猴痘正在全球男同性戀者中傳播
控制良好的愛滋病毒感染者風險並未增加
資料來源：利茲.海利曼 / 2022 年 5 月 25 日 / aidsmap / 財團法人台灣紅絲帶基金會編譯
圖片：英國衛生安全局
世界衛生組織（WHO）現已在十多個國家確認了近100例猴痘病例，其中英國最多。雖然迄今為止大多數病例發生在男同性戀和雙性戀男性中，但衛生官員強調，任何人都可以透過密切的個人接觸感染病毒。
英國衛生安全局 (UKHSA) 於 5 月 7 日報告了當前爆發的首例病例，該病例是一名最近前往猴痘流行的奈及利亞的男子。緊隨其後的是另外兩個同住一個家庭的病例和四個男同性戀和雙性戀男性病例，他們似乎都是在本土當地感染了病毒。截至 5 月 23 日，英國健康服務署(UKHSA)報告了英格蘭 70 例確診病例和蘇格蘭 1 例確診病例。
世衛組織 5 月 21 日的最新更新列出了 92 例確診病例和 28 例疑似病例。在英國之後，西班牙和葡萄牙報告的病例最多，其他幾個歐洲國家、加拿大、美國和澳大利亞的病例數量較少。 Global.health 根據各種來源編制的非正式統計數據列出了截至 5 月 25 日全球 300 多例確診或疑似病例。
據世界衛生組織稱，到目前為止，病例「主要但不完全是在男男性行為者中發現的」。在已知性別和年齡的 Global.health 病例中，除三人外，其餘均為年輕或中年男性。許多受影響的男性認為自己是同性戀或雙性戀或在性健康診所尋求治療。據報導，有幾起案件與西班牙的桑拿浴室和比利時的戀物節有關。許多男性報告了最近的國際旅行。
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猴痘背景
猴痘與天花有關，並不是一種新疾病。儘管它的名字，它最常與囓齒動物有關。雖然主要見於中非和西非，但偶爾在歐洲和其他地方報告孤立病例，通常涉及旅行者。目前的疫情是非洲以外有史以來規模最大的一次。
天花疫苗接種也可以預防猴痘，自從常規天花疫苗接種停止以來，猴痘病例在過去幾十年中一直在上升；世界衛生組織於 1980 年宣布天花已在世界範圍內根除。這意味著只有老年人才有疫苗誘導的免疫力。
猴痘不像天花那麼嚴重，通常會引起流感樣症狀（例如發燒、疲勞、肌肉酸痛）、淋巴結腫大和皮疹。皮疹可能出現在面部、生殖器、手掌、腳底和身體其他部位。瘡口可以是扁平的、凸起的或充滿膿液的，並且可能類似於皰疹、梅毒或水痘等其他疾病。在本次疫情中，一些病例最初出現生殖器皮疹，有些病例沒有報告其他症狀。該病毒的潛伏期長達三週，疾病通常持續兩到四周。
猴痘病毒透過密切的個人接觸傳播，包括皮膚接觸和接吻。密切接觸可能涉及家庭成員和醫護人員。該病毒還可以透過接觸過瘡液的衣服或床單傳播。衛生官員說，猴痘可以透過呼吸道飛沫近距離傳播，但病毒似乎不像導致 COVID-19 的 SARS-CoV-2 冠狀病毒那樣透過空氣傳播更遠距離。
猴痘一般不被認為是性傳播感染，並不清楚是否可以透過性交時的精液傳播。「猴痘不是典型意義上的性傳播感染，但它可以在性接觸和親密接觸中傳播」，美國疾病控制和預防中心的流行病學家約翰·布魯克斯博士在 5 月 23 日的新聞發布會上說。
專家們歷來認為猴痘不容易在人與人之間傳播，目前尚不清楚為什麼它現在傳播得更廣泛。一些人認為該病毒可能已經進化為更容易傳播，但到目前為止，基因測序並不支持這一假設。更有可能的是，該病毒偶然進入了社交網絡或性網絡，並找到了傳播的有利條件。
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公共衛生建議
衛生官員敦促任何身體任何部位，尤其是生殖器出現異常皮疹或病變的人，聯繫他們的醫療保健提供者或性健康診所。建議懷疑自己可能患有猴痘的人在接受檢測前不要進行密切的社交接觸。已知病例的高危接觸者應隔離並自我監測症狀長達 21 天。根據歐洲疾病預防和控制中心 (ECDC) 的說法，確診猴痘的人應隔離、避免性活動並避免密切的身體接觸，直到皮疹完全癒合。
「如果有人懷疑他們身體的任何部位可能出現皮疹或病變，特別是如果他們最近有了新的性伴侶，他們應該限制與他人的接觸，並儘快聯繫 NHS 111 或當地的性健康服務——並請在本人出現之前提前打電話」，英國健康服務署(UKHSA)首席醫療顧問蘇珊.霍普金斯博士說。
患有猴痘的人通常無需治療即可康復。在歐洲流行的病毒株致死率約為 1%；在目前的爆發中沒有死亡報告。猴痘更有可能在兒童、孕婦和免疫功能低下的人群中引起嚴重疾病。
英國性健康與愛滋病協會主席 Claire Dewsnap 博士在 aidsmap的一個聊天版中談論猴痘。
然而，正在接受抗反轉錄病毒治療而其病毒受抑制且 CD4 計數超過 200 的 HIV 感染者「沒有任何特別的風險會變得更加不適」，英國性健康與 HIV 協會主席 Claire Dewsnap 博士在5 月 23 日aidsmap的聊天版上說道。
「目前幾乎沒有數據可以衡量 HIV 對與猴痘相關的發病率和死亡率的影響」，根據歐洲愛滋病臨床協會的說法。「患有晚期和不受控制的愛滋病毒的人可能罹患嚴重疾病和更高的風險會長時間排出病毒」。
猴痘可以透過環形疫苗接種來控制，換句話說，針對受感染個體的密切接觸者進行有針對性的天花疫苗接種。此次疫情引發了恢復普遍接種天花疫苗的呼聲，但專家表示，目前沒有必要在普通人群中控制猴痘。
較舊的活天花疫苗（由稱為牛痘的病毒製成）可能會導致不良事件，尤其是在免疫功能低下的人群中，但有一種更新、更安全的非複制型天花和猴痘疫苗（商品名為 Imvanex 或 Jynneos）。它分別於 2013 年和 2019 年獲得歐洲和美國監管機構的批准，並被英國當局推薦用於當前的疫情。英國和其他國家儲備了天花疫苗以防生物恐怖主義，並正在增加供應。
現在正在向已知病例的高風險接觸者和醫療保健提供者接種天花疫苗。由於猴痘的潛伏期很長，因此在接觸猴痘後最多兩週內接種疫苗可以降低出現症狀感染或嚴重疾病的風險。新疫苗已經過測試，證明對愛滋病毒感染者是安全的。對於 CD4 計數較高的抗反轉錄病毒藥物患者，Dewsnap 建議：「如果您已被提供了天花疫苗，那您就應該接種」。
用於治療天花的抗病毒藥物也可用於治療猴痘，包括可防止病毒從細胞中排出的 tecovirimat (TPOXX)，以及核苷類似物 cidofovir（Vistide；熟悉用於治療鉅細胞病毒性視網膜炎）和 brincidofovir (Tembexa)。
衛生官員和研究人員仍在了解正在進行的疫情，但猴痘不像 COVID-19 那樣容易傳播，且大多數人預計不會出現如此規模的新流行病。專家預計猴痘病例會隨著社交和性網絡中的新人暴露以及先前暴露的個體進入潛伏期而增加。但他們希望接觸者追踪、隔離和疫苗接種能夠控制疫情。
根據歐洲疾病預防和控制中心(ECDC)的流行病學評估，「猴痘在歐盟/歐洲經濟區擁有多個性伴侶的人中傳播的可能性被認為很高」。但鑑於迄今為止該疾病是輕微的，因此該群體的總體風險被認為是中等的，而對於更廣泛的人群來說總體風險較低。
於此同時，LGBT 社區中的許多人擔心，主要襲擊男同性戀和雙性戀男性的疾病可能會導致與愛滋病毒和愛滋病相同的責備和污名。認知誰是受影響最大的入對於集中目標提供教育和資源很重要，但污名可能會阻止生病或已暴露的人尋求照護，且將其稱為「同性戀疾病」可能會導致其他人認為他們沒有風險。「它是一種病毒——它不會選擇、不會判斷、沒有任何道德」，aidsmap 執行董事馬修·霍德森 (Matthew Hodson) 說。「與疾病作鬥爭，但不要與可能具更大感染風險的人作鬥爭」。
Monkeypox is spreading among gay men worldwide
People with well-controlled HIV are not at increased risk
Liz Highleyman / 25 May 2022
Image: UK Health Security Agency
The World Health Organization (WHO) has now confirmed nearly 100 cases of monkeypox in over a dozen countries, with the largest number in the UK. While most cases so far are among gay and bisexual men, health officials emphasise that anyone can contract the virus through close personal contact.
The UK Health Security Agency (UKHSA) reported the first case in the current outbreak on 7 May in a man who had recently travelled to Nigeria, where monkeypox is endemic. This was soon followed by two additional cases who share a household and four cases among gay and bisexual men, all of whom appear to have contracted the virus locally. As of 23 May, UKHSA has reported 70 confirmed cases in England and one in Scotland.
The latest WHO update on 21 May listed 92 confirmed and 28 suspected cases. After the UK, the most cases have been reported in Spain and Portugal, with smaller numbers in several other European countries, Canada, the United States and Australia. An informal tally by Global.health, compiled from various sources, listed more than 300 confirmed or suspected cases worldwide as of 25 May.
Cases so far have “mainly but not exclusively been identified amongst men who have sex with men,” according to WHO. Among the Global.health cases with a known sex and age, all but three are young or middle-aged men. Many of the affected men identify as gay or bisexual or sought care at sexual health clinics. Several cases are reportedly linked to a sauna in Spain and a fetish festival in Belgium. Many of the men reported recent international travel.
Monkeypox background
Monkeypox, which is related to smallpox, is not a new disease. Despite its name, it is most commonly associated with rodents. Although primarily seen in Central and West Africa, isolated cases are occasionally reported in Europe and elsewhere, often involving travellers. The current outbreak is the largest ever seen outside of Africa.
Smallpox vaccination prevents monkeypox as well, and monkeypox cases have been rising over the past few decades since routine smallpox vaccination was discontinued; WHO declared that smallpox had been eradicated worldwide in 1980. This means only older people have vaccine-induced immunity.
Less severe than smallpox, monkeypox typically causes flu-like symptoms (e.g., fever, fatigue, muscle aches), swollen lymph nodes and a rash. The rash can appear on the face, genitals, palms, soles of the feet and elsewhere on the body. The sores can be flat, raised or pus-filled, and may resemble other conditions such as herpes, syphilis or chickenpox. In the current outbreak, several cases initially presented with a genital rash, and some did not report other symptoms. The virus has an incubation period of up to three weeks, and the illness typically lasts two to four weeks.
The monkeypox virus is transmitted through close personal contact, including skin-to-skin contact and kissing. Close contact may involve household members and health care workers. The virus can also spread via clothes or linens that have been in contact with fluid from sores. Health officials say monkeypox can be transmitted via respiratory droplets at close range, but the virus does not appear to spread through the air over longer distances in the same way as the SARS-CoV-2 coronavirus that causes COVID-19.
Monkeypox is generally not considered a sexually transmitted infection, and it is not known whether it can be transmitted through semen during intercourse. “Monkeypox is not a sexually transmitted infection in the typical sense, but it can be transmitted during sexual and intimate contact,” Dr John Brooks, an epidemiologist with the US Centers for Disease Control and Prevention, said during a 23 May media briefing.
Experts historically thought monkeypox was not easily transmitted between humans, and it is unclear why it is now spreading more extensively. Some have suggested the virus may have evolved to become more easily transmissible, but so far genetic sequencing does not support this hypothesis. More likely, the virus entered a social or sexual network by chance and found favourable conditions for transmission.
Public health advice
Health officials are urging anyone with an unusual rash or lesions on any part of their body, especially the genitals, to contact their health care provider or a sexual health clinic. People who suspect they may have monkeypox are advised to refrain from close social contact until they get tested. High-risk contacts of known cases should isolate and self-monitor for symptoms for up to 21 days. People with confirmed monkeypox should isolate, abstain from sexual activity and avoid close physical contact until the rash heals completely, according to the European Centre for Disease Prevention and Control (ECDC).
“If anyone suspects they might have rashes or lesions on any part of their body, particularly if they have recently had a new sexual partner, they should limit their contact with others and contact NHS 111 or their local sexual health service as soon as possible—though please phone ahead before attending in person,” said UKHSA chief medical adviser Dr Susan Hopkins.
People with monkeypox usually recover without treatment. The strain circulating in Europe has a fatality rate of around 1%; there have been no deaths reported in the current outbreak. Monkeypox is more likely to cause severe illness in children, pregnant women and immunocompromised people.
Dr Claire Dewsnap, President of the British Association for Sexual Health and HIV, talks about monkeypox in aidsmapCHAT.
However, people with HIV who are on antiretroviral treatment with viral suppression and a CD4 count above 200 “are not at any particular risk of becoming significantly more unwell,” Dr Claire Dewsnap, president of the British Association for Sexual Health and HIV, said during a 23 May aidsmapCHAT.
“There is little data currently to gauge the impact of HIV on morbidity and mortality associated with monkeypox,” according to the European AIDS Clinical Society. “It is likely that persons with advanced and uncontrolled HIV may be at a higher risk of severe disease and prolonged viral shedding.”
Monkeypox can be controlled through ring vaccination, in other words targeted smallpox vaccination for close contacts of an infected individual. The outbreak has spurred calls for resuming universal smallpox vaccination, but experts say this is not necessary to control monkeypox in the general population at this time.
The older live smallpox vaccine (made from a virus called vaccinia) can cause adverse events, especially in immunocompromised people, but there is a newer, safer non-replicating smallpox and monkeypox vaccine (brand names Imvanex or Jynneos). It was approved by European and US regulators in 2013 and 2019 respectively, and is recommended for use in the current outbreak by UK authorities. The UK and other countries maintain a stockpile of smallpox vaccine in case of bioterrorism and are increasing their supplies.
Smallpox vaccines are now being given to high-risk contacts of known cases and health care providers. Because the monkeypox incubation period is so long, vaccination up to two weeks after exposure can reduce the risk of symptomatic infection or severe illness. The new vaccine has been tested and shown to be safe for people with HIV. For people on antiretrovirals with a high CD4 count, Dewsnap advised, “If you’re offered a smallpox vaccine, you should take it.”
Antiviral medications used to treat smallpox can also be used for monkeypox, including tecovirimat (TPOXX), which prevents viral egress from cells, and the nucleoside analogues cidofovir (Vistide; familiar as a treatment for cytomegalovirus retinitis) and brincidofovir (Tembexa).
Health officials and researchers are still learning about the ongoing outbreak, but monkeypox does not spread as easily as COVID-19, and most do not expect a new pandemic of that scale. Experts expect monkeypox cases to increase as new people within social and sexual networks are exposed and previously-exposed individuals move through the incubation period. But they hope contact tracing, isolation and vaccination can bring the outbreak under control.
Based on an ECDC epidemiological assessment, “the likelihood of monkeypox spreading in persons having multiple sexual partners in the European Union/European Economic Area is considered high.” But given that the disease has so far been mild, the overall risk is considered moderate for this group and low for the broader population.
Meanwhile, many in the LGBT community are concerned that a disease primarily striking gay and bisexual men could lead to the same kind of blame and stigma seen with HIV and AIDS. Acknowledging who is most affected is important for targeting education and resources, but stigma could discourage ill or exposed people from seeking care, and calling it a “gay disease” could lead others to assume they’re not at risk.
“It’s a virus – it doesn’t choose, it doesn’t judge, it doesn’t have any morality to it,” aidsmap executive director Matthew Hodson said. “Fight the disease, don’t fight people who might be a greater risk for acquiring the infection.”