西班牙一家穿孔和紋身機構爆發猴痘
資料來源：www.thelancet.com/infection 第 22 卷 2022 年 11 月 / 財團法人台灣紅絲帶基金會編譯
2022 年 7 月 23 日，世衛組織宣布 2022 年猴痘暴發是國際關注的突發公共衛生事件。迄今為止，本次暴發中最常描述的病毒傳播機制是在高危性行為背景下的密切接觸，主要發生在男男性行為者之間。
猴痘病毒屬於痘病毒科正痘病毒屬，已知其在環境中具有長期穩定性。來自猴痘病毒個體（例如皮膚結痂）和受污染污染物的樣本可在較長時間內保持傳染性。
2022 年 7 月 19 日，西班牙加的斯的安達盧西亞流行病學監測系統報告了與穿孔和紋身機構有關的猴痘疫情。五個人被診斷出患有猴痘，並且都具有流行病學關聯。 7 月 6 日，所有 5 人都有在同一設施進行過耳穿孔的歷史。在此，我們描述了 7 月 19 日至 8 月 3 日在歐洲穿孔和紋身機構首次報告的猴痘爆發的臨床和流行病學調查。 .
病例在 2022 年 7 月 19 日至 8 月 3 日期間被通報至安達盧西亞流行病學監測系統。從每個疑似病例中收集水皰病變標本。對猴痘病毒進行了特異性實時 PCR，並確定了 20 個人感染了該病毒。
穿孔和紋身機構只有一名工人，即擁有者。她沒有提供任何與感染相關的流行病學關聯或臨床表現，她的家人、寵物和社會交往也沒有。然而，她報告說在 7 月 6 日接觸了一個可能的指標病例。該客戶在前幾天曾前往馬德里參加社交活動，在進入該機構時，穿刺部位發炎並有泛發皮膚病變，他認為這是服用抗生素的不利影響。由於業主沒有客戶名單，無法確認該客戶是否患有猴痘；因此，在調查期間無法識別此人。 7 月 6 日被認為是疫情爆發的日期，因為可能的指標病例和所有確診感染者從 7 月 6 日起都到了該機構（圖）。
圖：2022 年 7 月 6 日至 7 月 27 日猴痘病毒潛伏期和症狀出現日期的時間表 *在該場所進行了紋身的個人。
總計識別出54名暴露者，發病率為37%。在 20 名確診感染者中，女性 13 人（65%），男性 7 人（35%）。中位年齡為 26 歲 [IQR 16-40;範圍 13-45 歲）。八名 (40%) 人的年齡小於 18 歲。
主要的臨床特徵是皮疹，在所有 20 人的穿孔或紋身區域都發現了皮疹，儘管它也影響了其他部位。最常見的首發臨床表現是穿孔或紋身皮疹（18 [90%] 人）。 11 人 (55%) 存在淋巴結病變，頸部是最常見的位置（5 人 [45%]）。 8 名 (40%) 人出現發燒。在所有個體中，臨床症狀都很輕微，沒有人需要住院。
19 (95%) 人報告有穿孔史，其中 18 (95%) 人有耳洞。一個 (5%) 人的前臂上有紋身。確診感染的個體均未報告針對天花、免疫缺陷或併發疾病的疫苗接種。所有 20 人都不知道或沒有報告與已知的猴痘病例有過接觸。確定密切接觸者96人，無繼發病例報告。
在對企業進行正式檢查期間，發現了多項衛生違規行為，例如衛生條件和無菌條件差。 於 7 月 22 日進行了表面採樣，包括三個區域：支撐工作檯面、工作桌椅和銳器等工作儀器。所有三個樣本均呈猴痘病毒陽性。 7 月 27 日進行了第二次抽樣，重點是銳器和工作工具。 16 個樣本中有 15 個（94%）被發現病毒呈陽性，根據循環閾值，鑷子和剪刀尖的病毒載量最高。
總之，這些研究結果顯示，猴痘病毒可以透過接觸受污染的穿孔或紋身材料傳播，並且由於無菌措施和材料處理不善，可能透過受污染的手傳播。
為了盡量減少進一步傳播的風險，我們將繼續積極與社區合作。這次暴發凸顯了在穿刺和紋身期間接觸猴痘病毒是一種病毒傳播機制。
我們聲明沒有競爭利益。如果沒有安達盧西亞衛生系統中許多同事的貢獻，就不可能發表此評論。我們感謝濱海門大學醫院團隊和 Bahíade Cádiz-La Janda 團隊在疫情調查和控制方面所做的重要工作。我們還要感謝參與疫情監測的安達盧西亞流行病學監測系統的所有成員，以及所有在患者診斷和管理方面合作的醫療保健專業人員。
*Valme del Río García, Jesús García Palacios, Ana Monroy Morcillo, Enric Duran-Pla, Berta Suárez Rodríguez, Nicola Lorusso valme.rio.sspa@juntadeandalucia.es
西班牙加的斯濱海門大學醫院，預防醫學和公共衛生服務（VdRG，AMM）； 西班牙加的斯 Bahíade Cádiz–La Janda 衛生區公共衛生部門 (JGP)； 西班牙塞維利亞衛生和消費部公共衛生和藥品監管總局 (NL) 監測和職業健康服務 (VdRG, ED-P)； 西班牙馬德里衛生部公共衛生總局衛生警報和緊急情況協調中心 (BSR)
Monkeypox outbreak in a piercing and tattoo establishment in Spain
www.thelancet.com/infection Vol 22 November 2022
On July 23, 2022, WHO declared that the 2022 monkeypox outbreak was a public health emergency of international concern. To date, the most commonly described mechanism of viral transmission in this outbreak is close contact in the context of high-risk sexual behaviour, mainly between men who have sex with men.
The monkeypox virus belongs to the orthopoxvirus genus of the Poxviridae family, which is known to have long-lasting stability in the environment. Samples from individuals with monkeypox virus (eg, dermal crusts) and from contaminated fomites can remain infectious for an extended period of time.
On July 19, 2022, a monkeypox outbreak linked to a piercing and tattoo establishment was reported to the Andalusian Epidemiological Surveillance System in Cádiz, Spain. Five individuals were diagnosed with monkeypox and all shared an epidemiological link. All five individuals had a history of ear piercing performed at the same facility, on July 6. Herein, we describe the clinical and epidemiological investigations of the first reported outbreak of monkeypox in a piercing and tattoo establishment in Europe, from July 19 to August 3.
Cases were notified to the Andalusian Epidemiological Surveillance System between July 19 and Aug 3, 2022. Vesicular lesion specimens were collected from each suspected case. Specific real-time PCR for monkeypox virus was performed and 20 individuals were identified to have the virus.
The piercing and tattoo establishment had only one worker, the owner. She did not present any epidemiological link or clinical picture related to the infection,6 nor did her family, pets, and social contacts. However, she reported being in contact with a possible index case on July 6. This client had travelled to Madrid for a social function in the previous days and, when attending the establishment, had inflammation of the area where the piercing was placed and generalised skin lesions, which he thought to be an adverse effect of taking antibiotics. It could not be confirmed whether this client had monkeypox because the owner had no list of clients; therefore, it was not possible to identify this person during the investigation. July 6 was considered to be the date of outbreak onset, given that the probable index case and all individuals with confirmed infection attended the establishment from July 6 onwards (figure).
Figure: Timeline of the incubation period of monkeypox virus and dates of symptom onset from July 6 to July 27, 2022 *Individual who had a tattoo done at the establishment.
54 exposed individuals were identified and the attack rate was 37%. Among the 20 individuals with confirmed infection, 13 (65%) were women and seven (35%) were men. Median age was 26 years [IQR 16–40; range 13–45 years). Eight (40%) individuals were younger than 18 years.
The predominant clinical feature was rash, found in all 20 individuals in the area of piercing or tattoo, although it also affected other locations. The most frequent first clinical manifestation was piercing or tattoo rash (18 [90%] individuals). Lymphadenopathy was present in 11 (55%) individuals, and the cervical location was the most frequent location (five [45%]). Fever was present in eight (40%) individuals. In all individuals, clinical symptoms were mild and no one required hospitalisation.
19 (95%) individuals reported a history of piercing, of whom 18 (95%) had an ear piercing. One (5%) person had a tattoo done on their forearm. None of the individuals with confirmed infection reported vaccination against smallpox, immunodeficiencies, or concurrent diseases. All 20 individuals were unaware of or reported no contact with a known case of monkeypox. 96 close contacts were identified, with no secondary cases reported.
During the official inspection of the establishment, numerous sanitary irregularities were found, such as poor hygiene and aseptic conditions. Surface sampling was performed on July 22, including three areas: the support work surfaces, the work tables and chairs, and sharps and other work instruments. All three samples were positive for monkeypox virus. A second sampling was performed on July 27, focusing on sharps and work tools. 15 (94%) of 16 samples were found to be positive for the virus, with tweezers and scissors tips having the highest viral load according to cycle threshold values.
Together, these findings suggest that monkeypox virus can be transmitted through exposure to contaminated piercing or tattoo material and, potentially through contaminated hands, due to poor aseptic measures and handling of materials.8
To minimise the risk of further transmission, we continue to actively work with the community. This outbreak highlights that exposure to monkeypox virus during piercing and tattooing is a mechanism of viral transmission.
We declare no competing interests. This Comment would not have been possible without the contribution of many colleagues in the Andalusian health system. We thank the Hospital Universitario Puerta del Mar team and the Bahía de Cádiz–La Janda team, for their important work in the outbreak investigation and control. We also thank all of the members of the Andalusian Epidemiological Surveillance System who have participated in the outbreak surveillance and all of the healthcare professionals who collaborated in the diagnosis and management of patients. *Valme del Río García, Jesús García Palacios, Ana Monroy Morcillo, Enric Duran-Pla, Berta Suárez Rodríguez, Nicola Lorusso valme.rio.sspa@juntadeandalucia.es
Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Puerta del Mar, Cadiz, Spain (VdRG, AMM); Unidad de Salud Pública, Distrito Sanitario Bahía de Cádiz–La Janda, Cadiz, Spain (JGP); Servicio de Vigilancia y Salud Laboral (VdRG, ED-P), Dirección General de Salud Pública y Ordenación Farmacéutica (NL), Consejería de Salud y Consumo, Junta de Andalucía, Seville, Spain; Centro de Coordinación de Alertas y Emergencias Sanitarias, Dirección General de Salud Pública, Ministerio de Sanidad, Madrid, Spain (BSR)