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Since the outset of the global monkeypox outbreak in May, public health
and infectious disease experts have told the public that the virus is
largely transmitting through skin-to-skin contact, in particular during
sex between men.

Now, however, an expanding cadre of experts has come to believe that sex between men itself — both anal as well as oral intercourse — is likely the
main driver of global monkeypox transmission. The skin contact that comes
with sex, these experts say, is probably much less of a risk factor.

In recent weeks, a growing body of scientific evidence — including a trio
of studies published in peer-reviewed journals, as well as reports from national, regional and global health authorities — has suggested that
experts may have framed monkeypox’s typical transmission route precisely backward.


Biden administration moves to stretch out monkeypox vaccine supply amid criticism
AUG. 9, 202203:24
Reconceiving the primary risk factors for transmission is crucial because
of how it may affect guidance on reducing the risk of infection, including
the question of whether demanding that people with the virus self-isolate
has any substantial impact on transmission.

“A growing body of evidence supports that sexual transmission,
particularly through seminal fluids, is occurring with the current MPX outbreak,” said Dr. Aniruddha Hazra, medical director of the University of Chicago Sexual Wellness Clinic, referring to monkeypox and to recent
studies that found the virus in semen.

Consequently, scientists told NBC News that the Centers for Disease
Control and Prevention and other public health authorities should update
their monkeypox communication strategies to more strongly emphasize the centrality of intercourse among gay and bisexual men, who comprise nearly
all U.S. cases, to the virus’ spread.

On Aug. 14, Dr. Jeffrey Klausner, an infectious disease physician at the University of Southern California, and Dr. Lao-Tzu Allan-Blitz, a resident physician in global health at Brigham and Women’s Hospital in Boston,
published an essay on Medium in which they reviewed the science supporting
the argument that during the current outbreak, monkeypox is largely transmitting through anal and oral intercourse between men.

“It looks very clear to us that this is an infection that is transmitting sexually the vast majority of the time,” Allan-Blitz said.

This debate, however, is far from settled.

Dr. Rosamund Lewis, technical lead for monkeypox at the World Health Organization, told NBC News it was “unfortunate but true” that “we don’t
know yet” whether the virus is predominantly transmitted through
intercourse.

“Completely reading the situation as uniquely due to anal or oral sex is
highly likely to be overreach,” she said. “The correlation may appear to
be strong, but that does not explain the whole picture of disease caused
by this virus. So we need to keep an open mind.”

Some experts in infectious disease see evidence supporting the argument
that monkeypox at least transmits more readily through intercourse.

“At this point,” said Dr. Paul Adamson, an infectious disease specialist
at the UCLA School of Medicine, “I’m not sure we can say it is primarily
the sexual transmission and not the skin-to-skin contact that also occurs during sex that is contributing to the most transmission during this
current outbreak. However, emerging data seem to suggest that monkeypox
might be more efficiently transmitted sexually.”

Parsing the evidence
In an interview, Klausner, who has submitted a version of his and Allan- Blitz’s essay to a scientific journal for publication, distilled the
evidence that he said supports the hypothesis that sex itself fuels the
global outbreak into four major points.

First, he noted that, according to the WHO, more than three quarters of
global monkeypox cases are among men 18 to 44 years old. This is a typical
age breakdown for diagnoses of sexually transmitted infections among gay
and bisexual men, he said. What’s more, in recent studies of pooled
monkeypox cases among this demographic, 17% to 32% of those diagnosed with
the virus received a sexually transmitted infection (STI) diagnosis at the
same time.

Second, during the global outbreak, atypical to what has historically been
seen in the 11 African nations where the virus has become endemic since
first being identified in humans in 1970, monkeypox lesions have in the majority of cases occurred in men’s genital and anorectal areas. This,
experts told NBC News, suggests that these were the sites where the virus
first passed into the body.

In a study of 197 monkeypox cases in London men published July 28 in The
BMJ, the British Medical Association’s journal, researchers found that 56%
had lesions in the genital area and 42% had them in their anorectal
regions. And in a study published July 21 in The New England Journal of Medicine, a global team of researchers pooled 538 monkeypox cases — also
all in men — from around the world and found that 73% had lesions in the genital or anorectal areas.

Third, researchers have found monkeypox in semen and have been able to
culture that virus, which suggests it could transmit through ejaculation.
Also, the authors of two recent studies have detected the virus after
taking anal swabs among men who had monkeypox but were asymptomatic, which indicates that the virus might transmit from the anorectal area during
anal intercourse before people develop symptoms. Experts say more research
is needed on both these fronts.

Referring to bodily fluids such as semen, vaginal fluids and blood, the
WHO’s Lewis said, “Research is underway to find out more about whether
people can spread monkeypox through the exchange of these fluids during
and after symptomatic infection.”

Finally, Klausner noted that scientists have identified an association
between specific sexual acts and the location of monkeypox lesions.

The authors of a paper published Aug. 8 in The Lancet documenting 181
cases of the virus in Spain found that 38% of the men who reported having receptive anal intercourse, called “bottoming,” developed proctitis, or inflammation of the rectum. Just 7% of the men who reported sex with men without bottoming developed this potentially excruciating symptom. Additionally, 95% of the men with tonsillitis reported performing oral sex
on a man.


Biden administration declares monkeypox a public health emergency
AUG. 4, 202200:34

Dr. Oriol Mitjà, an associate professor in infectious disease at the
University Hospital Germans Trias i Pujol in Spain and the joint senior co-author of the study in The Lancet, said monkeypox transmits most
efficiently when lesions come into contact with mucus membranes in the anorectal area, genitals, mouth and throat.

Monkeypox is more likely to transmit through oral or anal sex than through contact with external skin, which would need some sort of defect, such as
a wound, to allow entry of the virus, Mitjà said.

Dr. Dimie Ogoina, a professor of medicine and infectious diseases at Niger Delta University in Nigeria, acknowledged Mitjà’s research supporting the connection between types of sex between men and monkeypox outcomes.

“This is not to say that females or heterosexuals are not at risk of
monkeypox or that the female genital mucosa is not prone to abrasions
during sexual activity,” Ogoina said.

Global trends
Some experts, like the WHO’s Lewis, maintain that the main mode of
monkeypox transmission remains skin-to-skin contact — including during
sex. Others, like Klausner and Adamson, say a number of infectious disease experts may resist believing intercourse is a predominant driver of the
current outbreak because that is not how monkeypox has tended to spread in
past decades.

“Historically, the primary mode of transmission of monkeypox was through skin-skin contact, though there might have been some suggestion of sexual transmission in prior outbreaks. It takes some time and additional data to overturn our understanding of transmission,” Adamson said.

Monkeypox has been diagnosed in 38,019 people in 93 countries during this current global outbreak, according to the CDC. And the WHO reports that
among cases with proper data, 97% have been diagnosed in gay, bisexual and other men who have sex with men. The consistency with which cases have
remained so overwhelmingly in this demographic, some experts argue, is
further evidence that the virus transmits among them through a behavior
that is exclusive to the group — anal intercourse and oral sex between
men.

Meanwhile, across the global outbreak, the virus is also apparently
following the same transmission patterns traditionally seen in Africa. But experts assert that just as in those African nations, when the virus
transmits through nonsexual means, it does so with dramatically lower efficiency — and thus at a rate similar to the relatively slow spread seen
in Africa.

Specifically, the authors of The New England Journal of Medicine paper estimated that just 0.8% of the cases they analyzed were due to nonsexual
close contact and 0.6% were due to household contact. By contrast, 95% of
these cases were likely acquired during sex between men. The authors of
the Lancet paper estimated that 3% of the cases they analyzed transmitted through nonsexual household contact.

Dr. Monica Gandhi, an infectious disease physician at University of
California, San Francisco, said the small number of global monkeypox cases
in children have likely been transmitted through cuddling or hugging. She pointed to various STIs, including herpes, that in rare cases can also
transmit nonsexually.

“STIs such as syphilis or chancroid are commonly found in children in the tropics, where abrasions on the arms and legs are common,” Mitjà said.

Referring to the recent rapid expansion of the global outbreak, Ogoina
said, “It is all about numbers — the more sexual partners, the greater the likelihood for many to become exposed.”

If monkeypox is indeed overwhelmingly being transmitted through
intercourse and rarely through more casual means, this challenges
burdensome public health guidelines recommending that people with the
virus isolate for the course of their illness, which can last for weeks,
Mitjà and his coauthors argued in their paper.

Klausner called for updated communications from the CDC and other health authorities to emphasize the importance of sexual intercourse to
monkeypox’s transmission.

“If we accept that this is how it’s spread, we know how to reduce the
spread: by awareness and education and encouraging people for the time
being to reduce sex with multiple partners until they get vaccinated,”
Klausner said “And if they can’t reduce the behavior, to try to use a
condom.”

CDC spokesperson Kristen Nordlund said the agency’s recent analyses “show
most diagnosed cases of monkeypox in the United States are associated with sexual and intimate contact, which can involve a range of behaviors.
Additional analyses are needed to understand if specific sexual and
intimate behaviors that occur during sex are disproportionately
contributing to spread.”

Harvard’s Lao-Tzu Allan-Blitz acknowledged the pervasive concern that
telling the public that monkeypox transmits sexually among gay men will
fuel homophobia. He said there is, however, also a cost to keeping quiet
about how the virus apparently transmits: This keeps people at risk from
best understanding how to protect themselves.

“In our silence, we can also do harm,” he said.

https://www.nbcnews.com/nbc-out/out-health-and-wellness/sex-men-not-skin- contact-fueling-monkeypox-new-research-suggests-rcna43484

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