A recent study published in The Lancet described the clinical and epidemiological features of monkeypox virus (MPXV) infection in cisgender (cis) and transgender (trans) females and non-binary individuals.

Study: Human monkeypox virus infection in females and nonbinary individuals during the 2022 outbreaks: A global case series.  Image Credit: Dotted Yeti/Shutterstock
Study: Human monkeypox virus infection in females and nonbinary individuals during the 2022 outbreaks: A global case series. Image Credit: Dotted Yeti/Shutterstock

Background

From May to November 2022, more than 78,000 MPXV infections were reported in more than 100 countries that have historically had no documented MPXV infections, with the monkeypox (MPX) outbreak designated a Public Health Emergency of International Concern by the Organization World Health Organization (WHO) in July 2022. Sexually active gays, bisexuals and other men who have sex with men (GBMSM) have been affected almost exclusively by MPXV in the ongoing outbreak.

About 28% to 47% of people diagnosed with MPX are living with human immunodeficiency virus (HIV). Sustained deployment of MPX has not yet occurred outside GBMSM networks; however, shedding of MPXV to females is a significant concern, primarily due to potentially serious consequences to fetuses if pregnant individuals contract MPXV.

Epidemiological surveillance datasets did not distinguish between cis and trans women. Of more than 25,000 cases of MPX in the United States, 3.8% were reported to have occurred in cis women and 0.8% in trans women. The number of MPXV infections among women is probably unknown and likely underreported, given international case definitions that specify GBMSM as a risk group.

About the study

In the present study, researchers described the clinical and epidemiological characteristics of MPXV infection in a cohort of women and non-binary individuals from 15 countries. Participating physicians identified non-binary MPXV-infected individuals and women and asked them to participate.

Confirmed MPX was defined as having a polymerase chain reaction (PCR) test specific for MPXV in specimens collected from any anatomical site. Contributing centers were provided with unidentified, structured spreadsheets developed and adapted by participating physicians to include variables relevant to women and non-nary individuals.

The spreadsheets used free text fields and drop-down menus to allow doctors to capture data from paper or electronic medical records. The spreadsheets mainly focused on demographic characteristics, occupation, potential exposures, clinical outcomes, HIV status, early symptoms, diagnosis, co-occurring sexually transmitted infections (STIs), complications, and HIV status.

Results

The present case series included 136 women and non-binary individuals from 15 countries and three WHO regions who presented from 11 May to 4 October 2022. Of these, 68 were from the European Region, 65 from the Americas Region and three were from the African region. The median age was 34, with the majority of individuals being Latinx (45%), followed by white (29%) and black (21%) individuals.

Sixty-nine individuals were cis women, 62 were trans women, and five were nonbinary individuals assigned female at birth. Overall, 89% of participants reported sexual activity with men in the past month. Thirty-four trans women, two cis women, and nonbinary individuals reported active/current sex work.

Nineteen people had children, including one non-binary person; two children subsequently contracted MPXV. Thirty-seven people had HIV, mostly trans women. Of these, 36 were on antiretroviral therapy. Trans women had more sexual partners in the past three months than others.

Sexual contact was suspected to be the most likely route of transmission in 100 MPX cases. Suspected nonsexual transmission routes included occupational exposure, household contact, and close nonsexual contact. Seventeen individuals had a co-occurring STI. Forty-one trans women presented to HIV or sexual health clinics, and 13 presented to emergency departments. Nonbinary individuals and cis women frequently presented to emergency departments and sexual health/HIV clinics.

The median incubation period was seven days, based on assumed exposure and available symptom onset dates for 51 participants. Seventy-six individuals had systemic features. Skin lesions were observed in 124 individuals. At least one anogenital lesion was present in 95 individuals.

Mucosal lesions involving the eye, anus, vagina, or oropharynx occurred in 65 participants. Vulvar lesions were present in 42 cis women and non-binary persons assigned female at birth. Perianal skin lesions were observed in 45 trans and 17 cis women and in non-binary individuals.

Vaginal sex was reported by 35 of 46 subjects with vaginal lesions and anal sex by 49 subjects with anal lesions. Overall, thirty-four participants had no anogenital lesions. The median number of lesions (10) was similar for cis and trans women. All skin and vaginal swabs were positive for MPXV, while 73% of nasopharyngeal swabs were positive.

Seventeen participants were hospitalized for cellulitis, bacterial superinfection, severe anorectal pain, abscess, odynophagia, ocular lesions, infection control purposes, or impaired mental balance. MPXV infection was treated with tecovirimat. Treatment with tecovirimat was more common among people with HIV infection than those without. Six participants received postexposure vaccination and 11 received preexposure vaccination.

Conclusions

In summary, the current case series has offered insights into the clinical features and epidemiology of MPX in cis women, trans women, and nonbinary people. The authors noted that prominent mucosal and genital features commonly seen in men in the current epidemic were replicated in cis/trans women and non-binary individuals.

The anogenital lesions reflected sexual practices; that is, most participants who reported vaginal and anal sex had lesions near those anatomical sites. Together, these findings will help clinicians diagnosed with MPX in cis/trans women and non-binary people and emphasize the significance of sexual history and STI testing.

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