Over 16,000 monkeypox infections have been confirmed in 68 countries as of July 22, 2022, with most infections occurring in men who are in a sexual relationship with men. The World Health Organization (WHO) declared the current monkeypox epidemic a global health emergency on July 23. 


A large majority of monkeypox infections have been observed in men who are involved in sexual activity with multiple men, media reports said. The average number of persons infected with monkeypox by a single infected person is between 1.4 and 1.8 in men having sex with men, models presented to the WHO suggest. In other populations, the average number of persons infected by a single person is less than one. 


The first monkeypox case was confirmed in Delhi on July 24, after a 34-year-old man tested positive for the monkeypox virus. The rate of increase in new monkeypox cases has been slowing down in Europe in recent weeks, with the large majority of infections still occurring in men involved in sexual activity with other men. 


About 97 per cent of the monkeypox cases in the United Kingdom have been reported in men who have sex with other men. 


Monkeypox Concentrated Among ‘Men Who Have Sex With Men’: WHO Director-General


Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region, has said that “monkeypox has been spreading rapidly and to many countries that have not seen it before, which is a matter of great concern”. She added that with cases concentrated among men who have sex with men, it is possible to curtail further spread of the disease with focused efforts among at-risk population. 


WHO Director-General Tedros Adhanom Ghebreyesus said in a media briefing last week that for the moment, monkeypox is an “outbreak that is concentrated among men who have sex with men”. 


Of late, experts have been debating whether monkeypox is currently a sexually transmitted disease. Though it is known that monkeypox is spread during sexual activity, labelling it a sexually transmitted disease (STD) would not be practical because the disease may spread through any intimate contact, even when one is wearing barrier devices such as condoms during sexual intercourse. 


Large Case Study Series To Date Identifies New Clinical Symptoms Of Monkeypox Infection


An international collaboration of clinicians have recently identified new clinical symptoms in people with monkeypox virus in the largest case study series to date. The case study series is the result of an international collaboration across 16 countries, and identified new clinical symptoms of monkeypox infection. This will improve the accuracy of future diagnosis and help slow the spread of infection. 


The study, led by researchers at Queen Mary University of London, was published July 21 in the New England Journal of Medicine. The scientists carried out the study in response to the emerging global health threat, and reported on 528 confirmed infections at 43 sites between April 27 and June 24, 2022.


98% Of People Infected With Monkeypox Are Gay Or Bisexual Men


According to the study, the current spread of the monkeypox virus disproportionately affects gay and bisexual men. About 98 per cent of the people infected with monkeypox virus belong to the communities of gay and bisexual men. 


The most likely route of transmission in most monkeypox cases is sexual closeness. However, researchers note that monkeypox virus can be transmitted by any close physical contact through large respiratory droplets and also through clothing and other surfaces. 


Genital Lesions, Sores In Mouth Or Anus Observed In Infected Individuals


According to the study, many of the infected individuals reviewed by the authors were found to show symptoms not recognised in current medical definitions of monkeypox. The infected individuals had symptoms such as single genital lesions and sores in the mouth or anus. The clinical symptoms observed in the infected persons are similar to those of sexually transmitted infections (STIs). These symptoms can easily lead to misdiagnosis. 


Some people who showed anal and oral symptoms were hospitalised because they could had extreme pain and difficulty swallowing.


It is important to recognise these new clinical symptoms so that healthcare professionals can be educated on how to identify and manage the monkeypox disease. 


Misdiagnosis slows detection and poses a hindrance to efforts to control the spread of the virus. The findings of the study are important because they can lead to increased rates of diagnosis when persons from at-risk groups show traditional STI symptoms.


What Experts Say


In a statement released by Queen Mary University of London, Chloe Orkin, Professor of HIV Medicine at the university, said viruses know no borders and monkeypox infections have been described in 70 countries and more than 13,000 people. She further said that the current international case definitions need to be expanded to add symptoms that are not currently included, such as sores in the mouth, on the anal mucosa, and singlet ulcers. Since the symptoms can be severe and have led to hospital admissions, it is important to make a diagnosis. 


Dr John Thornhill, Consultant Physician in HIV and Sexual Health at Queen Mary University of London, said it is important to stress that monkeypox is "not a sexually transmitted infection" in the traditional sense. This is because it can be acquired through any kind of close physical contact. 


He added that the new case study suggests that most transmissions so far have been related to sexual activity – mainly, but not exclusively, amongst men who have sex with men.


He explained that the research study explained the understanding of the ways monkeypox is spread and allows researchers to offer prevention strategies, such as vaccines, to the individuals at higher risk.


Thornhill further said that the researchers identified new clinical presentations in people with monkeypox. They found that one in ten people had only a single skin lesion in the genital area, and 15 per cent had anal and/or rectal pain. 


Thornhill stated that these different presentations highlight that monkeypox infections could be missed or easily confused with common sexually transmitted infections such as syphillis or herpes. "We therefore suggest broadening the current case definitions," he said.


Thornhill further said that the researchers also found monkeypox virus in a large proportion of the semen samples tested from people with monkeypox. However, he added, this may be incidental as it is not known that monkeypox is present at high enough levels to facilitate sexual transmission. He said that more work is needed to understand this better.