The news is spreading on social networks that the monkeypox disease, which is worrying the world community today, does not affect women.
Back in 2022, it was reported that monkeypox could threaten Uzbekistan.
On August 14, 2024, the World Health Organization declared the spread of monkeypox a "public health emergency of international concern." For many months, events have been developing according to an alarming scenario. A type of the virus that is considered more dangerous is spreading in African countries. And it has found new ways of transmission. For example, through sex. In mid-August, this virus was also discovered in Sweden. We explain what is important to know about the new monkeypox and whether the world is threatened by a new pandemic.
According to the WHO, the name monkeypox originated from the initial discovery of the virus in monkeys in a Danish laboratory in 1958.
Human monkeypox was first discovered in 1970 in a 9-year-old boy in the Democratic Republic of the Congo — where smallpox was eliminated in 1968.
Since 1970, human cases of monkeypox have been reported in 11 African countries.
Monkeypox is a zoonotic virus, which transmits disease from animals to humans. Cases typically occur near tropical rainforests, where animals that carry the virus live.
The monkeypox virus is a member of the orthopoxvirus family. It also has two distinct genetic strains or cladesTrusted Source: the Central African (Congo Basin) clade and the West African clade. The Congo Basin clade is known to spread more easily and cause more severe symptoms.
What are the signs & symptoms of Monkeypox?
Monkeypox symptoms are similar to but milder than smallpox symptoms. Early signs of monkeypox include flu-like symptoms such as:
Fever.
Chills.
Headache.
Muscle aches.
Fatigue.
Swollen lymph nodes.
After one to three days, a rash with raised bumps develops. The rash often starts on your face and then spreads to other parts of your body, including the palms of your hands and soles of your feet. The rash starts as flat, red bumps. The bumps turn into blisters, which fill with pus. After several days, the blisters crust over and fall off.
Is there a treatment for Monkeypox?
Currently, NO treatment is available for monkeypox. Smallpox vaccine has been reported to reduce the risk of monkeypox among previously vaccinated persons in Africa. CDC is assessing the potential role of postexposure use of smallpox vaccine as well as therapeutic use of the antiviral drug cidofovir.
How do you prevent Monkeypox virus?
A smallpox vaccine can provide protection against monkeypox, but its use is currently limited to people who work in a lab with the variola (smallpox) virus. Prevention depends on decreasing human contact with infected animals and limiting person-to-person spread.
You can prevent monkeypox virus by:
Avoiding contact with infected animals (especially sick or dead animals).
Avoiding contact with bedding and other materials contaminated with the virus.
Washing your hands with soap and water after coming into contact with an infected animal.
Thoroughly cooking all foods that contain animal meat or parts.
Avoiding contact with people who may be infected with the virus.
Using personal protective equipment (PPE) when caring for people infected with the virus
Uzbekistan’s airports are implementing a series of measures to prevent the spread of monkeypox. These steps are aimed at protecting the population and preventing the disease from being imported from abroad, even though the main focus of the virus’s spread is in African countries that do not have direct air connections with Uzbekistan.
Additionally, all international airports in the republic have intensified their sanitary and educational work with staff. Airport employees are provided with simplified information about the symptoms and prevention of monkeypox and are given visual training to identify signs of the disease. These measures will help staff promptly identify potential cases of the disease and take appropriate action.
One of the important tools in combating the possible spread of the virus is the permanent installation of thermal imaging cameras. These devices allow for the remote measurement of passengers’ temperatures, enabling the quick identification of individuals with fever, which may be one of the symptoms of the disease.
According to information provided by the Medical Support Development Department of Uzbekistan Airports, based on data from the World Health Organization (WHO), the new strain of monkeypox is spreading mainly in African countries that do not have direct air connections with Uzbekistan. Nevertheless, the precautionary measures being taken play an important role in ensuring the safety of the population and preventing potential threats.
The measures taken underscore the serious attitude of Uzbekistan’s authorities towards public health issues and their readiness to respond quickly to potential epidemiological challenges. In the context of global population mobility, these measures represent an important element of protection and prevention of disease spread through international transport hubs.
Scientific literature on human monkeypox virus infection began in the 1970s, and two periods can be distinguished: before and since 2022. Before 2022, scientific reports focused on outbreaks in central and western Africa, where the disease is endemic, and on sporadic imported cases and very limited outbreaks in high-income countries. 30–50% of infections were reported in women. The 2022 global outbreaks began with monkeypox virus infections being reported almost exclusively among gay, bisexual, and other men who have sex with men and in countries not historically affected by this disease. We searched PubMed for the terms “monkeypox AND (women OR females)” from May 10 to Oct 16, 2022 with no language restrictions. Most publications were letters, perspectives, and case reports. One preprint described seven cases in heterosexual women in Nigeria occurring since May, 2022. We also reviewed epidemiological reports from WHO and the US Centers for Disease Control and Prevention in 2022. In these series, women represented 3·8% of infections, without distinction between cisgender (cis) women, transgender (trans) women, and non-binary individuals (ie, with gender identities outside the gender binary) who were assigned female at birth. There were no published series or cohorts of women diagnosed with monkeypox virus infection in 2022. Therefore, data on transmission routes and clinical features among women and non-binary individuals are scarce.
Ours is the first case series to focus on and describe the risk factors and clinical presentations of monkeypox virus infection in cis and trans women and non-binary individuals assigned female at birth during the 2022 global outbreak. Previously published series or cohorts included almost exclusively men, primarily sexually active GBMSM, with the proportion of women ranging from 0% to 3·8%.
Furthermore, most epidemiological surveillance datasets have not distinguished between cis and trans women, thereby prohibiting a detailed description and characterisation of any differences in these two subpopulations, which are generally under-represented and under-reported in HIV and sexual health research. Although women account for a minority of infections reported in the current monkeypox outbreak (<5%), we anticipate that this might change as the outbreak evolves. It is important to collect and report on these infections to investigate sex and gender specificities in disease presentation. We observed many similarities in transmission and clinical characteristics in trans women to those that we previously reported for men,
but noted several differences for cis women and non-binary individuals.
Inequalities and social determinants of health have been reported as a significant underlying problem, especially for Black and Latinx people in the USA, who have been disproportionately affected by monkeypox during the current outbreak .
In our case series, White women and non-binary individuals represented only around a third of cases. Almost half of our cohort were trans women, a group more likely to be negatively affected by social determinants of health. Trans women have higher rates of HIV and STIs than cis women and non-binary individuals, which might influence the acquisition and clinical course of monkeypox virus infection, and also face barriers to accessing health care and social support.
Our data showed that a higher proportion of trans women engaged in sex work (55%) compared with the proportion of cis women and non-binary people (3%), suggesting higher levels of precarity and vulnerability, which might include factors like homelessness, injection drug use, and migrant status.
Although 121 (89%) of the 136 individuals in this global case series reported having sex with men, 59% of cis women and non-binary individuals had a regular male partner, whereas 73% of trans women had multiple male partners. Having multiple sexual partners was a common risk factor for monkeypox virus infection in previous series in men.
Sexual contact was thought to be the most likely route of transmission in 74% of our cohort overall. This value is lower than the 95–100% reported in series of men.
However, we found differences in trans women compared with cis women and non-binary individuals. Although clinicians were required to select a single choice for the suspected route of transmission, no trans women (of those with a reported suspected route of transmission) were thought to have acquired monkeypox virus infection outside of sexual contact. Attendance at LGBTQ+ Pride events and large gatherings has been a prominent association in men during the global outbreak (32–36% attendance); by contrast, only 7% of all individuals in our series attended LGBTQ+ Pride or other large gatherings within the month preceding symptom onset.
18 (24%) of 74 cis women and non-binary individuals were thought to have contracted monkeypox without sexual contact, including via occupational contact and close non-sexual contact within and outside the household. Notably, those who acquired monkeypox through non-sexual routes were less likely to have the anogenital lesions that have been characteristic of the global outbreak. More cis women and non-binary individuals were reported as having known contact with people with confirmed monkeypox virus infection (43%) than did trans women (10%).
HIV has emerged as a highly significant association during the multicountry 2022 outbreak, with the CDC reporting HIV co-infection in 46% of individuals with monkeypox in the USA,
and other cohorts reporting an HIV prevalence of 28–47% among individuals diagnosed with monkeypox virus infection.
In the current case series, the HIV prevalence among trans women was very high at 50% (31 of 62 individuals), and much lower (six [8%] of 74), but still substantial, in cis women and non-binary individuals. Similar to global case series in men, the median CD4 cell count in the 37 individuals living with HIV in the current case series was high at 600 cells per μL (IQR 487–805), and 36 (97%) were on antiretroviral therapy.
In reports of the current monkeypox virus outbreak, 57–95% of individuals with monkeypox virus infection and without HIV were reported to be using PrEP. In the current series, PrEP use was reported in 19 (19%) of 99 all individuals without known HIV infection, but was markedly more common in trans women (18 [58%] of 31) than cis women and non-binary individuals (one [2%] of 68) without HIV.
65% of trans women and 53% of cis women and non-binary individuals without known HIV were tested for HIV at presentation for monkeypox, suggesting that the strong association between a monkeypox virus diagnosis and HIV infection has, regrettably, still not translated into systematic HIV screening for all individuals with monkeypox virus infection.
More concurrent STIs were documented in trans women (21%) than in cis women and in non-binary individuals (7%). However, it is notable that in some countries, screening for Chlamydia trachomatis and Neisseria gonorrhoeae infections were not routinely done because of laboratory restrictions relating to biosafety.
In the historic literature, children are known to be at a higher risk of severe disease if infected with monkeypox virus. Transmission from women (and men) to children has been a great concern during the current outbreak.
In our case series, despite children being in the home of 19 (26%) of 74 cis women and non-binary people, only two transmissions to a child were reported, suggesting very limited chains of transmission, similar to what has been previously reported.
Severe consequences of monkeypox for pregnancy outcomes have also previously been reported, with high risks of severe congenital infection, pregnancy loss, and maternal morbidity and mortality. We reported only two cases in pregnant individuals who have not yet delivered, and hence the outcomes are unknown.
Although 66% of trans women in the current series presented to sexual health or HIV clinics, this proportion was much lower for cis women and non-binary individuals (28%), who presented to a wide variety of medical specialties, reinforcing the importance of awareness of the clinical features of monkeypox beyond sexual health, infectious diseases, and HIV specialists. Given that case definitions have emphasised the increased risk of monkeypox virus infection among GBMSM, women might be less commonly diagnosed. This observation is supported by the higher rates of misdiagnosis and multiple appointments before confirmation of diagnosis in cis women and non-binary individuals compared with trans women. This finding also highlights the overlap between the clinical manifestations of monkeypox virus and other clinical syndromes (such as varicella; hand, foot, and mouth disease; herpes simplex; and syphilis) and the need for ongoing clinician education to better recognise and test for monkeypox virus infection.
Trans women, as in the male case series, often had more localised infections with mucocutaneous involvement, not always accompanied by systemic symptoms.
The type of sexual activity individuals reported was varied: among cis women and non-binary individuals, 69% reported vaginal sex and 14% reported anal sex, whereas no trans women reported vaginal sex and all reported anal sex, correlating with the clinical presentation.
This finding is not surprising given the very low prevalence of vaginoplasty in the USA (around 12%) and the likelihood of lower prevalence in low-income and middle-income countries.
Vulvovaginal lesions were more common in individuals who engaged in vaginal sex, and anal lesions or proctitis were more common when anal sex was reported. This is consistent with findings from a Spanish cohort, which showed that GBMSM who reported anal-receptive sex were significantly more likely to have proctitis than those who did not were.
Hospital admission rates within different cohorts have ranged from 2% to 13%.
In our series, 13% of individuals overall were managed as inpatients. It is not clear why more trans women received tecovirimat in comparison with cis women and non-binary people, but it could relate to the higher prevalence of HIV infection or decreased access to antivirals in low-income and middle-income countries.
Several limitations of our study should be highlighted. Our data are derived from an observational retrospective convenience case series from countries with high numbers of monkeypox virus infections. It is neither a population-based sample nor a prospective cohort. We are, therefore, unable to assess how well our sample represents the entire population of women and non-binary individuals with monkeypox virus infection. Our series includes individuals in whom monkeypox virus infection was confirmed with various (locally approved) PCR platforms, except for nine individuals in France (where PCR testing was restricted in individuals in whom classic symptoms of and known contacts with monkeypox virus were reported). Individuals in this case series had symptoms that led them to seek medical care, thus individuals who were asymptomatic, had milder symptoms, were pauci-symptomatic, or had little or no access to medical care could have been missed.
Women and non-binary individuals might also be less likely to be investigated for monkeypox virus given the inclusion of GBMSM as the main at-risk group in case definitions.
Due to data collection from multiple sites with different health systems across many countries, some characteristics might have been collected in a heterogeneous manner. In our series, based on the recorded medical history, clinicians were asked to designate a single route of likely transmission (or “unknown”), and might not have captured all the potential transmission routes for some individuals. Furthermore, the relatively few individuals included, especially when we distinguish cis women and non-binary people from trans women, limits the generalisability of our findings. Data on paediatric infections were reported by individuals affected and were not verified, and are therefore subject to the potential biases of patient-reported outcomes.
Finally, the incubation period was estimated on the basis of reported date of presumed exposure and the reported date of first symptom. As in other case series, the accuracy of an individual's recollection of their potential exposure and symptom dates cannot be confirmed, and early and subtle symptoms might have been unrecognised and under-reported, limiting the accuracy of the estimated incubation period.
In summary, this series provides new insights on the epidemiology and clinical characteristics of monkeypox virus infection in cis women, non-binary individuals assigned female at birth, and trans women worldwide, who previously have been a small, undifferentiated percentage in international surveillance reports. It also reinforces emerging data correlating sexual practices with the clinical presenting lesions. Indeed, the prominent genital and mucosal features, which have been a defining feature of the global outbreak in men, have been replicated in cis women and non-binary individuals and trans women, as has the pattern of fewer lesions than previously described in the historical literature. We hope these findings will help clinicians consider the diagnosis and avoid misdiagnosis of monkeypox in women and non-binary individuals wherever they present, and emphasise the importance of a detailed sexual history and testing for other STIs, including HIV.
While monkeypox is indeed less common in women, researchers warn that their proportion will increase as the epidemic progresses.
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