Although at the moment, the majority of monkeypox cases in Europe are among men who have sex with men (MSM), the current outbreak is not a reason to cancel mass gatherings, says the World Health Organization (WHO), as the Northern hemisphere enters the summer season of music festivals and Pride (the celebration of the lesbian, gay, bisexual, transgender, queer plus (LGBTQ+) community) events.
"It is an opportunity to leverage these events to drive our engagement," said Dr Hans Henri P. Kluge, WHO Regional Director for Europe today. "These events are powerful opportunities to engage with young, sexually active, and highly mobile people."
Previously, as reported on Medscape UK, the WHO has warned of a strong likelihood that cases of monkeypox could escalate in Europe over the summer months, with transmission of the virus boosted by people gathering at festivals and other large-scale events.
Dr Kluge added that most people with monkeypox report multiple and sometimes anonymous sexual partners, and as such, "identifying, tracing and notifying sexual partners quickly is, therefore, often difficult but, remains critical in order to stop wide spread."
But the monkeypox virus is not, of itself, attached to any particular group, he asserted. "Stigmatising any one population undermines the public health response…Monkeypox is opportunistic in its fight for survival and will spread according to the conditions provided it."
However, the ECDC published a risk assessment in May, where the likelihood of further spread among men who have sex with men (MSM) was considered as high, while likelihood of spread among the broader population was likely to be low. The risk assessment document reads: "The predominance, in the current outbreak, of diagnosed human MPX [monkeypox] cases among men having sex with men (MSM), and the nature of the presenting lesions in some cases, suggest transmission occurred during sexual intercourse."
In response to the WHO announcement not to ban festivals, Mr Steve Taylor, Secretary-General of Copenhagen Pride & EuroPride Board Member noted this is the 50th year that pride has been celebrated in Europe, where around 750 Pride events will take place. "We are reassured by the clear statement from WHO that major events, including Pride, should not be cancelled or curtailed because of the outbreak of monkeypox."
Latest Incidence Figures
As of Wednesday, there are over 1500 cases in the European region, and the large majority are in the European Union/European Economic Area (Eu/EEA) region. Here specifically, there are 1160 confirmed cases from 22 countries, reported Dr Andrea Ammon, Director of European Centre for Disease Prevention & Control (ECDC), speaking at the WHO briefing alongside Dr Kluge.
Data from the UK Health Security Agency (UKHSA) released Wednesday said the Agency has detected 52 additional cases of monkeypox in England, one additional case in Scotland and one in Wales, bringing the total number confirmed in the UK to 524. There are currently 504 confirmed cases in England, 13 in Scotland, 5 in Wales, and 2 in Northern Ireland.
Raising Awareness to Prevent Transmission but Avoiding Stigma
On Tuesday, the ECDC published guidance not only for public health authorities, but for MSM, on how to approach this summer festival season. "This direct engagement with these communities it's important to raise awareness that people come forward when they have symptoms," said Dr Ammon.
"On the one hand, large gatherings represent an easy environment for the transmission of monkeypox virus with close and prolonged frequent interactions among people, in particular sexual activity. On the other hand, these events represent an excellent opportunity for outreach. As such we have advised against closure and event cancellations because the activities may still occur but to be less amenable to awareness raising," she said.
Referring to the counter-productivity of stigma, and its inappropriateness, Dr Ammon reinforced that, "the virus does not select according to sexual orientation, it just uses opportunities for transmission."
She added that after diagnosis and contact-tracing, the next step was isolation at home until the lesions are completely healed, and until the scabs fall off the lesions remain infectious.
Also speaking was Dr Catherine Smallwood, monkeypox incident manager at WHO/Europe, and she noted that the WHO already has recommendations for precautionary measures for patients who have fully recovered. "For patients with monkeypox, during the time they are ill until the moment that their rash has fully resolved we recommend that they do not undertake sexual activity. After that period, we recommend as a precautionary measure that they use condoms when they have sex to prevent any ongoing transition that could occur, but we still don't know if that does occur from semen."
MSM and Potential Transmission Via Semen
Evidence from earlier this week from the Lazzaro Spallanzani Institute, Rome, Italy, and published in Eurosurveillance on June 2, attests to fragments of monkeypox virus being spread in semen, potentially suggesting sexual contact as a route of transmission. This study has not yet been peer reviewed.
Six out of seven patients at the facility had semen containing the virus' genetic material, with one carrying enough virus to be capable of both replicating and infecting another person, as reported by Reuters.
At this morning's WHO briefing, Medscape UK asked WHO about whether they felt these data from Italy changed understanding and response to the outbreak.
"We welcome the data from the Spallanzani Institute and call for more research into this current outbreak," remarked the WHO, via email.
"Currently, WHO is not changing its guidance on sexual activity for confirmed or suspected cases. Our guidance remains that individuals should ABSTAIN from sex if they are showing symptoms or have tested positive for monkeypox. They should only resume sexual activity once they have fully recovered."
They stressed that, "monkeypox is NOT a sexually transmitted infection, as it can be caught without sexual activity taking place," adding that, "we do not yet know whether the monkeypox virus can also spread from one person to another through semen or vaginal fluids, nor whether the virus could persist in these bodily fluids for longer periods of time."
"As a disease with an incubation period of 21 days, because we are only one month into trying to understand this outbreak it is too early to conclude as to how this disease will be spreading among the general population," said Dr Smallwood. "We do have some cases that are not in the MSM community so family customers and others, she added." We need to focus on the most frequent mode of transmission which is skin to skin contact."
Responding to suggestions that transmission via sexual fluids represents a change in the virus, she said that it was unknown, she explained, "this might have been something we were unaware of about this disease which highlights what a neglected disease has been."
Dr Ammon pointed out that understanding what is potentially different about this outbreak beyond previous outbreaks, that have mostly occurred in West Africa where monkeypox is endemic, is of concern to the WHO. "We want to know how the pattern of transmission is different, we want to know what the transmission patterns are in endemic countries as well as non-endemic countries, and we are also looking at the clinical presentations to understand how they differ."
"Currently there is no significant evidence to point to a change in the virus," she said, adding that “these remain some of the big unanswered questions that we are addressing".
However, a UKHSA technical briefing earlier this week, reported by Medscape UK, noted that the current UK monkeypox strain contained 48 single mutations in its genome relative to the 2018 UK monkeypox strain.
It said that 27 of these mutations were 'silent' and did not change any of the viral proteins, whilst 21 did cause changes in viral proteins.
It also classed three mutations in one protein as high priority. These were B21/B22 (D209N, P722S, M1741I), a T-cell inhibitor previously linked to an increase in cowpox severity and mortality in laboratory settings. Four other mutations were classified at medium priority.
Vaccines and Universal Availability
Mass vaccination is not recommended nor needed at this time. "Targeted vaccination either before or after exposure to the virus benefits contacts of patients including health workers, yet we see a rush in some quarters to stockpile vaccines," said Dr Kluge.
There are still several steps to addressing the demand issue for vaccines, whether they are high or lower and middle-income countries, he added. "Currently there is only one vaccine that has been approved for monkeypox and production capacity has not yet been scaled up, nor has the regulatory work been done yet, but we are working in partnership with member states to design an equal mechanism for a fair system of distribution of vaccines for all countries independent of their income status."
Returning to the summer festivals that are already underway in Europe, Mr Taylor said that his organisation, among others, would be encouraging Pride event organisers across Europe to raise awareness of the facts around monkeypox, “so people can protect themselves, their loved ones, and their communities”.
However, he highlighted that some people who oppose Pride have taken the opportunity with monkeypox to call for Pride events to be banned. "There's no depth to which our opponents won't descend to try and stop Pride and we are pleased the WHO guidance is clear that Pride and major events should not be affected and are in fact opportunities to share import into public health messaging."
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