西班牙的猴痘：迄今為止的故事
資料來源：格蕾塔·休森 / 2022 年 10 月 6 日 / aidsmap / 財團法人台灣紅絲帶基金會編譯
最近的猴痘疫情影響了歐洲地區的國家，西班牙報告的病例數是迄今為止最多的。
密切參與西班牙應對工作的皮膚科醫生剋里斯蒂娜·加爾萬博士在此回顧了迄今為止應對疫情的經驗。
您是如何參與猴痘應對的？
作為一名對被忽視的皮膚病和研究感興趣的皮膚科醫生，我與一個研究團隊合作，專注於新興的感染和具有影響皮膚症狀的傳染性疾病。
猴痘爆發時，我把其他項目放在一邊，全身心投入。我們的團隊目前在幾條研究方向上處於領先地位，我在某種程度上都在進行合作。其中，我參與的最多的是疫苗功效研究。
您是如何第成為一個知道西班牙有人被診斷出罹患有猴痘的？
我聽說在英國被診斷出一種不尋常的皮疹，PCR 檢測顯示是由猴痘引起的，不久之後在西班牙和其他歐洲國家被診斷出來。
這強烈地引起了我的興趣。這種感染對我來說並不新鮮，但具有非常不同的臨床和流行病學模式。我經常在非洲農村擔任皮膚科醫生，當我在現場或透過遠程皮膚科看到患者時，我的腦海中總是會出現診斷，這些患者的症狀與猴痘的臨床表現相符。儘管由於在這些被忽視的地區無法獲得診斷測試，我們無法確認診斷，但有兩次我們在遠程皮膚科看到的病例中高度懷疑猴痘。
在歐洲爆發時，人們所經歷的皮疹和症狀的收集截然不同。不同國家同時突然爆發大量病例，與此前猴痘的流行病學模式不符。潛伏期、傳播方式和感染途徑似乎大相徑庭。
我們肯定需要知道更多。我聯繫了在性健康診所工作並治療第一批西班牙病例的同事。作為一個團隊，我們了解了這次疫情的臨床和流行病學特徵，並開始努力尋找這種疾病的答案。這是一種我們已經知道的疾病，但它以不同的方式呈現給我們。
您如何描述疫情爆發初期發生的事情？
描述我們在疫情爆發初期的活動最準確的詞是「忙碌」。我在山裡度假，但我大部分時間都在手機上工作，聯繫同事，尋找可以為我們提供流行病學線索的數據，挖掘以前的猴痘病例和舊的天花之出版物上的少量證據，以了解並能夠採取措施阻止傳播。
在很短的時間內，我們與其他研究小組合作設計了協議和問卷，盡量不丟失任何案例的信息。我們知道並與在我們國家和世界其他地方監測病例的衛生當局保持聯繫。
如果你要問我，我們和衛生當局的反應是否足夠迅速和足夠好，我會說不。我們在以前的知識的基礎上工作。我們習慣於在以前的知識的基礎上工作，當新的健康相關情況出現時，反應不夠快。總是有改進的餘地。這就是為什麼我認為從每種情況中學習非常重要，這樣我們才能在新情況出現時變得更好。
您是最近一項關於猴痘臨床表現的研究的合著者。你從中學到了什麼？
從那項研究中我了解到，正如我們所懷疑的那樣，主要傳播途徑是透過一個受影響的人和另一個人之間的皮膚和/或粘膜的密切接觸。
我們的研究是第一個透過在從皮膚損傷處採集的樣本中發現更高的 PCR 陽性和病毒載量來證明這一點的研究，與其他樣本相比，例如上呼吸道粘膜。這對於去組織預防措施和避免那些不是真正必要的措施很重要。
我了解到，與性行為相關的風險因素直接參與了感染的傳播，類似於其他性傳播感染。我還了解到，與我們之前在其他地方看到的猴痘相比，這次爆發的猴痘的臨床過程更溫和，對生命的威脅也更小。然而，症狀可能非常不舒服，很大比例的患者需要治療以控制疼痛。對於直腸和喉嚨受累的人來說尤其如此。
從社會和人類的角度來看，在與受影響者的訪談中，我了解到目前受影響最大的人群（同性戀、雙性戀和其他男男性接觸者）非常配合研究，總是願意幫助科學，不管我們透過採樣並用冗長而私密的問題詢問他們的時間所產生的不便。對我來說，支持這個社區、避免污名化並提供證據來扭轉疫情絕對至關重要。
西班牙現在情況如何？
西班牙的病例正在穩步下降。患者照護有所改善，因為目前，醫療保健專業人員和受猴痘影響的人能夠使用已發表的各種研究中產生的證據。
還有很多東西要學，我們不能放鬆警惕，但毫無疑問，我們正以一種比以前更少壓力和更少擔憂的方式面對這種疾病。
我們的主要擔憂之一是疫苗短缺。並非所有符合條件的人群都將在短期內接種疫苗。此外，目前西班牙推薦的疫苗接種計畫並不是標準的批准方案。同意這種變化是為了讓更多人接種疫苗，但這意味著我們不知道它在現實生活中的有效性。
你認為現在需要什麼來根除西班牙的猴痘？
我們已經掌握了很多信息，但仍有一些事情我們需要知道。
要阻止這種疾病，我們需要知道真正需要哪些保護和隔離措施；我們需要知道疫苗的真正保護作用；我們需要為所有高危人群接種疫苗。
為了實現這一目標，衛生當局、衛生專業人員和有猴痘風險因素的人與研究計畫合作至關重要。這些研究對於得出指導我們應對和阻止猴痘的結論非常必要。
此詳情首次出現在 2022 年 10 月版的《性健康和愛滋病毒政策歐洲公報》中
Monkeypox in Spain: the story so far
Greta Hughson / 6 October 2022 / aidsmap
The recent monkeypox outbreak has affected countries across the European region, and Spain has reported the highest number of cases to date.
Dr Cristina Galván, a dermatologist who was closely involved in the Spanish response, reflects here on the experience of working on the outbreak so far.
How were you involved in the monkeypox response?
As a dermatologist interested in neglected skin diseases and in research, I work with a research team focused on emerging infections and transmissible diseases which have symptoms affecting the skin.
When the monkeypox outbreak began, I put aside other projects and devoted all my time to it. Our group is leading on several lines of research at the moment and I collaborate in all of them to some extent. Among them, I’m most involved in a vaccine efficacy study.
How did you first become aware of people being diagnosed with monkeypox in Spain?
I heard that an unusual rash, which PCR testing showed was caused by monkeypox, was being diagnosed in England and shortly afterwards in Spain and other European countries.
This strongly aroused my interest. The infection was not new to me, but with a very different clinical and epidemiological pattern. I regularly work as a dermatologist in rural Africa and the diagnosis was always in my mind when I saw patients, on site or remotely through tele-dermatology, with symptoms compatible with the clinical picture for monkeypox. Although we couldn’t confirm the diagnosis due to lack of access to diagnostic tests in these neglected areas, on two occasions we had a high suspicion of monkeypox in cases seen by tele-dermatology.
In the European outbreak, the rash and the collection of symptoms people were experiencing were strikingly different. The sudden outbreak of a large number of cases in different countries at the same time did not fit the epidemiological pattern previously seen with monkeypox. The incubation periods, the mode of transmission and the route of acquiring infection seemed quite different.
We definitely needed to know more. I contacted my colleagues who work in sexual health clinics and who treated the first Spanish cases. As a team, we learned the clinical and epidemiological characteristics of this outbreak and started working hard on trying to find answers to this disease. It was a disease which we already knew, but it was being presented to us in a different way.
How would you describe what happened in the early days of the outbreak?
The most accurate word to describe our activity in the early days of the outbreak is ‘hectic’. I was on holiday in the mountains, but I spent most of my time working on my mobile phone, contacting colleagues, looking for data that could give us epidemiological clues, digging through the scant evidence of previous monkeypox cases and old smallpox publications, to understand and be able to take measures that could stop the spread.
In a short time, we designed protocols and questionnaires, in collaboration with other research groups, trying not to lose information from any case. And we were aware of and in contact with the health authorities monitoring the cases, in our countries and the rest of the world.
If you were to ask me whether our response and that of the health authorities was quick and good enough, I would say no. We worked on the basis of previous knowledge. We are used to working on the basis of previous knowledge and when a new health-related situation comes along, the response is not quick enough. There is always room for improvement. That is why I consider it so important to learn from each situation, so that we can be better when a new one arises.
You were a co-author on a recent study on clinical presentation of monkeypox. What did you learn from that?
From that study I learned that, as we suspected, the main route of transmission is through close contact of the skin and/or mucous membranes between one affected person and another.
Our study was the first to demonstrate this by finding higher PCR positivity and viral load in samples taken from skin lesions compared to others, such as the upper respiratory mucosa. This is important for organising prevention measures, and avoiding those that are not really necessary.
I learned that risk factors related to sexual practices are directly involved in the spread of the infection, similar to other sexually transmitted infections. I also learned that the clinical course of monkeypox in this outbreak is milder and less life-threatening than the monkeypox disease we have seen previously elsewhere. However, symptoms can be very uncomfortable, with a high percentage of patients needing treatment for pain control. This is especially true for those with rectal and throat involvement.
From a social and human point of view, during my interviews with those affected, I learned that the population currently most affected (gay, bisexual and other men who have sex with men) is very cooperative with research, always willing to help science, regardless of the inconvenience we generate by taking samples and asking for their time with long and intimate questions. For me it is absolutely vital to support this community, avoid stigma and generate evidence to reverse the outbreak.
What is the situation in Spain now?
Cases in Spain are steadily declining. Patient care has improved because, currently, healthcare professionals and people affected by monkeypox are able to use the evidence that was generated in the various studies that have already been published.
There is still so much to learn and we must not let our guard down, but we are undoubtedly facing the disease in a less stressful and worrying way than before.
One of the main concerns we have are vaccine shortages. Not all of the eligible population will be vaccinated in the short term. Moreover, the recommended vaccination schedule in Spain at the moment is not the standard approved regimen. This variation was agreed in order to have more people immunised, but it means we do not know its effectiveness in real life.
What do you think is needed now to eradicate monkeypox in Spain?
We have a lot of information already, but there are still things we need to know.
To stop the disease, we need to know what protection and isolation measures are really needed; we need to know the real protection of the vaccine; and we need to get the whole at-risk population vaccinated.
To achieve this, it is vital that health authorities, health professionals and people with risk factors for monkeypox collaborate with research initiatives. These studies are so necessary to reach the conclusions that will guide our response and stop monkeypox.
This feature first appeared in the October 2022 edition of the Sexual Health and HIV Policy Eurobulletin.