研究描述了順性別和跨性別女性的猴痘病例
資料來源：Liz Highleyman / 2022 年 11 月 17 日 / aidsmap / 財團法人台灣紅絲帶基金會編譯
圖片：Artem Furman/Shutterstock.com
雖然當前爆發的大多數猴痘患者都是男同性戀者，但一些女性也易感。 今天發表在《刺胳針》雜誌上的一項新研究描述了 15 個國家的順性別和跨性別女性以及非二元性別個體中的 136 個案例。
男性、順性別女性和跨性別女性病例的流行病學、臨床表現和結果在許多方面相似，但研究揭示了一些顯著差異。 雖然今年夏天猴痘在性活躍的男同性戀者中迅速傳播，但病例系列中的順性女性的性伴侶要少得多，而且她們的病例不太可能導致繼續傳播。 到目前為止，還沒有男男性行為者網絡持續傳播到外部。
儘管如此，女性感染病例仍值得關注，部分原因是猴痘可導致懷孕期間出現併發症。 這項研究強調了順式女性診斷不足的可能性以及處於危險中的跨性別女性的社會不穩定地位。
「在全球爆發期間，病例定義正確地關注了受影響最嚴重的群體，即與男性發生性關係的性活躍男性」。 倫敦瑪麗女王大學的 Chloe Orkin 教授說，公共衛生應對措施是針對這一群體量身定制的，她是臨床醫生國際合作研究猴痘的帶頭人。 「然而，隨著疫情的發展，重要的是還要將注意力集中在女性和非二元個體等代表性不足的群體上，以更好地了解他們的風險……這些經驗將有助於告知和調整有效的公共衛生措施，以包容這些群體 」。
正如 aidsmap 先前報導的那樣，英國衛生安全局 (UKHSA) 在 5 月初報告了本次疫情中的首例猴痘病例。 截至 11 月 14 日，UKHSA 已在英國確定了 3,700 多例確診或疑似病例。 截至 11 月 16 日，世界衛生組織 (WHO) 已統計全球有 80,000 多例病例，其中大部分發生在歷史上未報告過猴痘的國家，導致 51 人死亡。
在有可用數據的病例中，大約 97% 是男性，86% 確定為男男性行為者，大約一半的已知狀況感染了 HIV。 這與中非和西非的歷史模式不同，那裡三分之一到一半的猴痘患者是女性，兒童病例並不罕見。
猴痘發病率已從 7 月份的高峰期大幅下降，最近幾周英國的新增病例數降至個位數。 然而，許多專家認為該病毒不會被消滅，而是會繼續低水平傳播，尤其是在弱勢群體中。
Orkin 和 SHARE-net 國際臨床網絡中的一大批合作者先前描述了在爆發的頭幾個月內診斷出的 500 多例猴痘病例，主要是男同性戀者。
現在，合作者發布了一個新的病例系列，描述了 69 名順性別女性、62 名變性女性和 5 名出生時被指定為女性的非二元性別個體，她們在 2022 年 5 月 11 日至 10 月 4 日期間被診斷出患有猴痘。中位年齡為 34 歲，略低於較早前對男同性戀者的分析中 39 歲的中位數更年輕。 大多數是拉丁裔 (45%)、白人 (29%) 或黑人 (21%)。 大約一半生活在歐洲，一半生活在美洲； 只有三個在非洲。
猴痘傳播
雖然性接觸是早期病例系列中幾乎所有男性的疑似傳播途徑，但在新分析中這一比例降至 74%。 但順式和跨式女性的比率存在差異。 雖然 61% 的順性別女性和非二元性別者被認為是透過性行為感染了猴痘，但跨性別女性這一比例上升到了 89%； 分別有 15% 和 11% 的人有未知的傳播途徑。
所有跨性別女性和 14% 的順性別女性和非雙性戀者都報告了肛交，而 69% 的順性別女性和沒有跨性別女性報告了陰道性行為（很少有跨性別女性接受過陰道成形術或性別確認「底部」手術） . 跨性別女性在過去三個月中擁有 10 個性伴侶的中位數，73% 的女性報告有多個男性伴侶。 與此同時，順式女性的中位數只有一個伴侶，並且比跨性別女性更有可能說她們只有一個固定伴侶（分別為 61% 和 13%）。
超過一半 (55%) 的跨性別女性報告有性工作，而只有 3% 的順性別女性和非二元性別者報告過性工作。 在接受測試的人中，21% 的跨性別女性和 7% 的順性別女性同時患有性傳播感染 (STI)。 十分之一的人報告注射吸毒（11% 的跨性別女性和 9% 的順式女性）。 八個人 (6%) 無家可歸，四人 (3%) 是移民。
只有順性別女性懷疑有非性傳播途徑，包括家庭接觸（10%）、非性密切接觸（10%）和醫護人員的職業接觸（5%）。 該病例系列包括兩名護士，他們可能是在照顧猴痘患者時感染了病毒。 一名在採集病灶樣本時不慎被手術刀劃傷，另一名在處理猴痘病毒樣本時無法使用個人防護設備。 令人欣慰的是，儘管大約四分之一的順勢女性有孩子住在同一家庭，但只有兩個孩子感染了猴痘，這顯示「傳播鏈非常有限」，研究作者寫道。
在已知身份的女性中，略多於四分之一 (27%) 感染了 HIV，略低於早期對大多數男同性戀者的分析中 41% 的比率。 但同樣，總體比率掩蓋了跨性別女性（50% HIV 陽性）與順式女性和非二元性別者（8% 陽性）之間的巨大差異。 幾乎每個 HIV 感染者都在接受抗反轉錄病毒治療，81% 的病毒載量檢測不到，CD4 計數的中位數為 600。在 HIV 陰性的個體中，58% 的跨性別女性，但只有 2% 的順式女性，正在使用預防性暴露預防 (PrEP)。
紐約市卡倫洛德社區健康中心的合著者 Asa Radix 博士說：「將跨性別女性和非二元性別個體納入該系列說明了按性別和性別分類的人口統計和結果數據的重要性」。 .
然而，尚未對變性男性進行此類分析，其中一些是男同性戀性網絡的一部分，因此有患猴痘的風險。 美國疾病控制和預防中心報告了大約 70 例跨性別男人。
症狀和照護
與早期病例系列中的男同性戀者一樣，大多數疑似患有猴痘的跨性別女性都去過性健康或 HIV 診所。 相比之下，順性別女性出現在急診科、性健康或 HIV 診所、醫院皮膚科或產科/婦科或初級保健提供者。「這加強了對性健康診所以外的衛生專業人員進行教育的必要性，以確保猴痘症狀不會被誤診並限制繼續傳播」，研究作者說。
總的來說，本病例系列中的女性報告的症狀與早期分析中的男性相似。 幾乎每個人 (93%) 都出現皮疹或皮損，中位數為 10 個瘡。 順式和跨式女性，以及性傳播和非性傳播途徑的人，都有相似數量的病變。 超過 60% 的人有全身症狀，例如發燒和疲勞。 與順性別女性相比，跨性別女性更常出現不伴有全身症狀的局部感染，正如早期男性分析中所見。
近四分之三 (74%) 的人至少有一個肛門或生殖器病變，而大約四分之一的人有口腔病變。 大多數順性別女性和非二元性別者的外陰（外生殖器）或陰道有病變。 大多數跨性別女性和大約四分之一的順式女性有外部或內部肛門或直腸病變或直腸炎（直腸炎症）。 這些症狀通常類似於其他性傳播感染，34% 的順式女性和 10% 的跨性別女性最初被誤診。
「隨著疫情的發展，將注意力集中在女性和非二元性別個體等代表性不足的群體上也很重要」。
「[T] 病變部位在很大程度上與報告的性活動類型相對應」，研究作者指出。「必須讓臨床醫生了解根據性別認同和性行為的不同臨床表現」。疑似非性傳播的人發生肛門或生殖器病變的可能性要小得多，但有些人確實發生了。
在收集了陰道拭子的所有 14 名女性中都檢測到了猴痘 DNA，在早期分析中，32 名男性中有 29 人的精液樣本也是如此。 此外，大約四分之三的肛門/直腸拭子、口腔拭子和血液樣本檢測呈陽性。 這組作者說：「這增加了透過體液和皮膚接觸進行性傳播的可能性」。其他研究顯示，猴痘可能在沒有症狀的情況下傳播。
大多數患有猴痘的人都平安無事地康復了，也沒有死亡報告。 然而，13% 的患者需要住院治療，主要是為了緩解疼痛、吞嚥困難和細菌雙重感染。 HIV 陽性和 HIV 陰性人群的住院率相似。 報告時有兩名婦女懷孕，到目前為止沒有報告併發症。
跨性別女性接受 tecovirimat (TPOXX) 治療的可能性是順式女性的兩倍，分別為 34% 和 16%。 只有 6 人接種了猴痘疫苗以進行暴露後預防。 八名感染猴痘的跨性別女性和兩名順式女性報告說，她們在這次疫情爆發期間接種了暴露前疫苗。
該國際案例系列「為女性猴痘的臨床特徵提供了寶貴的見解」，亞特蘭大埃默里大學的共同作者 Boghuma Titanji 博士說。「重要的是，它還突出了需要我們緊急和有針對性地關注的新出現的不平等領域……隨著猴痘疫情的發展，我們必須吸取這些新出現的教訓，並對女性猴痘採取更全面的方法。 這將確保女性在應對其他疾病時不會像往常一樣落在後面」。
參考文獻：
Thornhill JP et al. 2022 年爆發期間女性和非二元個體的人類猴痘病毒感染：全球病例系列。刺胳針 2022。
Study describes monkeypox cases among cisgender and transgender women
Liz Highleyman / 17 November 2022 / aidsmap
Artem Furman/Shutterstock.com
While most people with monkeypox in the current outbreak have been gay men, some women are susceptible as well. A new study published today in The Lancet describes 136 cases among cisgender and transgender women and non-binary individuals in 15 countries.
The epidemiology, clinical presentation and outcomes of cases among men, cis women and trans women are similar in many respects, but the study reveals some notable differences. While monkeypox spread rapidly this summer among highly sexually active gay men, the cisgender women in the case series have far fewer sex partners and their cases are less likely to result in onward transmission. So far, there has been no sustained spread outside networks of men who have sex with men.
Nonetheless, cases among women warrant attention, in part because monkeypox can lead to complications during pregnancy. This research highlights the potential for under-diagnosis of cis women and the socially precarious position of at-risk trans women.
“During the global outbreak, case definitions have rightly focused on the most affected group, sexually active men who have sex with men. The public health response has been tailored to reach this group,” said Professor Chloe Orkin of Queen Mary University of London, who spearheads an international collaboration of clinicians studying monkeypox. “However, as the outbreak progresses, it’s important to also focus attention on under-represented groups such as women and non-binary individuals to better understand their risk…These learnings will help inform and tailor effective public health measures to be inclusive of these groups.”
As aidsmap previously reported, the UK Health Security Agency (UKHSA) reported the first monkeypox cases in the current outbreak in early May. As of 14 November, UKHSA has identified more than 3700 confirmed or probable cases in the UK. As of 16 November, the World Health Organisation (WHO) has tallied more than 80,000 cases worldwide, mostly in countries that have not historically reported monkeypox, resulting in 51 deaths.
Among cases with available data, about 97% are men, 86% identify as men who have sex with men and around half with a known status are living with HIV. This differs from the historical pattern in central and western Africa, where a third to a half of people with monkeypox are women and cases among children are not unusual.
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Monkeypox incidence has declined dramatically from its July peak, with new cases in the UK falling to single digits in recent weeks. However, many experts think the virus will not be eliminated but rather could continue to circulate at low levels, especially among disadvantaged communities.
Orkin and a large team of collaborators in the SHARE-net international clinical network previously described more than 500 monkeypox cases diagnosed during the first months of the outbreak, primarily among gay men.
Now, the collaborators have published a new case series that describes 69 cisgender women, 62 transgender women and five non-binary individuals assigned female at birth who were diagnosed with monkeypox between 11 May and 4 October 2022. The median age was 34 years, slightly younger that the median of 39 in the earlier analysis of gay men. Most were Latina (45%), White (29%) or Black (21%). About half lived in Europe and half in the Americas; only three were in Africa.
Monkeypox transmission
While sexual contact was the suspected route of transmission for nearly all of the men in the earlier case series, this fell to 74% in the new analysis. But rates diverged for cis and trans women. While 61% of the cisgender women and non-binary people are thought to have acquired monkeypox via sex, this rose to 89% for the trans women; 15% and 11%, respectively, had an unknown transmission route.
All trans women and 14% of cis women and non-binary people reported anal sex, while 69% of cis women and no trans women reported vaginal sex (few of the trans women had undergone vaginoplasty, or gender-affirming ‘bottom’ surgery). Trans women had a median of 10 sex partners in the past three months, and 73% reported multiple male partners. Meanwhile, cis women had a median of one partner and were much more likely than trans women to say they had a single regular partner (61% vs 13%, respectively).
More than half (55%) of the trans women reported sex work, compared with just 3% of the cis women and non-binary people. Among those tested, 21% of trans women and 7% of cis women had concurrent sexually transmitted infections (STIs). One in 10 reported injection drug use (11% of trans women and 9% of cis women). Eight individuals (6%) were experiencing homelessness and four (3%) were migrants.
Only cisgender women had suspected non-sexual routes of transmission, including household contact (10%), non-sexual close contact (10%) and occupational exposure of healthcare workers (5%). The case series includes two nurses who presumably contracted the virus while caring for patients with monkeypox. One sustained an accidental scalpel wound while taking a lesion sample and the other did not have access to personal protective equipment while handling monkeypox virus samples. Reassuringly, although about a quarter of the cis women had children living in the same household, only two children acquired monkeypox, suggesting “very limited chains of transmission,” the study authors wrote.
Just over a quarter (27%) of the women with a known status were living with HIV, somewhat lower than the 41% rate seen in the earlier analysis of mostly gay men. But again, the overall rate hides the wide disparity between trans women (50% HIV positive) and cis women and non-binary people (8% positive). Almost everyone with HIV was on antiretroviral therapy, 81% had an undetectable viral load and the median CD4 count was 600. Among HIV-negative individuals, 58% of the trans women, but only 2% of the cis women, were using pre-exposure prophylaxis (PrEP).
“The inclusion of transgender women and non-binary individuals in this series illustrates the importance of demographic and outcome data being disaggregated by both sex and gender,” said co-author Dr Asa Radix of the Callen-Lorde Community Health Center in New York City.
However, this type of analysis has not yet been done for transgender men, some of whom are part of gay men’s sexual networks and therefore at risk for monkeypox. The US Centers for Disease Control and Prevention reports some 70 cases among trans men.
Symptoms and care
Like the gay men in the earlier case series, a majority of trans women with suspected monkeypox visited sexual health or HIV clinics. Cisgender women, in contrast, presented at emergency departments, sexual health or HIV clinics, hospital dermatology or obstetrics/gynaecology departments or primary care providers. “This reinforces the need for education for health professionals beyond sexual health clinics to ensure that monkeypox symptoms are not misdiagnosed and to limit onward transmission,” say the study authors.
In general, women in this case series reported symptoms similar to those of men in the earlier analysis. Almost everyone (93%) developed a skin rash or lesions, with a median of 10 sores. Cis and trans women, and people with sexual and non-sexual routes of transmission, had similar numbers of lesions. Just over 60% had systemic symptoms such as fever and fatigue. Compared with cis women, trans women more often had localised infections unaccompanied by systemic symptoms, as was seen in the earlier men’s analysis.
Nearly three quarters (74%) had at least one anal or genital lesion while about a quarter had oral lesions. A majority of cisgender women and non-binary people had lesions on the vulva (outer genitalia) or in the vagina. Most trans women and about a quarter of cis women had external or internal anal or rectal lesions or proctitis (rectal inflammation). These symptoms often resembled other sexually transmitted infections, and 34% of cis women and 10% of trans women were initially misdiagnosed.
“As the outbreak progresses, it’s important to also focus attention on under-represented groups such as women and non-binary individuals.”
“[T]he site of the lesions largely corresponded to the type of sexual activity reported,” the study authors noted. “Clinicians must be made aware of the differing clinical presentations according to gender identity and sexual practices.” People with suspected non-sexual transmission were much less likely to develop anal or genital lesions, but some did.
Monkeypox DNA was detected in all 14 women who had vaginal swabs collected, as was the case for 29 of the 32 men with semen samples in the earlier analysis. What’s more, about three quarters of anal/rectal swabs, oral swabs and blood samples tested positive. “This strengthens the likelihood of sexual transmission through bodily fluids as well as skin-to-skin contact,” according to the authors. Other studies suggest that monkeypox could potentially be transmitted in the absence of symptoms.
Most people with monkeypox recovered without incident, and no deaths were reported. However, 13% required hospitalisation, mostly for pain management, difficulty swallowing and bacterial superinfections. Hospitalisation rates were similar for HIV-positive and HIV-negative people. Two women were pregnant at the time of the report with no complications reported so far.
Trans women were about twice as likely as cis women to be treated with tecovirimat (TPOXX), 34% vs 16%, respectively. Only six people received monkeypox vaccination for post-exposure prophylaxis. Eight trans women and two cis women who acquired monkeypox reported that they had received pre-exposure vaccines during this outbreak.
This international case series “provides valuable insights into the clinical features of monkeypox in women,” said co-author Dr Boghuma Titanji of Emory University in Atlanta. “Importantly, it also highlights emerging areas of inequity which require our urgent and targeted attention…As the monkeypox outbreaks evolve, we must draw from these emerging lessons and have a more holistic approach to monkeypox in women. This will ensure that women are not left behind as they often are when addressing other diseases.”
References
Thornhill JP et al. Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series. The Lancet 2022.