Mpox (monkeypox) risk and mortality associated with HIV infection: a national case-control study in Nigeria

Mpox and Lessons Learned in the Light of the Recent Outbreak: A Narrative Review

According to the WHO, more than 90,000 cases of mpox have been reported since the 2022 worldwide outbreak, which resulted in 167 deaths, while a new outbreak in Africa since 2023 has resulted in over 18,000 cases and 617 deaths. Mpox is a zoonosis caused by the monkeypox virus, a double-stranded DNA virus belonging to the Orthopoxvirus genus, which causes smallpox-like illness. Until 2022, cases were predominately located in West and Central Africa, with only sporadic cases and outbreaks reported in other parts of the world. During the 2022 outbreak, the primary mode of transmission was sexual contact among men who have sex with men. The changing epidemiology of mpox resulted in new disease phenotypes and populations at risk, disproportionally affecting people who live with HIV. Commonly presenting as a mild, self-limiting illness, mpox can cause severe and protracted disease in people with HIV with a CD4 count < 200 cell/mm3. The global emergence of mpox that followed and intersected with COVID-19 mobilized the scientific community and healthcare stakeholders to provide accurate diagnostics, preventive vaccines and treatment to those most affected. Despite existing gaps, this rapid response helped to contain the outbreak, but challenges remain as new variants emerge. Preparedness and readiness to respond to the next outbreak is crucial in order to minimize the impact to the most vulnerable.

An evaluation of the preprints produced at the beginning of the 2022 mpox public health emergency

BACKGROUND

Preprints are scientific articles that have not undergone the peer-review process. They allow the latest evidence to be rapidly shared, however it is unclear whether they can be confidently used for decision-making during a public health emergency. This study aimed to compare the data and quality of preprints released during the first four months of the 2022 mpox outbreak to their published versions.

METHODS

Eligible preprints (n = 76) posted between May to August 2022 were identified through an established mpox literature database and followed to July 2024 for changes in publication status. Quality of preprints and published studies was assessed by two independent reviewers to evaluate changes in quality, using validated tools that were available for the study design (n = 33). Tools included the Newcastle-Ottawa Scale; Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2); and JBI Critical Appraisal Checklists. The questions in each tool led to an overall quality assessment of high quality (no concerns with study design, conduct, and/or analysis), moderate quality (minor concerns) or low quality (several concerns). Changes in data (e.g. methods, outcomes, results) for preprint-published pairs (n = 60) were assessed by one reviewer and verified by a second.

RESULTS

Preprints and published versions that could be evaluated for quality (n = 25 pairs) were mostly assessed as low quality. Minimal to no change in quality from preprint to published was identified: all observational studies (10/10), most case series (6/7) and all surveillance data analyses (3/3) had no change in overall quality, while some diagnostic test accuracy studies (3/5) improved or worsened their quality assessment scores. Among all pairs (n = 60), outcomes were often added in the published version (58%) and less commonly removed (18%). Numerical results changed from preprint to published in 53% of studies, however most of these studies (22/32) had changes that were minor and did not impact main conclusions of the study.

CONCLUSIONS

This study suggests the minimal changes in quality, results and main conclusions from preprint to published versions supports the use of preprints, and the use of the same critical evaluation tools on preprints as applied to published studies, in decision-making during a public health emergency.

Socio-Demographic Factors Influencing Monkeypox Vaccination Intentions Among Healthcare Workers and the General Population of Makurdi, Nigeria: A Cross-Sectional Study

Background Monkeypox, now known as mpox, is a viral zoonotic disease caused by the monkeypox virus (MPXV) and is endemic to parts of Central and West Africa. Historically considered a regional health issue, mpox has gained global attention due to recent outbreaks in non-endemic regions. In 2022, the World Health Organization (WHO) declared mpox a Public Health Emergency of International Concern (PHEIC) following widespread transmission in countries where the virus had not been previously reported. This declaration was renewed in August 2024 after a surge in cases, particularly across Africa, including the Democratic Republic of Congo (DRC) and neighboring countries, where a more transmissible strain (Clade 1b) has rapidly spread, complicating efforts to control its transmission. Objective This study evaluated the socio-demographic factors that influenced monkeypox vaccination intentions among healthcare workers and the general population in Benue State, Nigeria. The findings provide insights into key determinants of vaccine hesitancy and acceptance, aimed at informing future public health interventions to improve vaccine uptake. Methodology This cross-sectional study, conducted from July to September 2024 in Makurdi, Benue State, Nigeria, evaluated socio-demographic factors influencing monkeypox vaccination intentions among healthcare workers (HCWs) and high-risk populations. The study, prompted by the WHO's declaration of monkeypox as a PHEIC, surveyed 377+ participants including HCWs, people living with HIV, and men who have sex with men. Results Key findings revealed significant differences in vaccination intentions based on marital status (p-value = 0.02), with no significant variations by gender or age. COVID-19 vaccination status was associated with monkeypox vaccination intentions. The 30-60 age group demonstrated the highest monkeypox awareness (75.2%). Healthcare workers showed high vaccination intent (83%) and were identified as the most reliable information source (p-value = 0.03). Higher education levels correlated with greater vaccine trust (p-value = 0.003), while lower education was linked to reduced awareness and increased stigma perceptions. Conclusion The study recommends enhancing HCW training, addressing socioeconomic barriers to vaccination, implementing targeted education campaigns, and focusing on trust-building strategies. Limitations include the study's urban focus and potential language barriers. In conclusion, socio-demographic factors significantly influence monkeypox vaccination intentions, underscoring the need for targeted interventions and improved vaccine access to mitigate the impact of monkeypox in Nigeria and affected regions.

Mpox Epidemiology and Risk Factors, Nigeria, 2022

To investigate epidemiology of and risk factors for laboratory-confirmed mpox during the 2022 outbreak in Nigeria, we enrolled 265 persons with suspected mpox. A total of 163 (61.5%) were confirmed to have mpox; 137 (84.0%) were adults, 112 (68.7%) male, 143 (87.7%) urban/semi-urban dwellers, 12 (7.4%) self-reported gay men, and 3 (1.8%) female sex workers. Significant risk factors for adults were sexual and nonsexual contact with persons who had mpox, as well as risky sexual behavior. For children, risk factors were close contact with an mpox-positive person and prior animal exposure. Odds of being mpox positive were higher for adults with HIV and lower for those co-infected with varicella zoster virus (VZV). No children were HIV-seropositive; odds of being mpox positive were higher for children with VZV infection. Our findings indicate mpox affects primarily adults in Nigeria, partially driven by sexual activity; childhood cases were driven by close contact, animal exposure, and VZV co-infection.

Epidemiological and clinical characteristics of monkeypox among people with and without HIV in Peru: a national observational study

BACKGROUND

In Latin America, Peru has the second highest number of cases of monkeypox (Mpox), of which more than 50 % are Human Immunodeficiency Virus (HIV)-positive. Here, we compared the epidemiological and clinical characteristics of Mpox between people with and without HIV in Peru.

METHODS

We conducted a national retrospective study using data on confirmed cases of Mpox reported by the Peruvian National Surveillance System from 15 June 2022 to 31 December 2023.

RESULTS

A total of 3561 confirmed cases of Mpox were included. Of these, 2123 (60 %) patients were people living with HIV (PLWH), with increased odds for those aged 30 years or older, homosexual (adjusted odds ratio [aOR] 8.58 [6.95-10.59], p<0.0001), bisexual (aOR=4.44 [3.46-5.69], p<0.0001), sex workers (aOR=2.24 [1.07-4.68], p=0.032), people with a history of syphilis (aOR=2.07 [1.66-2.58], p<0.001), and hospitalized (aOR=3.08 [2.03-4.68], p<0.001). PLWH were more likely to have proctitis (aOR=1.73 [1.26-2.37], p=0.001). The overall mortality was 20 of 3561 (0.56 %). Among PLWH and Mpox, more deaths occurred in hospitalized (p<0.001) and non-ART (p<0.001) individuals.

CONCLUSION

Our findings highlight that HIV infection among Mpox cases in Peru is associated with high-risk sexual behaviour and a high likelihood of hospitalization.

Clinical characteristics, viral dynamics, and antibody response of monkeypox virus infections among men with and without HIV infection in Guangzhou, China

Background

Monkeypox virus (MPXV) is spreading globally and nearly half of the infected people were human immunodeficiency virus (HIV) positive. Therefore, an in-depth understanding of the effects of HIV infection on the outcomes of MPXV infection is urgently needed. This study aimed to explore the clinical features, viral dynamics, and antibody response to MPXV infections in men who had sex with men (MSM) with and without HIV co-infection.

Design or methods

MPXV-infected patients diagnosed by PCR were recruited in this study and were divided into MPXV and MPXV + HIV groups based on whether they were co-infected with HIV. Clinical data and samples were collected during of the hospital stay and follow up interviews. The symptoms and signs, laboratory examinations, viral shedding in various body fluids or swabs, antibody dynamics were tracked and compared between the two groups.

Results

A total of 41 MPXV patients were recruited through June 2023 to September 2023 in Guangzhou. The MPXV group and MPXV + HIV group comprised 20 and 21 MSM, respectively. Patients in the two groups exhibited similar clinical characteristics except for pruritus and eschar, both were significantly fewer in MPXV + HIV group than in MPXV only group. Among the 355 clinical samples collected, MPXV DNA was detected in 100% of scabs, 97.4% of skin swabs, and 92.3% of exudate swabs from lesions, while the positive rate was 87.5% from oropharyngeal swabs, 59% from saliva, 51.3% from anal swabs, 50% from feces, 30.6% from urine samples, 37.5% of semen, and 28.2% from sera. Dynamics analysis revealed that viral DNA was undetectable in most patients 20 days after symptom onset. IgM and IgG antibodies to MPXV were detected in all patients with 3-5 days earlier in the MPXV group than in the MPXV + HIV group.

Conclusion

This cohort analysis based on a large outbreak among MSM in Guangzhou indicated no obvious differences in clinical symptoms, viral DNA data, but antibody responses were 3-5 days later in mpox patients with HIV infection.