資料來源：www.thelancet.com 2023 年 1 月 17 日
譯註：目前亞洲之疫情正方興未艾，故本文針對區域性疫情的分析仍值得參考。
自 2022 年 5 月以來，世衛組織所有六個區域均報告了 mpox 病（以前稱為猴痘），實驗室確診病例達 84,330 例（截至 2023 年 1 月 6 日）。 儘管歐洲最初報告的病例數量很多（非洲以外第一個報告 mpox 病例的地區），但透過有效的接觸者追踪、治療和有針對性的預防措施迅速遏制了疫情，將嚴重程度降至最低。 同樣的事情並沒有發生在美洲。 在全球報告的 74 例 mpox 死亡病例中，有 54 例發生在美洲，該地區的疾病負擔最高。 美洲是全球受影響最嚴重的十個國家中的六個（美國、巴西、哥倫比亞、秘魯、墨西哥和加拿大），截至 2023 年 1 月，這些國家報告的確診病例超過 57,000 例。在本期《刺胳針》區域健康特刊中 – 美洲，我們展示了一系列論文，探討該地區當前緊急情況的臨床、心理、政治和人道主義方面，特別關注巴西和墨西哥，並呼籲共同努力，以實現全球消除 mpox，不留下任何區域。
持續爆發的流行病學顯示大多數傳播是透過性接觸發生的，將 mpox 確立為一種新出現的性傳播感染 (STI)。 儘管監測數據仍然不完整，但非洲以外的大多數確診病例都是男男性行為者 (MSM)，現有信息顯示 mpox、HIV 和其他 STI 之間存在重要的交叉點。 巴西和墨西哥的兩個案例系列重現了全球模式，這是拉丁美洲國家的第一份詳細報告。 在巴西，Silva 及其同事發現，里約熱內盧 89·7% 的確診病例是由 MSM 報告的，53·2% 為 HIV 陽性，21·2% 患有梅毒，33·0% 患有其他 STI。 在墨西哥世代中，Núñez 及其同事發現 97⋅6% 的確診病例是由 MSM 報告的，52⋅9% 為 HIV 陽性。 mpox 和其他 STI 之間的重疊是一線希望，因為它可以為實施和加強聯合的、有針對性的行動提供動力，以增加對高危人群中幾種同時發生的 STI 的診斷和治療。 可悲的是，當前的疫情與對該疾病的高度污名化、阻礙疑似病例尋求診斷和治療、阻礙公眾消除傳播的努力以及煽動錯誤信息和歧視有關。 20世紀80年代初愛滋病流行期間也面臨類似問題，我們不能再重蹈覆轍。
在美洲遏制和消除 mpox 的努力正在進行中，但取得了不同程度的成功。 美國 MSM 報告病例數有所下降似乎與與關鍵社區的有效溝通和接觸有關，同時對高危人群和病例接觸者進行了疫苗接種。 然而，與 COVID-19 大流行初期類似，缺乏分類數據可能掩蓋了對某些群體的不成比例的影響和不平等的訪問。 Nsoesie 和 Vu 引用了美國喬治亞州的案例，2022 年 8 月，黑人居民佔 mpox 陽性病例的 79%，但只有 45% 的 mpox 疫苗 Jynneos 接受者。 在巴西，缺乏對緊急情況的領導承諾可能有利於案件的激增。 時任總統博爾索納羅在疫情最嚴重的時刻發表的恐同聲明加劇了人們對這種疾病的污名化，該國現在缺乏唯一獲得國家批准的治療藥物 (Tecovirimat)，而且疫苗劑量延遲到達。 在本期特刊中，Scheffer 及其同事以及 Gadelha 及其同事討論了巴西的 mpox 應對案例，並提出了可以幫助該地區克服衛生緊急情況的行動建議。 減少獲得緊急批准的抗病毒藥物和天花疫苗 (MVA-BN) 是所有拉丁美洲和加勒比 (LAC) 國家的一個反復出現的問題，這些國家依賴外部提供的藥物和疫苗，並在我的公共運動下遏制疫情和消除傳播 。 泛美衛生組織循環基金已透過巴伐利亞北歐藥廠獲得一些第三代疫苗，供拉丁美洲和加勒比國家使用，並呼籲採取更多合作行動來阻止該地區的疫情爆發。
由於mpox 多國收疫情故於 2022 年 7 月 23 日被宣佈為國際關注的突發公共衛生事件 (PHEIC)，WHO 秘書長譚德塞博士希望能夠在 2023 年宣布 mpox 的 PHEIC 結束。這是根據當前全球趨勢，每周病例數較 2022 年 8 月的峰值下降了 90% 以上； 然而，全球情況並不相同。 如果我們只看美洲，幾個國家的每周病例繼續增加，該地區是唯一一個在世衛組織評估中仍被視為高風險的地區。 儘管全球趨勢顯示情況似乎正在走向解決，但消除 mpox 必須是一項國際努力。 如果美國和非洲國家仍然是病毒庫，那麼在歐洲實現零新增病例並不能解決問題。 過去二十年忽視非洲 mpox 的流行可能是我們現在與多國健康威脅作鬥爭的主要原因。 透過每個地區的視角來看待緊急情況對於公平和以人口為中心的反應很重要。 有了這個特刊，我們呼籲統一響應，旨在全球消除 mpox，以防止歷史重演。 在每個人都安全之前，沒有人是安全的。
▪ 剌胳針區域衛生——美洲
The cycle of neglect: the mpox emergency in the Americas is far from ending
www.thelancet.com Vol 17 January, 2023
Since May 2022, mpox disease (formerly monkeypox) has been reported across all six WHO regions, accounting for 84330 laboratory-confirmed cases (as of January 06, 2023). Despite the high number of cases initially reported in Europe (the first region outside Africa to report mpox cases), the outbreak was quickly contained using effective contact tracing, treatment, and targeted preventive measures that kept serious outcomes to a minimum. The same did not happen in the Americas. Out of the 74 mpox deaths reported worldwide, 54 happened in the Americas, and the region has the highest disease burden. The Americas house six of the ten most affected countries globally (USA, Brazil, Colombia, Peru, Mexico, and Canada), from which more than 57,000 confirmed cases were reported as of January, 2023. In this special issue of The Lancet Regional Health – Americas, we present a collection of papers that explore the clinical, psychological, political, and humanitarian aspects of the current emergency in the region, with a special focus on Brazil and Mexico, and call for unified efforts that aim at a global elimination of mpox, leaving no region behind.
The epidemiology of the ongoing outbreak suggests most transmissions happened through sexual contact, establishing mpox as an emerging sexually transmissible infection (STI). Although surveillance data remain incomplete, most confirmed cases outside Africa have been among men who have sex with men (MSM) and the available information suggests an important intersection between mpox, HIV, and other STIs. The global pattern was reproduced in two case series from Brazil and Mexico, the first detailed reports from Latin American countries. In Brazil, Silva and colleagues found that 89⋅7% of confirmed cases in Rio de Janeiro were reported by MSM, 53⋅2% were HIVpositive, 21⋅2% had syphilis, and 33⋅0% had other STIs. In a Mexican cohort, Núñez and colleagues found that 97⋅6% of confirmed cases were reported by MSM, and 52⋅9% were HIV-positive. The overlap between mpox and other STIs is a silver lining as it can provide impetus for the implementation and strengthening of combined, targeted actions to increase diagnosis and treatment for several co-occurring STIs in high-risk groups. Sadly, the current outbreak has been linked to high levels of stigmatisation of the disease, discouraging suspected cases from seeking diagnosis and treatment, hindering public efforts to eliminate transmission, and fomenting misinformation and discrimination. Similar issues were faced in the early 1980s during the HIV epidemic, and it is unacceptable for us to repeat the same mistakes.
Efforts to contain and eliminate mpox in the Americas are underway, but with varying degrees of success. Some decline in reported cases among MSM in the USA appears to be linked to effective communication and engagement with key communities, paired with vaccination of at-risk populations and case-contacts. However, similar to the early days of the COVID-19 pandemic, the lack of disaggregated data may hide the disproportionate impact and unequal access for certain groups. Nsoesie and Vu cite the case of Georgia, USA, where in August, 2022, Black residents made up 79% of the positive mpox cases but only 45% of the recipients of the mpox vaccine Jynneos. In Brazil, the lack of leadership commitment to the emergency may have favoured the explosion of cases. Homophobic declarations by thenPresident Bolsonaro during the worst moments of the outbreak cemented the stigmatisation of the disease, and the country now has a shortage of the only nationally approved treatment (Tecovirimat) and delayed arrival of vaccine doses. In this special issue, Scheffer and colleagues and Gadelha and colleagues discuss the case of the mpox response in Brazil and propose actions that could help the region overcome the health emergency. Reduced access to emergency-approved antivirals and the smallpox vaccine (MVA-BN) is a recurrent issue for all Latin American and Caribbean (LAC) countries that rely on externally provided drugs and vaccines and undermine public campaigns to contain the outbreak and eliminate transmission. The PAHO Revolving Fund has secured some of the third generation vaccines through Bavarian Nordic to be made available for LAC countries and called for more collaborative action to stop the outbreak in the region.
The multicountry mpox outbreak was declared a Public Health Emergency of International Concern (PHEIC) on July 23, 2022, and the WHO directorgeneral, Dr Tedros Adhanom Ghebreyesus, hopes to be able to declare the end of PHEIC for mpox in 2023. This is based on the current global trend that weekly cases have declined more than 90% from the peak in August, 2022; however, the global picture is not an homogeneous one. If we look at the Americas alone, weekly cases continue to increase in several countries, and the region is the only one still considered at high risk under WHO assessments. Although the global trend indicates that the situation seems to be moving towards resolution, eliminating mpox must be an international effort. Achieving zero new cases in Europe does not solve the problem if American and African countries remain a reservoir of viruses. Neglecting the endemic circulation of mpox in Africa for the past two decades is probably the main reason we are now battling a multicountry health threat. Looking at the emergency through each region’s lenses is important for an equitable and population-centred response. With this special issue, we call for a unified response that aims for global mpox elimination to prevent history from repeating itself. No one is safe until everyone is.
▪ The Lancet Regional Health – Americas