In women and non-binary people, cases of monkeypox may have been missed
During the monkeypox epidemic that unfolded this summer in the United States and dozens of other countries, men who have sex with men were most at risk. But thousands of women were also infected, and many more cases were likely missed, according to the first-ever study of women and non-binary people who had contracted the disease.
As with men, sexual contact was most likely to be the source of infection in transgender women, accounting for 89% of cases, according to the case series. published Thursday in the Lancet journal. But among cisgender women and non-binary people who were designated female at birth, only 61% of cases could be linked to sexual contact.
Almost a quarter of the cisgender women in the study could have been infected without sexual interaction with an infected person, said Dr Chloe Orkin, a doctor and researcher at Queen Mary University of London. The women are believed to have been infected through exposure at work or home or through other types of close contact.
“The lesson here is that everyone should know about this,” Dr. Orkin said. While it’s appropriate that public health messaging is aimed primarily at men who have sex with men, she added, “it’s important to recognize that this isn’t the only group.”
After several months of rapidly increasing case numbers, the monkeypox outbreak in the United States has slowed, thanks in part to a vaccination campaign and behavioral changes by many high-risk people. Since May, there have been just over 29,000 cases in the United States, but only about a thousand cases have been diagnosed in the past month.
Yet as the disease fades from public attention, scientists are only just beginning to understand when and how it spreads and who is at risk.
In the new study, Dr. Orkin and his colleagues found monkeypox virus genetic material in all 14 vaginal swabs they tested, suggesting that the virus can be transmitted through genital secretions. Studies in humans have also found the virus in seminal fluid.
Yet public health authorities have been reluctant to label monkeypox a sexually transmitted infection, arguing that the virus can spread through close physical contact of any kind.
But some experts disagree: The fact that monkeypox can be transmitted by other means should not preclude its classification as a sexually transmitted disease, as other diseases like herpes and syphilis can also spread through close non-sexual contact, some have said.
Last month, New York State added monkeypox to its list of sexually transmitted infections, but the Centers for Disease Control and Prevention did not make the change. The agency will leave that categorization to individual states, said Dr. Demetre Daskalakis, deputy White House monkeypox response coordinator. But it is clear that sexual behavior drives cases, he said.
“If you took away our sex, would we have had an epidemic of monkeypox? Probably not,” he added. Even though the primary reason for the spread is skin-to-skin contact during sexual activity, “it is definitely sexually associated transmission.”
This year, Dr. Orkin led an international collaboration to characterize the symptoms of monkeypox in 500 patients. The results led Britain, the United States and other countries to refine their case definitions of the disease.
And last month the UK Health Security Agency published a study suggesting that between about 40% and 60% of monkeypox transmission may occur before infected people develop symptoms.
That makes intuitive sense because once patients develop painful blisters, they’re unlikely to have sex, noted Tom Ward, an infectious disease modeler for the agency. A small percentage of infected people may never develop symptoms, he said.
Contact tracing during a monkeypox outbreak is extremely difficult due to the sensitive and often anonymous nature of the spread; no test can detect monkeypox until the characteristic rash appears.
“What it basically highlights is that we still need a lot of research into the nature of asymptomatic and pre-symptomatic transmission of monkeypox,” Dr Ward said.
Some people may have mild generic symptoms like a sore throat before developing the rash.
These people should stay home to protect others, Dr Daskalakis said. But ultimately, he said, the possibility of pre-symptomatic spread doesn’t change the public health message to those at risk: vaccinate against monkeypox.
“Probably the strongest recommendation is that if there is a history that would make you think you are at risk for monkeypox, it is important to get vaccinated, and if there is potential for future risk, it is important to get vaccinated,” he added. .
The new study is the first to describe monkeypox in transgender or non-binary people, who often have little access to quality health care and are rarely included in research studies.
“It’s very, very important that we account for both sex and gender differences because both are important and in some cases they overlap,” Dr Orkin said.
In the study, researchers from 15 countries provided clinical information on 69 cisgender women, 62 transgender women and five non-binary people who were diagnosed with monkeypox between May 11 and October 4. About 45% of the women were Latino, 29% were white, and 21% were black.
More than half of the patients in the study had sores in the anus, genitals, mouth or eyes. But some women — especially cisgender women — were initially misdiagnosed with other sexually transmitted infections.
Experts had predicted that monkeypox “would likely have a slightly different pattern of transmission depending on social behaviors and norms within certain groups,” said Dr. Abraar Karan, an infectious disease physician at Stanford University.
The new study supported this inference. Unlike male monkeypox patients who have sex with men, only 7% of patients in the study said they had attended a Pride event or other similar gatherings. While the transgender women in the study had had about 10 partners on average in the previous month, cisgender women had one, and 7% of cisgender women said they had had no sexual partners in the previous month.
“So the driver was not the same,” Dr Karan said.
Many of the transgender women in the study had other risk factors for monkeypox, including undiagnosed and untreated HIV, homelessness and injection drug use. Half of the transgender women in the study were HIV positive compared to 8% of cisgender women, and more than half of transgender women were involved in the sex trade compared to 3% of cisgender women.
“While the absolute numbers of people who are trans and engaged in sex work may not be very high, the extremely high prevalence of HIV and now monkeypox and other sexually transmitted infections means that public health agencies need to think about ways to raise awareness in this population,” said Dr. Jay Varma, director of the Cornell Center for Pandemic Prevention and Response.
While many transgender women sought care at sexual health clinics, the cisgender women in the study went to primary care providers or emergency departments, where doctors were more likely not to. know the symptoms of monkeypox. About one in three cisgender women were diagnosed late or with another condition; some were probably never diagnosed.
“It’s very likely that infections were missed and not detected at all,” Dr Orkin said.
About one in four cisgender women in the study lived with children, but doctors only identified two cases of monkeypox among them. The CDC’s observations are consistent with this conclusion.
But Dr Karan warned that cases in children could be underreported due to the stigma associated with monkeypox. More studies are needed to understand how symptoms may vary in different populations, especially in countries where the virus has caused outbreaks for years, he said.