As of June 8, 1,177 cases of monkeypox have been confirmed, with Europe being the worst affected with 704 cases, as per the European Centre for Disease Prevention and Control. Monkeypox cases have been detected in 18 countries in Europe, mainly in the U.K., Spain and Portugal. The U.S. has confirmed 45 cases of monkeypox virus cases as of June 9.
Most of the cases reported so far have been in men who have sex with men and bisexual men. However, the risk of monkeypox virus is not restricted to men who have sex with men. “People who closely interact with someone who is infectious, including health workers, household members and sexual partners are at greater risk for infection, the World Health Organization (WHO) says. “You can catch monkeypox if you have close physical contact with someone who is showing symptoms. This includes touching and being face-to-face. Monkeypox can spread through close skin-to-skin contact during sex, including kissing, touching, oral and penetrative sex with someone who has symptoms.”
The WHO also stresses that it is currently not clear if monkeypox virus can spread through semen or vaginal fluids. “But direct skin-to-skin contact with lesions during sexual activities can spread the virus. Monkeypox rashes are sometimes found on genitals and in the mouth, which is likely to contribute to transmission during sexual contact. Mouth-to-skin contact could cause transmission where skin or mouth lesions are present,” WHO adds.
The virus can also spread through large respiratory droplets and contact with bedding, towels, etc. that a person with monkeypox infection has used.
Virus in semen
But a study published on June 2 in Eurosurveillance found the virus in the seminal fluid of four men who tested positive for monkeypox virus. The researchers have ruled out the possibility of sample contamination. Based on the findings, they say, “Although these findings cannot be considered definitive evidence of infectivity, they demonstrate viral shedding whose efficiency in terms of transmission cannot be ruled out.”
They say that further studies are needed to “assess presence, persistence and contagiousness of the virus in different body fluids”. But the researchers also mention that all four men had sex with many men and the lesions were initially seen mostly in the anal and genital areas. “These suggest that close contact during sexual intercourse was important for virus transmission,” they note.
“Direct [skin-to-skin] contact is the primary route of monkeypox virus transmission,” says Dr. Gagandeep Kang, Professor of Microbiology at CMC Vellore. The presence of the virus in the seminal fluid in all four men cannot be considered as proof of sexual transmission unless proven that virus transmission could not have happened any other way, Dr. Kang adds.
In the case of HIV, besides sexual route of virus transmission, the virus can be transmitted from the mother to the child (vertical transmission) during pregnancy, labour, delivery or breastfeeding and also through injection drug use. Yet, HIV is called a sexually transmitted disease.
“HIV spread is predominantly sexual/parenteral, while monkeypox is mainly direct contact,” Dr. Kang says.
Though most of the cases have been reported in men who have sex with men and presenting with lesions mostly seen in the anal and genital areas as well as the mouth, monkeypox is not considered to be sexually transmitted. Instead, intimate, skin-to-skin contact is considered key to transmission. Even if other studies find infectious monkeypox viruses in the seminal fluid, it is unlikely that monkeypox would be called as a sexually transmitted infection.
Sexually transmitted?
Virologist Boghuma Kabisen Titanji from Emory University thinks otherwise. In a tweet thread on June 3, Dr. Titanji says, “So far the data on the 800 plus cases of monkeypox happening in non-endemic countries point at sexual contact (intimacy through sex) playing an important role in transmission. Whether this is happening through semen, vaginal secretions or skin-to-skin contact is semantics.”
She also adds that definition of sexually transmitted infections is not clear and it is important to clarify this while trying to contain a large outbreak. She cites scabies, herpes, syphilis, pubic lice “crabs”, which are STIs that are transmitted through close contact.
“Anybody can get scabies but scabies can be sexually transmitted by close contact during sex. So can monkeypox. Calling an infection as sexually transmitted doesn’t mean that is the sole mode of spread,” Dr. Boghuma Titanji tells The Hindu in a message.
“The reason why it is important to use the correct terminology and highlight the mode of spread which may be important is that it allows for targeted interventions to stop an outbreak,” she says. “A lot of the cases in the present monkeypox outbreak have clustered in sexual networks. Therefore, it is important to highlight this in communication while providing caveats that this is not the sole mechanism of spread.”
The CDC Atlanta, in its new guidelines issued on June 8, has specifically addressed the point that Dr. Titanji has raised. The new guidance categorically states the risks of virus spread in certain high-risk situations.
“Enclosed spaces, such as back rooms, saunas, or sex clubs, where there is minimal or no clothing and where intimate sexual contact occurs, have a higher likelihood of spreading monkeypox,” the guidance notes. “A rave, party, or club where there is minimal clothing and where there is direct, personal, often skin-to-skin contact, has some risk.”
Question of stigma
On whether calling monkeypox as a sexually transmitted infection will lead to more stigma and discrimination, Dr. Titanji told The Hindu, “I am worried about stigma too and that is the challenge in public health messaging. [But] shrouding this in taboo will breed stigma, and stigma is bad for controlling outbreaks.”
She adds, “Calling any disease that spreads through sexual contact an STI is not intended to stigmatise. It is intended to identify and address risk factors and offer interventions to help folks manage their risk.”
She elaborated this in a tweet, “Calling an infection an STI is not intended to be stigmatising. It allows for people to understand how they could be exposed and potentially infected, it also helps with tracing partners, notifying them so they are aware of their exposures to seek treatment.”
