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Yang X, Yang X, Jiang W, Luo N, Hu Y, Yang Y, Yang X, Hou L, Zhang J, Hu C, Lin J. A cross-sectional investigation of factors influencing mpox vaccine hesitancy for students in Southwest China. Hum Vaccin Immunother 2024; 20:2309704. [PMID: 38300140 PMCID: PMC10841021 DOI: 10.1080/21645515.2024.2309704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/21/2024] [Indexed: 02/02/2024] Open
Abstract
From July to September 2023, China reported over 1, 400 confirmed cases of mpox transmitted mainly through sexual contact between males. Meanwhile, the percentage of men who have sex with men at universities in southwestern China is increasing every year, which is likely to lead to a potential spread of mpox on campuses. Vaccination is an effective preventive measure against infectious diseases, this study examined the willingness of university students in Southwest China to receive the mpox vaccine and analyzed the factors influencing their decision. A cross-sectional survey was conducted among 7311 university students from 10 universities in Southwest China between August 13 and September 1, 2023. The survey revealed a hesitancy rate of 56.13% toward the mpox vaccine, with the most common reason being concerns about vaccine safety (1407/4104, 34.29%). Univariate analysis identified 13 variables that significantly differed between the vaccine acceptance and vaccine hesitancy groups. Multivariate logistic regression analyses indicated protective factors for vaccine hesitancy, such as sexually transmitted diseases, previous knowledge about mpox, frequent information about mpox, people can get reinfection of mpox, and worries about mpox endemic in China. Additionally, the confidence and convenience dimensions in the 3Cs model were identified as risk factors for mpox vaccine hesitancy. This study found a high rate of vaccine hesitancy among university students in Southwest China regarding the mpox vaccine. Collaboration between university and healthcare departments is recommended to address mpox vaccine hesitancy among college students, thereby promoting their willingness to receive the mpox vaccine.
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Affiliation(s)
- Xiu Yang
- Wound Healing Basic Research and Clinical Application Key Laboratory of LuZhou, School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Xuetao Yang
- Wound Healing Basic Research and Clinical Application Key Laboratory of LuZhou, School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Wenyi Jiang
- Wound Healing Basic Research and Clinical Application Key Laboratory of LuZhou, School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Na Luo
- Department of Operation Room, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China
| | - Yibo Hu
- Department of Stomatology, School of Medicine, Nankai University, Tianjin, China
| | - Ya Yang
- Wound Healing Basic Research and Clinical Application Key Laboratory of LuZhou, School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Xidan Yang
- Wound Healing Basic Research and Clinical Application Key Laboratory of LuZhou, School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Lingli Hou
- Wound Healing Basic Research and Clinical Application Key Laboratory of LuZhou, School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Jingjing Zhang
- Wound Healing Basic Research and Clinical Application Key Laboratory of LuZhou, School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Congxia Hu
- Wound Healing Basic Research and Clinical Application Key Laboratory of LuZhou, School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Jihui Lin
- Wound Healing Basic Research and Clinical Application Key Laboratory of LuZhou, School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
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Qiao H, Paansri P, Escobar LE. Global Mpox spread due to increased air travel. GEOSPATIAL HEALTH 2024; 19. [PMID: 38872388 DOI: 10.4081/gh.2024.1261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/04/2024] [Indexed: 06/15/2024]
Abstract
Mpox is an emerging, infectious disease that has caused outbreaks in at least 91 countries from May to August 2022. We assessed the link between international air travel patterns and Mpox transmission risk, and the relationship between the translocation of Mpox and human mobility dynamics after travel restrictions due to the COVID-19 pandemic had been lifted. Our three novel observations were that: i) more people traveled internationally after the removal of travel restrictions in the summer of 2022 compared to pre-pandemic levels; ii) countries with a high concentration of global air travel have the most recorded Mpox cases; and iii) Mpox transmission includes a number of previously nonendemic regions. These results suggest that international airports should be a primary location for monitoring the risk of emerging communicable diseases. Findings highlight the need for global collaboration concerning proactive measures emphasizing realtime surveillance.
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Affiliation(s)
- Huijie Qiao
- Institute of Zoology, Chinese Academy of Sciences, Beijing.
| | - Paanwaris Paansri
- Department of Fish and Wildlife Conservation, Virginia Tech, Blacksburg, VA.
| | - Luis E Escobar
- Department of Fish and Wildlife Conservation, Virginia Tech, Blacksburg, VA, United States; Global Change Center, Virginia Tech, Blacksburg, VA, United States; Center for Emerging Zoonotic and Arthropod-borne Pathogens, Virginia Tech, Blacksburg, VA, United States; Kellogg Center for Philosophy, Politics, and Economics, Virginia Tech, Blacksburg, VA.
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Okoli GN, Van Caeseele P, Askin N, Abou-Setta AM. A global systematic evidence review with meta-analysis of the epidemiological characteristics of the 2022 Mpox outbreaks. Infection 2024; 52:901-921. [PMID: 38051425 DOI: 10.1007/s15010-023-02133-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/31/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND In 2022, there were outbreaks of Mpox where the disease is not endemic. We summarized published full-text epidemiological data from the outbreaks. METHODS A global evidence review (protocol: osf.io/j3kb7) with systematic literature search up to February 09, 2023. We focused on experimental/observational studies of laboratory confirmed Mpox, excluding case reports and case series of < 5 cases. Epidemiological data were pooled using an inverse variance, random-effects model, and pooled estimates presented with associated 95% confidence intervals. RESULTS We included 66 studies. Mean incubation period was 7.8 days (6.6-9.0 days, 8 studies: 560 cases), reproductive number 1.8 (1.7-1.9, 6 studies), mean duration from symptom onset to diagnosis 5.8 days (4.8-6.8 days, 4 studies: 982 cases), mean symptom duration 17.5 days (14.7-20.2 days, 3 studies: 292 cases), mean serial interval 8.5 days (7.3-9.9 days, 1 study), hospitalisation 6% (4-9%, 26 studies: 5339 cases), and vaccine effectiveness 78% (65-91%, 3 studies: 953 cases). Highly relevant clinical manifestations were pleomorphic skin lesions 82% (68-94%, 26 studies: 4093 cases), anogenital lesions 64% (51-77%, 9 studies: 10,398 cases), fever 54% (50-57%, 52 studies: 25,992 cases), and lymphadenopathy 51% (46-57%, 42 studies: 17,803 cases), with cases mostly men who have sex with men (MSM). Possibly relevant manifestations were perianal lesions, fatigue, asthenia, myalgia, and headache. CONCLUSIONS The 2022 Mpox outbreaks presented with sex-related clinical manifestations and were mostly reported among MSM.
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Affiliation(s)
- George N Okoli
- George & Fay Yee Centre for Healthcare Innovation, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, R3E 0T6, Canada.
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Paul Van Caeseele
- Department of Medical Microbiology & Infectious Diseases, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Cadham Provincial Laboratory, Winnipeg, MB, Canada
| | - Nicole Askin
- Neil John Maclean Library, University of Manitoba, Winnipeg, MB, Canada
| | - Ahmed M Abou-Setta
- George & Fay Yee Centre for Healthcare Innovation, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, R3E 0T6, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Taha AM, Elrosasy A, Mahmoud AM, Saed SAA, Moawad WAET, Hamouda E, Nguyen D, Tran VP, Pham HT, Sah S, Barboza JJ, Sah R. The effect of HIV and mpox co-infection on clinical outcomes: Systematic review and meta-analysis. HIV Med 2024. [PMID: 38443319 DOI: 10.1111/hiv.13622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/05/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Co-infection with HIV and mpox is a significant issue for public health because of the potential combined impact on clinical outcomes. However, the existing literature lacks a comprehensive synthesis of the available evidence. The purpose of this meta-analysis is to provide insight into the impact of HIV and mpox co-infection on clinical outcomes. METHODS We systematically searched major electronic databases (PubMed, Embase, Cochrane Central, and Web of Science) for pertinent studies published up to June 2023. Included were studies that described the clinical outcomes of people who had both mpox and HIV. We performed the analysis using OpenMeta and STATA 17 software. RESULTS With an overall number of participants of 35 207, 21 studies that met the inclusion criteria were considered. The greatest number of the studies (n = 10) were cohort designs, with three being cross-sectional and eight being case series studies. The meta-analysis found that people who had both HIV and mpox had a higher hospitalization rate than those who only had mpox (odds ratio [OR] 1.848; 95% confidence interval [CI] 0.918-3.719, p = 0.085, I2 = 60.19%, p = 0.020). Furthermore, co-infected patients had higher mortality rates than those who did not have HIV co-infection (OR 3.887; 95% CI 2.272-6.650, p < 0.001). Meta-regression analysis showed that CD4 levels can significantly predict the risk of hospitalization (p = 0.016) and death (p = 0.031). DISCUSSION HIV causes immunosuppression, making it difficult for the body to mount an effective immune response against pathogens such as mpox. Individuals who are co-infected are at a higher risk of severe disease and death, according to our findings. Although hospitalization rates did not differ significantly between the two groups, it is critical to prioritize interventions and improve management strategies tailored specifically for people living with HIV. CONCLUSION This meta-analysis provides substantial evidence that HIV and mpox co-infection has a negative impact on clinical outcomes. Co-infected individuals had higher hospitalization and significantly higher mortality rates. These findings highlight the significance of early diagnosis, prompt treatment initiation, and effective management strategies for people living with HIV and mpox.
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Affiliation(s)
| | - Amr Elrosasy
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | | | - Esraa Hamouda
- Faculty of Medicine, Menoufia University, Menoufia, Egypt
- Department of Microbiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Dang Nguyen
- Massachusetts General Hospital, Corrigan Minehan Heart Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Hoang Tran Pham
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Sanjit Sah
- Research Scientist, Global Consortium for Public Health and Research, Datta Meghe Institute of Higher Education and Research, Jawaharlal Nehru Medical College, Wardha, India
- SR Sanjeevani Hospital, Siraha, Nepal
| | | | - Ranjit Sah
- Department of Microbiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
- Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, India
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Maan I, Kohli M, Gilson R. Mpox in people living with HIV. Curr Opin Infect Dis 2024; 37:1-7. [PMID: 38112084 DOI: 10.1097/qco.0000000000000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW The 2022 global outbreak of mpox disproportionally affected people with HIV (PWH). We review the data on the presentation, treatment, and prevention of mpox in PWH. RECENT FINDINGS Most PWH with mpox had a mild and self-limiting illness, no different to people without HIV. A higher rate of rectal symptoms has been reported among PWH and those with advanced HIV disease were at higher risk of severe disease, hospitalization, and death. Treatment with antivirals was widely used in hospitalized patients without any randomized control trial data to support its use and without any data specifically in PWH. Use of smallpox vaccines to prevent mpox is safe in PWH regardless of CD4+ cell count. There is limited data on efficacy in those with lower CD4+ cell count and on long-term protective efficacy. SUMMARY PWH should be offered vaccination against mpox in line with national guidelines. PWH should be individually risk-assessed for severe mpox, based on their CD4+ cell count and co-morbidities and ideally recruited into treatment trials to build an evidence base on efficacy. HIV and other sexually transmitted infection testing should be offered to all people diagnosed with mpox.
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Affiliation(s)
- Irfaan Maan
- Institute for Global Health, University College London
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Manik Kohli
- Institute for Global Health, University College London
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Richard Gilson
- Institute for Global Health, University College London
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
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Sönmez İ, Martínez Riveros H, Folch C, Suñer C, Díaz Y, Alonso L, Agusti C, Mendoza A, Tarín-Vicente EJ, Oller X, Alemany A, Rivero À, Orviz E, Silva-Klug A, Mitjà O, Casabona J. Egocentric sexual network analysis among gay and bisexual men who have sex with men with and without mpox infection. Sex Transm Infect 2023; 99:541-547. [PMID: 37704363 DOI: 10.1136/sextrans-2023-055901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/29/2023] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVES Recent outbreaks of the mpox (monkeypox) virus have been detected in dense sexual networks of gay and bisexual men who have sex with men (GBMSM). The objective of this study is to describe and compare the epidemiological and behavioural characteristics, as well as the sexual networks, of GBMSM diagnosed with mild mpox in Spain. METHODS A prospective case-control study was conducted in Spain from July 2022 to February 2023. The study targeted a key population of GBMSM aged 18 years or older. Study participants were categorised into cases, those who were diagnosed with mpox virus infection; and controls, those who were not diagnosed. We examined and compared the sexual network characteristics of the two groups-mpox-positive (mpox-P) and mpox-negative (mpox-N) egos-using χ2, t-test and Wilcoxon test to examine the differences between the two groups in each section. Finally, we conducted univariable and multivariable logistic regressions to determine the factors associated with mpox infection. RESULTS Among the 105 participants, 35 (33.3%) were mpox-P. Compared with mpox-N, mpox-P respondents more frequently reported syphilis (mpox-P: 31.4%; mpox-N: 12.9%) and HIV (mpox-P: 45.7%; mpox-N: 18.6%), and mpox-P individuals to have had at least one sexual contact with a confirmed mpox case (mpox-P: 62.5%; mpox-N: 8.3%). In the egocentric network analysis, mpox-P respondents had a higher prevalence of group sex with alters (mpox-P: 18.5%; mpox-N: 8.9%) and one-time sexual partners (mpox-P: 46.1%; mpox-N: 31.7%). Multivariable logistic regressions showed that reporting stranger/client ties (adjusted OR (aOR)=10.3, 95% CI 1.39 to 76.6) with alters, being vaccinated for mpox (aOR=0.07, 95% CI 0.02 to 0.24) and tie strength heterogeneity (aOR=0.01, 95% CI 0.00 to 0.42) were associated with mpox infection. CONCLUSIONS Our findings highlight the role of demographic, epidemiological and sexual network characteristics in the transmission of mpox virus during the outbreak in Spain. These findings have important implications for future prevention efforts.
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Affiliation(s)
| | - Héctor Martínez Riveros
- CEEISCAT, Badalona, Spain
- Department of Pediatrics, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Cinta Folch
- CEEISCAT, Badalona, Spain
- CIBERESP, Madrid, Spain
| | - Clara Suñer
- Fundació Lluita Contra la Sida, Badalona, Spain
| | | | - Lucía Alonso
- CEEISCAT, Badalona, Spain
- Fundació Lluita Contra la Sida, Badalona, Spain
| | - Cristina Agusti
- CIBERESP, Madrid, Spain
- Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT)-Public Health Agency of Catalonia (ASPC), Badalona, Spain
| | - Adrià Mendoza
- Hospital Can Ruti, Badalona, Spain
- Checkpoint Barcelona, Barcelona, Spain
| | | | - Xènia Oller
- Fundació Lluita Contra la Sida, Badalona, Spain
| | | | - Àngel Rivero
- Checkpoint Barcelona, Barcelona, Spain
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Eva Orviz
- Centro Sanitario Sandoval, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Ana Silva-Klug
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Oriol Mitjà
- Fundació Lluita Contra la Sida, Badalona, Spain
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Ibrahim AM, Zaghamir DF. Knowledge and attitudes towards mpox and effect of intervention among College of Applied Medical Sciences students. Libyan J Med 2023; 18:2222448. [PMID: 37300843 DOI: 10.1080/19932820.2023.2222448] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023] Open
Abstract
Objectives: This research aims to assess the base level of knowledge and attitude of Applied Medical Sciences Students regarding mpox and whether an educational intervention could improve their knowledge and attitude. Methods: A quasi-experimental research was used, involving 960 medical students from Applied Medical Sciences College at Prince Sattam Bin Abdulaziz University, KSA. They were recruited from the beginning of November 2022 till the mid of January 2023 based on the non-randomized sampling method. A standardized, anonymous, and closed-ended questionnaire was used, compromising three main sections: participants' demographics, knowledge, and attitudes toward the mpox epidemic. Results: Total knowledge scores of the studied sample in the pretest phase were 45.43 ± 6.29 compared to 65.03 ± 2.93 in the post-test phase. Besides, total attitude scores were 48.62 ± 4.78 before program implementation, while after conducting the program reached 70.65 ± 5.13. There was a notable improvement in the total knowledge score of the sample studied after the intervention was implemented, particularly for neurological manifestations. Conclusion: After the program's implementation, there was an obvious improvement in the medical students' total knowledge and attitude scores concerning the mpox epidemic. It is necessary to initiate well-organized training initiatives for all other medical faculties, paramedics, and applied health institutions in Saudi Arabia.
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Affiliation(s)
- Ateya Megahed Ibrahim
- Nursing, Prince Sattam Bin Abdulaziz University, College of Applied Medical Sciences, Alkarj, Kingdom of Saudi Arabia
- Family and Community Health Nursing department, Faculty of Nursing, Port Said University, Port Said, Egypt
| | - Donia Fathi Zaghamir
- Nursing, Prince Sattam Bin Abdulaziz University, College of Applied Medical Sciences, Alkarj, Kingdom of Saudi Arabia
- Lecturer of Pediatric Nursing, Faculty of Nursing, Port Said University, Port Said, Egypt
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Iroezindu MO, Crowell TA, Ogoina D, Yinka-Ogunleye A. Human Mpox in People Living with HIV: Epidemiologic and Clinical Perspectives from Nigeria. AIDS Res Hum Retroviruses 2023; 39:593-600. [PMID: 37646422 DOI: 10.1089/aid.2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Sub-Saharan Africa (SSA) is disproportionately affected by mpox and HIV. We described epidemiologic trends and clinical experiences in the management of mpox in people living with HIV (PLWH) in Nigeria and further examined how the rapidly accumulating body of knowledge from the 2022 global mpox outbreak might be explored to improve mpox care in PLWH in SSA. During the 2017/2018 Nigerian mpox outbreak, we reported that 9/40 (22.5%) hospitalized mpox patients with known HIV status were PLWH. In the 2022 global mpox outbreak, 52% of confirmed mpox cases with known HIV status were PLWH, predominantly sexual and gender minority groups. However, substantial missing data on HIV status of confirmed mpox cases highlights a critical gap in HIV testing as a component of mpox management. Before 2022, sexual activity was not commonly linked to mpox transmission, but this was identified as a major driver of transmission during the 2022 mpox outbreak. Notable sexual history observed in Nigerian mpox patients in 2017/2018 suggests that the contribution of sexual activity in human-to-human mpox transmission might have been underappreciated for years. Our cohort of PLWH with mpox, predominantly individuals with advanced or uncontrolled HIV, were significantly more likely to experience severe mpox manifestations and prolonged disease compared with those without HIV. This contrasts with the generally less remarkable differences in mpox presentation between people with and without HIV in Western countries, an observation that can be at least partially explained by more stable HIV disease. The unavailability of mpox antiviral drugs and vaccines in SSA highlights global inequity in mpox response, which requires an urgent attention. As mpox countermeasures become available in SSA, lessons learned from their use in Western countries could provide important guidance for care providers in SSA. Public health measures to mitigate stigmatization in PLWH with mpox is also critical.
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Affiliation(s)
- Michael O Iroezindu
- Clinical Research Center, HJF Medical Research International, Abuja, Nigeria
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Trevor A Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Dimie Ogoina
- Infectious Disease Unit, Niger Delta University Teaching Hospital, Okolobiri, Nigeria
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Shang W, Cao G, Wu Y, Kang L, Wang Y, Gao P, Liu J, Liu M. Spatiotemporal cluster of mpox in men who have sex with men: A modeling study in 83 countries. J Med Virol 2023; 95:e29166. [PMID: 37822046 DOI: 10.1002/jmv.29166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/11/2023] [Accepted: 09/30/2023] [Indexed: 10/13/2023]
Abstract
Mpox outbroke globally during 2022-2023, with more than 90% of cases occurring in men who have sex with men (MSM). However, the spatiotemporal distribution of mpox is not well established yet. This study aimed to explore the spatiotemporal clustering of mpox cases in MSM worldwide. We obtained the numbers of mpox cases from Our World in Data, the number of MSM from the Joint United Nations Programme on HIV/AIDS (UNAIDS), UNAIDS DATA 2021 and UNAIDS Global AIDS Update 2022 and literature. We evaluated the spatiotemporal cluster of mpox in MSM using retrospective space-time analyses method. The total number of mpox cases was 85 795 during May 1, 2022 to March 31, 2023. The most likely cluster was Spain (likelihood ratio = 4764.97; p < 0.001), with a cluster period from July 26 to August 14, 2022. There were 11 secondary clusters, which included 46 countries located in western Europe, eastern and northern South America, northern Europe, Canada, Central Africa, southern and central Europe, Latin America, Turkey, Dominican Republic, New Zealand, and Australia. The findings may inform current and future control strategies of mpox and might provide references for the identification of the spatiotemporal distribution of new and emerging infectious diseases in specific populations.
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Affiliation(s)
- Weijing Shang
- School of Public Health, Peking University, Beijing, China
| | - Guiying Cao
- School of Public Health, Peking University, Beijing, China
| | - Yu Wu
- School of Public Health, Peking University, Beijing, China
| | - Liangyu Kang
- School of Public Health, Peking University, Beijing, China
| | - Yaping Wang
- School of Public Health, Peking University, Beijing, China
| | - Peng Gao
- School of Public Health, Peking University, Beijing, China
| | - Jue Liu
- School of Public Health, Peking University, Beijing, China
| | - Min Liu
- School of Public Health, Peking University, Beijing, China
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Gandhi AP, Padhi BK, Sandeep M, Shamim MA, Suvvari TK, Satapathy P, Siddiq A, Sah R, Rustagi S, Al-Qaim ZH, Khubchandani J. Monkeypox Patients Living with HIV: A Systematic Review and Meta-Analysis of Geographic and Temporal Variations. EPIDEMIOLOGIA 2023; 4:352-369. [PMID: 37754280 PMCID: PMC10528863 DOI: 10.3390/epidemiologia4030033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023] Open
Abstract
This index meta-analysis estimated the pooled prevalence of human immunodeficiency virus (HIV) among individuals with monkeypox (mpox) globally. We searched seven databases: PubMed, Scopus, Web of Science, EMBASE, ProQuest, EBSCOHost, and Cochrane, for human studies published in English till 4 January 2023, as per International Prospective Register of Systematic Reviews (PROSPERO) registration protocol (CRD42022383275). A random effects regression model was used to estimate the pooled prevalence owing to high heterogeneity. The risk of bias in the included studies was assessed using the National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool. The systematic search yielded 677 articles; finally, 32 studies were found eligible for systematic review and 29 studies for meta-analysis. The pooled prevalence of HIV infection was 41% (95% confidence interval [CI], 35-48). All studies were rated as fair or good quality. Studies from Europe and North America reported a high prevalence of HIV infection among individuals with mpox- 41% (95% CI 33-49) and 52% (95% CI 28-76), respectively, while studies from Nigeria, Africa reported a relatively low prevalence of HIV infection of 21% (95% CI 15-26). A history of sexual orientation and sexual partners in the last 21 days must be taken from individuals with mpox to identify the potential source and contacts for quarantining and testing them.
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Affiliation(s)
- Aravind P. Gandhi
- Department of Community Medicine, ESIC Medical College & Hospital, Sanathnagar, Hyderabad 500038, India;
| | - Bijaya K. Padhi
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India;
| | - Mokanpally Sandeep
- School of Medical Sciences, University of Hyderabad, Hyderabad 500046, India;
| | - Muhammad Aaqib Shamim
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur 342005, India;
| | - Tarun K. Suvvari
- Medical School, Rangaraya Medical College, Kakinada 533001, India;
| | | | | | - Ranjit Sah
- Department of Microbiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu 44600, Nepal;
- Department of Microbiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune 411018, India
| | - Sarvesh Rustagi
- School of Applied and Life Sciences, Uttaranchal University, Dehradun 248007, India;
| | - Zahraa H. Al-Qaim
- Department of Anesthesia Techniques, Al-Mustaqbal University College, Hillah 51001, Iraq;
| | - Jagdish Khubchandani
- Department of Public Health Sciences, New Mexico State University, Las Cruces, NM 88003, USA
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Patel P, Purohit B. HIV Patient With a Complicated and Unique Presentation of the Monkeypox Virus. Cureus 2023; 15:e44607. [PMID: 37711267 PMCID: PMC10498935 DOI: 10.7759/cureus.44607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2023] [Indexed: 09/16/2023] Open
Abstract
Monkeypox virus presents a concerning challenge, as it is known for its ability to spread through a diverse range of transmission routes, including established pathways like direct contact and shared living spaces, with the spectrum of potential methods appearing to be limitless. This immunocompromised 43-year-old HIV patient presented to the emergency department (ED) in the United States with shortness of breath, cough, and painful lesions for several months. Numerous consults and a full panel of testing revealed an odd case of the monkeypox virus that strayed away from the predefined classifications for the disease. The case sheds light on the need for further research in immunocompromised patient populations as their presentations may be different from what research currently suggests.
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Affiliation(s)
- Prachi Patel
- Internal Medicine, Philadelphia College of Osteopathic Medicine, Atlanta, USA
| | - Bhavi Purohit
- Internal Medicine, Wellstar North Fulton Hospital, Roswell, USA
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Patalon T, Perez G, Saciuk Y, Refaeli Z, Gazit S. Mpox Patient Journey in Israel. Microorganisms 2023; 11:microorganisms11041042. [PMID: 37110465 PMCID: PMC10145053 DOI: 10.3390/microorganisms11041042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Reports on Mpox have, thus far, characterized the disease, but mostly through a single timepoint view. The aim of this study was to characterize Mpox in the Israeli setting, in general, alongside compiling a detailed patient journey from multiple in-depth interviews with infected individuals. This descriptive study followed two complimentary paths: retrospective and prospective. The first consisted of interviews with Mpox patients, while the retrospective part included the retrieval of anonymized electronic medical records of patients diagnosed with Mpox between May and November 2022. Patient characteristics in Israel were, overall, comparable to global reports. We found that the median time from symptoms to first suspicion of Mpox was 3.5 days, while the median time from the first symptom to a confirmatory test was 6.5 days, which could explain the surge in Israel. The duration of lesions did not alter in terms of their anatomical location, while lower Ct values correlated both with a longer symptom duration and more symptoms. Most patients reported anxiety to a high degree. Clinical trials that consist of a long-term relationship with the medical researchers contribute greatly to a deeper understanding of the patient journey, especially for unfamiliar or stigmatized diseases. Emerging infections, such as Mpox, should be further investigated to assess asymptomatic carriers, especially when rapidly spreading.
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Affiliation(s)
- Tal Patalon
- Kahn Sagol Maccabi (KSM) Research & Innovation Center, Maccabi Healthcare Services, Tel Aviv 68125, Israel
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv 68125, Israel
| | - Galit Perez
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv 68125, Israel
- Department of Health Policy and Management, School of Public Health, Ben Gurion University of the Negev, Beer Sheva 84105, Israel
| | - Yaki Saciuk
- Kahn Sagol Maccabi (KSM) Research & Innovation Center, Maccabi Healthcare Services, Tel Aviv 68125, Israel
| | - Ziva Refaeli
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv 68125, Israel
| | - Sivan Gazit
- Kahn Sagol Maccabi (KSM) Research & Innovation Center, Maccabi Healthcare Services, Tel Aviv 68125, Israel
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv 68125, Israel
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Hatami H, Jamshidi P, Arbabi M, Safavi-Naini SAA, Farokh P, Izadi-Jorshari G, Mohammadzadeh B, Nasiri MJ, Zandi M, Nayebzade A, Sechi LA. Demographic, Epidemiologic, and Clinical Characteristics of Human Monkeypox Disease Pre- and Post-2022 Outbreaks: A Systematic Review and Meta-Analysis. Biomedicines 2023; 11:957. [PMID: 36979936 PMCID: PMC10045775 DOI: 10.3390/biomedicines11030957] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/28/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
(1) Background: In early May 2022, an increasing number of human monkeypox (mpox) cases were reported in non-endemic disparate regions of the world, which raised concerns. Here, we provide a systematic review and meta-analysis of mpox-confirmed patients presented in peer-reviewed publications over the 10 years before and during the 2022 outbreak from demographic, epidemiological, and clinical perspectives. (2) Methods: A systematic search was performed for relevant studies published in Pubmed/Medline, Embase, Scopus, and Google Scholar from 1 January 2012 up to 15 February 2023. Pooled frequencies with 95% confidence intervals (CIs) were assessed using the random or fixed effect model due to the estimated heterogeneity of the true effect sizes. (3) Results: Out of 10,163 articles, 67 met the inclusion criteria, and 31 cross-sectional studies were included for meta-analysis. Animal-to-human transmission was dominant in pre-2022 cases (61.64%), but almost all post-2022 reported cases had a history of human contact, especially sexual contact. The pooled frequency of MSM individuals was 93.5% (95% CI 91.0-95.4, I2: 86.60%) and was reported only in post-2022 included studies. The male gender was predominant in both pre- and post-2022 outbreaks, and the mean age of confirmed cases was 29.92 years (5.77-41, SD: 9.38). The most common clinical manifestations were rash, fever, lymphadenopathy, and malaise/fatigue. Proctalgia/proctitis (16.6%, 95% CI 10.3-25.6, I2: 97.76) and anal/perianal lesions (39.8%, 95% CI 30.4-49.9, I2: 98.10) were the unprecedented clinical manifestations during the 2022 outbreak, which were not described before. Genitalia involvement was more common in post-2022 mpox patients (55.6%, 95% CI 51.7-59.4, I2: 88.11). (4) Conclusions: There are speculations about the possibility of changes in the pathogenic properties of the virus. It seems that post-2022 mpox cases experience a milder disease with fewer rashes and lower mortality rates. Moreover, the vast majority of post-2022 cases are managed on an outpatient basis. Our study could serve as a basis for ongoing investigations to identify the different aspects of previous mpox outbreaks and compare them with the current ones.
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Affiliation(s)
- Hossein Hatami
- Department of Public Health, School of Public Health and Environmental and Occupational Hazards Control Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran;
| | - Parnian Jamshidi
- Department of Public Health, School of Public Health and Environmental and Occupational Hazards Control Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran;
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran; (M.A.); (P.F.); (B.M.); (M.J.N.)
| | - Mahta Arbabi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran; (M.A.); (P.F.); (B.M.); (M.J.N.)
| | - Seyed Amir Ahmad Safavi-Naini
- Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran;
| | - Parisa Farokh
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran; (M.A.); (P.F.); (B.M.); (M.J.N.)
| | - Ghazal Izadi-Jorshari
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran;
| | - Benyamin Mohammadzadeh
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran; (M.A.); (P.F.); (B.M.); (M.J.N.)
| | - Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran; (M.A.); (P.F.); (B.M.); (M.J.N.)
| | - Milad Zandi
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran 1417613151, Iran;
| | - Amirhossein Nayebzade
- Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1985717443, Iran;
| | - Leonardo A. Sechi
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy
- SC Microbiologia e Virologia, Azienda Ospedaliera Universitaria, 07100 Sassari, Italy
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Mpox infection in people living with HIV. AIDS 2023; 37:701-703. [PMID: 36815525 DOI: 10.1097/qad.0000000000003495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Liu Q, Fu L, Wang B, Sun Y, Wu X, Peng X, Li Y, Lin YF, Fitzpatrick T, Vermund SH, Zou H. Clinical Characteristics of Human Mpox (Monkeypox) in 2022: A Systematic Review and Meta-Analysis. Pathogens 2023; 12:146. [PMID: 36678494 PMCID: PMC9861547 DOI: 10.3390/pathogens12010146] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/26/2022] [Accepted: 01/03/2023] [Indexed: 01/17/2023] Open
Abstract
Since May 2022, large numbers of human mpox (previously known as monkeypox) cases have been reported in non-endemic regions. We conducted a systematic review and meta-analysis to elucidate clinical characteristics of the current mpox outbreak. Our systematic review and meta-analysis were undertaken according to PRISMA and MOOSE guidelines. We searched PubMed, EMBASE, and Web of Science for publications between 1 January and 11 November 2022. Random-effects models were used to pool results. Heterogeneity was assessed using I2. This study is registered with PROSPERO, CRD42022355590. Skin lesions (95.2%, 95% CI [93.3-96.9%]), fever (58.4%, [54.9-61.8%]) and lymphadenopathy (53.0%, [48.7-57.3%]) were the most common symptoms. The most common dermatological manifestations were anogenital lesions (65.7%, [57.8-73.0%]), and the most common lymphadenopathy was inguinal (46.8%, [40.6-53.0%]). There were no differences in symptoms including malaise, fever, headache, and genital, anal, and oropharyngeal lesions according to HIV infection status. Median age of patients varied from 15 to 57.5 years (median, 35 years). The median proportion of men who had sex with men (MSM) was 100.0% (20.6-100.0%). The median proportion of patients who reported recent sexual exposure was 99.2% (14.3-100.0%). The median proportion of PLHIV was 42.2% (0.0-100.0%). Skin lesions, fever, inguinal lymphadenopathy, and anogenital lesions were the most common symptoms of mpox reported in the current outbreak. Existing guidelines should be updated to reflect these clinical manifestations and groups at highest risk of infection, MSM in particular.
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Affiliation(s)
- Qi Liu
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen 518107, China
| | - Leiwen Fu
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen 518107, China
| | - Bingyi Wang
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen 518107, China
| | - Yinghui Sun
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen 518107, China
| | - Xinsheng Wu
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen 518107, China
| | - Xin Peng
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen 518107, China
| | - Yuwei Li
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen 518107, China
| | - Yi-Fan Lin
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen 518107, China
| | | | - Sten H. Vermund
- Yale School of Public Health, Yale University, New Haven, CT 06520, USA
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen 518107, China
- Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia
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Silva MST, Coutinho C, Torres TS, Peixoto E, Ismério R, Lessa F, Nunes EP, Hoagland B, Echeverria Guevara AD, Bastos MO, Ferreira Tavares IC, Diniz Ribeiro MP, Meneguetti Seravalli Ramos MR, Andrade HB, Lovetro Santana AP, Santini-Oliveira M, Santos Netto JB, Reges P, Magalhães MA, Silva Rosadas LA, Nazer S, Velasque L, Cardoso SW, da Silva EE, Veloso VG, Wakimoto MD, Grinsztejn B, Trepow M, Ferreira IG, Villela L, Fraga RT, Castro de Souza Pires M, Otavio da Silva Escada R, Paiva de Sousa L, Umaña Robleda GL, Santos DV, Siqueira Camacho LR, Amparo P, Jaegger de França JV, de Oliveira Heluy Correa F, Costa de Sousa BI, Vicari do Valle B, Bortot Soares JP, Fonseca Ferreira LC, da Silva Martins P, Mesquita MB, Hildebrant Coutinho JR, de Moraes Perlingeiro R, Peixoto de Castro Oliveira P, Pedroso Barbosa HP, Accetta AF, Cunha M, Eiras RV, Martins dos Santos T, Davila da Silva W, Silveira MDV, de Souza Brum T, Calvet GA, Menezes RC, Pereira SA. Ambulatory and hospitalized patients with suspected and confirmed mpox: an observational cohort study from Brazil. LANCET REGIONAL HEALTH. AMERICAS 2022; 17:100406. [PMID: 36776570 PMCID: PMC9904017 DOI: 10.1016/j.lana.2022.100406] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/06/2022] [Accepted: 11/11/2022] [Indexed: 12/14/2022]
Abstract
Background By October 30, 2022, 76,871 cases of mpox were reported worldwide, with 20,614 cases in Latin America. This study reports characteristics of a case series of suspected and confirmed mpox cases at a referral infectious diseases center in Rio de Janeiro, Brazil. Methods This was a single-center, prospective, observational cohort study that enrolled all patients with suspected mpox between June 12 and August 19, 2022. Mpox was confirmed by a PCR test. We compared characteristics of confirmed and non-confirmed cases, and among confirmed cases according to HIV status using distribution tests. Kernel estimation was used for exploratory spatial analysis. Findings Of 342 individuals with suspected mpox, 208 (60.8%) were confirmed cases. Compared to non-confirmed cases, confirmed cases were more frequent among individuals aged 30-39 years, cisgender men (96.2% vs. 66.4%; p < 0.0001), reporting recent sexual intercourse (95.0% vs. 69.4%; p < 0.0001) and using PrEP (31.6% vs. 10.1%; p < 0.0001). HIV (53.2% vs. 20.2%; p < 0.0001), HCV (9.8% vs. 1.1%; p = 0.0046), syphilis (21.2% vs. 16.3%; p = 0.43) and other STIs (33.0% vs. 21.6%; p = 0.042) were more frequent among confirmed mpox cases. Confirmed cases presented more genital (77.3% vs. 39.8%; p < 0.0001) and anal lesions (33.1% vs. 11.5%; p < 0.0001), proctitis (37.1% vs. 13.3%; p < 0.0001) and systemic signs and symptoms (83.2% vs. 64.5%; p = 0.0003) than non-confirmed cases. Compared to confirmed mpox HIV-negative, HIV-positive individuals were older, had more HCV coinfection (15.2% vs. 3.7%; p = 0.011), anal lesions (45.7% vs. 20.5%; p < 0.001) and clinical features of proctitis (45.2% vs. 29.3%; p = 0.058). Interpretation Mpox transmission in Rio de Janeiro, Brazil, rapidly evolved into a local epidemic, with sexual contact playing a crucial role in its dynamics and high rates of coinfections with other STI. Preventive measures must address stigma and social vulnerabilities. Funding Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz).
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Affiliation(s)
- Mayara Secco Torres Silva
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Carolina Coutinho
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Thiago Silva Torres
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Eduardo Peixoto
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Ronaldo Ismério
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Flavia Lessa
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Estevão Portela Nunes
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Brenda Hoagland
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | | | - Matheus Oliveira Bastos
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | | | - Maria Pia Diniz Ribeiro
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | | | - Hugo Boechat Andrade
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Ana Paula Lovetro Santana
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Marilia Santini-Oliveira
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Juliana Barbosa Santos Netto
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Paula Reges
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Monica Avelar Magalhães
- Instituto de Comunicação e Informação Científica e Tecnológica em Saúde, Fundação Oswaldo Cruz (ICICT-Fiocruz), Rio de Janeiro, RJ, Brazil
| | | | - Sandro Nazer
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Luciane Velasque
- Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Departamento de Matemática e Estatística, Rio de Janeiro, RJ, Brazil
| | - Sandra Wagner Cardoso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Edson Elias da Silva
- Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (IOC-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Valdilea Gonçalves Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Mayumi Duarte Wakimoto
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil,Corresponding author. Av Brasil 4365 Manguinhos, Rio de Janeiro, RJ, Brazil.
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