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Diversity & Inclusion The Monkeypox Outbreak in the MSM Community
The Monkeypox Outbreak in the MSM Community
By Ben Weigel, MD; Michelle Suh, MD; and Dustin Williams, MD, on behalf of the SAEM Academy of Diversity and Inclusion in Emergency Medicine
A 28-year-old male presents to your emergency department (ED) with fever and a painful penile rash. He reports anal and oral sex with over 20 men in the past month, and he is worried he may have syphilis because of the rash. His partner started to have diffuse myalgias but no other symptoms. He had negative STI testing last month, and he has no other medical conditions. He denies penile discharge, urinary symptoms, or rashes anywhere else. His physical exam is significant for multiple umbilicated lesions on the base of his penis and tender bilateral inguinal lymphadenopathy. You contact the city health department which agrees to swab the patient for monkeypox and perform contact tracing. Given his risk factors, you order other STI tests.
Monkeypox is an infectious disease caused by the monkeypox virus, a member of the Poxviridae family. The most common presentation involves a viral prodrome of fevers, malaise, lymphadenopathy, and myalgias followed by rash several days after the initial systemic symptoms. The rash originates as itchy, papular lesions which evolve to become vesicular and eventually scab. Typically, lesions will be at the same stage at a given site. The clinical presentation resembles that of smallpox but results in less severe illness and is less contagious. Monkeypox is transmitted through close, physical contact with infected individuals including: direct contact with monkeypox sores or rash, exposure to respiratory droplets or oral secretions, or exposure to contaminated materials such as clothing or bedding. Monkeypox is a self-limited disease with symptoms that typically last 2-4 weeks. Monkeypox is considered a zoonotic infection with most cases historically occurring in Central and West Africa. In the ED, physicians and other health care providers should maintain a high index of suspicion for monkeypox in patients with fever, rash, myalgias, and risk factors. In addition to testing for monkeypox, consider STI testing and counseling for safe sex. Furthermore, the local health department must be alerted to conduct contact tracing and update the local case count. Ultimately, most patients do not require hospitalization. Patients should be able to quarantine until no longer contagious (all lesions have scabbed over and scabs have fallen off). If the patient is undomiciled or faces other social barriers, consider reaching out to a social worker for assistance. Since early May through August 2022, more than 20,000 monkeypox cases have been confirmed globally in countries where the virus is not endemic. Researchers have observed ongoing human-to-human transmission, defying established medical knowledge about the disease. Data from the European Surveillance System suggest that more than 96% of cases are
being diagnosed in men who have sex with men (MSM). Although the current outbreak has disproportionately affected the gay and bisexual communities, it is important to note that anyone can contract monkeypox regardless of their sexual orientation.
In the United States, the outbreak mirrors the situation in Europe with nearly all monkeypox patients identifying as MSM. Specifically, men who report multiple sex partners, attendance at sex parties, or visitation to gay bathhouses seem to be at highest risk. Epidemiologic survey data suggest sustained transmission within sexual networks of MSM rarely leading to cases in the general population.
As public health officials race to contain the outbreak, critics argue that access to testing has been inadequate and cases are likely being undercounted. There have been reports of patients presenting with concerning lesions who clinicians were unable to test because their facility lacked a testing protocol. Other patients describe waiting greater than five days to receive their test result, or failure to get any test result at all. Last month, monkeypox testing was exclusively being performed at the Centers for Disease Control and CDC, but testing has since expanded to five commercial laboratories.
Vaccination efforts in the U.S. have been criticized for inequitable and delayed distribution. The only FDAapproved vaccine for monkeypox is Jynneos (also known as Imvamune or Imvanex). Since the sharp uptick in cases this year, global demand for the vaccine has soared, far exceeding supply. The U.S. has purchased nearly seven million doses in total but has received only 300,000 of them, with 150,000 doses distributed throughout the nation. Vaccine rollout has been marred with issues related to notifying the public and offering appointments. In New York City, most of the vaccines have gone to the websavvy and well-connected, rather than to targeted high-risk groups.
There are currently no FDA-approved treatments specifically for monkeypox. An antiviral, tecovirimat (TPOXX), is approved for smallpox and may be effective for monkeypox, but there is limited clinical data on its efficacy. The drug is currently only available for monkeypox through a compassionate-use protocol, which requires submitting tedious paperwork to the CDC for each patient. Anecdotally, patients that have received TPOXX report immediate improvement in symptoms and have rallied for its expanded use.
Tragically, the monkeypox outbreak is occurring against a backdrop of anti-LGBTQ+ legislation and sentiment within the U.S. Many members of the LGBTQ+ community have argued that the monkeypox outbreak has not received adequate public attention or government resources, drawing parallels with the early HIV/AIDS epidemic. Others feel that public health communications have been too tentative. Perhaps fear of further stigmatizing LGBTQ+ people has led to a situation where authorities fail to name who is most at risk, which sexual behaviors confer higher risk, and what people can do to mitigate that risk. Importantly, monkeypox should not be dismissed primarily as a “gay disease” and other groups should be appropriately cautioned as well.
On July 23, 2022, the World Health Organization declared monkeypox a global health emergency. The lag in testing, contact tracing, and vaccination has allowed for sustained community spread, echoing the early days of COVID-19. Many epidemiologists now doubt that containment remains a realistic goal. As cases rise, the focus will turn toward mitigating the contagion by investing more resources in vaccination and treatment. The LGBTQ+ population has a long-documented history of preexisting health inequities compared to the general population. A coordinated public health response is needed to prevent further exacerbation of these inequities and gain control of the monkeypox outbreak.
ABOUT THE AUTHORS
Dr. Weigel (he/him) is a current PGY-3 and chief resident at the Baylor College of Medicine Emergency Medicine Residency Program.
Dr. Suh (she/her) is a current PGY-3 at Baylor College of Medicine Emergency Medicine Residency Program. Her interests include race and gender, carceral health, and medical education. @MSuh25 Dr. Williams is an associate professor of emergency medicine at UT-Southwestern Medical Center where he also serves as the residency program director. He also serves as the current cochair for the ADIEM LGBTQIA+ subcommittee.
About ADIEM
The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the goal of diversifying the physician workforce at all levels, eliminating disparities in health care and outcomes, and insuring that all emergency physicians are delivering culturally competent care. Membership in SAEM's academies and interest groups is free. To participate in one more groups: 1.) log into SAEM.org; 2.) click “My Participation” in the upper navigation bar; and 3) click “Update (+/-) Academies or Interest Groups.”
