Researchers at the National Institute of Virology, Pune, had recently posted the case report of the first two imported monkeypox cases that were detected in Kerala. But the people who tested positive for monkeypox virus had returned from the United Arab Emirates just days before they were detected with monkeypox infection. In a preprint (which is yet to be peer-reviewed), the researchers have detailed the clinical presentation of the infection in these people, and based on genome sequencing data have designated them as belonging to the A.2 clade.
The likely mode for transmission of monkeypox virus (MPXV) in both cases has not been mentioned in the preprint. In the first case — a 35-year-old male — the researchers say multiple vesicular rashes were seen in the “oral cavity and lips followed by a single lesion on the genital organ”. The person had revealed similar lesions in people whom he had come in contact with a week before the onset of symptoms but denied any sexual contact.
In the second case, genital swelling was seen on July 8, 2022, and two days later, multiple vesicular rashes developed on the genital organ and on both hands; lesions were seen in a few other parts of the body couple of days later. This person, too, had denied any sexual or physical contact with anyone with suspected or confirmed monkeypox infection.
As per the global update by WHO, as of August 10, 98.7% of 18,940 people with confirmed infection were men. Among cases with known data on sexual orientation, 97.2% (8,224 of 8,462) identified as men who have sex with men (MSM). Of the 5,473 cases where the route of transmission was reported, 91.5% was through a sexual encounter. This would mean that in about 8.5% of cases the route of transmission was not sexual.
Route of infection
While the first two people in India who tested positive for the monkeypox virus had developed initial symptoms (rashes/lesions), including in the genital area, even before travelling from the United Arab Emirates to Kerala, both had denied sexual contact with anyone with confirmed or suspected infection. While other routes of transmission cannot be ruled out in both cases, it is pertinent to note that lesions were first seen in the genital and/or oral areas.
The reasons for denying the sexual route of transmission could be due to fear of stigma and discrimination.
“There is both a legal and social issue for denying sexual route of transmission,” says Dr. Vinod Scaria, a senior scientist at the Institute of Genomics and Integrative Biology (CSIR-IGIB). “Homosexuality is a crime in UAE and people can get prosecuted. So, expatriates who develop lesions fly back to their respective countries.”
Since genome sequence data are posted along with the date and place, it is possible to identify the infected people and trace them, especially since only two sequences have been posted from India. “So even if they had declared the route of transmission as sexual, it is important not to reveal it in the study,” says Dr. Scaria.
Multiple routes of spread
As per WHO, majority of cases are among men who have sex with men, and sexual encounter is the route of transmission in 91.5% of cases with the known routes of spread. Both legal and social acceptance of men who have sex with men is very high in the U.S. and many countries in South America and Europe. Despite homosexuality being decriminalised in India, the acceptance is not the same in India, the reason why some people may not disclose the sexual route of transmission of monkeypox virus.
“That is why public health communication about the different routes of transmission is critical. Also, the demographics could change as we go ahead. The communication from India’s health ministry has been quite straight on this. It clearly states that anyone can get infected,” says Dr. Scaria.
Globally, the virus has already spread beyond the MSM networks. Among the people for whom the route of transmission is known, 8.5% of cases are outside the MSM networks. So even though the majority of cases are being reported in men who have sex with men, anyone who comes in direct contact with an infected person or even with towels and bedsheets used by an infected person can get infected.
“While the majority of cases are in the MSM community globally, anyone can get infected through other routes. All efforts and attempts should be directed at ensuring that people who have been infected do not face any stigma and discrimination. Else, we will end up driving monkeypox spread under the radar,” says Dr. Anant Bhan, a researcher in global health, bioethics and health policy.
Nine cases
As of August 11, 184 suspected cases have been tested and nine monkeypox cases have been detected in India. All the five cases detected in Kerala are imported, while all four people detected in Delhi have no international travel history and the index case has not been identified for all three. A Mumbai-based doctor, Dr. Ishwar Gilada, told Bloomberg that two people with suspected monkeypox infection refused to get tested about two months before the first case was reported in Kerala.
The importance of timely testing and isolation of cases to limit virus spread cannot be overemphasised. Equally, sequencing the genomes and posting the data on global databases is imperative. NIV Pune has so far shared only two genome sequences on GISAID. Besides NIV Pune, 15 Viral Research and Diagnostic Laboratories (VRDL) of ICMR have been testing for the virus. All 15 VRDL labs are required to send the positive samples to NIV for confirmation.
Currently, NIV holds all the positive samples only it can sequence the genomes and share them. A large number of SARS-CoV-2 genomes were sequenced and shared nationally and in global databases only when many government labs outside the ICMR were allowed to both test and sequence the genomes.
As of August 11, over 33,000 monkeypox cases have been reported globally. The U.S., with nearly 10,400 cases, accounts for one-third of the total cases, and 41 countries in Europe reported over 17,500 cases.
