Monkeypox virus infection in women and non-binary people: uncommon or neglected?

Abstract

In 2022, amid the COVID-19 pandemic, monkeypox re-emerged globally as a new and additional infectious threat for countries outside Africa, and it was declared a Public Health Emergency of International Concern by WHO.1Sah R Reda A Lashin BI Mohanty A Abdelaal A Rodriguez-Morales AJ Public health emergencies of international concern in the 21st century.Ann Med Surg. 2022; 81: 104417Crossref Scopus (3) Google Scholar, 2Farahat RA Sah R El-Sakka AA et al.Human monkeypox disease (MPX).Infez Med. 2022; 30: 372-391Google Scholar During this multicountry monkeypox outbreak, which has comprised more than 80 488 cases to Nov 21, 2022 according to the US Centers for Disease Control and Prevention, new epidemiological and clinical features have been observed, including genital primary presentation, an association with sexual activity, and a predominance among men, particularly adult men who have sex with men.3Adler H Gould S Hine P et al.Clinical features and management of human monkeypox: a retrospective observational study in the UK.Lancet Infect Dis. 2022; 22: 1153-1162Summary Full Text Full Text PDF PubMed Scopus (267) Google Scholar, 4Thornhill JP Barkati S Walmsley S et al.Monkeypox virus infection in humans across 16 countries—April–June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (243) Google Scholar Although epidemiological data and various studies have shown that the disease occurs primarily in men,5DeWitt ME Polk C Williamson J et al.Global monkeypox case hospitalisation rates: a rapid systematic review and meta-analysis.EClinicalMedicine. 2022; 54: 101710Summary Full Text Full Text PDF Scopus (1) Google Scholar monkeypox can also affect other groups, including children,6Hennessee I Shelus V McArdle CE et al.Epidemiologic and clinical features of children and adolescents aged <18 years with monkeypox—United States, May 17–September 24, 2022.MMWR Morb Mortal Wkly Rep. 2022; 71: 1407-1411Crossref Scopus (1) Google Scholar older populations, and women.7Zayat N Huang S Wafai J Philadelphia M Monkeypox virus infection in 22-year-old woman after sexual intercourse, New York, USA.Emerg Infect Dis. 2022; (published online Nov 10.)https://doi.org/10.3201/eid2901.221662Google Scholar, 8Bruno G Fabrizio C Rodano L Buccoliero GB Monkeypox in a 71-year-old woman.J Med Virol. 2022; (published online July 13.)https://doi.org/10.1002/jmv.27993Google Scholar In The Lancet,9Thornhill JP Palich R Ghosn J et al.Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series.Lancet. 2022; 400: 1943-1965Google Scholar John P Thornhill and colleagues report a series of 136 cases of monkeypox virus infection in women and non-binary individuals from 15 countries, showing its clinical importance. 62 individuals in the case series were transgender (trans) women, 69 were cisgender (cis) women, and five were non-binary individuals assigned female at birth (the latter two groups were pooled to form a group of 74 people assigned female at birth for the purpose of comparison). The median age in the whole cohort was 34 years (IQR 28–40; range 19–84), meaning that most individuals were in age groups likely to be sexually active. 43 (69%) trans women and 65 (88%) cis women and non-binary people were heterosexual or had sex with men. In addition to the presence of previously known clinical features of rash (124 [93%] of 134 individuals), anogenital lesions (95 [74%] of 129), and vesiculopustular rash (105 [87%] of 121) in the cohort, monkeypox viral DNA was detected in the vaginal fluid of all tested individuals (n=14). Previous studies have identified viral DNA in semen in 78% of cases.10Reda A Abdelaal A Brakat AM et al.Monkeypox viral detection in semen specimens of confirmed cases: a systematic review and meta-analysis.J Med Virol. 2022; (published online Oct 22.)https://doi.org/10.1002/jmv.28250Google Scholar Although the implications of such detections are still to be defined, these findings are essential in the understanding and future investigation of potential sexual transmission of this disease. As shown in Thornhill and colleagues’ study,9Thornhill JP Palich R Ghosn J et al.Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series.Lancet. 2022; 400: 1943-1965Google Scholar prominent genital and mucosal features of the disease, which have been a defining feature of the global outbreak in men,4Thornhill JP Barkati S Walmsley S et al.Monkeypox virus infection in humans across 16 countries—April–June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (243) Google Scholar are also present in cis and trans women and non-binary individuals (mucosal lesions involving the vagina, anus, oropharynx, or eye occurred in 65 [55%] of 119 individuals with available data), with fewer lesions per individual (median 10 [IQR 5–24; range 1–200]) than previously described; in previous studies, skin lesion severity scores were severe (100–250) or very severe (>250).9Thornhill JP Palich R Ghosn J et al.Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series.Lancet. 2022; 400: 1943-1965Google Scholar, 11Whitehouse ER Bonwitt J Hughes CM et al.Clinical and epidemiological findings from enhanced monkeypox surveillance in Tshuapa province, Democratic Republic of the Congo during 2011–2015.J Infect Dis. 2021; 223: 1870-1878Crossref Scopus (24) Google Scholar However, a clinical pattern of serious and profuse lesions in the vagina was observed. The absolute number and proportion of monkeypox cases among individuals could be increased by multiple factors, especially different sexual practices. In the current case series, 45 (73%) of 62 trans women and nine (12%) of 74 cis women and non-binary individuals had multiple male sexual partners. The inclusion of trans women in this study could help to close a knowledge gap regarding this under-studied population.12Silva MST Jalil EM Torres TS et al.Monkeypox and transgender women: the need for a global initiative.Travel Med Infect Dis. 2022; 50: 102479Crossref PubMed Scopus (2) Google Scholar, 13Gandrakota N Lee H Nwosu O Kulshreshtha A Monkeypox coinfection with neurosyphilis in a transgender with HIV in Atlanta, USA.Travel Med Infect Dis. 2022; 50: 102454Crossref Scopus (4) Google Scholar Although some case reports of trans women have been published, no studies were previously available. Collecting data from this population is especially important because of the higher rates of HIV and other sexually transmitted infections in trans women.2Farahat RA Sah R El-Sakka AA et al.Human monkeypox disease (MPX).Infez Med. 2022; 30: 372-391Google Scholar, 9Thornhill JP Palich R Ghosn J et al.Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series.Lancet. 2022; 400: 1943-1965Google Scholar, 13Gandrakota N Lee H Nwosu O Kulshreshtha A Monkeypox coinfection with neurosyphilis in a transgender with HIV in Atlanta, USA.Travel Med Infect Dis. 2022; 50: 102454Crossref Scopus (4) Google Scholar, 14Sah R Mohanty A Abdelaal A Reda A Rodriguez-Morales AJ Henao-Martinez AF First monkeypox deaths outside Africa: no room for complacency.Ther Adv Infect Dis. 2022; 9 (20499361221124027)Google Scholar Co-infections of this type could influence the acquisition and clinical course of monkeypox virus infection, especially in people who are immunosuppressed, and in some cases could lead to fatal outcomes (42 deaths have so far been reported in 12 countries where monkeypox was not previously endemic as of Nov 21, 2022, according to the US Centers for Disease Control and Prevention, with evidence that HIV or other STI co-infection was an important factor in some of these deaths).14Sah R Mohanty A Abdelaal A Reda A Rodriguez-Morales AJ Henao-Martinez AF First monkeypox deaths outside Africa: no room for complacency.Ther Adv Infect Dis. 2022; 9 (20499361221124027)Google Scholar The current case series showed a high prevalence of HIV among infected individuals and particularly trans women (31 [50%], compared with six [8%] cis women and non-binary individuals). Trans women also frequently face barriers to accessing health care and social support, among other related issues. Furthermore, 34 (55%) trans women in this international case series reported engaging in sex work,9Thornhill JP Palich R Ghosn J et al.Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series.Lancet. 2022; 400: 1943-1965Google Scholar suggesting that this group might have a high level of precarity and vulnerability, which might include factors such as homelessness, injection drug use, migrant status (three [5%] of trans women were migrants), or having multiple sexual partners, which could compound the level of stigma they face.9Thornhill JP Palich R Ghosn J et al.Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series.Lancet. 2022; 400: 1943-1965Google Scholar, 15Sah R Mohanty A Reda A Padhi BK Rodriguez-Morales AJ Stigma during monkeypox outbreak.Front Public Health. 2022; 10: 1023519Crossref Scopus (2) Google Scholar More studies are needed to understand the differences in risk, transmission, and clinical consequences of monkeypox virus infection among different populations. Crucially, concerted efforts are needed to determine a comprehensive approach for differentiated integral case management that improves early detection and treatment, when required, especially among people at high risk. In terms of clinical practice, findings from Thornhill and colleagues’ case series could help to expand preparedness and increase the knowledge available to physicians and health-care workers in sexual health clinics, gynaecology and obstetrics (3% of cis women and non-binary individuals were pregnant at the time of infection), and female and reproductive medicine, among other related areas, to improve diagnosis, treatment, and support. During the current monkeypox outbreak, it is important to consider this infection among differential diagnoses, especially given that 25 (34%) of 74 cis women and non-binary individuals in Thornhill and colleagues’ case series were misdiagnosed before monkeypox diagnosis. Such misdiagnosis might be more common in regions where there are still few or no confirmed cases of monkeypox, such in as the Middle East, where additional stigma and discrimination against people with monkeypox, especially the LGBTQ+ population,15Sah R Mohanty A Reda A Padhi BK Rodriguez-Morales AJ Stigma during monkeypox outbreak.Front Public Health. 2022; 10: 1023519Crossref Scopus (2) Google Scholar might exist in health services as well as society more broadly. Equitable access to care, treatment, removal of stigma, and prevention for monkeypox is crucial at this time while the world is learning about this re-emerging threat. Finally, prioritisation should consider discussing vaccination and other preventive measures for women and non-binary individuals. Future studies should consider gender differences in transmission routes, viral loads in different sample types, risk of severity, and therapeutic and vaccination responses. We declare no competing interests. Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case seriesThe clinical features of monkeypox in women and non-binary individuals were similar to those described in men, including the presence of anal and genital lesions with prominent mucosal involvement. Anatomically, anogenital lesions were reflective of sexual practices: vulvovaginal lesions predominated in cis women and non-binary individuals and anorectal features predominated in trans women. The prevalence of HIV co-infection in the cohort was high. Full-Text PDF Open Access