In Women and Nonbinary People, Monkeypox Cases May Have Been Missed

During the chickenpox outbreak that broke out this summer in the United States and dozens of other countries, men who have sex with men are most at risk. But thousands of women have also been infected and many more cases may have been missed, according to the first study of women and non-twins who have contracted the disease.

As in men, sex was the most likely source of infection among transgender women, accounting for 89% of cases, by case series, published on Thursday in the Lancet journal. But among transgender women and non-twins who were designated female at birth, only 61% of cases could be related to sex.

Dr Chloe Orkin, doctor and researcher at Queen Mary University of London, said almost a quarter of transgender women in the study could have been infected without having had sex with an infected person. . The women are believed to have been infected by exposure at work or their home or through other forms of close contact.

“The lesson here is that people need to know about this,” Dr. Orkin said. While it is appropriate that public health messages are primarily aimed at men who have sex with men, she adds, “it is important to realize this is not the only group that best.”

After several months of rapidly escalating cases, the chickenpox outbreak in the United States has slowed, thanks in part to vaccination campaigns and changes in behavior among many high-risk people. Since May, there have beenjust over 29,000 cases in the United States, but only about a thousand cases were diagnosed in the last month.

However, as the disease fell out of public attention, scientists were just beginning to understand when and how it spread and who was at risk.

In the new study, Dr Orkin and her colleagues found chickenpox virus genetic material in all 14 vaginal swabs they tested, suggesting the virus can be transmitted by genital secretions. Studies in men have also found the same virus in seminal fluid.

However, public health authorities have been hesitant to call chickenpox a sexually transmitted disease, arguing that the virus can spread through close physical contact of any kind.

But some experts disagree: The fact that monkeypox can be transmitted in other ways shouldn’t preclude its classification as a sexually transmitted disease, because other diseases such as herpes and syphilis. It can also be spread through close non-sexual contact, some people have said.

Last month, New York State added chickenpox to its list of sexually transmitted diseases, but the Centers for Disease Control and Prevention did not make that change. Demetre Daskalakis, the White House’s deputy coordinator for the chickenpox response, said the agency would leave that classification to individual states. But it is clear that sexual behavior drives the cases, he said.

“If you eliminate sex, will we have a chickenpox outbreak? Probably not,” he added. Even if the main reason for the spread is skin-to-skin contact during sex, “it’s definitely sexual transmission.”

This year, Dr. Orkin led an international collaboration to Characteristic symptoms of chickenpox in 500 patients. The findings made Britain, the United States and other countries refine their case definition of disease.

And last month, the UK Health Security Agency publish a study suggests that about 40 percent to 60 percent of chickenpox transmission may occur before an infected person develops symptoms.

Tom Ward, an infectious disease modeler for the agency, notes: “This makes intuitive sense because once a patient develops painful blisters, it becomes difficult for them to have sex. sex. A small percentage of people infected may never develop symptoms, he said.

Tracing contacts during a chickenpox outbreak is extremely difficult because of the sensitive and often anonymous nature of transmission; There is no test that can detect monkeypox before the characteristic skin rash appears.

“What is fundamentally striking is that we still need more research into the nature of asymptomatic and presymptomatic monkeypox transmission,” said Dr.

Some people may have mild, general symptoms such as a sore throat before the rash appears.

Dr Daskalakis said that such individuals should stay at home to protect others. But in the end, he said, the ability to spread before symptoms appear doesn’t change the public health message for those at risk: get vaccinated against chickenpox.

“Perhaps the strongest guideline is that if there is a history that makes you think you are at risk for chickenpox, it is important to get vaccinated, and if there is a chance of future risk, it is important to get vaccinated. It is important to get vaccinated,” he added.

This new study is the first to describe chickenpox in transgender or non-twins, who often have little access to quality health care and are rarely included. research.

“It is very, very important that we report on both sexes and sex differences, because both are important and in some cases they intersect,” said Dr Orkin.

In this study, researchers from 15 countries contributed clinical information from 69 transgender women, 62 transgender women, and 5 non-bisexuals diagnosed with chickenpox between May 11 to October 4. About 45% of the women are Latino, 29% white, and 21 percent black.

More than half of the patients in the study had sores on the anus, genitals, mouth, or eyes. But some women – especially transgender women – are initially misdiagnosed with other STIs.

Dr Abraar Karan, an infectious disease physician at Stanford University, said experts had predicted that chickenpox “will probably have a slightly different transmission pattern depending on behaviors and norms. society within certain groups”.

New research backs that up. In contrast to male chickenpox patients who had sex with men, only 7% of patients in the study reported attending a Pride event or other similar gatherings. While transgender women in the study had an average of 10 sexual partners in the last month, transgender women had one and 7% of transgender women reported having no sexual partners in the previous month.

“So the driver is not the same,” says Dr. Karan.

Many of the transgender women in the study had other risk factors for chickenpox, including undiagnosed and untreated HIV, homelessness, and drug use. Half of transgender women in the study were infected with HIV compared with 8% of transgender women, and more than half of transgender women engaged in commercial sex work compared with 3% of transgender women.

“While the absolute numbers of transgender and sex workers may not be very large, the extremely high rates of HIV infection and now chickenpox and other sexually transmitted diseases mean that is that public health agencies need to think of ways to deal with this. Jay Varma, director of the Cornell Center for Pandemic Response and Prevention, said.

While many transgender women seek care at sexual health clinics, the transgender women in the study went to primary care providers or emergency departments, where doctors can Most likely not familiar with the symptoms of chickenpox. About a third of transgender women are diagnosed late or have another medical condition; some are probably never diagnosed.

“It is very likely that the infections were missed and undetected,” Dr. Orkin said.

About a quarter of the transgender women in the study lived with children, but doctors identified only two cases of chickenpox among them. The CDC observations are consistent with that finding.

But Dr Karan warns that cases in children may be underreported due to the stigma associated with chickenpox. More research is needed to understand how symptoms can vary in different populations, he said, especially in countries where the virus has been outbreaks for many years.


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