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A study, published in The Lancet Infectious Diseases, looked at 54 patients with monkeypox in London, describing demographic and clinical characteristics.
Dr Jake Dunning, Senior Researcher in Emerging and High Consequence Infectious Diseases, Pandemic Sciences Institute, University of Oxford, said:
“This is an important, rapid clinical case series describing mostly patients with monkeypox who did not require admission to hospital, from one of the UK’s busiest providers of sexual health services. Sharing this information will help raise awareness amongst health professionals and the public, and adds to information being shared by other countries with outbreaks.
“Monkeypox transmits through close contact, and although monkeypox is not a classical ‘sexually transmitted infection’, sex typically involves close contact, so it appears to be an effective route for transmission. The role of transmission during sex or intimate contact in outbreaks in African countries is less clear, and an important area for future research. Globally, we see that some individuals have more lesions or worse lesions on their genitals and/or anus and rectum than on other parts of their body; this supports the idea that worse disease may occur in parts of the body exposed to a lot of virus during contact, in this case, a lesion on someone’s genitals could shed a lot of virus onto someone else’s genitals, anus or mouth during sex, and this then leads to a lot of infection in those heavily exposed areas. Exposure to respiratory droplets or seminal fluid containing virus could also play a part in transmission during sex, as well as exposure to a contaminated environment, such as the linen on the bed of someone with monkeypox. More research is needed to understand transmission routes, and routes may differ according to different contexts of interactions, and possibly different countries and populations. It is vital that we link data from studies describing the clinical disease with information about the type of sex or close contact people have had.
“It’s good that we are not hearing of deaths occurring during the outbreaks occurring outside Africa, but we know that monkeypox can and does cause serious disease and deaths in endemic countries in Africa. This is a global health problem. Although people often describe the majority of cases of monkeypox being reported in the UK as ‘mild’, it is still an unpleasant infection for many people, even if they are not admitted to hospital. The lesions can be incredibly painful, wherever they occur on the body. Some patients need pain killers that have to be given in hospital, and some require antibiotics for secondary bacterial skin infections.
“It’s important that we use tools already available to us to prevent and treat monkeypox infections: recognition of signs and symptoms to obtain appropriate medical care and prevent transmission to others; use of preventative vaccines in some people; and antiviral treatments like tecovirimat, which is already being given to some people with severe monkeypox being cared for in specialist hospitals in England. Clinical trials will hopefully commence soon in Europe, to look at who is most likely to benefit from tecovirimat treatment, and whether it may also be useful in treating patients who do not require admission to hospital. Studies of tecovirimat are also underway and others are being planned in affected countries in Africa. In England, individuals identified as being at significantly greater risk of exposure to monkeypox will soon be offered vaccination; hopefully people who live in endemic countries in Africa and are at increased risk of exposure to monkeypox will also be offered effective vaccines, as that is where the greatest burden of severe disease is seen and healthcare resources are often more limited.”
Dr Boghuma Kabisen Titanji, Assistant Professor of Medicine, Emory University, Atlanta, said:
“This is an interesting and comprehensive retrospective cohort reporting on 54 cases on Monkeypox in the UK. It provides useful insights on the demographic characteristics and clinical presentations in the ongoing outbreak. The findings are similar to those reported in cohorts from EU countries and the USA i.e. cases are among MSM, atypical presentations are common (anogenital lesions, clinical course is mild to moderate). One in four individuals in this cohort had a concurrent STI which may reflect the study being conducted in sexual health clinics but could also reflect the overlap between how monkeypox is presenting in the ongoing outbreak and common STIs. It highlights the need to clarify the mechanisms of transmission in the current outbreak to better inform policies and approaches to contain the outbreak.”
Dr Hugh Adler, Department of Clinical Sciences, Liverpool School of Tropical Medicine, said:
“This paper corroborates previous, smaller reports from other countries affected by the current monkeypox outbreak: the initial presentation can be subtle and can mimic many sexually transmitted infections. Co-infection with monkeypox and more “traditional” STIs is another important diagnostic consideration. The current UK case definitions are broader than they were when the data was collected for this paper, and do allow for clinician discretion in patients who are at high risk of infection. Any new skin rash in a man who has sex with men should prompt consideration for monkeypox testing in the current climate, even if they have no other symptoms.”
Prof Paul Hunter, Professor in Medicine, UEA, said:
“This is effectively an observational study that described what we call a case series. So it is sound as far as it goes and that is describing peoples’ symptoms. These types of studies are used a lot in medicine and whilst very valuable in helping other doctors understand the range of presentations they may see, such studies do not provide conclusion evidence on issues like risk factors. These types of study are valuable educational sources for doctors.
“The most useful thing is the description of the anal and genital lesions which would help a doctor better know where to look and what to look for. The other important finding is that ¼ are HIV positive (a possible risk factor for severe diseases) and ¼ had another sexually transmitted disease.
“I don’t think there is a need to change the UK’s case definitions as these are actually very broad (https://www.gov.uk/guidance/monkeypox-case-definitions) and I think cover the presentations reported here.
“The evidence on anal genital lesions is important. This has been described already but such lesions can be missed. Not a problem if there are rashes elsewhere but if the only lesions than could be missed if not looked for. These haven’t really been reported in cases in African reports but I am not sure you would have really looked before.”
‘Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: an observational analysis’ by Nicolò Girometti et al. was published in The Lancet Infectious Diseases at 23:30 UK time on Friday 1 July.
DOI: https://doi.org/10.1016/S1473-3099(22)00411-X
Declared interests
Dr Hugh Adler: No COI
None others received