What Nonsexual Monkeypox Transmission May Look Like

A new report states that a man in his 20s saw his first lesion "after he attended a large, crowded outdoor event at which he had close contact with others."

HealthIn Depth
What Nonsexual Monkeypox Transmission May Look Like
Healthcare and LGBTQ rights activists hold signs as they stage a protest outside of the San Francisco Federal Building on August 08, 2022, in San Francisco, California. Photo:Justin Sullivan (Getty Images)

In July, the World Health Organization convened a panel of experts who declined to classify monkeypox as a sexually transmitted infection. Instead, a WHO adviser, via Buzzfeed, told reporters, “they’re comfortable in describing this as sexually transmittable.” The vast majority of reported transmission events, though, according to WHO data, have been through sexual contact (91.1 percent), and the vast majority of cases (97.2 percent) have been observed in men who have sex with men.

The Buzzfeed story does a good job of relaying the thorniness of the situation—as cases continue to climb globally (they jumped 20 percent in the week of August 8-14, according to WHO data), there has been a lot of discussion in just how to convey the threat facing men who have sex with men without stigmatizing an already marginalized community. Or repeating many of the mistakes that were made with the public discussion of and reporting on AIDS.

“What’s challenging is communicating that while this is not a ‘gay disease,’ our limited resources need to go to the people at the highest risk, currently GBMSM,” Canadian virologist Angie Rasmussen told Buzzfeed. “And it’s also important to communicate the risk is highest with sexual activity without shaming the queer community that has already been profoundly harmed by medical stigmatization.”

Given the way that LGBTQ people have been baselessly vilified for apparently political reasons, anyone with half a brain, a sense of compassion, and an interest in public health understands that the needle at hand is a tough one to thread.

Which makes a recent case study out of the Stanford University School of Medicine important reading. The article, “Human Monkeypox without Viral Prodrome or Sexual Exposure, California, USA, 2022,” set to be published in the October issue of the Emerging Infectious Diseases journal, describes a bisexual man in his 20s whose first monkeypox lesion appeared around 14 days “after he attended a large, crowded outdoor event at which he had close contact with others, including close dancing, for a few hours.” The subject had recently traveled to the U.K. and “reported no recent sexual contacts during his travels or in the preceding 3 months.”

Of the event, which the study heavily suggests was the site of the subject’s transmission, the authors write:

He said that many attendees were in sleeveless tops and shorts. He wore pants and a short-sleeved top. He did not notice any skin lesions on anyone present, nor did he notice anyone who seemed sick. He shared an e-cigarette with a woman that he met while there. The event was not a rave and was not attended specifically or mostly by persons identifying as gay or bisexual. He attended other similar outdoor events over 4 days. He reported consuming alcohol but no other drug use at these events. He did not wear a mask at these events. He had contact with domestic dogs that he petted.

It is important to emphasize that the subject’s lack of sexual contact was self-reported. The study notes that “detectable viral DNA in the rectal swab specimen in the absence of visible anal lesions or pain indicates a potential for sustained sexual transmission, although the viral DNA levels were low; contamination during self-collection cannot be ruled out. We were unable to assess whether internal rectal lesions were present.” Still, there were no genital lesions, and he did not report viral prodrome (early onset symptoms of monkeypox like a high temperature or headache). Therefore it is concluded that:

His primary risk factor was close, nonsexual contact with numerous unknown persons at a crowded outdoor event. His case highlights the potential for spread at such gatherings, which may have implications for epidemic control. The lack of both sexual exposure and anogenital involvement indicates that mode of transmission may be associated with clinical symptoms; fomites (hotel bedding and sheets, high-touch areas in public settings) may be alternative modes of transmission. Overall, the viral inoculum required for all possible modes of transmission remains an area of active investigation.

Whether monkeypox can be contained before it hits pandemic proportions remains to be seen. Certainly, frustrations with vaccine supply and distribution have not boded well. CDC guidelines that include suggestions to limit one’s sexual partners, for the time being, have also been controversial. Clearly, without headway on a systemic level, cases like the one in the Stanford report are bound to become more and more common.

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