The monkeypox virus (MPXV) that causes the monkeypox (MPX) disease, was first discovered in 1958. This double-stranded DNA virus shares the Orthopox genus of the Poxviridae family with Smallpoxvirus.¹ Geographically, it is divided into two types, Central Africa (Congo Basin) and West Africa.²

The first time an outbreak outside the Africa was noted in 2003, due to the import of wild rodents in the United States of America and this was entirely an animal-to-human transmission classify the disease as a zoonotic infection that spreads via direct contact with the animals' lesions, body fluids, and blood.¹ Consumption of undercooked meat has been identified as a means of transmission as well.¹

The disease progresses in three phases, starting from an incubation period of about 6−13 days, followed by an onset period where signs and symptoms such as fever, headaches, backaches, muscle aches, fatigue, weakness, and swollen lymph nodes predominate, followed by a rash period whereby rashes mainly on the face and limbs arise in combination with skin manifestations such as papules, vesicles, pustules, umbilical pus, ulcerative lesions, and scabs.² All the lesions before the formation of the scab are contagious.¹ Some of the complications that can develop as a result of this infection include pneumonitis, encephalitis, keratitis, and secondary bacterial infections.³

It was after the MPX outbreak in the Democratic Republic of Congo during 1996−1997, that human-to-human transmission started to surface.¹ This mode of transmission was previously confined and mostly affected the ones who visited an endemic area.²

From 2018 onwards, sporadic cases of MPX started appearing in the United Kingdom, Singapore, and the United States of America.⁴ In May 2022, the MPX outbreak was confirmed.¹ According to World Health Organization (WHO), from January 1 to June 22, 2022, about 3413 laboratory-confirmed cases and 1 death have been reported from 50 countries.⁵ Among these, the majority of the cases (86%) belonged to WHO European region, 2% were from the African region, 11% were from the regions of the Americas, and <1% were from the Eastern Mediterraneann Region Western Pacific Region.⁵

Interestingly, the unique pattern of sexual transmission was observed this year. The national public health agency of the United States, the Centers for Disease Control and Prevention reported that hugging, kissing, and contact with the anus or genitals of an infected person via oral, anal, or vaginal sex can all contribute to the transmission the disease.⁶ There have been multiple reports from different countries that suggest this sexual transmission, particularly in men who have sex with men (MSM).⁶

A British study reported two British men with no recent history of travel who indulged in a condomless sexual relationship with each other and later presented with perioral, genital, and perianal lesions 24 and 48 h after the intercourse, respectively.⁷ The swab from their lesions came out to be positive for MPXV.⁷ Ten days before their sexual encounter, one of these men had kissed an individual with the crusted oral lesion, suggesting a possible source of entry of the virus.⁷ The other partner of this sexual encounter had a history of Human immunodeficiency virus (HIV), well controlled on antiretroviral.⁷

MSM pattern has been reported as a mode of transmission of MPX in Germany whereby two men involved in a sexual relationship presented with the features of MPX including white spots on tonsils and inguinal lymphadenopathy 4 and 10 days after the sex, respectively.⁶ One of them was a sex worker and a HIV patient on a controlled treatment regime and immunologically well, and the other one was involved in multiple homosexual relationships before and after this particular sexual encounter.⁶ Their blood, semen samples, skin and throat swabs all came positive for MPX.⁶

Epidemiological data from Madrid confirmed 508 MPX cases during the first 5 weeks of the outbreak in Madrid, out of which 99% were seen in MSM with lesions in genital, perineal and perianal areas, and inguinal lymphadenopathy.⁸

Italy also reported four MPX cases between May 17 and 22, 2022. All these four people were males, in their 30s, and engaged in MSM.⁹ They all had a travel history in the earlier half of May during which they were involved in condomless sexual interactions with different male partners.⁹ All four had a history of sexually transmitted infections (STIs).⁹ Two of them had HIV history and had received required antiretroviral therapy, while the other two were on antiretroviral preexposure prophylaxis.⁹ They all had genital and perianal lesions in common.⁹ Their samples from skin, genital and anal lesions, serum, plasma, seminal fluid, feces, and nasopharynx all came out to be positive for MPXV DNA in real-time PCR.⁹

Case series data from four WHO regions (Europe, Americas, Western Pacific, and Eastern Mediterranean) reported 528 infections from 16 countries over a 2-month time about 98%, via sexual transmission in gays or bisexual men.³ About 41% of persons were HIV patients and in the majority of them, HIV was effectively controlled.³

The presence of genital, and perianal lesions, inguinal lymphadenopathy, and the semen analysis confirm the presence of MPXV and sexual partners particularly MSM reporting similar features of the disease, all conclude MPX as a sexually transmitted disease, with an increased tendency to affect MSM. Among the risk factors of the disease include young age, male gender, MSM, condomless sex, HIV positivity, and a history of previous STIs.⁴ Some of these risk factors also predispose one to contract HIV as it has been shown to be associated with other STIs.⁴ Thus, understanding the sexual transmission of the MPXV is crucial, particularly for those practicing MSM patterns, LGBTQ community and sex workers. It is important to educate them about the mode of transmission of the MPX in a non-stigmatizing manner. The significance of safe sex should be highlighted. They should avoid engaging themselves in unprotected sex and be encouraged to use condoms, as well as immunize themselves against preventable STIs.¹⁰ Patients presenting with MPXV features should be thoroughly investigated for other STIs. Any close contact of the infected person should be informed to abstain from any sexual intercourse or physical contact with others and should be closely monitored for any signs and symptoms up to 21 days.⁸ Contact tracing of close contacts, especially sexual partners, and informing them should be a priority to prevent the rapid spread.

Racial and homophobic stereotypes can be anticipated in response to the propagation of the disease on social media and public platforms.¹¹ Thus, it is important to acknowledge and address the stigma of this disease¹¹ to curb reluctance among affected patients to seek help and also avoid unjust delays to patient care.¹² Studies have shown, educational practices can enlighten the community and encourage a professional help-seeking approach.¹² Chang et al.,¹¹ have proposed a modified five-level stigma mitigation framework derived from the socioecological model proposed by Salihu et al. to counteract the stigma. According to this, a five-level scheme should be incorporated targeting as follows; (1) the individuals and their families, who should be provided with ample psychological support and involved in designing public health initiatives that may cultivate a pattern of empowerment, self-efficacy, and coping in them. Patients should be made aware of their rights and acts of discrimination in which case they could demand justice. (2) Organizational level, in this case, hospitals should express a more neutral language while communicating about the disease. Training sessions should be conducted for all healthcare staff to discuss the latest data on MPX and ways to reduce discrimination and the importance of medical ethics. (3) Community level, since communities, share common beliefs and practices, and one of the contributors to stigma is their lack of awareness regarding the cause and available treatment options for the disease, it is imperative to address the community as a whole. This can be achieved by arranging mass awareness campaigns for the general public, sermons delivered by special faith-based groups that are influential to people, and using cultural and religious events as a means to talk about the disease, especially with the presence of influential personalities. (4) Public policy level, whereby policies should be devised to tackle the stigma pertaining to any infectious disease outbreak. (5) Evidence-based research level, where a mutual relation between researchers and policymakers should be nurtured to execute evidence-based policies. Two groups should communicate better to implement policies and conduct relevant research that may be informative. The negative impact of stigma, on direct healthcare costs because of delayed treatment, and indirect social costs as a result of disease spread, productivity loss, or premature death should be calibrated. Following this, the cost-effectiveness and the efficacy of stigma reduction policies should be regularly checked and their fate decided in terms of continual, alteration, or termination.¹¹

Although in light of recent literature, MPX disease exhibits a sexual mode of transmission disproportionately affecting the MSM, it is important to realize sexual mode is not the only means of its transmission.¹ Pathogens don't tend to have an inclination toward a particular sexual orientation, race, ethnicity, nationality, or religion.¹⁰ Thus, some of the nonsexual ways of preventing the disease include preventing contact with lesions, social distancing from those infected, not sharing beddings, towels, and so forth,¹² not interacting with wild or laboratory animals, and thoroughly cooking animal meat.¹⁰ There is some data to prove the efficacy of the Smallpox vaccine against MPX, about 85% efficacy,¹ as these two viruses from the same genus share similarities, and hence the potential of this vaccine against MPX should be further researched so that it may help to mitigate the spread of MPX.

With the uplifting of travel restrictions due to COVID-19 and an established sexual transmission, strict cautionary measures are needed to prevent the spread of MPX.

AUTHOR CONTRIBUTIONS

Summaiya Waheed and Shukrullah Aziz conceived the idea. Summaiya Waheed, Shukrullah Aziz, Abdul Waris, Abdul Jabbar, and Irfan Ullah retrieved the data, did write up of letter and finally Abdul Jabbar and Irfan Ullah reviewed and provided inputs. All authors approved the final version of manuscript.

CONFLICT OF INTEREST

The authors declare no conflict of interest.