Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series

Incidental diagnosis of mpox virus infection in patients undergoing sexually transmitted infection screening-findings from a study in France

OBJECTIVES

This study aimed to investigate the prevalence of mpox virus (MPXV) infections in the general population consulting for routine sexually transmitted infections (STIs) in our Marseille public hospital. In fact, the recent worldwide MPXV outbreak mainly impacted men who have sex with men and the prevalence of MPXV infections in the general population remains poorly defined.

METHODS

All samples addressed routinely to our microbiological laboratory for STIs between July 1 and October 15, 2022 were screened with MPXV-specific quantitative polymerase chain reaction.

RESULTS

A total of 2688 samples from 1896 patients suspected of having STIs were tested and eight (0.4%) patients were incidentally diagnosed with MPXV infection, including six men and two women. MPXV was detected in rectal swabs (n = 2), urine (n = 2), vaginal swabs (n = 2), a urethral swab (n = 1), and a skin swab (n = 1).

CONCLUSIONS

This study suggests that some MPXV infections are likely to be underdiagnosed because of their non-specific clinical presentation and/or insufficient clinical knowledge of the disease. Our data showed that systematic screening was particularly useful for detecting MPXV in patients without classic lesions or cases of asymptomatic carriage in patients reporting recent high-risk exposure and in patients presenting no obvious risk factor.

Machine learning in epidemiology: Neural networks forecasting of monkeypox cases

This study integrates advanced machine learning techniques, namely Artificial Neural Networks, Long Short-Term Memory, and Gated Recurrent Unit models, to forecast monkeypox outbreaks in Canada, Spain, the USA, and Portugal. The research focuses on the effectiveness of these models in predicting the spread and severity of cases using data from June 3 to December 31, 2022, and evaluates them against test data from January 1 to February 7, 2023. The study highlights the potential of neural networks in epidemiology, especially concerning recent monkeypox outbreaks. It provides a comparative analysis of the models, emphasizing their capabilities in public health strategies. The research identifies optimal model configurations and underscores the efficiency of the Levenberg-Marquardt algorithm in training. The findings suggest that ANN models, particularly those with optimized Root Mean Squared Error, Mean Absolute Percentage Error, and the Coefficient of Determination values, are effective in infectious disease forecasting and can significantly enhance public health responses.

Mpox outbreak in Rio de Janeiro, Brazil: A translational approach

Mpox is a zoonotic disease historically reported in Africa. Since 2003, limited outbreaks have occurred outside Africa. In 2022, the global spread of cases with sustained interhuman transmission and unusual disease features raised public health concerns. We explore the mpox outbreak in Rio de Janeiro (RJ) state, Brazil, in an observational study of mpox-suspected cases from June to December 2022. Data collection relied on a public healthcare notification form. Diagnosis was determined by MPXV-PCR. In 46 confirmed cases, anti-OPXV IgG was determined by ELISA, and seven MPXV genomes were sequenced. A total of 3095 cases were included, 816 (26.3%) with positive MPXV-PCR results. Most positive cases were men in their 30 s and MSM. A total of 285 (34.9%) MPXV-PCR+ patients live with HIV. Eight were coinfected with varicella-zoster virus. Anogenital lesions and adenomegaly were associated with the diagnosis of mpox. Females and individuals under 18 represented 9.4% and 5.4% of all confirmed cases, respectively, showing higher PCR cycle threshold (Ct) values and fewer anogenital lesions compared to adult men. Anti-OPXV IgG was detected in 29/46 (63.0%) patients. All analyzed sequences belonged to clade IIb. In RJ state, mpox presented a diverse clinical picture, represented mainly by mild cases with low complication rates and prominent genital involvement. The incidence in females and children was higher than usually reported. The observation of a bimodal distribution of Ct values, with few positive results, may suggest the need to review the diagnostic criteria in these groups.

Mpox across countries from Central and Eastern Europe - 2022 outbreak

BACKGROUND

The aim of the study was to assess socio-demographical characteristics, clinical presentation, and outcomes in patients diagnosed with mpox.

METHODS

A survey on patients diagnosed with mpox was performed in 14 countries from Central and Eastern Europe. Data was compared according to HIV status and country of origin (EU vs. non-EU). Mpox diagnosis was confirmed by RT-PCR from oropharyngeal swabs, skin lesions, and other body fluids.

RESULTS

Out of 154 patients confirmed with mpox in 2022, 99.3% were males, with a median age (years) of 35 (IQR 30-39), 90.2% MSM and 48.7% PLWH. Compared to HIV-negative subjects, PLWH had more frequent high-risk behaviours:chemsex (p = 0.015), group sex (p = 0.027), and a history of sexually transmitted infections (STIs) (p = 0.004). Persons from EU were more often PLWH (p = 0.042), MSM (p < 0.0001), had multiple sexual partners (p = 0.025), practiced chemsex (p = 0.008) or group-sex (p = 0.005) and had more often history of STIs (p < 0.0001). The median CD4 cell count/mL at mpox diagnosis was 713 (IQR 486-996) and 73.5% had undetectable HIV VL. The commonest clinical features were fever (108 cases), lymphadenopathy (78), and vesiculo-pustular rash: penile (76), perianal (48), limbs (67). Fifty-one (31%) persons were hospitalized due to complications or epidemiological reasons. Three patients received tecovirimat or cidofovir. The outcome was favorable for all patients, including 4 with severe forms.

CONCLUSIONS

Mpox was diagnosed predominantly in young MSM, with high-risk behaviors and history of STIs. Effective contact tracing and vaccination are important strategic pillars to control mpox outbreaks.

Household Transmission of Mpox to Children and Adolescents, California, 2022

BACKGROUND

In California, the 2022 mpox outbreak cumulated 5572 cases, 20% of US cases, as of November 28, 2022; 0.3% of cases were among children <16 years old. The secondary attack rate (SAR) for children sharing households with infected adults is unknown.

METHODS

A line list of pediatric mpox household contacts aged <16 years reported through August 31, 2022 was created. It included demographic and clinical information on the contacts. Pediatric contact lists were crossmatched with the state vaccination database to identify those who received postexposure prophylaxis (PEP) with the JYNNEOS vaccine.

RESULTS

We identified 129 pediatric household contacts with median age of 7 years (range, 0-15 years). Among 18 symptomatic contacts, 12 (66.7%) underwent mpox testing; 5 (41.2%) were confirmed cases, 6 (50%) were negative, and 1 (0.8%) had an indeterminate result. Six symptomatic children were not tested for mpox (33.3%). Overall, 6 infected contacts were identified, resulting in a SAR of 4.7% (6 of 129). The majority of pediatric household contacts and 4 of 6 infected children identified as Hispanic/Latino. Only 18 children (14%) reported receiving PEP.

CONCLUSIONS

The SAR was overall low among pediatric household contacts; none had severe disease. This may be underestimated given low testing rates.

Association of Tecovirimat Therapy With Mpox Symptom Improvement: A Cross-sectional Study-King County, Washington, May-October 2022

Background

Data on tecovirimat effectiveness for human mpox are limited. We conducted a retrospective cross-sectional interview-based study to identify associations between tecovirimat treatment and the mpox clinical course.

Methods

Using public health surveillance data from King County, Washington, we recruited and interviewed persons diagnosed with mpox during May-October 2022. We calculated descriptive statistics on demographics, vaccination status, comorbidities, and symptoms including 3 self-reported dates (symptom onset, first date of symptom improvement, and illness resolution). We used multivariable linear regression, stratified by illness severity, to evaluate the association of tecovirimat treatment with time to symptom improvement and time to illness resolution. We compared individuals who did not receive tecovirimat to participants who started tecovirimat early (≤5 days from symptom onset) and late (>5 days and ≤28 days from symptom onset) in their illness.

Results

Of 465 individuals diagnosed with mpox, 115 (25%) participated in this study. Eighty participants (70%) received tecovirimat and 43 (37%) initiated tecovirimat early. Sixty-eight (59%) reported severe symptoms during their illness, including proctitis (n = 38 [33%]), rectal bleeding (n = 27 [24%]), or severe pain (n = 24 [21%]). In the multivariable analysis, early tecovirimat was associated with shorter time to symptom improvement (-5.5 days, P = .04) among participants with severe illness but not among those with nonsevere illness (0.9 day, P = .66). Early tecovirimat was not associated with faster illness resolution, regardless of severity.

Conclusions

Our small study suggests that early tecovirimat initiation may hasten subjective symptomatic improvement in people with severe mpox. Larger randomized trials are needed to evaluate this finding.

Combination of Extended Antivirals With Antiretrovirals for Severe Mpox in Advanced Human Immunodeficiency Virus Infection: Case Series of 4 Patients

To gauge the safety and utility of extended tecovirimat/cidofovir for severe mpox, here we report our experience caring for 4 patients with mpox and advanced human immunodeficiency virus (HIV) at the Hospitals of the University of Pennsylvania during the 2022 global outbreak. Three patients had recurrent courses complicated by superinfections, coinfections and insufficient nutrition/housing, requiring extended tecovirimat (5-16 weeks) and cidofovir (1-12 doses) with probenecid and fluids. At follow-up, patients had undetectable HIV RNA on antiretrovirals, improved ulcers and stable renal function on antivirals. Serology guided cessation for one 7-month cidofovir course. Overall findings support a comprehensive approach of prolonged tecovirimat/cidofovir with antiretrovirals for severe mpox, while addressing social factors.

Effectiveness of Modified Vaccinia Ankara-Bavaria Nordic Vaccination in a Population at High Risk of Mpox: A Spanish Cohort Study

BACKGROUND

With more than 7500 cases reported since April 2022, Spain has experienced the highest incidence of mpox in Europe. From 12 July onward, the modified vaccinia Ankara-Bavaria Nordic (MVA-BN) smallpox vaccine was offered as pre-exposure prophylaxis for those receiving pre-exposure prophylaxis for human immunodeficiency virus (HIV-PrEP). Our aim was to assess the effectiveness of 1 dose of MVA-BN vaccine as pre-exposure prophylaxis against mpox virus (MPXV) infection in persons on HIV-PrEP.

METHODS

National retrospective cohort study between 12 July and 12 December 2022. Individuals aged ≥18 years receiving HIV-PrEP as of 12 July with no previous MPXV infection or vaccination were eligible. Each day, we matched individuals receiving a first dose of vaccine and unvaccinated controls of the same age and region. We used a Kaplan-Meier estimator, calculated risk ratios (RR) and vaccine effectiveness (VE = [1 - RR]x100).

RESULTS

We included 5660 matched pairs, with a median follow-up of 62 days (interquartile range, 24-97). Mpox cumulative incidence was 5.6 per 1000 (25 cases) in unvaccinated and 3.5 per 1000 (18 cases) in vaccinated. No effect was found during days 0-6 post-vaccination (VE, -38.3; 95% confidence interval [CI], -332.7 to 46.4), but VE was 65% at ≥7 days (95% CI, 22.9 to 88.0) and 79% at ≥14 days (95% CI, 33.3 to 100.0) post-vaccination.

CONCLUSIONS

One dose of MVA-BN vaccine offered protection against mpox in most-at-risk population shortly after the vaccination. Further studies need to assess the VE of a second dose and the duration of protection over time.

Integrated Network Analysis of Symptom Clusters Across Monkeypox Epidemics From 1970 to 2023: Systematic Review and Meta-Analysis

BACKGROUND

The worldwide spread of monkeypox (mpox) has witnessed a significant increase, particularly in nonendemic countries.

OBJECTIVE

We aimed to investigate the changing clinical symptoms associated with mpox from 1970 to 2023 and explore their interrelations.

METHODS

In this systematic review and meta-analysis, 3 electronic databases were searched for English peer-reviewed studies conducted from January 1970 to April 2023 that reported any symptoms among confirmed mpox cases. We categorized the mpox epidemics into 3 periods: 1970-2002 (period 1, within the African region), 2003-2021(period 2, epidemics outside Africa), and 2022-2023 (period 3, worldwide outbreak). Following PRISMA guidelines, a meta-analysis was performed to estimate the pooled prevalence for each symptom. The correlation among symptoms was analyzed and visualized using network analysis.

RESULTS

The meta-analysis included 61 studies that reported 21 symptoms in 720 patients from period 1, 39 symptoms in 1756 patients from period 2, and 37 symptoms in 12,277 patients from period 3. The most common symptom among patients from all 3 periods was rash (period 1: 92.6%, 95% CI 78.2%-100%; period 2: 100%, 95% CI 99.9%-100%; and period 3: 94.8%, 95% CI 90.9%-98.8%), followed by lymphadenopathy (period 1: 59.8%, 95% CI 50.3%-69.2%; period 2: 74.1%, 95% CI 64.2%-84.1%; and period 3: 61.1%, 95% CI 54.2%-68.1%). Fever (99%, 95% CI 97%-100%), enlarged lymph nodes (80.5%, 95% CI 75.4%-85.0%), and headache (69.1%, 95% CI 4%-100%) were the main symptoms in period 1, with a significant decrease in period 3: 37.9%, 31.2%, and 28.7%, respectively. Chills/rigors (73.3%, 95% CI 60.9%-85.7%), fatigue (68.2%, 95% CI 51.6%-84.8%), and dysphagia/swallowing difficulty (61.2%, 95% CI 10.5%-100%) emerged as primary new symptoms in period 2 and decreased significantly in period 3. Most other symptoms remained unchanged or decreased in period 3 compared to the former 2 periods. Nausea/vomiting had the highest degree of correlation (with 13 symptoms) and was highly positively correlated with lymphadenopathy (r=0.908) and conjunctivitis (r=0.900) in period 2. In contrast, rash and headache were 2 symptoms with the highest degree of correlation (with 21 and 21 symptoms, respectively) in period 3 and were highly positively correlated with fever (r=0.918 and 0.789, respectively).

CONCLUSIONS

The manifestation of symptoms in patients with mpox has become more diverse, leading to an increase in their correlation. Although the prevalence of rash remains steady, other symptoms have decreased. It is necessary to surveil the evolving nature of mpox and the consequential changes in clinical characteristics. Epidemic countries may shift their focus on the potential association among symptoms and the high synergy risk.

TRIAL REGISTRATION

PROSPERO Registration: CRD42023403282; http://tinyurl.com/yruuas5n.

The Current State and Progress of Mpox Vaccine Research

On July 23, 2022, the World Health Organization (WHO) declared the monkeypox (mpox) outbreak a "Public Health Emergency of International Concern." Since 2022, outbreaks of mpox in many countries around the world have primarily resulted in fatalities among immunocompromised individuals, such as untreated HIV/AIDS patients. Since the eradication of smallpox was declared by the WHO in 1980, the global vaccination against smallpox has been gradually discontinued. China also stopped routine smallpox vaccination in 1981. The protective effect of the smallpox vaccine has decreased over time due to aging and declining immunity in those who were vaccinated. For individuals, timely vaccination against smallpox is an effective means of protection against mpox. However, due to safety concerns with the smallpox vaccine and the limitations of current mpox vaccines, there is no vaccine that is safe, effective, and has low side effects applied in clinical settings. This article provides a comprehensive review of the development of mpox virus (MPXV) vaccines, their application in special populations, and the current state of vaccine research, considering the etiology, transmission, and prevention of the MPXV. Vaccination, as an effective method of epidemic prevention, can provide long-term immune protection and effectively reduce the severity of infection. However, as there is no licensed specific MPXV vaccine available globally, the vaccines currently used for mpox prevention are mostly smallpox vaccines. These smallpox vaccines can offer some degree of protection against mpox by activating cross-protection in the body.

Messenger RNA Therapy for Female Reproductive Health

Female reproductive health has traditionally been an underrepresented area of research in the drug delivery sciences. This disparity is also seen in the emerging field of mRNA therapeutics, a class of medicines that promises to treat and prevent disease by upregulating protein expression in the body. Here, we review advances in mRNA therapies through the lens of improving female reproductive health. Specifically, we begin our review by discussing the fundamental structure and biochemical modifications associated with mRNA-based drugs. Then, we discuss various packaging technologies, including lipid nanoparticles, that can be utilized to protect and transport mRNA drugs to target cells in the body. Last, we conclude our review by discussing the usage of mRNA therapy for addressing pregnancy-related health and vaccination against sexually transmitted diseases in women. Of note, we also highlight relevant clinical trials using mRNA for female reproductive health while also providing their corresponding National Clinical Trial identifiers. In undertaking this review, our aim is to provide a fundamental background understanding of mRNA therapy and its usage to specifically address female health issues with an overarching goal of providing information toward addressing gender disparity in certain aspects of health research.

Mpox in people living with HIV

PURPOSE OF REVIEW

The 2022 global outbreak of mpox disproportionally affected people with HIV (PWH). We review the data on the presentation, treatment, and prevention of mpox in PWH.

RECENT FINDINGS

Most PWH with mpox had a mild and self-limiting illness, no different to people without HIV. A higher rate of rectal symptoms has been reported among PWH and those with advanced HIV disease were at higher risk of severe disease, hospitalization, and death. Treatment with antivirals was widely used in hospitalized patients without any randomized control trial data to support its use and without any data specifically in PWH. Use of smallpox vaccines to prevent mpox is safe in PWH regardless of CD4+ cell count. There is limited data on efficacy in those with lower CD4+ cell count and on long-term protective efficacy.

SUMMARY

PWH should be offered vaccination against mpox in line with national guidelines. PWH should be individually risk-assessed for severe mpox, based on their CD4+ cell count and co-morbidities and ideally recruited into treatment trials to build an evidence base on efficacy. HIV and other sexually transmitted infection testing should be offered to all people diagnosed with mpox.

Mpox: The Reemergence of an Old Disease and Inequities

Mpox, previously known as monkeypox, is caused by an Orthopoxvirus related to the variola virus that causes smallpox. Prior to 2022, mpox was considered a zoonotic disease endemic to central and west Africa. Since May 2022, more than 86,000 cases of mpox from 110 countries have been identified across the world, predominantly in men who have sex with men, most often acquired through close physical contact or during sexual activity. The classical clinical presentation of mpox is a prodrome including fever, lethargy, and lymphadenopathy followed by a characteristic vesiculopustular rash. The recent 2022 outbreak included novel presentations of mpox with a predominance of anogenital lesions, mucosal lesions, and other features such as anorectal pain, proctitis, oropharyngeal lesions, tonsillitis, and multiphasic skin lesions. We describe the demographics and clinical spectrum of classical and novel mpox, outlining the potential complications and management.

Cross-sectional survey of sexual health professionals' experiences and perceptions of the 2022 mpox outbreak in the UK

OBJECTIVE

To understand the experiences and perceptions of sexual health professionals responding to the May 2022 mpox outbreak in the UK.

DESIGN

Cross-sectional, anonymous, online survey collecting quantitative and qualitative data. Convenience sample recruited via an international network of sexual health and HIV clinicians responding to mpox and promoted through clinical associations and social media. Survey domains included: clinical workload; preparedness, support, and training; safety at work; vaccination; and well-being. Qualitative descriptive analysis of open-text responses was conducted to support interpretation of the quantitative data.

PARTICIPANTS

Participants who were employed as sexual health professionals in the UK and had direct clinical experience of mpox were included in the analysis. The survey was completed between 11 August and 31 October 2022 by 139 respondents, the majority of whom were doctors (72.7%), cis-female (70.5%) and White (78.4%).

RESULTS

70.3% reported that they were required to respond to mpox in addition to their existing clinical responsibilities, with 46.8% working longer hours as a result. In the open-text data, respondents highlighted that workload pressures were exacerbated by a lack of additional funding for mpox, pre-existing pressures on sexual health services, and unrealistic expectations around capacity. 67.6% of respondents reported experiencing negative emotional impact due to their mpox work, with stress (59.0%), fatigue (43.2%) and anxiety (36.0%) being the most common symptoms. 35.8% stated that they were less likely to remain in their profession because of their experiences during the mpox outbreak. In the open-text data, these feelings were ascribed to post-COVID exhaustion, understaffing and frustration among some participants at the handling of the mpox response.

CONCLUSIONS

These findings indicate that sexual health services require increased funding and resources, along with evidence-based well-being interventions, to support sexual health professionals' outbreak preparedness and recovery.

Cases of Monkeypox show highly-overlapping co-infection with HIV and syphilis

Purpose

Ongoing Monkeypox (MPX) outbreaks in countries outside Africa have unique characteristics. However, data on cohorts of confirmed cases in China is limited. The study provides important epidemiological, diagnostic, and clinical information about this disease in China.

Methods

We report a series of Chinese individuals with confirmed MPX infections identified at Beijing Youan Hospital (China) from June 10 to July 15, 2023. Samples were taken from the skin, anus, throat, and blood. An epidemiological questionnaire was used to collect demographic and clinical data. Further, we compared the MPX viral (MPXV) loads across different anatomical sites.

Results

66 samples were collected from 20 patients, all of whom were cisgender men. Median patient age was 29 years. Notably, 19 (95%) patients reported unprotected sexual encounters with men in the preceding month, and 13 (65%) were human immunodeficiency virus (HIV)-positive. Among those with HIV, 12 (92%) were receiving antiretroviral therapy, and 11 (85%) had well-controlled infections (HIV viral load <40/mL). The median CD4+ T cell count was 667 cells/mm3. In the HIV-negative group, three (43%) patients were taking preexposure prophylaxis. Fifteen patients (75%) had concurrent sexually transmitted infections (50% had syphilis and 65% had HIV) and eight (40%) had HIV and syphilis co-infection. MPXV loads were significantly higher in samples from the skin (cycle threshold value [Ct value]: 19·0) and anus (Ct value: 23.0) compared to samples from the throat (Ct value: 31.0) or blood (Ct value: 34.5). All patients had skin lesions (85% of whom presented with anogenital lesions). Common systemic symptoms included fever (85%) and lymphadenopathy (55%). The median incubation period was 8 d [interquartile range (IQR): 6-16 d]. The median time from the onset of skin lesions to scab removal was 14 d (IQR: 10-16 d). No deaths or severe cases were reported.

Conclusion

MPXV primarily affects young homosexual men. The high MPXV viral loads in skin and anal lesions indicate that transmission most likely occurs through direct and close body contact. This study also reports high rates of HIV and syphilis co-infection. Therefore, preventive efforts should focus on homosexual men.

Clade I-Associated Mpox Cases Associated with Sexual Contact, the Democratic Republic of the Congo

We report a cluster of clade I monkeypox virus infections linked to sexual contact in the Democratic Republic of the Congo. Case investigations resulted in 5 reverse transcription PCR-confirmed infections; genome sequencing suggest they belonged to the same transmission chain. This finding demonstrates that mpox transmission through sexual contact extends beyond clade IIb.

Emerging and re-emerging pediatric viral diseases: a continuing global challenge

The twenty-first century has been marked by a surge in viral epidemics and pandemics, highlighting the global health challenge posed by emerging and re-emerging pediatric viral diseases. This review article explores the complex dynamics contributing to this challenge, including climate change, globalization, socio-economic interconnectedness, geopolitical tensions, vaccine hesitancy, misinformation, and disparities in access to healthcare resources. Understanding the interactions between the environment, socioeconomics, and health is crucial for effectively addressing current and future outbreaks. This scoping review focuses on emerging and re-emerging viral infectious diseases, with an emphasis on pediatric vulnerability. It highlights the urgent need for prevention, preparedness, and response efforts, particularly in resource-limited communities disproportionately affected by climate change and spillover events. Adopting a One Health/Planetary Health approach, which integrates human, animal, and ecosystem health, can enhance equity and resilience in global communities. IMPACT: We provide a scoping review of emerging and re-emerging viral threats to global pediatric populations This review provides an update on current pediatric viral threats in the context of the COVID-19 pandemic This review aims to sensitize clinicians, epidemiologists, public health practitioners, and policy stakeholders/decision-makers to the role these viral diseases have in persistent pediatric morbidity and mortality.

[Monkeypox: case series]

Introduction

the recent mpox outbreak was considered an international public health emergency.

Objective

describe the epidemiological and clinical characteristics of mpox in a hospital in the province of Buenos Aires.

Methods

case series study in patients ≥15 years of age in the Dermatology service of the Hospital Interzonal General de Agudos "San Martín" in La Plata between August and November 2022.

Results

10 patients were included. The mean age of presentation was 35 years. Seven of the patients were men and the remaining three were women. Most of them presented risky sexual intercourse as an epidemiological history. Pseudopustules were observed in 70% of the patients and all had genital, gluteal or perianal lesions. The complications observed were: local edema, proctitis, conjunctivitis and pharyngitis.

Conclusion

we present 3 female patients out of a total of 24 women reported in the country, which represent only 2% of mpox infections in Argentina. In most cases we observe pseudopustules, an elementary lesion recently described for this entity. One patient presented ocular involvement, a complication reported in 1% of cases in the current outbreak.

Environmental detection and spreading of mpox in healthcare settings: a narrative review

Monkeypox virus (MPXV), which causes Monkeypox (Mpox), has recently been found outside its usual geographic distribution and has spread to 117 different nations. The World Health Organization (WHO) designated the epidemic a Public Health Emergency of International Concern (PHEIC). Humans are at risk from MPXV's spread, which has raised concerns, particularly in the wake of the SARS-CoV-2 epidemic. The risk of virus transmission may rise due to the persistence of MPXV on surfaces or in wastewater. The risk of infection may also increase due to insufficient wastewater treatment allowing the virus to survive in the environment. To manage the infection cycle, it is essential to investigate the viral shedding from various lesions, the persistence of MPXV on multiple surfaces, and the length of surface contamination. Environmental contamination may contribute to virus persistence and future infection transmission. The best possible infection control and disinfection techniques depend on this knowledge. It is thought to spread mainly through intimate contact. However, the idea of virus transmission by environmental contamination creates great concern and discussion. There are more cases of environmental surfaces and wastewater contamination. We will talk about wastewater contamination, methods of disinfection, and the present wastewater treatment in this review as well as the persistence of MPXV on various environmental surfaces.

A global systematic evidence review with meta-analysis of the epidemiological characteristics of the 2022 Mpox outbreaks

BACKGROUND

In 2022, there were outbreaks of Mpox where the disease is not endemic. We summarized published full-text epidemiological data from the outbreaks.

METHODS

A global evidence review (protocol: osf.io/j3kb7) with systematic literature search up to February 09, 2023. We focused on experimental/observational studies of laboratory confirmed Mpox, excluding case reports and case series of < 5 cases. Epidemiological data were pooled using an inverse variance, random-effects model, and pooled estimates presented with associated 95% confidence intervals.

RESULTS

We included 66 studies. Mean incubation period was 7.8 days (6.6-9.0 days, 8 studies: 560 cases), reproductive number 1.8 (1.7-1.9, 6 studies), mean duration from symptom onset to diagnosis 5.8 days (4.8-6.8 days, 4 studies: 982 cases), mean symptom duration 17.5 days (14.7-20.2 days, 3 studies: 292 cases), mean serial interval 8.5 days (7.3-9.9 days, 1 study), hospitalisation 6% (4-9%, 26 studies: 5339 cases), and vaccine effectiveness 78% (65-91%, 3 studies: 953 cases). Highly relevant clinical manifestations were pleomorphic skin lesions 82% (68-94%, 26 studies: 4093 cases), anogenital lesions 64% (51-77%, 9 studies: 10,398 cases), fever 54% (50-57%, 52 studies: 25,992 cases), and lymphadenopathy 51% (46-57%, 42 studies: 17,803 cases), with cases mostly men who have sex with men (MSM). Possibly relevant manifestations were perianal lesions, fatigue, asthenia, myalgia, and headache.

CONCLUSIONS

The 2022 Mpox outbreaks presented with sex-related clinical manifestations and were mostly reported among MSM.

Clinical, epidemiological, and virological features of Mpox in Beijing, China - May 31-June 21, 2023

The first locally acquired case in the Chinese mainland was reported on May 31, 2023, lagging behind other countries. In this study, we aimed to examine the early clinical and epidemiological characteristics of the earliest cases of Mpox in Beijing, China. Additionally, we investigated the sequence and transmission patterns of the Mpox virus (MPXV). We analyzed 37 reported cases of Mpox in Beijing from May 31, 2023 to June 21, 2023. The age range of the subjects was 24-51 years. Thirty-six cases (97.3%) were identified in men who have sex with men (MSM), and 19 cases (51.4%) tested positive for the human immunodeficiency virus. Thirty-three cases were symptomatic, while four were asymptomatic. Skin lesions were observed in 32 cases (97.0%), fever in 26 (78.8%), and swollen lymph nodes in 17 (51.5%). Rash typically appeared in the genital or perianal area 1-3 days before fever onset, with a minimum incubation period of 2 days. For individuals with skin rashes, the skin lesion samples showed 100% positivity and low Ct values. There were high oropharyngeal swab (75.8%) and blood (84.6%) positivity rates. All MPXV strains belonged to the B.1.3 branch of the West African lineage. These strains carried 76-86 nucleotide substitutions compared with the reference human MPXV genome, and genetic diversity was observed. Our findings provide the first insights into the landscape of early transmission of Mpox in Beijing and help inform policy formulation in the Chinese mainland.

Clinical characteristics and predictors of human mpox outcome during the 2022 outbreak in Nigeria: a cohort study

BACKGROUND

Research from sub-Saharan Africa that contributes to our understanding of the 2022 mpox (formerly known as monkeypox) global outbreak is insufficient. Here, we describe the clinical presentation and predictors of severe disease among patients with mpox diagnosed between Feb 1, 2022, and Jan 30, 2023 in Nigeria.

METHODS

We did a cohort study among laboratory-confirmed and probable mpox cases seen in 22 mpox-treatment centres and outpatient clinics across Nigeria. All individuals with confirmed and probable mpox were eligible for inclusion. Exclusion criteria were individuals who could not be examined for clinical characterisation and those who had unknown mortality outcomes. Skin lesion swabs or crust samples were collected from each patient for mpox diagnosis by PCR. A structured questionnaire was used to document sociodemographic and clinical data, including HIV status, complications, and treatment outcomes from the time of diagnosis to discharge or death. Severe disease was defined as mpox associated with death or with a life-threatening complication. Two logistic regression models were used to identify clinical characteristics associated with severe disease and potential risk factors for severe disease. The primary outcome was the clinical characteristics of mpox and disease severity.

FINDINGS

We enrolled 160 people with mpox from 22 states in Nigeria, including 134 (84%) adults, 114 (71%) males, 46 (29%) females, and 25 (16%) people with HIV. Of the 160 patients, distinct febrile prodrome (n=94, 59%), rash count greater than 250 (90, 56%), concomitant varicella zoster virus infection (n=48, 30%), and hospital admission (n=70, 48%) were observed. Nine (6%) of the 160 patients died, including seven (78%) deaths attributable to sepsis. The clinical features independently associated with severe disease were a rash count greater than 10 000 (adjusted odds ratio 26·1, 95% CI 5·2-135·0, p<0·0001) and confluent or semi-confluent rash (6·7, 95% CI 1·9-23·9). Independent risk factors for severe disease were concomitant varicella zoster virus infection (3·6, 95% CI 1·1-11·5) and advanced HIV disease (35·9, 95% CI 4·1-252·9).

INTERPRETATION

During the 2022 global outbreak, mpox in Nigeria was more severe among those with advanced HIV disease and concomitant varicella zoster virus infection. Proactive screening, management of co-infections, the integration and strengthening of mpox and HIV surveillance, and preventive and treatment services should be prioritised in Nigeria and across Africa.

FUNDING

None.

Clinical, molecular, and histological characteristics of severely necrotic and fatal mpox in HIV-infected patients

BACKGROUND

This case series of 5 patients with severely necrotic mpox highlights the predominantly necrotic nature of lesions seen in cases of severe mpox as shown by skin and lung biopsy, as well as the extensive dissemination of the infection, as shown by polymerase chain reaction (PCR) assessment in different body sites.

CASE PRESENTATIONS

Patients were male, the median age was 37, all lived with HIV (2 previously undiagnosed), the median CD4+ cell count was 106 cells/mm3, and 2/5 were not receiving antiretroviral treatment. The most common complication was soft tissue infection. Skin and lung biopsies showed extensive areas of necrosis. Mpox PCR was positive in various sites, including skin, urine, serum, and cerebrospinal fluid. The initiation of antiretroviral treatment, worsened the disease, like that seen in immune reconstitution syndrome. Three patients died due to multiple organ failure, presumably associated with mpox since coinfections and opportunistic pathogens were ruled out.

CONCLUSIONS

Severely necrotic manifestations of mpox in people living with advanced and untreated HIV are related to adverse outcomes.

Knowledge, Attitudes, and Willingness of Healthcare Workers in Iraq's Kurdistan Region to Vaccinate against Human Monkeypox: A Nationwide Cross-Sectional Study

Although human monkeypox infections had not been recorded in the Kurdistan region of Iraq as of August 2023, the rapid growth of cases worldwide and the detection of monkeypox in neighboring Middle Eastern nations call for careful planning and timely response measures. Educating and empowering frontline healthcare workers (HCWs) so that they can act to curb the spread of monkeypox infections are core elements of primary prevention and protecting public health. Therefore, this study aimed to assess HCWs' knowledge and attitudes about monkeypox and their willingness to vaccinate against monkeypox. By employing a convenience sampling method, an online survey was disseminated via Google Forms between 1 November 2022 and 15 January 2023. The researchers utilized regression analyses to ascertain the factors associated with the three parameters: knowledge, attitude, and the willingness to vaccinate. A total of 637 HCWs were included in the analysis (ages ranged between 21 and 51 years). The mean overall scores were 8.18 of a max score of 16 (SD 3.37), 3.4 of 5 (SD 1.37), and 2.41 of 5 (SD 1.25) for knowledge, attitude, and willingness to vaccinate, respectively. A multivariate logistic regression analysis demonstrated that HCWs who had heard about monkeypox before 2022 rather than later had a higher level of knowledge (AOR: 4.85; 95% CI: 2.81-8.36; p < 0.001). In addition, those who had newly joined the workforce or had less than 1 year experience in practice had more positive attitudes about curbing monkeypox (AOR: 0.35; 95% CI: 0.20-0.59; p < 0.01) than those who practiced for longer. No significant predictors of willingness to vaccinate against monkeypox were identified. The research revealed that HCWs exhibited a relatively low level of monkeypox knowledge. They also had poor attitudes towards monkeypox vaccination and were therefore reluctant to receive the vaccines. Imparting knowledge about the infectious disease can cultivate better awareness and attitudes among HCWs as to their roles in mitigating the spread of an epidemic in the foreseeable future.

HIV and mpox: a rapid review

In this review, we discuss the history and epidemiology of mpox, prevention strategies, clinical characteristics and management, severity of mpox among persons with advanced HIV, and areas for future research relevant to persons with HIV.

Mpox: Clinical Outcomes and Impact of Vaccination in People with and without HIV: A Population-Wide Study

We investigated differences in mpox clinical outcomes in people with HIV (PWH) and without HIV (PWoH) and the impact of vaccination in Catalonia, Spain. We used surveillance data and the PISCIS HIV cohort. We included all confirmed mpox cases (May-December 2022). Of 2122 mpox cases, the majority had mild disease, 56% were Spanish, and 24% were from Latin America. A total of 40% were PWH, with a median CD4+T-cell of 715 cells/μL; 83% had HIV-RNA < 50 copies/mL; and 1.8% CD4+T-cell < 200 cells/μL. PWH had no increased risk for complications, except those with CD4+T-cell < 200 cells/μL. PWH with CD4+T-cell < 200 cells/μL were more likely to be from Latin America, had more generalized exanthema, and required hospitalization more frequently (p = 0.001). Diagnosis of other sexually transmitted infections (STIs) was common, both at mpox diagnosis (17%) and two years before (43%). Dose-sparing smallpox intradermal vaccination was accompanied by a sharp decrease in mpox incidence in both populations (p < 0.0001). In conclusion, unless immunosuppressed, PWH were not at increased risk of severe disease or hospitalization. Mpox is a marker of high-risk sexual behavior and was associated with high HIV and STI rates, supporting the need for screening in all mpox cases. Ethnicity disparities demonstrate the need for interventions to ensure equitable healthcare access. Dose-sparing smallpox vaccination retained effectiveness.

Characteristics of women diagnosed with mpox infection compared to men: A case series from Brazil

BACKGROUND

Cisgender men were mostly affected during the 2022 mpox multinational outbreak, with few cases reported in women. This study compares the characteristics of individuals diagnosed with mpox infection according to gender in Rio de Janeiro.

METHODS

We obtained surveillance data of mpox cases notified to Rio de Janeiro State Health Department (June 12 to December 15, 2022). We compared women (cisgender or transgender) to men (cisgender or transgender) using chi-squared, Fisher's exact, and Mood's median tests.

RESULTS

A total of 1306 mpox cases were reported; 1188 (91.0%) men (99.8% cisgender, 0.2% transgender), 108 (8.3%) women (87.0% cisgender, 13.0% transgender), and 10 (0.8%) non-binary persons. Compared to men, women were more frequently older (40+years: 34.3% vs. 25.1%; p < 0.001), reported more frequent non-sexual contact with a potential mpox case (21.4% vs. 9.8%; p = 0.004), fewer sexual partnerships (10.9 vs. 54.8%; p < 0.001), less sexual contact with a potential mpox case (18.5% vs. 43.0%; p < 0.001), fewer genital lesions (31.8% vs. 57.9%; p < 0.001), fewer systemic mpox signs/symptoms (38.0% vs. 50.1%; p = 0.015) and had a lower HIV prevalence (8.3% vs. 46.3%; p < 0.001), with all cases among transgender women. Eight women were hospitalized; no deaths occurred. The highest number of cases among women were notified in epidemiological week 34, when the number of cases among men started to decrease.

CONCLUSIONS

Women diagnosed with mpox presented differences in epidemiological, behavioral, and clinical characteristics compared to men. Health services should provide a comprehensive assessment that accounts for gender diversity.

Surveillance of Mpox Cases Attending Sexual Health Services in England (SOMASS): design, implementation and initial findings from the SOMASS data collection tool, 2022

OBJECTIVES

We aimed to design and implement a data collection tool to support the 2022 mpox (monkeypox) outbreak, and to describe clinical and epidemiological data from individuals with mpox attending sexual health services (SHSs) in England.

METHODS

The UK Health Security Agency and the British Association for Sexual Health and HIV established the Surveillance of Mpox Cases Attending Sexual Health Services in England (SOMASS) system.Descriptive data were collected via a secure web-based data collection tool, completed by SHS clinicians following consultation with individuals with suspected mpox. Data were collected on patient demographics, clinical presentation and severity, exposures and behavioural characteristics.

RESULTS

As of 17 November 2022, 276 SOMASS responses were submitted from 31 SHSs in England.Where recorded, most (245 of 261; 94%) individuals identified as gay, bisexual or men who have sex with men (GBMSM), of whom two-thirds were HIV negative (170 of 257; 66%) and taking HIV pre-exposure prophylaxis (87 of 140; 62%), with a median age of 37 years (IQR: 30-43). Where known, thirty-nine per cent (63 of 161) had a concurrent sexually transmitted infection (STI) at the time of their mpox diagnosis.For 46% of individuals (127 of 276), dermatological lesions were the initial symptom. Lesions were mostly asymmetrical and polymorphic, predominately affecting the genital area and perianal areas.Nine per cent (24 of 276) of individuals were hospitalised. We report an association between receptive anal intercourse among GBMSM and proctitis (27 of 115; 24% vs 7 of 130; 5%; p<0.0001), and the presence of perianal lesions as the primary lesion site (46 of 115; 40% vs 25 of 130; 19%; p=0.0003).

CONCLUSIONS

We demonstrate multidisciplinary and responsive working to develop a robust data collection tool, which improved surveillance and strengthened the knowledge base. The SOMASS tool will allow data collection if mpox resurges in England. The model for developing the tool can be adapted to facilitate the preparedness and response to future STI outbreaks.

Monkeypox Patients Living with HIV: A Systematic Review and Meta-Analysis of Geographic and Temporal Variations

This index meta-analysis estimated the pooled prevalence of human immunodeficiency virus (HIV) among individuals with monkeypox (mpox) globally. We searched seven databases: PubMed, Scopus, Web of Science, EMBASE, ProQuest, EBSCOHost, and Cochrane, for human studies published in English till 4 January 2023, as per International Prospective Register of Systematic Reviews (PROSPERO) registration protocol (CRD42022383275). A random effects regression model was used to estimate the pooled prevalence owing to high heterogeneity. The risk of bias in the included studies was assessed using the National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool. The systematic search yielded 677 articles; finally, 32 studies were found eligible for systematic review and 29 studies for meta-analysis. The pooled prevalence of HIV infection was 41% (95% confidence interval [CI], 35-48). All studies were rated as fair or good quality. Studies from Europe and North America reported a high prevalence of HIV infection among individuals with mpox- 41% (95% CI 33-49) and 52% (95% CI 28-76), respectively, while studies from Nigeria, Africa reported a relatively low prevalence of HIV infection of 21% (95% CI 15-26). A history of sexual orientation and sexual partners in the last 21 days must be taken from individuals with mpox to identify the potential source and contacts for quarantining and testing them.

Pandemic potential of poxviruses: From an ancient killer causing smallpox to the surge of monkeypox

Smallpox caused by the variola virus (VARV) was one of the greatest infectious killers of mankind. Historical records trace back smallpox for at least a millennium while phylogenetic analysis dated the ancestor of VARV circulating in the 20th century into the 19th century. The discrepancy was solved by the detection of distinct VARV sequences first in 17th-century mummies and then in human skeletons dated to the 7th century. The historical records noted marked variability in VARV virulence which scientists tentatively associated with gene losses occurring when broad-host poxviruses narrow their host range to a single host. VARV split from camel and gerbil poxviruses and had no animal reservoir, a prerequisite for its eradication led by WHO. The search for residual pockets of VARV led to the discovery of the monkeypox virus (MPXV); followed by the detection of endemic smallpox-like monkeypox (mpox) disease in Africa. Mpox is caused by less virulent clade 2 MPXV in West Africa and more virulent clade 1 MPXV in Central Africa. Exported clade 2 mpox cases associated with the pet animal trade were observed in 2003 in the USA. In 2022 a world-wide mpox epidemic infecting more than 80,000 people was noted, peaking in August 2022 although waning rapidly. The cases displayed particular epidemiological characteristics affecting nearly exclusively young men having sex with men (MSM). In contrast, mpox in Africa mostly affects children by non-sexual transmission routes possibly from uncharacterized animal reservoirs. While African children show a classical smallpox picture, MSM mpox cases show few mostly anogenital lesions, low-hospitalization rates and 140 fatal cases worldwide. MPXV strains from North America and Europe are closely related, derived from clade 2 African MPXV. Distinct transmission mechanisms are more likely causes for the epidemiological and clinical differences between endemic African cases and the 2022 epidemic cases than viral traits.

Sub-lineage B.1.6 of hMPXV in a global context: Phylogeny and epidemiology

During the 2022 COVID-19 pandemic, monkeypox emerged as a significant threat to global health. The virus responsible for the disease, the human monkeypox virus (hMPXV), underwent various genetic changes, resulting in the emergence of over a dozen distinct lineages, which could be identified by only a small number of unique mutations. As of January 25, 2023, genomic information of hMPXV generated had reached 4632 accessions in the GISAID database. In this study, we aimed to investigate the epidemiological and phylogenetic characteristics of the B.1.6 sub-lineage of hMPXV in Peru, compared with other circulating sub-lineages during the global outbreak. The B.1.6 sub-lineage, characterized by the 111029G>A mutation, was estimated to have emerged in June 2022 and was found mainly in Peru. Most cases (95.8%) were men with an average age of 33 years, and nearly half of the patients had HIV, of whom only 77.35% received antiretroviral therapy. Our findings revealed that the B.1.6, B.1.4, and B.1.2 sub-lineages were well represented and had a higher number of mutations despite having the lowest media substitution rates per site per year. Moreover, it was estimated that B.1.2 and B.1.4 appeared in February 2022 and were the first two sub-lineages to emerge. A mutation profile was also obtained for each sub-lineage, reflecting that several mutations had a pattern similar to the characteristic mutation. This study provides the first estimation of the substitution rate and ancestry of each monkeypox sub-lineage belonging to the 2022 outbreak. Based on our findings, continued genomic surveillance of monkeypox is necessary to understand better and track the evolution of the virus.

Mpox Outbreak 2022: A Comparative Analysis of the Characteristics of Individuals Receiving MVA-BN Vaccination and People Diagnosed with Mpox Infection in Milan, Italy

Mpox caused a worldwide outbreak in 2022, disproportionately affecting MSM reporting high-risk sexual behaviors. The aim of this study was to compare the characteristics of people receiving MVA-BN vaccination with those of individuals diagnosed with mpox to guide future vaccination policies. This was a retrospective study on people with mpox infection or vaccination at San Raffaele Scientific Institute, Milan, Italy, from May to November 2022. Characteristics were compared using Mann-Whitney or chi-square/Fisher's exact tests; multivariable logistic regression and classification tree analysis were applied. Overall, 473 vaccinated individuals and 135 with mpox were included; 472/473 and 134/135 were MSM. People with mpox were more frequently living with HIV (48.9% vs. 22.4%, p < 0.001), had ≥1 previous STI (75.6% vs. 35.7%, p < 0.001), were chemsex users (37.8% vs. 6.34%, p < 0.001), were with a higher number of partners (23.0% vs. 1.69%, p < 0.001), and had engaged in group sex (55.6% vs. 24.1%, p < 0.001). At multivariable analysis, PLWH (aOR = 2.86, 95%CI = 1.59-5.19, p < 0.001), chemsex users (aOR = 2.96, 95%CI = 1.52-5.79, p = 0.001), those with previous syphilis (aOR = 4.11, 95%CI = 2.22-7.72, p < 0.001), and those with >10 partners (aOR = 11.56, 95%CI = 6.60-21.09, p < 0.001) had a higher risk of infection. This study underscores the importance of prioritizing MSM with prior STIs and multiple partners as well as chemsex users in vaccination policies to curb mpox spread. A destigmatized assessment of sexual history is vital for comprehensive sexual health strategies.

A Case of Severe Mpox Complicated with Streptococcus pyogenes Sepsis in a Patient with HIV Infection

Since May 2022, a global outbreak of human Mpox has rapidly spread in non-endemic countries. We report a case of a 34-year-old man admitted to hospital for a six-day history of fever associated with vesiculo-pustular rash involving the face, limbs, trunk and perianal region, lymphadenopathy and severe proctitis and pharyngitis. He was HIV-positive and virologically suppressed by stable antiretroviral therapy. On admission, Mpox virus-specific RT-PCR was positive from multiple samples. Additionally, blood cultures yielded Streptococcus pyogenes, prompting a 14-day-course of penicillin G and clindamycin. Due to the worsening of proctitis along with right ocular mucosa involvement, tecovirimat treatment was started with a rapid improvement in both skin and mucosal involvement. The patient was discharged after 21 days of hospitalization and the complete clinical resolution occurred 38 days after symptom onset. This is a case of Mpox with extensive multi-mucosal (ocular, pharyngeal and rectal) and cutaneous extension and S. pyogenes bacteraemia probably related to bacterial translocation from the skin or oral cavity that was eased by Mpox lesions/inflammation. The HIVinfection, although well controlled by antiretroviral therapy, could have played a role in the severe course of Mpox, suggesting the importance of a prompt antiviral treatment in HIV-positive patients.

Impact of Monkeypox Virus Infection on Immune Parameters in a Woman With Human Immunodeficiency Virus Receiving Clinically Effective Antiretroviral Therapy

We describe the immunologic and virologic impact of monkeypox (mpox) infection in a woman with human immunodeficiency virus (HIV) whose plasma HIV viremia was suppressed by clinically effective antiretroviral therapy. Extensive phenotypic analyses of B and T cells in peripheral blood and biomarkers in plasma showed significant immunologic perturbations despite the presence of mild mpox disease. Dramatic shifts were noted in the frequencies of total B cells, plasmablasts, and plasmablast immunoglobulin isotypes. Flow cytometric analyses showed a dramatic increase in the frequency of CD38+HLA-DR+ CD8+ T cells after mpox infection. Our data offer guidance for future studies involving mpox infection in affected populations.

Mpox Virus: Control of In-Hospital Occupational Transmission Experience from a Tertiary Level Hospital in Milan, Italy

Mpox has caused a global outbreak since May 2022, particularly affecting people belonging to key populations, but cases among healthcare providers have been reported. The aim of this work is to present the experience of the Infectious Diseases Unit of San Raffaele Scientific Institute, Milan, Italy with respect to infection control and prevention of mpox occupational transmission. Between May-November 2022, 140 individuals were diagnosed with mpox and six required hospitalization. Overall, 12 medical doctors and 22 nurses provided care to people with mpox. A hospital policy aimed at controlling viral transmission was implemented in May 2022. Protective equipment was used for all healthcare providers. One accidental puncture occurred with a scalpel contaminated with blood from a mpox viremic individual (mpox plasma cycle threshold = 36); no mpox related symptoms were observed and mpox testing ruled out transmission. Six months following exposure, neutralizing antibodies were not detectable, ruling out contagion. Overall, we observed no mpox transmission among healthcare workers, despite the number of visits and procedures performed, including bodily-fluids sampling, and even following puncture with contaminated blood. Hospital preparedness for the management of new infectious disease outbreaks, with rapid implementation of policies aimed at controlling infection, is paramount to avoid occupational transmission.

Spectrum of ophthalmic manifestations in monkeypox virus infection worldwide: Systematic review and meta-analysis

Mpox virus infection is a significant public health concern worldwide due to its potential severity and the likelihood of outbreaks occurring across different regions. Ophthalmic manifestations of the disease have been linked with more severe cases, leading to the need for hospitalization and antiviral therapy. A systematic review and meta-analysis were conducted following PRISMA guidelines to summarize the literature available on this topic. The review revealed that ophthalmic manifestations, such as conjunctivitis and periocular umbilicated lesions, are the most common in Mpox virus infections. However, severe manifestations, such as corneal opacity, that can potentially cause blindness may also occur. Antiviral treatment with tecovirimat and topical management for conjunctivitis can be considered for severe cases. However, the evidence quality is poor due to the predominance of case reports and imprecise characterization of the ophthalmic manifestations. Overall, ophthalmologists and healthcare professionals should be aware of these manifestations for early diagnosis and timely treatment.

Mpox (Monkeypox) in Pregnancy: Viral Clade Differences and Their Associations with Varying Obstetrical and Fetal Outcomes

In African countries where mpox (monkeypox) is endemic, infection is caused by two genetically related clades-Clade I (formerly Congo Basin), and Clade IIa (formerly West Africa), both of which are potentially life-threatening infections. Prior to the 2022-2023 global outbreak, mpox infections among pregnant women caused by Clade I were reported to have a 75% perinatal case fatality rate in the Democratic Republic of Congo, including the only documented case of placental infection and stillbirth from the Congenital Mpox Syndrome, and the Clade IIa mpox infection was associated with stillbirths in Nigeria. The 2022-2023 global mpox outbreak, caused by a genetically distinct strain, Clade IIb, has focused attention on the effects of mpox on pregnant women and fetal outcomes. There have been at least 58 cases of mpox infection occurring in pregnant women during the 2022-2023 outbreak. No confirmed cases of adverse perinatal outcome, including stillbirth, have been reported. The absence of perinatal morbidity and mortality from Clade IIb corresponds to the overall case fatality rate among non-pregnant women of <0.1%, as this clade has been demonstrated to produce a less-severe disease than the mpox Clade I or IIa variants. Thus, there are apparently important differences between mpox clades affecting pregnant women and perinatal outcomes.

Evaluation of Mpox Knowledge, Stigma, and Willingness to Vaccinate for Mpox: Cross-Sectional Web-Based Survey Among Sexual and Gender Minorities

BACKGROUND

The 2022 multicountry mpox outbreak positioned the condition as a public health emergency of international concern. By May 2023, Brazil ranked second globally in the cumulative number of mpox cases and deaths. The higher incidence of mpox among gay and other men who have sex with men in the current mpox outbreak deepens the stigma and discrimination against sexual and gender minorities (SGM). This might worsen the structural barriers impacting access to health services, which ultimately leads to undertesting and underreporting of cases. There are no data available on mpox knowledge and stigma in Latin America.

OBJECTIVE

We aimed to evaluate mpox knowledge, stigma, and willingness to vaccinate for mpox among SGM, and to describe sociodemographic and behavioral characteristics according to self-reported mpox diagnosis.

METHODS

A cross-sectional, internet-based survey was conducted in a convenience sample of adults (aged >18 years) living in Brazil recruited through advertisements on dating apps, social media, referral institutions for infectious diseases websites, and mass media (October-November 2022). We compared participants' characteristics according to self-reported mpox diagnosis using chi-square test or Fisher exact test for qualitative variables and Kruskal-Wallis test for quantitative variables.

RESULTS

We enrolled 6236 participants: 5685 (91.2%) were cisgender men; 6032 (96.7%) were gay, bisexual, or pansexual; 3877 (62.2%) were White; 4902 (78.7%) had tertiary education; and 4070 (65.2%) reported low or middle income. Most participants (n=5258, 84.4%) agreed or strongly agreed that "LGBTQIA+ individuals are being discriminated and stigmatized due to mpox." Mpox awareness was 96.9% (n=6044), and 5008 (95.1%) were willing to get vaccinated for mpox. Overall, 324 (5.2%) reported an mpox diagnosis. Among these, 318 (98.1%) reported lesions, 178 (56%) local pain, and 316 (99.4%) sought health care. Among participants not reporting a diagnosis, 288 (4.9%) had a suspicious lesion, but only 158 (54.9%) of these had sought health care. Compared to participants with no diagnosis, those reporting an mpox diagnosis were younger (P<.001), reported more sex partners (P<.001), and changes in sexual behavior after mpox onset (P=.002). Moreover, participants diagnosed with mpox reported more frequently being tested for HIV in the prior 3 months (P<.001), living with HIV (P<.001), currently using HIV pre-exposure prophylaxis (P<.001), and previous sexually transmitted infection diagnosis (P<.001).

CONCLUSIONS

Our results point to high mpox knowledge and willingness to vaccinate among SGM in Brazil. Participants self-reporting mpox diagnosis more frequently reported to be living with HIV, STI diagnosis, and current pre-exposure prophylaxis use, highlighting the importance of an mpox assessment that includes comprehensive sexual health screenings. Efforts to decrease stigma related to mpox among SGM are necessary to avoid mpox underdiagnosis.

Prevalence of Mpox (Monkeypox) in patients undergoing STI screening in northern California, April-September 2022

BACKGROUND

Despite the sharp increase in mpox (formerly monkeypox) incidence and the wide geographic spread of mpox during the 2022 outbreak, the community prevalence of infection remains poorly characterized. This study is a retrospective epidemiologic survey to estimate mpox prevalence.

METHODS

Samples obtained for sexually transmitted infection (STI) testing from April to September 2022 in the public hospital and clinic system of San Mateo County, California were screened for mpox virus (MPXV) using polymerase chain reaction.

RESULTS

16/1,848 samples from 11/1,645 individuals were positive for MPXV by qPCR. 4/11 individuals with positive MPXV testing were cisgender women, 2 of whom were pregnant at the time of sample collection. Both deliveries were complicated by chorioamnionitis. Anorectal and oropharyngeal samples were the most likely to be positive for MPXV (4/60 anorectal samples and 4/66 oropharyngeal samples compared with 5/1,264 urine samples and 3/445 vaginal samples).

CONCLUSIONS

Our study is one of the first epidemiologic surveys for MPXV infection outside of sexual health/STI clinic settings. Relatively high rates of MPXV from oropharyngeal and anorectal samples reinforces the importance of MPXV testing at various anatomic sites, particularly if patients are presenting with non-lesional symptoms (pharyngitis, proctitis). However, the United States Food and Drug Administration (FDA) has not yet authorized non-lesional MPXV testing. The identification of MPXV in women in our cohort suggests that the rates of mpox in women may have previously been underestimated and highlights the risk of pregnancy complications associated with mpox.

Barriers and facilitators to HIV pre-exposure prophylaxis for cisgender and transgender women in the UK

Uptake of oral HIV pre-exposure prophylaxis (PrEP) among cisgender and transgender women in the UK has been low. In this Review, we explore the barriers and facilitators to PrEP access for these groups, with a focus on health equity. We included 20 studies, including seven abstracts presented at conferences. The study samples were disparate, with minimal overlap between papers. We identified barriers at the individual, interpersonal, and structural levels, including poor awareness and acceptability; stigma, race, and ethnicity; restricted access to PrEP; and exclusion from clinical trials. We found hidden subpopulations of women who could potentially benefit from PrEP, of whom little is known about their PrEP knowledge, preferences, and access due to a lack of UK research. These subpopulations include non-Black African women, transgender women, sex workers, migrant women, women experiencing intimate partner violence, incarcerated women, and women who inject drugs. We highlight opportunities to address these obstacles. Research on the use of PrEP by women in the UK is scarce, and existing research has poor granularity. Without a better understanding of the needs and preferences of the full spectrum of women who could benefit from PrEP, the UK will not reach zero transmissions by 2030.

Prevalence of mpox viral DNA in cutaneous specimens of monkeypox-infected patients: a systematic review and meta-analysis

Background

Human monkeypox (mpox) disease is a multicountry outbreak driven by human-human transmission which has resulted in an international public health emergency. However, there is limited evidence on the positivity rate of skin lesions for mpox viral DNA. We aim to fill this gap by estimating the pooled positivity rate of skin samples with mpox viral DNA from mpox patients globally.

Methods

In this systematic review and meta-analysis, seven databases and several preprint servers have been extensively searched until 17 January 2023 according to a prospectively registered protocol (PROSPERO: CRD42023392505). Articles including the positivity rate of skin samples with mpox viral DNA in mpox-confirmed patients were considered eligible. After a quality assessment, a random-effect meta-analysis was used for pooled prevalence. To explore and resolve heterogeneity, we used statistical methods for outlier detection, influence analysis, and sensitivity analysis.

Findings

Among the 331 articles retrieved after deduplication, 14 studies were finally included. The pooled positivity rate of the skin samples was 98.77% (95% CI: 94.74%-99.72%). After the removal of an influential outlier, I ² for heterogeneity dropped from 92.5% to 10.8%. Meta-regression did not reveal any significant moderator.

Conclusion/interpretation

The present findings reinforce that skin lesions act as a reservoir of mpox viral DNA and contribute to a high infectivity risk. This may be a prevailing basis of prompt transmission during the current multicountry outbreak and also needs further investigation. The present imperative outcome may benefit in producing valuable preventive and management procedures in an appropriate health strategy.

Viral Loads in Skin Samples of Patients with Monkeypox Virus Infection: A Systematic Review and Meta-Analysis

Despite monkeypox (mpox) being a public health emergency, there is limited knowledge about the risk of infectivity from skin viral loads during mpox infection. Thus, the aim of this study was to estimate cutaneous viral loads among mpox patients globally. Several databases, including Cochrane, EBSCOHost, EMBASE, ProQuest, PubMed, Scopus, and Web of Science, and preprint servers were searched concerning skin mpox viral loads in confirmed mpox subjects. In this systematic review and meta-analysis, a total of 331 articles were initially screened after the removal of duplicate entries. A total of nine articles were included in the systematic review and meta-analysis for the overall estimation of viral loads (Ct) using a random-effect model. The pooled cutaneous mpox viral load (lower Ct) was 21.71 (95% CI: 20.68-22.75) with a majority of positivity rates being 100%, highlighting a higher infectivity risk from skin lesions. The current results strongly support that skin mpox viral loads may be a dominant source of rapid transmission during current multi-national outbreaks. This important finding can help in constructing useful measures in relevant health policy.

Could it be monkeypox? Use of an AI-based epidemic early warning system to monitor rash and fever illness

OBJECTIVES

The EPIWATCH artificial intelligence (AI) system scans open-source data using automated technology and can be used to detect early warnings of infectious disease outbreaks. In May 2022, a multicountry outbreak of Mpox in non-endemic countries was confirmed by the World Health Organization. This study aimed to identify signals of fever and rash-like illness using EPIWATCH and, if detected, determine if they represented potential Mpox outbreaks.

STUDY DESIGN

The EPIWATCH AI system was used to detect global signals for syndromes of rash and fever that may have represented a missed diagnosis of Mpox from 1 month prior to the initial case confirmation in the United Kingdom (7 May 2022) to 2 months following.

METHODS

Articles were extracted from EPIWATCH and underwent review. A descriptive epidemiologic analysis was conducted to identify reports pertaining to each rash-like illness, locations of each outbreak and report publication dates for the entries from 2022, with 2021 as a control surveillance period.

RESULTS

Reports of rash-like illnesses in 2022 between 1 April and 11 July (n = 656 reports) were higher than in the same period in 2021 (n = 75 reports). The data showed an increase in reports from July 2021 to July 2022, and the Mann-Kendall trend test showed a significant upward trend (P = 0.015). The most frequently reported illness was hand-foot-and-mouth disease, and the country with the most reports was India.

CONCLUSIONS

Vast open-source data can be parsed using AI in systems such as EPIWATCH to assist in the early detection of disease outbreaks and monitor global trends.

Mpox: Fifty-Nine Consecutive Cases from a Mexican Public Hospital; Just the Tip of the STIs Iceberg

Monkeypox (Mpox) is a zoonotic viral infection endemic to Africa, which has caused a global outbreak since April 2022. The global Mpox outbreak is related to Clade IIb. The disease has primarily affected men who have sex with men. Skin lesions are concentrated in the genital area, with lymphadenopathy as well as concurrent sexually transmitted infections (STIs). This is an observational study of adult patients with a recent development of skin lesions and systemic symptoms, which could not be explained by other diseases present. Fifty-nine PCR-positive patients with prominent skin lesions in the genital area (77.9%), inguinal lymphadenopathy (49.1%), and fever (83.0%) were included. Twenty-five (42.3%) were known to be living with human immunodeficiency virus (HIV), and 14 of the HIV-naïve subjects (51.9%) were found to be positive during workup, totaling 39 (66.1%) patients with HIV. Eighteen patients (30.5%) had concurrent syphilis infections. It is worrisome that Mpox is present in large metropolitan areas of Mexico, but the underlying growth of cases of HIV infection and other STIs has not been well studied and should be evaluated in all at-risk adults and their contacts.

Monkeypox Outbreak in Peru

Monkeypox (Mpox) is a zoonotic disease caused by the Orthopoxvirus monkeypox virus (MPXV). Since 1970, outbreaks of MPXV have occurred in several Sub-Saharan African countries. However, from May 2022 to April 2023, recent outbreaks of Mpox occurred in several countries outside of Africa, and these cases quickly spread to over 100 non-endemic countries on all continents. Most of these cases were found in the region of the Americas and the Europe region. In Latin America, the highest all-age Mpox rates per million inhabitants were in Peru, Colombia, Chile, and Brazil. Given its global impact, Mpox was declared as an international Public Health Emergency by WHO in July 2022. MPXV infection disproportionately affects men who have sex with men and members of the HIV-infected population. Vaccination is the current strategy for controlling and preventing Mpox in high-risk groups. In this context, Peru has the fourth-highest number of Mpox cases in Latin America and faces significant challenges in disease control. Because of this, in this review, we discuss the epidemiology, public health indicators, and prevention of Mpox in the 2022 Peru outbreak so that health authorities can join forces to control MPXV transmission.