Biggest Monkeypox Study To Date Contains Hundreds Of Pictures And Details New Symptoms

Amid soaring case numbers worldwide, a new paper in the New England Journal of Medicine has studied over 500 infections of monkeypox, providing new information about who has been infected with the disease so far and what symptoms people tend to experience. The information about the cases was collected between April and June this year from 528 patients across 16 countries and the average age of monkeypox patients was 38.

Monkeypox has been endemic in parts of Africa for decades, but according to the scientist who led the effort, there are differences with this outbreak.

“We actually managed to find some things about this particular outbreak that’s happening now that hadn’t been described before,” said Chloe Orkin, MD, PhD, physician and Professor of HIV/AIDS medicine at Queen Mary University in London and lead author of the study. “People are having their first symptoms as sores inside the mouth and sores inside the anus. These mucosal symptoms, as we call them, are not included in the international case series definitions,” Orkin added.

Previous descriptions of monkeypox have found the first reported symptoms to be rashes and lesions on skin, but not in the sensitive mucosal areas, such as the inside of the mouth, anus or rectum. Many people who have had the disease have reported “excruciating pain,” with these sores and some have had to be hospitalized. Other reported common symptoms were fever, swollen lymph nodes, rashes and lethargy.

“It is vitally important to share what the disease looks like,” said Orkin. “We’re now in a situation where we’ve got more than 15,000 cases, and it’s spreading to different countries all the time,” Orkin added, noting that six new countries reported their first cases last week, meaning the disease has now been detected in more than 70 countries.

“Doctors there often have not seen this before. And people are presenting to emergency departments to primary care, to dermatology to sexual health clinics,” said Orkin.

Before this outbreak, many textbook pictures of monkeypox lesions were on Black skin due to the virus mostly being found in Africa. But in the study, three-quarters of the patients were white and the study authors wanted to create a resource to educate doctors about what monkeypox lesions look like from the current outbreak.

Pictures of the lesions can be found in the paper and supplementary information, but viewer discretion is advised as some of the photos are from anal and genital regions.

“In some cases, these symptoms have been so severe that people have been unable to swallow unable to go to the toilet and have needed pain relief. Some have had to be admitted to hospital,” said Orkin.

The researchers found that 98% of infected people in the study were gay or bisexual men, with three-quarters being white. Sexual activity was thought to be responsible for transmission in 95% of cases.

“Within our case series, it was exclusively men, and there were just 10 people who described themselves as heterosexual and everybody else described themselves as gay or bisexual men who have sex with men. So certainly, in our case series, this was the population that we saw,” said Orkin.

There have been headlines and even misleading public health messaging suggesting that only men who have sex with men are at risk of monkeypox. But growing numbers of cases in women and even children are now being reported. Orkin explains that although the outbreak originated in sexual networks involving gay and bisexual men, anybody can get monkeypox and it is now infecting others not in these networks.

“This is a disease that’s currently mostly spreading through sexual networks in gay and bisexual men. And it’s important to make that clear so that gay and bisexual men are aware of the options in terms of vaccination or treatment if needed. But it is also equally important not to make people think this is a disease that can only be contracted by gay and bisexual men. because that’s not the case,” said Orkin.

Vaccination efforts are underway in some places to provide protection to people at high risk. In New York, which is a hotspot for monkeypox transmission, the vaccine is being offered to anyone who has been exposed to the virus in the past two weeks and those at high risk of exposure, including members of the gay, bisexual, transgender, and gender non-conforming community who have engaged in intimate or skin-to-skin contact with others in the past 14 days.

“The smallpox vaccine can prevent monkeypox in 86% of cases if someone has been exposed and it’s given within the first four days and it can potentially prevent contraction of the disease. So if it’s possible to access this, and people are at high risk of infection, that’s something that’s helpful,” said Orkin.

However, Orkin is keen to state that vaccine disparities and supply limitations mean that even those who get the vaccine will likely currently only receive one dose of a normal two-shot regimen and that many countries don’t even have access to that.

“The lack of equity around access to vaccine means means that in many countries in the world, this outbreak is not going to be able to be stopped. There are going to be many countries which have no access to anything. And depending on what happens in those countries, and how much it spreads, that’s likely to determine what happens next,” said Orkin.

Although the outbreak continues to spread with case numbers growing rapidly, there is some good news insofar as there were no deaths reported in the more than 500 people involved in the study. But scientists aren’t exactly sure why this outbreak continues to grow so much, or why previous outbreaks have been contained with minimal transmission outside of close or household contacts.

“I’m going to say, I don’t know how this is going to go in the future. If there’s something that’s different about this outbreak, there’s no indication yet that there’s any difference in the virus at all. I think it’s more likely to do to do with human behavior,” said Orkin.