猴痘：全球警鐘

資料來源：www.thelancet.com Vol 400 July 30, 2022 / 財團法人台灣紅絲帶基金會編譯

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世衛組織 7 月 23 日宣布當前的猴痘疫情構成國際關注的突發公共衛生事件 (PHEIC)，這是史無前例的。這是第七次這樣的聲明，但第一次反對緊急委員會大多數成員的建議（九人反對，六人讚成）。譚德塞博士的決定是一個勇敢的決定。它需要充當全球警鐘。問題是它是否會促使控制疫情所需的努力升級。譚德塞博士就他的決定給出了三個廣泛的理由。「我們的疫情通過新的傳播方式迅速蔓延到世界各地，我們對此知之甚少，但符合《國際衛生條例》的標準」。這些細節構成了一個令人信服的案例。今年到目前為止，截至7月22日，已有75個國家報告了16,016例病例。在猴痘流行的地方，例如在剛果民主共和國，據報導在不同的人群中爆發了大規模的新疫情。目前，在西非和中非以外，疫情集中在男男性行為者 (MSM)。為什麼該疾病的流行病學發生了變化，以及疫情的許多其他方面都發生了變化。與以前的報告相比，來自非流行國家的近期病例系列顯示臨床特徵存在差異。嗜睡和發燒似乎不太常見，一些患者沒有前驅症狀。皮膚損傷主要見於生殖器或肛周區域。眾所周知，傳播是透過皮膚接觸發生的，但在患者的精液中發現了猴痘 DNA——它是否代表具有複制能力的病毒仍然未知。由於我們不確定的原因，一種疾病在全球範圍內的迅速傳播顯然是譚德塞博士過度關注的問題。現在需要進行緊急的充滿活力的研究工作，以了解與疫情相關的這些問題和其他問題。各國必須加強公共衛生準備和應對。隨著新數據的出現，病例定義應進行更新和協調，並加強監測、病例檢測和接觸者追踪。患者需要在隔離和治療中得到支持，高暴露風險人群可能需要有針對性的免疫接種。最近在 COVID-19 方面的經驗可能有助於各國制定這些措施，但許多衛生系統已經處於臨界點。還有一種風險是公眾對流行病及其控制的討論感到疲倦。關於猴痘的錯誤信息已經開始流傳。公眾需要參與並制定有針對性的風險溝通策略。猴痘不是 COVID-19。 R0 在 1 左右，傳播機制完全不同。似乎是造成此次爆發的猴痘進化枝在很大程度上導致了輕微的自限性疾病，儘管患者已經入院，主要是因為疼痛。確保對這些要點的廣泛理解是管理公眾焦慮的關鍵。自疫情爆發以來，許多 MSM 的參與度一直很高，而且這一人群一如既往地熱衷於照顧自己的健康（並儘自己的一份力量保護他人）。將同性戀定為犯罪和邊緣化 LGBTI+ 社區的國家會危及患者的福祉和控制傳播的機會。需要與污名和歧視作鬥爭。將猴痘歸類為 MSM 疾病是錯誤的。為 COVID-19 開發的醫療對策的研究、開發、監管批准和製造的快速途徑應重新用於猴痘。在一些國家，缺乏診斷測試阻礙了病例識別。 Tecovirimat 最初用於治療天花，已獲得歐洲監管機構的猴痘許可，但尚未獲得美國 FDA 的許可。其他有希望的治療方法，如西多福韋和布林西多福韋 (cidofovir and brincidofovir)，需要臨床研究。一種猴痘疫苗（在歐洲以 Imvanex 和在美國以 Jynneos 的名義銷售）已獲批准，但治療方法和疫苗的供應極為有限。世衛組織將不得不採取更加有力的方法來確保全球可及性並避免 COVID-19 應對措施的不公平現象。無論您是否同意世衛組織的決定，無疑都錯失了良機。猴痘並不新鮮。幾十年來，它一直在造成大量疾病和死亡。專家們長期以來一直呼籲採取負擔得起的對策、加強監測和更多的研究。但與伊波拉病毒和玆卡病毒一樣，猴痘病毒只有在襲擊以白人為主的高收入國家時才會引起全球關注。因此，防止猴痘在全球社區中蔓延的機會之窗正在關閉。現在是關鍵時刻。它需要全球最強大的醫學、科學和政治上之努力。

Monkeypox: a global wake-up call

資料來源：www.thelancet.com Vol 400 July 30, 2022 / 財團法人台灣紅絲帶基金會編譯

WHO’s declaration on July 23 that the current monkeypox outbreak constitutes a Public Health Emergency of International Concern (PHEIC) was unprecedented. It is the seventh such declaration, but the first made against the advice of a majority of the emergency committee (nine were against, six were for). Dr Tedros’ decision is a brave one. It needs to serve as a global wake-up call. The question is whether it will prompt the escalated efforts required to control the outbreak. Dr Tedros gave three broad reasons for his decision. “We have an outbreak that has spread around the world rapidly, through new modes of transmission about which we understand too little, and which meets the criteria in the International Health Regulations.” The details make for a compelling case. So far this year, up to July 22, 16 016 cases have been reported from 75 countries. Where monkeypox is endemic, such as in DR Congo, large new outbreaks have been reported in diverse populations. Outside of west and central Africa, the outbreak is concentrated, for now, in men-who-have-sex-with-men (MSM). Why the disease’s epidemiology has changed is still unclear, as are many other aspects of the outbreak. Recent case series from non-endemic countries have shown differences in clinical features compared with previous reports. Lethargy and fever seem to be less common, and several patients have no prodromal symptoms. Skin lesions are found predominantly in genital or perianal areas. Transmission is known to occur through skin-to-skin contact, but monkeypox DNA has been found in patients’ seminal fluid—whether it represents replication-competent virus remains unknown. The rapid worldwide spread of a disease, for reasons we are unsure of, was clearly an overriding concern for Dr Tedros. An urgent energised research effort is now needed to understand these and other issues related to the outbreak. Countries must strengthen public health preparedness and response. Case definitions should be updated and harmonised as new data emerge, with heightened surveillance, case detection, and contact tracing. Patients need to be supported in isolation and treatment, and targeted immunisation might be needed for people at high risk of exposure. Recent experience with COVID-19 might help countries institute these measures but many health systems are at breaking point already. There is a risk too that the public is fatigued by talk of pandemics and their control. Misinformation about monkeypox has already begun to circulate. The public need to be engaged and targeted risk-communication strategies developed. Monkeypox is not COVID-19. The R0 is around 1, and transmission mechanisms are entirely different. The clade of monkeypox that seems to be responsible for the outbreak largely causes mild self-limiting illness, although patients have been admitted to hospital, mainly for pain. Ensuring wide understanding of these points is key for managing public anxiety. Engagement among many MSM has been high since the outbreak started, and this population is—as ever— keen to take care of its health (and do their part to protect others). Countries that criminalise homosexuality and marginalise LGBTI+ communities risk both patients’ wellbeing and chances of controlling transmission. Stigma and discrimination need to be fought. It would be wrong to categorise monkeypox as a disease of MSM. The expedited pathways for research, development, regulatory approval, and manufacturing of medical countermeasures developed for COVID-19 should be repurposed for monkeypox. A lack of diagnostic tests is hampering case identification in some countries. Tecovirimat, originally produced to treat smallpox, has been licenced by European regulators for monkeypox, but not yet by the US FDA. Other promising treatments, such as cidofovir and brincidofovir, require clinical study. A monkeypox vaccine (sold as Imvanex in Europe and Jynneos in the USA) has been approved, but supplies of both treatments and vaccines are extremely limited. WHO will have to take a much more muscular approach to ensure global access and avoid the inequities of the COVID-19 response. Whether or not you agree with WHO’s decision, there has undoubtedly been a missed opportunity. Monkeypox is not new. It has been causing illness and death in large numbers for decades. Specialists have long called for affordable countermeasures, strengthened surveillance, and more study. But like Ebola and Zika, monkeypox only commands global attention when it hits high-income countries with predominantly White populations. As a result, the window of opportunity to prevent monkeypox becoming established in communities worldwide is closing. Now is a key moment. It warrants the strongest medical, scientific, and political global effort.