Narrative Shift: Now Global Monkeypox Is Being Spread Through Sex
Narrative Shift: Now Global Monkeypox Is Being Spread Through Sex
Reality Wins Again
The narrative arc on the global monkeypox outbreak is shifting, as more and more medical researchers are beginning to acknowledge the obvious—that the virus is being spread globally through sex. More importantly, some researchers are concluding that transmission is coming more through the sexual exchange of bodily fluids and less through the extensive skin-to-skin contact that is inevitable during sexual activities.
Since the outset of the global monkeypox outbreak in May, public health and infectious disease experts have told the public that the virus is largely transmitting through skin-to-skin contact, in particular during sex between men.
Now, however, an expanding cadre of experts has come to believe that sex between men itself — both anal as well as oral intercourse — is likely the main driver of global monkeypox transmission. The skin contact that comes with sex, these experts say, is probably much less of a risk factor.
Without explicitly using the term, researchers are admitting that what I have been saying for some time is correct: “global” monkeypox really is a sexually transmitted disease.
Shift Is Data Driven
Why is the narrative shifting? In large part the change is because doctors and researchers are simply unable to ignore the growing body of evidence supporting sexual transmission of monkeypox, including a number of studies and public health authority advisories, some of which have already been referenced within this substack:
There are the case studies from Italy which found monkeypox virus in semen samples along with other bodily fluids.1
There is the New England Journal Of Medicine study showing that 98% of global monkeypox cases are among gay and bisexual men, and 95% of cases could be attributed to sexual contact2.
There are case studies from Spain which also found monkeypox virus in a variety of bodily fluids, including semen3.
There is the study from The Lancet showing that nearly all study subjects had risk factors for sexually transmitted diseases.4
There is the observational study published in the BMJ on July 28 showing that 96% of monkeypox cases in London were among men who had sexual contact with a male partner within a 21-day period preceding onset of symptoms5.
There is the CDC Morbidity and Mortality Weekly Report (MMWR) from August 12 documenting that 94% of reported monkeypox cases involved sexual or close intimate contact6.
There is the UK Health Security Agency Technical Briefing on monkeypox from August 12 delineating close and/or sexual contact as the primary mode of transmission of the virus7.
There is the ECDC-WHO Monkeypox Surveillance Bulletin from August 17 establishing recent multiple sexual partners as a criterion for diagnosing a probable case of monkeypox.8
As this partial list demonstrates, the array of evidences establishing a sexual transmission vector for the global strain of monkeypox is extensive and diverse. This is not an isolated, non-reproducible bit of research, but rather an amalgamation of multiple independent research efforts all pointing to a common conclusion about the transmission of monkeypox outside of Africa.
That array of evidences led two medical researchers, Lao-Tzu Allan-Blitz of Brigham and Women’s Hospital and Jeffrey Klausner of the Keck School of Medicine of the University of Southern California, to argue in a Medium article that the global strain of monkeypox should be considered a sexually transmitted disease.
Taken in context, the temporal and anatomic association with various sex practices, the high prevalence of sexual risk behavior among patients with human monkeypox, and the in vitro infectivity of human monkeypox DNA isolated from semen strongly suggest that human monkeypox is transmitted through sexual activity.
When the narrative conflicts with the data, the narrative invariably gets trumped by that data.
Why It Matters
Within the realm of public health policy, this narrative shift both supports and furthers public health advisories and messages emphasizing safe sexual practices as a means of halting the spread of the virus and, by extension, protecting individuals against infection by the monkeypox virus.
…failure to appropriately identify and disseminate to the public the predominant mode of transmission will likely perpetuate behaviors that are driving transmission
At-risk populations—statistically, gay and bisexual men—are not well served by perpetuating false or inaccurate depictions of how monkeypox spreads among people. If the primary mode of transmission is sexual contact and sexual activity, the at-risk population is hardly helped by being told that monkeypox does not spread through sex.
However, a correct understanding of how the virus is spreading also allows for better post-infection response, including more informed guidelines on practices such as patient isolation. At the present time the CDC recommends infected individuals physically isolate themselves for up to four weeks9, based on the premise of viral transmission through contact with lesions, fluids and material shed from those lesions, or respiratory secretions; if the primary mode of transmission is sexual contact, these isolation guidelines are largely unnecessary.
A correct understanding of the actual modes of transmission for monkeypox also establishes whether the CDC’s current mitigation recommendations, including the use of face masks in public as well as avoiding public modes of transportation10, are either effective or necessary. If the primary mode of transmission is sexual contact, face masks are not likely to play any role at all in containing the disease, and the use of public transportation is simply a non-issue.
Perhaps most crucially, a correct understanding of the actual modes of transmission for monkeypox allows for a proper appreciation for the relevance of the Jynneos smallpox/monkeypox vaccine. It is already acknowledged that the vaccine carries a number of potentially serious risks, including cardiac symptoms. People who are demonstrably not at high risk for the disease have little or no need for a vaccine—which itself is an important understanding as Jynneos has never been formally tested against monkeypox and its efficacy is based largely on its observed immunogenicity: it produces antibodies, ergo it “works”.
That semi-educated guess on Jynneos’ actually efficacy as a monkeypox vaccine will only be further diminished by the reality that the global strain had evolved significantly from its West African ancestors.
Reliance on what is ultimately an untested vaccine product can never be anything more than a crapshoot, and so a proper appreciation regarding who is truly at risk from the disease, as well as non-pharmaceutical measures to minimize or eliminate that risk, is of utmost importance for anyone seeking to best manage their own personal health.
Again, Africa Is Different
It cannot be stated often enough that the ongoing monkeypox outbreak in Africa is demonstrably different from the overall global outbreak, so much so that it should rightly be considered a completely seperate outbreak of the disease.
The differences between the two outbreaks begin with the patient demographics. While ~99% of cases in the global outbreak are among gay and bisexual men, within Africa, the cases are spread more evenly between men and women, 65% male vs 35% female11. Additionally, there is little to no evidence of sexual activity as a mode of transmission either in the current African outbreak or historically.
Historically, the sexual component of transmission in the countries above has been thought to contribute less to human to human transmission of monkeypox than has been observed in the ongoing global outbreak. It should also be noted that there is limited testing capacity for monkeypox in many of these countries, which has led to underascertainment of monkeypox cases.
The strain of monkeypox found in the global outbreak is descended from the West African Clade of the virus, subsequently renamed “Clade IIa” by the WHO and referenced thus in their literature.
The proper naming structure will be represented by a Roman numeral for the clade and a lower-case alphanumeric character for the subclades. Thus, the new naming convention comprises Clade I, Clade IIa and Clade IIb, with the latter referring primarily to the group of variants largely circulating in the 2022 global outbreak. The naming of lineages will be as proposed by scientists as the outbreak evolves. Experts will be reconvened as needed.
However, as the new naming convention emphasizes, the outbreak in Africa is from a decidedly different strain of the virus, with markedly different transmission characteristics. Perversely, the acknowledgement that the global strain (Clade IIb in the new WHO nomenclature) is sexually transmitted is by imputation an admission that there are two monkeypox outbreaks rather than one, and that Africa’s cases should be viewed separately from the rest of the world.
Always Follow The Data
While the efforts of many to superimpose their preferred narrative on the scientific realities of monkeypox as they have on COVID-19 and healthcare overall are not likely to be deterred by this belated and backhanded climbdown over the transmission characteristics of the globally circulating strain of monkeyypox, the object lesson for the rational individual is yet again the simple dictum to always follow the data.
Facts and evidence are the foundation of the scientific method and are the cornerstone to rational understanding of the world around us. While the “experts” have dithered and prevaricated for weeks regarding how monkeypox was being spread, and the attendant broader implications for public health policy, the data has always been clear, unambiguous, and emphatic: global monkeypox—”Clade IIb” to follow the WHO’s new nomenclature—is primarily a sexually transmitted disease, different and distinct from the primarily zoonotic infection from which it is descended and which is currently spreading in West and Central Africa.
If the global monkeypox outbreak teaches us anything it all, it is the reminder yet again to set aside ideologically driven and politically motivated narratives especially within the realms of science and medicine. Objective facts and empirical data remain the only reliable guides for understanding infectious pathogens and how they impact both individuals and society as a whole.
Antinori, Andrea et al. “Epidemiological, clinical and virological characteristics of four cases of monkeypox support transmission through sexual contact, Italy, May 2022.” Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin vol. 27,22 (2022): 2200421. doi:10.2807/1560-7917.ES.2022.27.22.2200421
Thornhill, John P et al. “Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022.” The New England journal of medicine, 10.1056/NEJMoa2207323. 21 Jul. 2022, doi:10.1056/NEJMoa2207323
Peiró-Mestres, Aida et al. “Frequent detection of monkeypox virus DNA in saliva, semen, and other clinical samples from 12 patients, Barcelona, Spain, May to June 2022.” Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin vol. 27,28 (2022): 2200503. doi:10.2807/1560-7917.ES.2022.27.28.2200503
Tarín-Vicente, Eloy José et al. “Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study.” Lancet (London, England), S0140-6736(22)01436-2. 8 Aug. 2022, doi:10.1016/S0140-6736(22)01436-2
Patel, Aatish et al. “Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series.” BMJ (Clinical research ed.) vol. 378 e072410. 28 Jul. 2022, doi:10.1136/bmj-2022-072410
Philpott, David et al. “Epidemiologic and Clinical Characteristics of Monkeypox Cases - United States, May 17-July 22, 2022.” MMWR. Morbidity and mortality weekly report vol. 71,32 1018-1022. 12 Aug. 2022, doi:10.15585/mmwr.mm7132e3
Investigation into Monkeypox Outbreak in England: Technical Briefing 5. 12 Aug. 2022, https://www.gov.uk/government/publications/monkeypox-outbreak-technical-briefings/investigation-into-monkeypox-outbreak-in-england-technical-briefing-5.
Joint ECDC-WHO Regional Office for Europe Monkeypox Surveillance Bulletin. 17 Aug. 2022, https://monkeypoxreport.ecdc.europa.eu/.
CDC. Isolation and Prevention Practices for People with Monkeypox. 2 Aug. 2022, https://www.cdc.gov/poxvirus/monkeypox/clinicians/isolation-procedures.html. Accessed August 17, 2022
CDC. Preventing Spread to Others. 29 July 2022, https://www.cdc.gov/poxvirus/monkeypox/if-sick/preventing-spread.html. Accessed August 17, 2022
World Health Organization. 2022 Monkeypox Outbreak:Global Trends. 18 Aug. 2022, https://worldhealthorg.shinyapps.io/mpx_global/#4_In_focus:_West_and_Central_Africa. Accessed August 18, 2022