全球北半球和非洲都需要更強的猴痘應對措施
資料來源：麗茲.海利曼 / 2022 年 8 月 3 日 / aidsmap / 財團法人台灣紅絲帶基金會編譯
AIDS 2022 的抗議者要求增加獲得猴痘疫苗和治療的機會。莉茲·海利曼攝
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本週在蒙特婁舉行的第 24 屆國際愛滋病大會（AIDS 2022）上，一些世界領先的猴痘專家和公共衛生官員討論了全球應對日益嚴重的疫情。但倡導者表示，世界在解決這場危機方面做得還不夠，這場危機主要影響的是男同性戀和雙性戀男性。
在周日的媒體圓桌會議上，世界衛生組織 (WHO) 的 Meg Doherty 博士介紹了疫情的最新情況。根據 8 月 2 日的最新情況報告，世衛組織已收到全球 23,351 例實驗室確診猴痘病例的報告，導致 8 人死亡。美國現在報告的病例最多（超過 6,000 例），其次是西班牙、德國和英國（超過 2,600 例）。
「隨著時間的推移，流行病學變得越來越清晰」，多爾蒂說。
疫情爆發三個月後，儘管對其他群體的檢測有所增加，但病例仍然絕大多數集中在男男性行為者身上。根據世界衛生組織的數據，99% 是男性，其中大多數人認為自己是同性戀或雙性戀，並報告說性是他們最可能的傳播途徑。在已知年齡的病例中，有 25 名是 4 歲以下的兒童。
蒙特婁之麥吉爾大學的瑪麗娜.克萊因博士描述了當地對猴痘的反應，這已經超越了許多其他國家。該市似乎有充足的疫苗供應，並為所有男男性行為者和性工作者提供疫苗。同一疫苗產品在加拿大的品牌名稱為 Imvanex，在美國的 Jynneos 和歐洲的 Imvanex。該市為與會者提供疫苗，其中許多是同性戀和雙性戀男性，他們回家後將沒有機會。
記者們在圓桌會議上提出了許多問題，但克萊恩承認，其中許多問題還沒有答案。我們不知道確切的傳播機制，呼吸道是否重要，或者人們是否可以在出現症狀之前傳播病毒。更重要的是，幾乎沒有臨床試驗數據顯示疫苗在接種一劑或兩劑後效果如何，以及使用 tecovirimat (TPOXX) 治療是否會減輕症狀或減少病毒釋出，這對隔離期有影響。
這種不確定性反映在不同的疫苗方案中。美國食品和藥物管理局 (FDA) 堅持認為 Jynneos 是一種兩劑疫苗，人們需要兩劑疫苗。許多城市和國家最初只注射一劑，以立即保護盡可能多的人，但對於第一劑提供多少保護以及人們何時需要獲得第二劑仍存在著混淆。HIV i-Base 的西蒙 .柯林斯說：「沒有人談論有效性，也沒有人談論保護時間」。「有些人正在停止他們的行為並竭盡全力在他們的手臂上打一針，但大多數人根本沒有得到任何信息……這可能會導致更嚴重的流行，因為人們會以為他們已受到保護而走出門去了」。
我們確實有更多答案的一個領域是「症狀」，這要歸功於第一線臨床醫生和分享他們故事的患者之努力。倫敦瑪麗女皇大學的 Chloe Orkin 教授和一個大型合作團隊最近發表了對 500 多例猴痘病例的分析，揭示了該病毒流行國家以前所沒有報導過的新症狀。
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「倡導者不願看到 COVID-19 的情況重演，在這種情況下，高收入國家的低風險人群比低收入國家的許多高風險人群有更好的機會」。
在該病例系列中已知 HIV 感染狀態的患者中，41% 為 HIV 陽性，其中大多數接受了有效的抗反轉錄病毒治療。 Orkin 說，令人欣慰的是，HIV 陽性和 HIV 陰性人群的總體結果沒有差異。然而，她指出，愛滋病毒感染者對第一劑 Jynneos 疫苗的反應較弱，這表明他們應該優先接種第二劑。
在媒體簡報和會議座談會上，Orkin 要求 WHO 和美國疾病控制與預防中心 (CDC) 更新他們的猴痘病例定義，以反映首次報告的新症狀，包括肛門病變和可能類似於常見的性傳播感染之單發的瘡。
奈及利亞之尼日爾三角洲大學的 Dimie Ogoina 博士以虛擬方式在周一的研討會上發表講話，描述了猴痘流行國家不斷變化的疫情。正如 NPR（全國公共廣播電台） 最近報導的那樣，Ogoina 是最早在 2017 年觀察到奈及利亞爆發期間，猴痘病例轉移到沒有傳統危險因素的年輕城市男性的學者之一，這表明該病毒是透過性接觸傳播的。
Ogoina說，自從歐洲和北美開始出現病例以來，奈司利亞的猴痘意識和監測有所提高，但「我們必須確保疫苗和治療藥物公平的分配」。
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需求的獲得
公共衛生官員、臨床醫生和倡導者都同意，全球猴痘疫苗供應跟不上需求，尤其是在高收入國家爭奪有限劑量的情況下。儘管西非和中非國家幾十年來一直面臨猴痘，但它們幾乎無法獲得疫苗和治療。
當疾病預防控制中心愛滋病預防科料長、新任命的美國猴痘應對副協調員 Demetre Daskalakis 博士準備在研討會上發言時，數十名活動家衝上了舞台。抗議者——包括資深的愛滋病活動家——要求在美國和世界範圍內增加獲得疫苗和治療的機會。
儘管美國已經擁有全球疫苗供應的最大份額，但倡導者尤其感到沮喪的是，丹麥的一家工廠有大約 800,000 劑成品延遲數週未使用在等待 FDA藥檢。美國和其他一些國家為生物恐怖主義做好準備，儲備了天花疫苗和治療劑（也適用於猴痘），但活動人士堅持認為，它們應該用於應對男同性戀者面臨的這場健康危機。
「我們現在需要採取行動」，帶頭宣傳猴痘的 PrEP4All ( PrEP for All) 組織的 James Krellenstein 說。 「我們正處於一場本可以很容易預防的惡化疫情中」。
活動人士要求的清單中包括世衛組織和聯合國在全球猴痘疫苗和治療獲取方面的「決定性領導」，包括擴大生產的努力。目前，丹麥只有一家工廠可以生產這種疫苗，每年的生產能力不到 5,000 萬劑。他們呼籲「立即將智慧產權、專有技術和技術轉讓」給世界各地能夠生產疫苗、治療和診斷方法的製造商。
活動人士還要求美國、加拿大、歐盟和其他高收入國家兌現其成為「世界疫苗庫」的承諾。倡導者厭惡看到 COVID-19 疫苗的情況再次重演，在這種情況下，一些高收入國家的低風險人群可能正在接受第二次的加強免疫，而低收入國家的許多高風險人群根本沒有接種過疫苗.
抗議者要求全球猴痘應對措施應優先考慮弱勢群體和社區，並呼籲為需要隔離的人提供資金和支持。但是，他們強調，增加對猴痘反應的資金不得危及對愛滋病毒、肺結核、C型肝炎和性傳播感染的反應。
Stronger monkeypox response needed in both the global North and Africa
Liz Highleyman / 3 August 2022
Protestors at AIDS 2022 demanding increased access to monkeypox vaccines and treatment. Photo by Liz Highleyman
Some of the world’s leading monkeypox experts and public health officials discussed the global response to the growing outbreak at the 24th International AIDS Conference (AIDS 2022) this week in Montreal. But advocates said the world is not doing enough to address the crisis, which is primarily affecting gay and bisexual men.
At a media roundtable on Sunday, Dr Meg Doherty of the World Health Organization (WHO) gave an update on the outbreak. According to its latest situation report, dated 2 August, WHO has received reports of 23,351 laboratory confirmed monkeypox cases worldwide, resulting in eight deaths. The United States is now reporting the most cases (exceeding 6000), followed by Spain, Germany and the United Kingdom (more than 2600).
“The epidemiology is becoming more clear as time goes on,” Doherty said.
Three months into the outbreak, cases remain overwhelmingly concentrated among men who have sex with men, even as testing for other groups has increased. According to WHO, 99% are among men, most of whom identify as gay or bisexual and report sex as their most likely transmission route. Of cases with a known age, 25 were children up to age 4.
Dr Marina Klein of McGill University in Montreal described the local monkeypox response, which has exceeded that of many other countries. The city appears to have an ample supply of the vaccine and is providing shots for all men who have sex with men and sex workers. The same vaccine product has the brand name Imvanex in Canada, Jynneos in the United States and Imvanex in Europe. The city offered vaccines to conference attendees, many of whom are gay and bisexual men who will not have that opportunity when they get home.
Reporters asked numerous questions at the roundtable, but Klein acknowledged that many of them don’t yet have answers. We don’t know the exact mechanisms of transmission, whether the respiratory route is important or whether people can transmit the virus before they develop symptoms. What’s more, there is little clinical trial data showing how well the vaccine works after one or two doses and whether treatment with tecovirimat (TPOXX) reduces symptoms or lessens virus shedding, which has implications for the isolation period.
That uncertainty is reflected in differing vaccine protocols. The US Food and Drug Administration (FDA) maintains that Jynneos is a two-dose vaccine and people need both doses. Many cities and countries are administering one dose initially, to partially protect as many people as possible right away, but there is confusion about how much protection the first dose offers and when people will need to get the second.
“No one is saying anything about efficacy and no one is saying anything about time to protection,” said Simon Collins of HIV i-Base. “You have people who are stopping their behavior and are doing everything they can to get a shot in their arm, but most people are not being given any information at all… That could contribute to a worse epidemic because people will go out thinking they’re protected.”
One area where we do have more answers is symptoms, thanks to the efforts of frontline clinicians and patients who have shared their stories. Professor Chloe Orkin of Queen Mary University of London and a large team of collaborators recently published an analysis of more than 500 monkeypox cases, revealing new symptoms not previously reported in countries where the virus is endemic.
“Advocates are loathe to see a repeat of the COVID-19 situation, where lower-risk people in high-income countries have better access than many high-risk people in low-income countries.”
Among those with a known HIV status in this case series, 41% were HIV positive, most of them on effective antiretroviral therapy. Reassuringly, there were no differences in outcomes overall between HIV-positive and HIV-negative people, Orkin said. However, she noted, people with HIV have a weaker response to the first dose of the Jynneos vaccine, suggesting they should be prioritised for second doses.
At both the media briefing and a conference symposium, Orkin asked the WHO and the US Centers for Disease Control and Prevention (CDC) to update their monkeypox case definitions to reflect new symptoms that are being reported for the first time, including anal lesions and single sores that may resemble common sexually transmitted infections.
Addressing the Monday symposium virtually, Dr Dimie Ogoina of Niger Delta University in Nigeria described the shifting outbreak in countries where monkeypox is endemic. As NPR recently reported, Ogoina was among the first to observe that during a 2017 outbreak in Nigeria, monkeypox cases shifted to young urban men without traditional risk factors, suggesting the virus was spreading through sexual contact.
Since cases started appearing in Europe and North America, there’s been increased monkeypox awareness and surveillance in Nigeria, Ogoina said, but “we must ensure there is equity in the distribution of vaccines and therapeutics.”
Demanding access
Public health officials, clinicians and advocates alike all agree that the global monkeypox vaccine supply is not keeping up with demand, especially as high-income countries vie for the limited number of doses. Although countries in west and central Africa have faced monkeypox for decades, they have virtually no access to vaccines and treatment.
As Dr Demetre Daskalakis, the director of the CDC’s Division of HIV Prevention and newly appointed deputy co-ordinator of the US monkeypox response, prepared to speak at the symposium, dozens of activists stormed the stage. The protesters – including veteran AIDS activists – demanded increased access to vaccines and treatment both in the US and worldwide.
Although the US already owns the lion’s share of the global vaccine supply, advocates are particularly frustrated that some 800,000 finished doses sat unused for weeks at a factory in Denmark awaiting a delayed FDA inspection. The US and some other countries stockpile smallpox vaccines and therapeutics (which also work for monkeypox) to be prepared for bioterrorism, but activists insist they should be used in this health crisis facing gay men.
“We need to act now,” said James Krellenstein of PrEP4All, which has spearheaded monkeypox advocacy. “We’re in a worsening outbreak that could have easily been prevented.”
The activists’ list of demands includes “decisive leadership” from WHO and the United Nations on global monkeypox vaccine and treatment access, including efforts to scale up production. Currently, only a single facility in Denmark can produce the vaccine, with a production capacity of less than 50 million doses per year. They called for “immediate transfer of intellectual property, know-how and technology” to manufacturers around the world that can make vaccines, treatments and diagnostics.
The activists also demanded that the US, Canada, the European Union and other higher-income countries make good on their commitment to be a “vaccine arsenal for the world.” Advocates are loathe to see a repeat of the situation with COVID-19 vaccines, where lower-risk people in some high-income countries may be on their second booster while many high-risk people in low-income countries have not been vaccinated at all.
The protesters demanded that the global monkeypox response prioritises vulnerable populations and communities and called for funding and support for people who need to isolate. But, they emphasised, increased funding for the monkeypox response must not jeopardise responses to HIV, tuberculosis, hepatitis C and sexually transmitted infections.