Attaching a stigma to the LGBTQI+ community should be avoided during the monkeypox epidemic

Beyond skin deep: shedding light on the neuropsychiatric consequences of Monkeypox (Mpox)

This review is attempted in view of World Health Organization (WHO) warning on Monkeypox virus (Mpox) to summarize the available data regarding the potential effect on central nervous system (CNS), its complications, and diagnostic methods. We combed various international databases (including Scopus, PubMed, Web of Science, and Google Scholar) for articles mentioning Mpox infection, orthopox infection, and the central nervous system that were published between the years 2000 and 2022. Further evidence was evaluated from relevant studies published in the literature. There is emerging evidence of central nervous system neurological involvement. In addition to encephalopathy, which is one of the most serious neurological complications of Mpox, the most common complications of Mpox infection are headache, weakness, myalgia, anorexia, and altered consciousness. Anxiety and depression have also been identified as the most common psychiatric symptoms in these patients.

Community led health promotion to counter stigma and increase trust amongst priority populations: lessons from the 2022-2023 UK mpox outbreak

BACKGROUND

Stigma, lack of trust in authorities, and poor knowledge can prevent health-seeking behaviour, worsen physical and mental health, and undermine efforts to control transmission during disease outbreaks. These factors are particularly salient with diseases such as mpox, for which 96% of cases in the 2022-2023 UK outbreak were identified among gay, bisexual, queer and men who have sex with men (MSM). This study explored stigma and health-seeking behaviour in Liverpool through the lens of the recent mpox outbreak.

METHODS

Primary sources of data were interviews with national and regional key informants involved in the mpox response, and participatory workshops with priority populations. Workshop recruitment targeted Grindr users (geosocial dating/hookup app) and at risk MSM; immigrant, black and ethnic minority MSM; and male sex workers in Liverpool. Data were analysed using a deductive framework approach, building on the Health Stigma and Discrimination Framework.

RESULTS

Key informant interviews (n = 11) and five workshops (n = 15) were conducted. There were prevalent reports of anticipated and experienced stigma due to mpox public health messaging alongside high demand and uptake of the mpox vaccine and regular attendance at sexual health clinics. Respondents believed the limited impact of stigma on health-seeking behaviour was due to actions by the LGBTQ + community, the third sector, and local sexual health clinics. Key informants from the LGBTQ + community and primary healthcare felt their collective action to tackle mpox was undermined by central public health authorities citing under-resourcing; a reliance on goodwill; poor communication; and tokenistic engagement. Mpox communication was further challenged by a lack of evidence on disease transmission and risk. This challenge was exacerbated by the impact of the COVID-19 pandemic on the scientific community, public perceptions of infectious disease, and trust in public health authorities.

CONCLUSIONS

The LGBTQ + community and local sexual health clinics took crucial actions to counter stigma and support health seeking behaviour during the 2022-2023 UK mpox outbreak. Lessons from rights based and inclusive community-led approaches during outbreaks should be heeded in the UK, working towards more meaningful and timely collaboration between affected communities, primary healthcare, and regional and national public health authorities.

Survey of pain and stigma experiences in people diagnosed with mpox in Baltimore, Maryland during 2022 global outbreak

A high prevalence of mpox in men who have sex with men and in people with HIV, plus visually striking and contagious lesions, have raised concerns for mpox stigma. 24 PCR-confirmed mpox patients were surveyed over the course of three months, utilizing an mpox stigma scale adapted from the HIV Stigma Scale plus assessment of pain, analgesic efficacy, and healthcare experiences. Participants were cis-male (100%), with male sexual partners (96%), mostly African-American (88%), and living with HIV (79%). Patients answered 4-16 of 24 (mean 10) stigma questions affirmatively, particularly related to negative effects of mpox on the LGBTQ community. 79% reported pain, most commonly of limbs and perianal area, with perianal pain being rated most severe. The most effective pain relief occurred with opioids (100% major relief, n = 2) and tecovirimat (63% major relief, 25% moderate, n = 16). Patients were satisfied with care provided at the studied clinics, but had negative experiences at all other mentioned sites.

Changes in Sexual Behaviors Due to Mpox: a Cross-Sectional Study of Sexual and Gender Minority Individuals in Illinois

The spread of the monkeypox virus (mpox) in 2022 primarily within the sexual networks of men who have sex with men (MSM) triggered a potentially stigmatizing public health response in the USA. Despite mpox being primarily spread through skin-to-skin contact, most messaging has promoted abstinence and/or reduction in sexual risk behaviors. More research is needed on decreases in sexual risk behaviors among sexual and gender minority (SGM) youth and young adults (YYA) related to the most recent mpox epidemic and whether there are factors associated with these decreases in sexual risk behavior. Participants within an ongoing cohort study of SGM YYA who reside in Illinois were offered the opportunity to participate in an mpox survey between September 10th and September 20th, 2022. Analyses looked at demographic factors associated with sexual activity since the start of the outbreak, as well as associations with two sexual risk reduction factors. Survey participation was 68.7% (322/469). Three-quarters of participants (82.6%) reported sexual activity since June 1st. Most sexually active participants (83.5%) adopted at least one sexual risk reduction behavior due to mpox. Black and Latinx individuals were less likely to be sexually active but more likely to report risk reduction behaviors (31.3% and 22.6%, respectively). Participants who received the mpox vaccine were more likely to report sexual activity. SGM YYA in Illinois reported that their sexual behaviors were impacted by the mpox outbreak. However, associations between vaccination and sexual behavior demonstrate that those who are vaccinated do adopt protective methods despite not decreasing sexual activity. Therefore, sex-positive communications and harm reduction messaging may be more appropriate as opposed to abstinence-only prevention, which can further stigmatize an already marginalized group.

Experiences of mpox illness and case management among cis and trans gay, bisexual and other men who have sex with men in England: a qualitative study

Background

The 2022-2024 global mpox outbreak, occurring primarily in the sexual networks of gay, bisexual and other men who have sex with men (GBMSM), has not been accompanied by a focus on patient perspectives of illness. We explore the experiences of GBMSM diagnosed with mpox in England to understand needs for social and clinical support.

Methods

In-depth interviews (March/July 2023) were conducted with 22 GBMSM diagnosed with mpox in 2022, randomly selected from a national mpox surveillance database, and 4 stakeholders from clinical/community-based organisations. Interviews covered experiences of illness, testing, diagnosis, treatment and contact tracing, and were recorded, transcribed and analysed with a thematic framework.

Findings

Media coverage drawing on homophobic stereotypes around sex between men contributed to feelings of stigma and shame. GBMSM living with HIV appeared to cope better with mpox stigma, drawing on their experiences of being diagnosed with HIV for resilience. Younger GBMSM with less experience of stigmatising illness found mpox diagnosis more traumatic and sometimes required support beyond what was provided. Accessing testing could be complicated when healthcare professionals did not recognise mpox symptoms. Men felt information on course of illness, isolation and vaccination after recovery was often inconsistent and contradictory. GBMSM described that care from sexual health and infectious disease units usually better met their emotional and medical needs. This was frequently linked by men to these services having skills in working with the GBMSM community and managing infection risk sensitively. General hospital services and centralised contact tracing could increase feelings and experiences of stigma as some staff were perceived to lack skills in supporting GBMSM and, sometimes, clinical knowledge. Long-term impacts described by men included mental health challenges, urethral/rectal symptoms and life-changing disability.

Interpretation

In this study stigma was a central feature of mpox illness among GBMSM and could be exacerbated or lessened depending on the clinical and social support provided. Involving communities affected by outbreaks in co-producing, planning and delivering care (including contact-tracing) may help improve support provided.

Funding

TCW, AJR, AS and FMB received support from the National Institute for Health and Care Research (NIHR) under its Programme Grants for Applied Research Programme (Ref: NIHR202038). CS and JS receive support from the National Institute for Health and Care Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in partnership with UKHSA; RV receives support from the NIHR HPRU in Emerging and Zoonotic Infections and NIHR HPRU in Gastrointestinal Infections. The views expressed are those of the author(s) and not necessarily those of the NIHR, UK Health Security Agency, World Health Organization or the Department of Health and Social Care.

Non-Healing Corneal Ulcer and Uveitis Following Monkeypox Disease: Diagnostic and Therapeutic Challenges

PURPOSE

The ocular manifestations of Monkeypox virus (Mpox) infection remain incompletely characterized. Our goal is to present a case series of non-healing corneal ulcers with associated uveitis caused by Mpox infection as well as management recommendations for Mpox-related ophthalmic disease (MPXROD).

METHODS

Retrospective case series.

RESULTS

Two male patients with recent hospitalization for systemic Mpox infection presented with non-healing corneal ulcer associated with anterior uveitis and severe IOP elevation. Despite initiation of conservative medical treatment including corticosteroid treatment for uveitis, in both cases, there was clinical progression with enlarging cornea lesions. Both cases received oral tecovirimat with complete healing of the corneal lesion.

CONCLUSIONS

Corneal ulcer and anterior uveitis are rare complications of Mpox infection. Although Mpox disease is generally anticipated to be self-limited, tecovirimat may be an effective intervention in poorly healing Mpox keratitis. Corticosteroids should be used with caution in Mpox uveitis, as they might lead to worsening infection.

Health activism, vaccine, and mpox discourse: BERTopic based mixed-method analyses of tweets from sexual minority men and gender diverse (SMMGD) individuals in the U.S

Objectives

To synthesize discussions among sexual minority men and gender diverse (SMMGD) individuals on mpox, given limited representation of SMMGD voices in existing mpox literature.

Methods

BERTopic (a topic modeling technique) was employed with human validations to analyze mpox-related tweets (n = 8,688; October 2020-September 2022) from 2,326 self-identified SMMGD individuals in the U.S.; followed by content analysis and geographic analysis.

Results

BERTopic identified 11 topics: health activism (29.81%); mpox vaccination (25.81%) and adverse events (0.98%); sarcasm, jokes, emotional expressions (14.04%); COVID-19 and mpox (7.32%); government/public health response (6.12%); mpox symptoms (2.74%); case reports (2.21%); puns on the virus' naming (i.e., monkeypox; 0.86%); media publicity (0.68%); mpox in children (0.67%). Mpox health activism negatively correlated with LGB social climate index at U.S. state level, ρ = -0.322, p = 0.031.

Conclusions

SMMGD discussions on mpox encompassed utilitarian (e.g., vaccine access, case reports, mpox symptoms) and emotionally-charged themes-advocating against homophobia, misinformation, and stigma. Mpox health activism was more prevalent in states with lower LGB social acceptance.

Public Health Implications

Findings illuminate SMMGD engagement with mpox discourse, underscoring the need for more inclusive health communication strategies in infectious disease outbreaks to control associated stigma.

Epidemiological and Clinical Characteristics of Mpox in Cisgender and Transgender Women and Non-Binary Individuals Assigned to the Female Sex at Birth: A Comprehensive, Critical Global Perspective

The 2022-2023 Mpox multi-country outbreak, identified in over 110 WHO Member States, revealed a predominant impact on cisgender men, particularly those engaging in sex with men, while less frequently affecting women. This disparity prompted a focused investigation into the gender-specific characteristics of Mpox infections, particularly among women, to address a notable knowledge gap. This review systematically gathers and analyzes the scientific literature and case reports concerning Mpox infections in women, covering a broad geographical spectrum including regions such as Argentina, Brazil, Colombia, Nigeria, Europe, Vietnam, and the United States. The analysis delves into various aspects of Mpox in women, including clinical features, epidemiology, psychological impacts, preparedness strategies, and case studies, with particular attention to pregnant women and those with underlying health conditions. Empirical data from multiple studies underscore the unique epidemiological and clinical patterns of Mpox in women. In the United States, a small percentage of Mpox cases were reported among cisgender women, with a notable portion involving non-Hispanic Black or African American, non-Hispanic White, and Hispanic or Latino ethnicities. The primary transmission route was identified as sexual or close intimate contact, with the virus predominantly manifesting on the legs, arms, and genital areas. Further, a study in Spain highlighted significant disparities in diagnosis delays, transmission modes, and clinical manifestations between genders, indicating a different risk profile and disease progression in women. Additionally, a case from Vietnam, linked to a new Mpox sub-lineage in women, emphasized the role of women in the transmission dynamics and the importance of genomic monitoring. This review emphasizes the necessity for inclusive surveillance and research to fully understand Mpox dynamics across diverse population groups, including women. Highlighting gender and sexual orientation in public health responses is crucial for an effective approach to managing the spread and impact of this disease. The findings advocate for a gender-diverse assessment in health services and further research to explore the nuances of Mpox transmission, behavior, and progression among different groups, thereby enhancing the global response to Mpox and similar public health challenges.

Characterizing Indicators of Engagement in HIV-Associated Healthcare and Clinical Outcomes among People with HIV and Mpox in Washington, DC: A Nested Case-Control Study of the DC Cohort

The high proportion of people with HIV (PWH) in the 2022-2023 mpox outbreak has raised questions surrounding the association between HIV and mpox. The objectives of this study were to evaluate the association between engagement in HIV-associated healthcare and mpox diagnosis, as well as to characterize cases of mpox among PWH. The DC Cohort is a longitudinal cohort of PWH in Washington, DC. We conducted a 5:1 (controls:cases) nested case-cohort study on male participants, matching age and care site. Cases were participants with an identified mpox diagnosis. Conditional logistic regression was used to assess the impact of indicators of engagement in HIV-associated healthcare on mpox diagnosis. We identified 70 cases of mpox in DC Cohort participants randomly matched to 323 controls, for a total of 393 participants included in the analysis. Study participants were primarily non-Hispanic Black (72.3%) with a median age of 41 (IQR: 36, 50). There was no association between engagement in care and mpox diagnosis; however, low CD4 was associated with increased odds of mpox diagnosis (aOR: 4.60 (95% CI: 1.23, 17.11)). Among a cohort of PWH, engagement in care was not associated with mpox diagnosis, suggesting that the overrepresentation of PWH among mpox cases is not due to surveillance bias.

Using a theoretical framework of Intervention Mapping to inform public health communication messages designed to increase vaccination uptake; the example of mpox in the Netherlands

INTRODUCTION

During an infectious disease outbreak, primary preventive pre-exposure vaccination (PPV) could substantially increase the potential for its control, if uptake is sufficiently high. An important tool to increase PPV uptake, are communication strategies, with tailored messages targeted to modify determinants for PPV uptake. Here, we take the example of the 2022 mpox multicountry outbreak, as we inform the development of communication strategies by applying a theoretical framework for selecting effective communication strategies.

METHODS

The theoretical framework Intervention Mapping (IM) was applied during the outbreak to inform communications [program]. Steps included: 1. Creating a logic model of the problem [not accepting PPV] by reviewing available literature, conducting an online survey among people at risk of mpox exposure, and consulting community-members, healthcare-and communication professionals; 2. Creating a matrix of change [from lower to higher PPV acceptance]; and 3. Selecting theory-based methods and practical applications for communication messages to achieve the intended behaviour change (getting vaccinated).

RESULTS

The program objective was to promote PPV uptake in people at risk of mpox exposure. Important changeable determinants identified included perceived risk and severity of mpox, importance to protect against mpox [attitude], experienced effectiveness of vaccination and side-effects [response efficacy], and social norm. Theory-based communication methods for optimizing these determinants include provision of facts [increasing knowledge], personalized risk and scenario-based risk information [addressing risk perception/severity], elaboration, arguments [stimulating a positive attitude], gain framing [increasing perceived response efficacy], guided practice [increasing skills/self-efficacy in overcoming barriers] and social norm approach [demonstrating positive norm]. Other key important factors include that communication delivery is uniform (across channels), clear, accessible, and with stigma-free messaging, and that is well-timed and repeated.

CONCLUSION

IM provided a valuable tool in selecting communication methods to promote mpox vaccination uptake. These methods can be used to (more quickly) produce and implement a communication program in the context of possible future, vaccine-preventable, infectious disease outbreaks.

Knowledge, Attitudes, and Willingness of Healthcare Workers in Iraq's Kurdistan Region to Vaccinate against Human Monkeypox: A Nationwide Cross-Sectional Study

Although human monkeypox infections had not been recorded in the Kurdistan region of Iraq as of August 2023, the rapid growth of cases worldwide and the detection of monkeypox in neighboring Middle Eastern nations call for careful planning and timely response measures. Educating and empowering frontline healthcare workers (HCWs) so that they can act to curb the spread of monkeypox infections are core elements of primary prevention and protecting public health. Therefore, this study aimed to assess HCWs' knowledge and attitudes about monkeypox and their willingness to vaccinate against monkeypox. By employing a convenience sampling method, an online survey was disseminated via Google Forms between 1 November 2022 and 15 January 2023. The researchers utilized regression analyses to ascertain the factors associated with the three parameters: knowledge, attitude, and the willingness to vaccinate. A total of 637 HCWs were included in the analysis (ages ranged between 21 and 51 years). The mean overall scores were 8.18 of a max score of 16 (SD 3.37), 3.4 of 5 (SD 1.37), and 2.41 of 5 (SD 1.25) for knowledge, attitude, and willingness to vaccinate, respectively. A multivariate logistic regression analysis demonstrated that HCWs who had heard about monkeypox before 2022 rather than later had a higher level of knowledge (AOR: 4.85; 95% CI: 2.81-8.36; p < 0.001). In addition, those who had newly joined the workforce or had less than 1 year experience in practice had more positive attitudes about curbing monkeypox (AOR: 0.35; 95% CI: 0.20-0.59; p < 0.01) than those who practiced for longer. No significant predictors of willingness to vaccinate against monkeypox were identified. The research revealed that HCWs exhibited a relatively low level of monkeypox knowledge. They also had poor attitudes towards monkeypox vaccination and were therefore reluctant to receive the vaccines. Imparting knowledge about the infectious disease can cultivate better awareness and attitudes among HCWs as to their roles in mitigating the spread of an epidemic in the foreseeable future.

Characteristics of women diagnosed with mpox infection compared to men: A case series from Brazil

BACKGROUND

Cisgender men were mostly affected during the 2022 mpox multinational outbreak, with few cases reported in women. This study compares the characteristics of individuals diagnosed with mpox infection according to gender in Rio de Janeiro.

METHODS

We obtained surveillance data of mpox cases notified to Rio de Janeiro State Health Department (June 12 to December 15, 2022). We compared women (cisgender or transgender) to men (cisgender or transgender) using chi-squared, Fisher's exact, and Mood's median tests.

RESULTS

A total of 1306 mpox cases were reported; 1188 (91.0%) men (99.8% cisgender, 0.2% transgender), 108 (8.3%) women (87.0% cisgender, 13.0% transgender), and 10 (0.8%) non-binary persons. Compared to men, women were more frequently older (40+years: 34.3% vs. 25.1%; p < 0.001), reported more frequent non-sexual contact with a potential mpox case (21.4% vs. 9.8%; p = 0.004), fewer sexual partnerships (10.9 vs. 54.8%; p < 0.001), less sexual contact with a potential mpox case (18.5% vs. 43.0%; p < 0.001), fewer genital lesions (31.8% vs. 57.9%; p < 0.001), fewer systemic mpox signs/symptoms (38.0% vs. 50.1%; p = 0.015) and had a lower HIV prevalence (8.3% vs. 46.3%; p < 0.001), with all cases among transgender women. Eight women were hospitalized; no deaths occurred. The highest number of cases among women were notified in epidemiological week 34, when the number of cases among men started to decrease.

CONCLUSIONS

Women diagnosed with mpox presented differences in epidemiological, behavioral, and clinical characteristics compared to men. Health services should provide a comprehensive assessment that accounts for gender diversity.

Mpox stigma among men who have sex with men in the Netherlands: Underlying beliefs and comparisons across other commonly stigmatized infections

People with or at risk for mpox are likely to be stigmatized because of analogies to other sexually transmitted infections. Stigma is driven by beliefs about the perceived severity of the condition and perceived responsibility for acquiring the condition, both in broader society and individual responsibility. We explored these beliefs and compared them across mpox, human immunodeficiency virus (HIV), syphilis, gonorrhoea, and chlamydia in an online survey, conducted in July 2022, with 394 men-who-have-sex-with-men in the Netherlands. We compared mean scores between infections using repeated measures analysis of variance and conducted hierarchical regression analyses to identify determinants of both mpox perceived responsibility endpoints. Results showed that participants expected that mpox would be seen as a "gay disease" and will be used to blame gay men. Compared to other infections, mpox was considered less severe than HIV, but more severe than syphilis, gonorrhoea, and chlamydia. Perceived responsibility was comparable across infections, but, for each infection, participants perceived attributed responsibility to be higher in society than individual responsibility. Both perceived responsibility endpoints were highly correlated with each other and with other stigma beliefs. These results provide insight on the underlying determinants of mpox stigma and demonstrate that anticipated mpox stigma is present in the Netherlands.

Evaluation of Mpox Knowledge, Stigma, and Willingness to Vaccinate for Mpox: Cross-Sectional Web-Based Survey Among Sexual and Gender Minorities

BACKGROUND

The 2022 multicountry mpox outbreak positioned the condition as a public health emergency of international concern. By May 2023, Brazil ranked second globally in the cumulative number of mpox cases and deaths. The higher incidence of mpox among gay and other men who have sex with men in the current mpox outbreak deepens the stigma and discrimination against sexual and gender minorities (SGM). This might worsen the structural barriers impacting access to health services, which ultimately leads to undertesting and underreporting of cases. There are no data available on mpox knowledge and stigma in Latin America.

OBJECTIVE

We aimed to evaluate mpox knowledge, stigma, and willingness to vaccinate for mpox among SGM, and to describe sociodemographic and behavioral characteristics according to self-reported mpox diagnosis.

METHODS

A cross-sectional, internet-based survey was conducted in a convenience sample of adults (aged >18 years) living in Brazil recruited through advertisements on dating apps, social media, referral institutions for infectious diseases websites, and mass media (October-November 2022). We compared participants' characteristics according to self-reported mpox diagnosis using chi-square test or Fisher exact test for qualitative variables and Kruskal-Wallis test for quantitative variables.

RESULTS

We enrolled 6236 participants: 5685 (91.2%) were cisgender men; 6032 (96.7%) were gay, bisexual, or pansexual; 3877 (62.2%) were White; 4902 (78.7%) had tertiary education; and 4070 (65.2%) reported low or middle income. Most participants (n=5258, 84.4%) agreed or strongly agreed that "LGBTQIA+ individuals are being discriminated and stigmatized due to mpox." Mpox awareness was 96.9% (n=6044), and 5008 (95.1%) were willing to get vaccinated for mpox. Overall, 324 (5.2%) reported an mpox diagnosis. Among these, 318 (98.1%) reported lesions, 178 (56%) local pain, and 316 (99.4%) sought health care. Among participants not reporting a diagnosis, 288 (4.9%) had a suspicious lesion, but only 158 (54.9%) of these had sought health care. Compared to participants with no diagnosis, those reporting an mpox diagnosis were younger (P<.001), reported more sex partners (P<.001), and changes in sexual behavior after mpox onset (P=.002). Moreover, participants diagnosed with mpox reported more frequently being tested for HIV in the prior 3 months (P<.001), living with HIV (P<.001), currently using HIV pre-exposure prophylaxis (P<.001), and previous sexually transmitted infection diagnosis (P<.001).

CONCLUSIONS

Our results point to high mpox knowledge and willingness to vaccinate among SGM in Brazil. Participants self-reporting mpox diagnosis more frequently reported to be living with HIV, STI diagnosis, and current pre-exposure prophylaxis use, highlighting the importance of an mpox assessment that includes comprehensive sexual health screenings. Efforts to decrease stigma related to mpox among SGM are necessary to avoid mpox underdiagnosis.

A Twitter dataset for Monkeypox, May 2022

After struggling with COVID-19 pandemic for two years, the world is finally recovering from this crisis. Nonetheless, another virus, Monkeypox, is quickly spreading throughout the world and in non-endemic regions and continents, threatening the world to a new pandemic. Twitter as a popular social media has successfully been used for predicting and controlling outbreaks. Much research previously has been done for building early warning systems, trend prediction, and misinformation and fake news detection. Since tweets are not accessible to all researchers, in this work, a publicly available dataset containing 2400202 tweets gathered from May first to December twenty-fifth, 2022 is presented. Twitter developers academic researcher API which returns all the tweets matching a given query was used to gather the dataset. To this end, the full archive search and keywords related to Monkeypox and its equivalents in other languages, i.e. Monkeypox or "monkey pox" or "viruela dei mono" or "variole du singe" or "variola do macoco" were used. The retweets were excluded using the negation operator, and the tweet ids and user ids were extracted and shared with public. Approximately, 1.79 percent (43047 number) of tweets were geotagged. To visualize the geotagged tweets, the longitude and latitude of the bounding box coordinates were averaged. This work will help researchers shed light on the news, patterns, and on-going discussions of Monkeypox on social media, identify hotspots, and help contain the Monkeypox virus.

Preventing and fighting stigma: a lesson from the first Mpox in Veneto region of Northeast Italy-A case report

Since the 1970s, human monkeypox (Mpox) has been referred to as a zoonotic endemic disease of specific regions of Africa until early 2022, when a worldwide epidemic outbreak developed. There are many hypotheses on how Mpox could spread to non-endemic regions; the dominant theory is that it spread from the UK and Spain among men who have sex with men (MSM). Therefore, the first clinical case in the Veneto region (Northeast of Italy) was analyzed-which represented a typical case report of the ongoing outbreak-with lesions located mainly in the areas associated with sexual behaviors (genital and oral). This case report highlights the new challenges of Mpox, as it seems to differ from the previous classic manifestation. Indeed, although the patient achieved restitution ad integrum of lesions and complete recovery from the disease, it is deemed necessary to offer communication strategies to involve a heterogeneous audience based on different risks of exposure but without stigmatizing attitudes, avoiding the mistakes made with HIV. The need for broad public involvement is demonstrated by identifying Mpox even in "anomalous cases." Stigma could be an obstacle in engaging patients in proper care and in getting honest answers while contact tracing, as happened in our patient's case; thus, WHO recently renamed monkeypox as Mpox. Abnormal outbreaks in non-endemic countries, with no causal links, must become a warning signal for governments and health policies to design national plans for managing unexpected outbreaks. For an effective public health response, health institutions must communicate effectively, focus on changes and prevention measures, and formulate a plan based on equity and inclusion of the most vulnerable groups.

COVID-19 infection and vaccination uptake in men and gender-diverse people who have sex with men in the UK: analyses of a large, online community cross-sectional survey (RiiSH-COVID) undertaken November-December 2021

BACKGROUND

Men and gender-diverse people who have sex with men are disproportionately affected by health conditions associated with increased risk of severe illness due to COVID-19 infection.

METHODS

An online cross-sectional survey of men and gender-diverse people who have sex with men in the UK recruited via social networking and dating applications from 22 November-12 December 2021. Eligible participants included self-identifying men, transgender women, or gender-diverse individuals assigned male at birth (AMAB), aged ≥ 16, who were UK residents, and self-reported having had sex with an individual AMAB in the last year. We calculated self-reported COVID-19 test-positivity, proportion reporting long COVID, and COVID-19 vaccination uptake anytime from pandemic start to survey completion (November/December 2021). Logistic regression was used to assess sociodemographic, clinical, and behavioural characteristics associated with SARS-CoV-2 (COVID-19) test positivity and complete vaccination (≥ 2 vaccine doses).

RESULTS

Among 1,039 participants (88.1% white, median age 41 years [interquartile range: 31-51]), 18.6% (95% CI: 16.3%-21.1%) reported COVID-19 test positivity, 8.3% (95% CI: 6.7%-10.1%) long COVID, and 94.5% (95% CI: 93.3%-96.1%) complete COVID-19 vaccination through late 2021. In multivariable models, COVID-19 test positivity was associated with UK country of residence (aOR: 2.22 [95% CI: 1.26-3.92], England vs outside England) and employment (aOR: 1.55 [95% CI: 1.01-2.38], current employment vs not employed). Complete COVID-19 vaccination was associated with age (aOR: 1.04 [95% CI: 1.01-1.06], per increasing year), gender (aOR: 0.26 [95% CI: 0.09-0.72], gender minority vs cisgender), education (aOR: 2.11 [95% CI: 1.12-3.98], degree-level or higher vs below degree-level), employment (aOR: 2.07 [95% CI: 1.08-3.94], current employment vs not employed), relationship status (aOR: 0.50 [95% CI: 0.25-1.00], single vs in a relationship), COVID-19 infection history (aOR: 0.47 [95% CI: 0.25-0.88], test positivity or self-perceived infection vs no history), known HPV vaccination (aOR: 3.32 [95% CI: 1.43-7.75]), and low self-worth (aOR: 0.29 [95% CI: 0.15-0.54]).

CONCLUSIONS

In this community sample, COVID-19 vaccine uptake was high overall, though lower among younger age-groups, gender minorities, and those with poorer well-being. Efforts are needed to limit COVID-19 related exacerbation of health inequalities in groups who already experience a greater burden of poor health relative to other men who have sex with men.

Risk profile and mode of transmission of Mpox: A rapid review and individual patient data meta-analysis of case studies

Since May 2022, an outbreak of Mpox in non-endemic countries has become a potential public health threat. The objective of this rapid review was to examine the risk profile and modes of transmission of Mpox. PubMed, Web of Science, and Scopus were searched from inception through July 30 to collect case reports/series on patients with Mpox infection. For meta-analysis, data on the total number of participants and deaths by binary categories of exposure (age, sex, country, other co-infections or existing conditions, and mode of contagion) were used. A total of 62 studies (4659 cases) were included. Most cases came from Africa (84.3%), followed by Europe (13.9%). In 63.6% of the cases, the mode of contagion was human contact, while 22.8% of the cases were by animal contact, and 13.5% were unknown or not reported. The mortality rate was 6.5% throughout these studies. The risk of mortality was higher in the younger age group (risk difference: 0.19; 95% CI: 0.02-0.36), in cases with other co-infections or current chronic conditions (risk difference: 0.03; 95% CI: 0.01-0.05) and in the category of low- and middle-income countries (risk difference: 0.06; 95% CI: 0.05-0.08). There were no significant differences with respect to sex or mode of contagion. These results help to understand the major infection pathways and mortality risk profiles of Mpox and underscores the importance of preventing outbreaks in specific settings, especially in settings densely populated by children, such as day care centres and schools.

Rural-urban differences in monkeypox behaviors and attitudes among men who have sex with men in the United States

PURPOSE

An outbreak of the monkeypox virus has been documented in the United States with most cases occurring among gay, bisexual, and other men who have sex with men (MSM). As monkeypox cases increase among relatively rural states, current public health messaging may not resonate with rural at-risk populations. Given this, there is a need to assess potential rural-urban differences in monkeypox behaviors and attitudes among MSM.

METHODS

A total of 582 eligible MSM completed an online cross-sectional survey between August 6 and 15, 2022. Participants answered questions about their demographics, sexual behaviors, monkeypox testing and vaccination behaviors, monkeypox media consumption and attitudes, and their intention and attitudes found in the Health Belief Model of getting the monkeypox vaccine. Rural-urban differences in behaviors and attitudes were assessed with a chi-square test of independence. Differences in intention to get vaccinated and Health Belief Model factors were assessed with a Mann-Whitney U test.

FINDINGS

Rural MSM, in comparison to their urban counterparts, were found to be less likely to report modifying their behaviors to decrease monkeypox exposure, being susceptible to monkeypox, or perceiving severe consequences acquiring monkeypox. Similarly, rural MSM had a lower intention to get vaccinated for monkeypox.

CONCLUSIONS

As vaccination uptake among rural populations for vaccine-preventable diseases remains suboptimal, results from this novel study can inform the development of monkeypox prevention, testing, and vaccination messaging campaigns geared toward rural MSM and other at-risk populations. It will be important to ensure that monkeypox prevention, testing, and vaccination interventions are available and accessible in rural areas.

Neuropsychiatric manifestations of monkeypox: A clinically oriented comprehensive review

Monkeypox (MPX) has emerged as a threatening outbreak in recent months. The understanding of disease pathogenesis and its systemic involvement has evolved with time. Both the virus and its vaccine, like other members of the Orthopoxvirus family, were always expected to have neuropsychiatric consequences. Several neurological complications have been reported with MPX and its vaccines that include but not limited to headaches, myalgia, encephalitis, and coma. Psychiatric complications like anxiety and depression have also been reported; however, we lack evidence to present a direct causality. We conducted a literature review to compile recent evidence on neuropsychiatric manifestations and underline the importance of evolving aspects and complications of MPX. We advocate for better reporting of cases and adverse events, to enhance our understanding of the disease, aiding physicians to make more informed decisions, thus facilitating timely diagnosis and treatment.

An Exploratory Study of the Mpox Media Consumption, Attitudes, and Preferences of Sexual and Gender Minority People Assigned Male at Birth in the United States

Purpose: This study examined the consumption of, attitudes toward, and preferences for mpox media among U.S. sexual and gender minority (SGM) people assigned male at birth (AMAB). Methods: A total of 496 SGM people AMAB completed an online cross-sectional survey between August 6 and 15, 2022. Data were analyzed with descriptive statistics and logistic regressions. Results: Approximately two-thirds of participants overall agreed that media-related content about mpox targeted (66.3%) and stigmatized gay, bisexual, and other men who have sex with men (69.2%). The three most preferred mpox content were the destigmatization of SGM people (44.2%), mpox vaccine accessibility (25.2%), and mpox transmission and prevention (19.2%). Rural participants had a lower likelihood of consuming mpox-related media than urban participants. Conclusion: SGM people AMAB prefer mpox messaging campaigns to be grounded in stigma-reduction to ensure that messages do not perpetrate stigma against them. Stigmatizing content might foster SGM people AMAB to distrust mpox interventions.

Monkeypox (mpox) Outbreak: More queries posed as cases soar globally

NONE

Is monkeypox a new, emerging sexually transmitted disease? A rapid review of the literature

Monkeypox, a milder disease compared to smallpox, is caused by a virus initially discovered and described in 1958 by the prominent Danish virologist von Magnus, who was investigating an infectious outbreak affecting monkey colonies. Currently, officially starting from May 2022, an outbreak of monkeypox is ongoing, with 51 000 cases being notified as of September 1, 2022-51 408 confirmed, 28 suspected, and 12 fatalities, for a grand total of 51 448 cases. More than 100 countries and territories are affected, from all the six World Health Organization regions. There are some striking features, that make this outbreak rather unusual when compared with previous outbreaks, including a shift on average age and the most affected age group, affected sex/gender, risk factors, clinical course, presentation, and the transmission route. Initially predominantly zoonotic, with an animal-to-human transmission, throughout the last decades, human-to-human transmission has become more and more sustained and effective. In particular, clusters of monkeypox have been described among men having sex with men, some of which have been epidemiologically linked to international travel to nonendemic countries and participation in mass gathering events/festivals, like the "Maspalomas (Gran Canaria) 2022 pride." This review will specifically focus on the "emerging" transmission route of the monkeypox virus, that is to say, the sexual transmission route, which, although not confirmed yet, seems highly likely in the diffusion of the infectious agent.

Epidemiological trends and clinical features of the ongoing monkeypox epidemic: A preliminary pooled data analysis and literature review

An emerging outbreak of monkeypox infection is quickly spreading worldwide, being currently reported in more than 30 countries, with slightly less than 1000 cases. In the present preliminary report, we collected and synthesized early data concerning epidemiological trends and clinical features of the ongoing outbreak and we compared them with those of previous outbreaks. Data were pooled from six clusters in Italy, Australia, the Czech Republic, Portugal, and the United Kingdom, totaling 124 cases (for 35 of which it was possible to retrieve detailed information). The ongoing epidemic differs from previous outbreaks in terms of age (54.29% of individuals in their thirties), sex/gender (most cases being males), risk factors, and transmission route, with sexual transmission being highly likely. Also, the clinical presentation is atypical and unusual, being characterized by anogenital lesions and rashes that relatively spare the face and extremities. The most prevalent sign/symptom reported was fever (in 54.29% of cases) followed by inguinal lymphadenopathy (45.71%) and exanthema (40.00%). Asthenia, fatigue, and headache were described in 22.86% and 25.71% of the subjects, respectively. Myalgia was present in 17.14% of the cases. Both genital and anal lesions (ulcers and vesicles) were reported in 31.43% of the cases. Finally, cervical lymphadenopathy was described in 11.43% of the sample, while the least commonly reported symptoms were diarrhea and axillary lymphadenopathy (5.71% of the case series for both symptoms). Some preliminary risk factors can be identified (being a young male, having sex with other men, engaging in risky behaviors and activities, including condomless sex, human immunodeficiency virus positivity (54.29% of the sample analyzed), and a story of previous sexually transmitted infections, including syphilis). On the other hand, being fully virally suppressed and undetectable may protect against a more severe infectious course. However, further research in the field is urgently needed.

Monkeypox Virus and Ophthalmology-A Primer on the 2022 Monkeypox Outbreak and Monkeypox-Related Ophthalmic Disease

Importance

An ongoing global monkeypox virus outbreak in 2022 includes the US and other nonendemic countries. Monkeypox ophthalmic manifestations may present to the ophthalmologist, or the ophthalmologist may be involved in comanagement. This narrative review creates a primer for the ophthalmologist of clinically relevant information regarding monkeypox, its ophthalmic manifestations, and the 2022 outbreak.

Observations

Monkeypox virus is an Orthopoxvirus (genus includes variola [smallpox] and vaccinia [smallpox vaccine]). The 2022 outbreak is of clade II (historically named West African clade), specifically subclade IIb. In addition to historic transmission patterns (skin lesions, bodily fluids, respiratory droplets), sexual transmission has also been theorized in the current outbreak due to disproportionate occurrence in men who have sex with men. Monkeypox causes a characteristic skin eruption and mucosal lesions and may cause ophthalmic disease. Monkeypox-related ophthalmic disease (MPXROD) includes a spectrum of ocular pathologies including eyelid/periorbital skin lesions, blepharoconjunctivitis, and keratitis). Smallpox vaccination may reduce MPXROD occurrence. MPXROD seems to be rarer in the 2022 outbreaks than in historical outbreaks. MPXROD may result in corneal scarring and blindness. Historical management strategies for MPXROD include lubrication and prevention/management of bacterial superinfection in monkeypox keratitis. Case reports and in vitro data for trifluridine suggest a possible role in MPXROD. Tecovirimat, cidofovoir, brincidofovir and vaccinia immune globulin intravenous may be used for systemic infection. There is a theoretical risk for monkeypox transmission by corneal transplantation, and the Eye Bank Association of America has provided guidance. Smallpox vaccines (JYNNEOS [Bavarian Nordic] and ACAM2000 [Emergent Product Development Gaithersburg Inc]) provide immunity against monkeypox.

Conclusions and Relevance

The ophthalmologist may play an important role in the diagnosis and management of monkeypox. MPXROD may be associated with severe ocular and visual morbidity. As the current outbreak evolves, up-to-date guidance from public health organizations and professional societies are critical.

Monkeypox Virus Infections in Humans

Human monkeypox is a viral zoonosis endemic to West and Central Africa that has recently generated increased interest and concern on a global scale as an emerging infectious disease threat in the midst of the slowly relenting COVID-2019 disease pandemic. The hallmark of infection is the development of a flu-like prodrome followed by the appearance of a smallpox-like exanthem. Precipitous person-to-person transmission of the virus among residents of 100 countries where it is nonendemic has motivated the immediate and widespread implementation of public health countermeasures. In this review, we discuss the origins and virology of monkeypox virus, its link with smallpox eradication, its record of causing outbreaks of human disease in regions where it is endemic in wildlife, its association with outbreaks in areas where it is nonendemic, the clinical manifestations of disease, laboratory diagnostic methods, case management, public health interventions, and future directions.

Mpox panic, infodemic, and stigmatization of the 2SLGBTQIAP+ community: geospatial analysis, topic modeling, and sentiment analysis of a large, multilingual social media database (Preprint)

BACKGROUND

The global Mpox (formerly, Monkeypox) outbreak is disproportionately affecting the gay and bisexual men having sex with men community.

OBJECTIVE

The aim of this study is to use social media to study country-level variations in topics and sentiments toward Mpox and Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, Intersex, Asexual (2SLGBTQIAP+)-related topics. Previous infectious outbreaks have shown that stigma intensifies an outbreak. This work helps health officials control fear and stop discrimination.

METHODS

In total, 125,424 Twitter and Facebook posts related to Mpox and the 2SLGBTQIAP+ community were extracted from May 1 to December 25, 2022, using Twitter application programming interface academic accounts and Facebook-scraper tools. The tweets' main topics were discovered using Latent Dirichlet Allocation in the sklearn library. The pysentimiento package was used to find the sentiments of English and Spanish posts, and the CamemBERT package was used to recognize the sentiments of French posts. The tweets' and Facebook posts' languages were understood using the Twitter application programming interface platform and pycld3 library, respectively. Using ArcGis Online, the hot spots of the geotagged tweets were identified. Mann-Whitney U, ANOVA, and Dunn tests were used to compare the sentiment polarity of different topics and countries.

RESULTS

The number of Mpox posts and the number of posts with Mpox and 2SLGBTQIAP+ keywords were 85% correlated (P<.001). Interestingly, the number of posts with Mpox and 2SLGBTQIAP+ keywords had a higher correlation with the number of Mpox cases (correlation=0.36, P<.001) than the number of posts on Mpox (correlation=0.24, P<.001). Of the 10 topics, 8 were aimed at stigmatizing the 2SLGBTQIAP+ community, 3 of which had a significantly lower sentiment score than other topics (ANOVA P<.001). The Mann-Whitney U test shows that negative sentiments have a lower intensity than neutral and positive sentiments (P<.001) and neutral sentiments have a lower intensity than positive sentiments (P<.001). In addition, English sentiments have a higher negative and lower neutral and positive intensities than Spanish and French sentiments (P<.001), and Spanish sentiments have a higher negative and lower positive intensities than French sentiments (P<.001). The hot spots of the tweets with Mpox and 2SLGBTQIAP+ keywords were recognized as the United States, the United Kingdom, Canada, Spain, Portugal, India, Ireland, and Italy. Canada was identified as having more tweets with negative polarity and a lower sentiment score (P<.04).

CONCLUSIONS

The 2SLGBTQIAP+ community is being widely stigmatized for spreading the Mpox virus on social media. This turns the community into a highly vulnerable population, widens the disparities, increases discrimination, and accelerates the spread of the virus. By identifying the hot spots and key topics of the related tweets, this work helps decision makers and health officials inform more targeted policies.

Attitudes towards Monkeypox vaccination and predictors of vaccination intentions among the US general public

Amidst an unprecedented Monkeypox outbreak, we aimed to measure knowledge, attitudes, practices and Monkeypox vaccination intentions among the U.S. adult population. We conducted an online cross-sectional survey, representative of the U.S. adult general public in June 2022. We asked participants whether they would receive a Monkeypox vaccine, if they were recommended to do so. Participants also answered questions on their self-assessed level of Monkeypox knowledge, risk perception, perceived exaggeration of the threat, and self-efficacy around Monkeypox. Furthermore, we asked about their trusted sources of information, COVID-19 vaccination status and administered the 6-item Vaccine Trust Indicator (VTI). Survey weights were created based on age, gender and race. We analyzed predictors of Monkeypox vaccination intentions using logistic regression, adjusted for education, age, race and ethnicity. A total of 856 respondents completed the survey, of which 51% (n = 436) were female and 41% (n = 348) had a college degree or higher. If recommended, 46% of respondents intended to get vaccinated against Monkeypox, 29% would not get vaccinated and 25% did not know. Almost half the respondents (47%) found their own knowledge level about Monkeypox poor or very poor. The most trusted sources of information about the outbreak were healthcare professionals and officials, but also known doctors and researchers with a large online following. Only 24% indicated that the U.S. Centers for Disease Control and Prevention should be in charge of the outbreak response. Being vaccinated against COVID-19 was a strong predictor of intention to receive a Monkeypox if recommended (adjusted Odds Ratio (aOR) 29.2, 95% Confidence Interval (CI) 13.1-65.3). Increased risk perception was positively associated with vaccination intentions (aOR 2.6, 95% CI 1.8-3.6), scoring high on the VTI as well (5.4, 95% CI (3.2-9.1). The low levels of self-assessed knowledge, vaccination intentions and influence of COVID-19 vaccination status point to a lack of clear communication.

MonkeyPox2022Tweets: A Large-Scale Twitter Dataset on the 2022 Monkeypox Outbreak, Findings from Analysis of Tweets, and Open Research Questions

The mining of Tweets to develop datasets on recent issues, global challenges, pandemics, virus outbreaks, emerging technologies, and trending matters has been of significant interest to the scientific community in the recent past, as such datasets serve as a rich data resource for the investigation of different research questions. Furthermore, the virus outbreaks of the past, such as COVID-19, Ebola, Zika virus, and flu, just to name a few, were associated with various works related to the analysis of the multimodal components of Tweets to infer the different characteristics of conversations on Twitter related to these respective outbreaks. The ongoing outbreak of the monkeypox virus, declared a Global Public Health Emergency (GPHE) by the World Health Organization (WHO), has resulted in a surge of conversations about this outbreak on Twitter, which is resulting in the generation of tremendous amounts of Big Data. There has been no prior work in this field thus far that has focused on mining such conversations to develop a Twitter dataset. Furthermore, no prior work has focused on performing a comprehensive analysis of Tweets about this ongoing outbreak. To address these challenges, this work makes three scientific contributions to this field. First, it presents an open-access dataset of 556,427 Tweets about monkeypox that have been posted on Twitter since the first detected case of this outbreak. A comparative study is also presented that compares this dataset with 36 prior works in this field that focused on the development of Twitter datasets to further uphold the novelty, relevance, and usefulness of this dataset. Second, the paper reports the results of a comprehensive analysis of the Tweets of this dataset. This analysis presents several novel findings; for instance, out of all the 34 languages supported by Twitter, English has been the most used language to post Tweets about monkeypox, about 40,000 Tweets related to monkeypox were posted on the day WHO declared monkeypox as a GPHE, a total of 5470 distinct hashtags have been used on Twitter about this outbreak out of which #monkeypox is the most used hashtag, and Twitter for iPhone has been the leading source of Tweets about the outbreak. The sentiment analysis of the Tweets was also performed, and the results show that despite a lot of discussions, debate, opinions, information, and misinformation, on Twitter on various topics in this regard, such as monkeypox and the LGBTQI+ community, monkeypox and COVID-19, vaccines for monkeypox, etc., "neutral" sentiment was present in most of the Tweets. It was followed by "negative" and "positive" sentiments, respectively. Finally, to support research and development in this field, the paper presents a list of 50 open research questions related to the outbreak in the areas of Big Data, Data Mining, Natural Language Processing, and Machine Learning that may be investigated based on this dataset.

Clinical, dermoscopic and histopathological findings in localized human monkeypox: a case from northern Italy

Collapse

Monkeypox Disease: An Emerging Public Health Concern in the Shadow of COVID-19 Pandemic: An Update

The last few decades have witnessed an appalling rise in several emerging and re-emerging viral and zoonotic outbreaks. Such outbreaks are a lesson to learn from and seek insight into better disease monitoring and surveillance, thus preventing future outbreaks. Monkeypox, a viral zoonotic illness caused by the monkeypox virus, may no longer be endemic to the tropical rainforests of Central and West Africa. However, the current monkeypox outbreak in nonendemic countries is most likely due to failure to curb the disease dissemination in endemic African regions despite decades of constant outbreaks. The clinical manifestations are typified by a prodromal phase (fever, myalgia, malaise, and lymphadenopathy) followed by maculopapular or vesicular, or pustular cutaneous eruptions that eventually form encrustations and peel off. Children and the elderly, pregnant females, and individuals living with comorbidities (diabetes, HIV/AIDS, and lymphoproliferative ailments) are at a high risk of severe disease. Monkeypox is a self-limiting disorder, but its complications and pandemic potential signify its immense public health relevance. The recent ongoing monkeypox outbreak in nonendemic nations areas was identified with increased propensity in men who have sex with men (MSMs) with no travel history to endemic regions, emphasizing the changing trends in disease transmission. This review article provides an updated overview of the monkeypox disease taxonomy, pathogenesis, transmission, epidemiology, clinical and oral features, diagnostic aids, differential diagnosis, preventive aspects, and treatment protocol.

Knowing the unknown: The underestimation of monkeypox cases. Insights and implications from an integrative review of the literature

Monkeypox is an emerging zoonotic disease caused by the monkeypox virus, which is an infectious agent belonging to the genus Orthopoxvirus. Currently, commencing from the end of April 2022, an outbreak of monkeypox is ongoing, with more than 43,000 cases reported as of 23 August 2022, involving 99 countries and territories across all the six World Health Organization (WHO) regions. On 23 July 2022, the Director-General of the WHO declared monkeypox a global public health emergency of international concern (PHEIC), since the outbreak represents an extraordinary, unusual, and unexpected event that poses a significant risk for international spread, requiring an immediate, coordinated international response. However, the real magnitude of the burden of disease could be masked by failures in ascertainment and under-detection. As such, underestimation affects the efficiency and reliability of surveillance and notification systems and compromises the possibility of making informed and evidence-based policy decisions in terms of the adoption and implementation of ad hoc adequate preventive measures. In this review, synthesizing 53 papers, we summarize the determinants of the underestimation of sexually transmitted diseases, in general, and, in particular, monkeypox, in terms of all their various components and dimensions (under-ascertainment, underreporting, under-detection, under-diagnosis, misdiagnosis/misclassification, and under-notification).

Assessing Healthcare Workers' Knowledge and Their Confidence in the Diagnosis and Management of Human Monkeypox: A Cross-Sectional Study in a Middle Eastern Country

The ongoing multi-country human monkeypox (HMPX) outbreak was declared as a public health emergency of international concern. Considering the key role of healthcare workers (HCWs) in mitigating the HMPX outbreak, we aimed to assess their level of knowledge and their confidence in diagnosis and management of the disease, besides the assessment of their attitude towards emerging virus infections from a conspiracy point of view. An online survey was distributed among HCWs in Jordan, a Middle Eastern country, during May−July 2022 using a questionnaire published in a previous study among university students in health schools in Jordan. The study sample comprised 606 HCWs, with about two-thirds being either physicians (n = 204, 33.7%) or nurses (n = 190, 31.4%). Four out of the 11 HMPX knowledge items had <50% correct responses with only 33.3% of the study respondents having previous knowledge that vaccination is available to prevent HMPX. A majority of study respondents (n = 356, 58.7%) strongly agreed, agreed or somewhat agreed that the spread of HMPX is related to a role of male homosexuals. Confidence in the ability of diagnosis based on the available monkeypox virus diagnostic tests was reported by 50.2% of the respondents, while the confidence levels were lower for the ability to manage (38.9%) and to diagnose (38.0%) HMPX cases based on their current level of knowledge and skills. Higher confidence levels for HMPX diagnosis and management were found among physicians compared to nurses. The endorsement of conspiracy beliefs about virus emergence was associated with lower HMPX knowledge, the belief in the role of male homosexuals in HMPX spread, and with lower diagnosis and management confidence levels. The current study highlighted the gaps in knowledge regarding HMPX among HCWs in Jordan as well as the lack of confidence to diagnose and manage cases among physicians and nurses. Raising the awareness about the disease is needed urgently considering the rapid escalation in the number of cases worldwide with reported cases in the Middle East. The attitude towards male homosexuals’ role in HMPX spread necessitates proper intervention measures to prevent stigma and discrimination among this risk group. The adoption of conspiratorial beliefs regarding virus emergence was widely prevalent and this issue needs to be addressed with proper and accurate knowledge considering its potential harmful impact.

Monkeypox Knowledge and Confidence in Diagnosis and Management with Evaluation of Emerging Virus Infection Conspiracies among Health Professionals in Kuwait

As the 2022 human monkeypox (HMPX) multi-country outbreak is spreading, the response of healthcare workers (HCWs) is central to mitigation efforts. The current study aimed to evaluate HMPX knowledge and confidence in diagnosis and management among HCWs in Kuwait. We used a self-administered questionnaire distributed in July–August 2022 through a snowball sampling approach. The survey items evaluated HMPX knowledge, confidence in diagnosis and management of the disease, and the belief in conspiracies regarding emerging virus infections (EVIs). The sample size was 896 HCWs: nurses (n = 485, 54.1%), pharmacists (n = 154, 17.2%), physicians (n = 108, 12.1%), medical technicians/allied health professionals (MT/AHP, n = 96, 10.7%), and dentists (n = 53, 5.9%). An overall low level of HMPX knowledge was noticed for items assessing virus transmission and non-cutaneous symptoms of the disease, with higher knowledge among physicians. Approximately one-fifth of the study sample agreed with the false notion that HMPX is exclusive to male homosexuals (n = 183, 20.4%), which was associated with lower knowledge with higher frequency among MT/AHP compared to nurses, physicians, and pharmacists. Confidence levels were low: confidence in diagnosis based on diagnostic tests (n = 449, 50.1%), confidence in the ability to manage the HMPX (n = 426, 47.5%), and confidence in the ability to diagnose HMPX clinically (n = 289, 32.3%). Higher confidence levels were found among nurses and participants with postgraduate degrees. Higher embrace of conspiracy beliefs regarding EVIs was noticed among participants with lower knowledge, and among those who agreed or were neutral/had no opinion regarding the false idea of HMPX exclusive occurrence among male homosexuals, while lower levels of belief in conspiracies were noticed among physicians, dentists, and pharmacists compared to MT/AHP. Variable levels of HMPX knowledge were observed in this study per item, with low level of knowledge regarding virus transmission. Differences in knowledge and confidence levels in diagnosis and management of HMPX should be considered in education and training aiming to prepare for outbreak response. The relatively high prevalence of embracing conspiratorial beliefs regarding EVIs is worrisome and needs proper interventions. The attitude towards male homosexuals’ role in monkeypox spread should be evaluated in future studies considering the possibility of stigma and discrimination in this most-at-risk group.

Monkeypox and Its Possible Sexual Transmission: Where Are We Now with Its Evidence?

Monkeypox is a rare disease but is increasing in incidence in different countries since the first case was diagnosed in the UK by the United Kingdom (UK) Health Security Agency on 6 May 2022. As of 9 August, almost 32,000 cases have been identified in 89 countries. In endemic areas, the monkeypox virus (MPXV) is commonly transmitted through zoonosis, while in non-endemic regions, it is spread through human-to-human transmission. Symptoms can include flu-like symptoms, rash, or sores on the hands, feet, genitalia, or anus. In addition, people who did not take the smallpox vaccine were more likely to be infected than others. The exact pathogenesis and mechanisms are still unclear; however, most identified cases are reported in men who have sex with other men (MSM). According to the CDC, transmission can happen with any sexual or non-sexual contact with the infected person. However, a recent pooled meta-analysis reported that sexual contact is involved in more than 91% of cases. Moreover, it is the first time that semen analysis for many patients has shown positive monkeypox virus DNA. Therefore, in this review, we will describe transmission methods for MPXV while focusing mainly on potential sexual transmission and associated sexually transmitted infections. We will also highlight the preventive measures that can limit the spread of the diseases in this regard.