. In addition, the Ct value in the patient's semen is also within the range of the Ct value detected in the nasopharyngeal swab."
However, the researchers say it needs to be considered that many other viruses that cause viremia can also be found in semen, but not as direct evidence of sexual transmission. This is because, for the virus, the blood-testis barrier is imperfect, especially in the presence of systemic or local inflammation, so in the case of viremia, the virus can sow seeds in the male reproductive tract. The virus may not replicate in the reproductive tract, but it persists.
Therefore, the researchers said, "The sexual behavior of this series and the lesions initially primarily in the anal and genital regions suggest that close contact during sexual intercourse is important for virus transmission. Further studies are needed to assess the role of monkeypox virus in different Presence, persistence and infectivity in bodily fluids."
Portugal reports 14 simultaneous HIV-positive cases of monkeypox patients
The Portuguese research team conducted an epidemiological survey of 96 confirmed cases of monkeypox in Portugal as of May 27. The researchers obtained the demographic characteristics, clinical manifestations and exposure of all 96 cases through face-to-face and telephone interviews. In total, in-depth information on 27 confirmed cases was collected.
Epidemiological studies show that the first cases of Portuguese monkeypox developed symptoms as early as April 29. This suggests that monkeypox virus has been circulating undetected in Europe since at least early April and may have been imported into Portugal. The outbreak curves also show different routes of exposure to the virus, including being in specific settings (such as saunas used for sexual contact), going abroad during the incubation period (Spain, UK, and Brazil), and exposure to non-Portuguese nationals. Most of the cases were not part of an established chain of transmission - only 1 had contact with another confirmed case, and few cases reported contact with someone with similar symptoms or a history of travel abroad.
In addition, the age of the cases ranged from 22 to 51 years (median 33 years). All cases were male. Almost all cases identified themselves as men who have sex with men (MSM), while one reported having sex only with women. In the 21 days prior to the onset of symptoms, most cases reported having sex with multiple partners, and 3 had contact with animals (2 with cats and 1 with pigs).
Figure 1: Schematic diagram of the flow of the first 41 cases in Portugal as of May 23. 1 case was a close contact of a known case, 8 cases had visited high-risk places involved, 4 cases had travel history during the incubation period, and the other infection routes were unknown.
The most common symptoms of patients were herpes (14 cases), inguinal lymphadenopathy (14 cases), fever (13 cases), and genital ulcers (6 cases). A total of 14 cases were infected with HIV. As of May 27, 2022, no deaths have been registered. One middle-aged case reported previous smallpox vaccination."The clinical presentation of monkeypox in this outbreak is atypical, with lesions starting in the genital area rather than the face, and contact tracing has been difficult because a large proportion of cases had sex with multiple or anonymous sexual partners," the researchers said.
Portuguese researchers emphasized that although monkeypox is a zoonotic disease, studies have shown that the genetic adaptation of monkeypox virus to human hosts is increasing, and the possibility of human-to-human transmission is increasing. Therefore, it is necessary for the relevant health agencies to carry out further preventive measures, "early risk communication and targeted preventive measures for sexual minorities living in Portugal, and careful consideration to ensure a non-stigmatizing approach. In addition, most importantly, The goal is to raise the awareness of medical staff and identify suspected cases."
"Although monkeypox virus is classified as moderately circulating, further genetic characterization of monkeypox virus isolates from Portugal and other European countries is required to elucidate the origin and disease dynamics of this outbreak," the researchers said. ."
Community spread of monkeypox in UK, divided into three separate incidents
The monkeypox outbreak in the UK has been divided into three distinct events, according to the British researchers. The first was the first confirmed case on May 7, an isolated case imported from Nigeria, a country endemic for monkeypox. Of the 116 close contacts identified, including healthcare workers, none developed monkeypox infection at the end of the 21-day follow-up period.
This was followed by a separate family cluster discovered on May 12. The first case in the cluster developed symptoms on April 17. He had no travel experience in monkeypox endemic countries and could not determine the source of infection. As of May 25, none of the 98 close contacts (including health care workers) linked to the household cluster had developed monkeypox infection.
Finally, four new confirmed cases of monkeypox infection were reported in England on 16 May. The patients were adult males (age ≥18 years). These new cases have no known links to previous cases and have not traveled to countries at risk for monkeypox. Two of them were sexual partners.
As of 25 May 2022, there have been 86 laboratory confirmed cases of monkeypox virus infection in the UK. The report describes available data on confirmed cases in the UK as of 25 May 2022.
Of these, 82 confirmed cases were associated with Event 3, and were not associated with either the first travel-related case (Event 1) nor the family clustered case (Event 2). Of the cases associated with Event 3, gender information was provided in 79 cases - all male. Of these, 66 (83%) were homosexual, or bisexual, or other men who had sex with men (GBMSM). Sexual orientation/behavior was unknown in 16 cases. The median age of the patients was 38 years. In the 21 days prior to the onset of symptoms, 18 reported travel to multiple countries outside Africa. Sexual health history has been identified as being associated with group sex, private sex parties, and use of dating apps.
Figure 2: Light blue squares represent cases related to event 1, yellow squares represent cases related to event 2, and dark blue squares represent cases related to event 3
There were also significant differences in the close contacts of the patients in these three separate events. Contacts of cases related to events 1 and 2 were primarily passengers who were on the same flight as the travel-related case or health care workers who had been in contact with the patient before the patient was identified as a suspected monkeypox case. By contrast, many of the contacts in Event 3 are in the community. The median number of community, household, or sexual contacts reported for each confirmed case in Event 3 was 4, with a maximum of 25. In Incident 3, a total of 356 community contacts were identified, including 83 households (23%), 78 sexual contacts (22%), 89 friends/shared spaces (25%), 82 workplaces (23%) %) and 24 community health care (7%).
“In some cases, it is difficult to determine the true number of sexual contacts due to circumstances such as group sex. Of the 78 sexual contacts reported in incident 3, only 28% reported names or contact details. Some cases Refusing to share personal details of their sexual encounters, or reporting multiple anonymous sexual encounters. This undoubtedly challenges public health action and calculations," the researchers said.
"This is the first time the UK has reported sustained transmission of monkeypox, and MSM is disproportionately represented in new cases based on case reporting in most countries, suggesting that the virus spreads person-to-person through close contact, including sexual networks. spread between.
The researchers concluded, "Our goal should still be to eliminate monkeypox virus, but success in public health requires a concerted international effort: this includes identifying cases and their contacts. Involving the community in case detection and prevention In addition, public health risk assessment and communication will be critical due to challenges in tracing close contacts in sexual networks. If we are not able to achieve epidemic control rapidly globally, then it is imperative to expand capacity for routine testing and Consider alternative vaccination methods, including pre-exposure vaccination and expanded vaccination for those at higher risk of infection."
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