Skin-to-skin contact during sex, key in the transmission of monkeypox

The current outbreak of monkeypox that has caused the World Health Organization (WHO) to decide to declare the disease as “public health emergency of international concern» presents symptoms, manifestations and complications different from those previously described in other outbreaks of this pathology.

This concludes the most exhaustive study on monkeypox carried out to date in Spain, carried out in the two most affected areas of the country, Madrid and Barcelona, ​​and published in the journal “The Lancet”.

The research, the result of collaboration between the 12 de Octubre University Hospital, the Germans Trias University Hospital and the Fight Against Infections Foundation and the Vall d’Hebron University Hospital, with the collaboration of the London School for Hygiene and Tropical Medicine (LSHTM ), points out that skin-to-skin contact during sexual intercourse is evidenced as the dominant factor in the transmission of monkeypox, above airborne transmission.

Our study, Cristina Galván, a dermatologist at the Hospital Universitario de Móstoles in Madrid, tells ABC, has found that skin samples are more frequently positive and reflect a greater abundance of viral genome than samples from other areas such as the throat» . In the context of a sexual relationship, she adds, “this intimate contact with the skin or external mucous membranes of an affected person certainly occurs. Positive PCR for monkeypox virus has been found in vaginal secretions and semen, but its infective capacity and, therefore, whether it can be transmitted through these fluids has yet to be determined.

At this time, he warns, with the data we have, rather than stating that it is a sexually transmitted infection, “we must say that it is an infection that is transmitted during sexual intercourse.”

This, the researchers write, entails a series of significant implications regarding the approach to the disease.

First, the authors say, the change in the route of transmission from respiratory contact to direct contact compared to previous outbreaks may promote the spread of the disease through sexual networks.

The current outbreak presents symptoms, manifestations and complications different from those previously described in other outbreaks of this pathology

Until now, Dr. Galván points out, the airway has been considered a mode of transmission in the classic form of this disease. In the current outbreak, “the entry point of the germ is different and this can generate an immune reaction of the affected person that is also different, which leads to an atypical clinical picture.”

Based on the epidemiological data of the cases of the current outbreak, the expert indicates, “it seems that the respiratory tract has not participated significantly in the transmission. The number of affected is already abundant and cases of transmission in circumstances other than sexual contact are almost non-existent.

But he prefers to be cautious. “In cases of classic monkeypox -which has affected endemic countries or in outbreaks limited to non-endemic countries after a trip or another episode of sporadic contagion- the presence of the virus in the respiratory mucous membranes can be demonstrated. As with its detection in genital fluids and saliva, research, already underway, is very important to determine its ability to transmit the infection.”

In your opinion, the implication of these analyzes is “crucial for determining the relevant public health measures. And the consequences for those affected are also, since they can significantly modify the restrictions and isolation to which they must submit after contagion.

Finally, “since monkeypox can present with atypical manifestations, health professionals should have a high index of suspicion for the disease, especially in those people who live in areas with high transmission, or with potential exposure.

In this sense, this researcher from the Lluita Foundation, STI Skin NTD Unit points out that, although it is true that the clinical presentation of the cases of the current outbreak is completely atypical, “however, except for doctors who treat patients in endemic areas and we needed to have this diagnosis among the possible ones, this disease was very unknown» and he believes that the medical community is learning about classical monkeypox thanks to this outbreak.

At the moment, says Galván, “we cannot know the percentage of patients who have remained undiagnosed, either because this possibility has not been taken into account or because they have had few symptoms. But we do have ongoing studies aimed at answering this question, which is so important for controlling the spread of the disease.”

Fortunately, he points out, the clinic is atypical compared to the classic one, but it follows patterns that facilitate diagnostic suspicion.

We cannot know the percentage of patients who have remained undiagnosed

Also, the article explains, that due to the short incubation period, “pre-exposure vaccination of high-risk groups is likely to be more effective than post-exposure vaccination for infection control.”

However, as this researcher acknowledges, “the availability of vaccines is, at the moment, insufficient. As long as this is the case, we must give priority to people with the highest risk of becoming infected or developing a serious illness.».

In the event that we had all the necessary doses, he adds, “all people at high risk of sexually transmitted disease would be vaccinated. That is, a population similar to the one that has an indication for HIV pre-exposure prophylaxis. It would also vaccinate intimate contacts, such as sexual ones, of an affected person and people who are especially vulnerable due to poor immunity, either close to people at risk or who have had close contact, although not intimate, with someone affected.”

In May 2022, the first autochthonous cases of monkeypox were reported in Europe, giving rise to an outbreak that is still active in 27 countries today and has caused more than 11,000 confirmed cases. Spain is the most affected country on the continent with more than 5,000 diagnosed casess.

The scientific community continues to have little information on the epidemiological, clinical and virological characteristics of the current outbreak of monkeypox.

Health professionals must have a high index of suspicion of the disease

The study published now includes an exhaustive evaluation of these three aspects (epidemiology, clinical and virological characteristics) of 181 participants diagnosed with the disease in three large hospitals in Spain.

The work confirms the clinical features observed in other retrospective analyses, but the larger sample size and systematic clinical examination revealed some previously unreported complications, including proctitis, tonsillar ulceration, and penile edema.

The article also establishes the relationship between types of sexual practices and clinical manifestations. One of the most important findings is the high viral load found in genital and oral lesions, as opposed to very low values ​​in the respiratory tract.

The results show that of the 181 confirmed cases, 175 (98%) are men, 166 of whom identify as men who have sex with men. The average duration of the incubation period of the disease is established in 7 days.


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