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Why has monkeypox spread now?



Since crossing the borders of Africa in May, the monkey pox (monkeypox) has now spread to 65 countries and infected nearly 10,000 people, says the latest report by World Health Organization (WHO), from last week. In Brazil, 592 cases have already been recorded, most in São Paulo – but experts believe that the virus is more widespread, amid difficulties in testing and diagnosis. The disease has been identified by science since 1958, but now doctors and researchers are trying to understand the causes of the speed of the new outbreak and debate the best way to contain this threat without increasing the stigma on the groups most vulnerable to the virus. Among the strategies, they advocate focused guidance campaigns and vaccines.

The WHO estimates that 98% of monkeypox cases reported worldwide are between “men who have relationships with men“(MSM), which includes the group of gays and bisexuals, but not limited to them. In Brazil, physicians in São Paulo report a similar perception and the most recent newsletter Ministry of Health points out that this population corresponds to 100% of patients who declared their sexual orientation at the time of diagnosis. It is not yet known why the contagion is greater in this group.


Previously, the disease was more restricted to rural areas of central and continental Africa. There is still no consensus on the reason for the faster contagion – sexual transmission is still being investigated by researchers. The most widespread theory among scientists is that this occurred because of a series of mutations in the virus, which later found a first niche for dissemination in the MSM population.

Despite the name, monkeypox is more common in rodents and was mostly restricted to African hunters, where it is considered endemic. “It was described this way for the first time because it had an outbreak in monkeys, which got sick just like us. They weren’t the ones who transmitted the disease to us”, explains Ana Gorini da Veiga, a professor at the Federal University of Health Sciences in Porto Alegre ( UFCSPA).

“We still don’t know why this outbreak is more comprehensive. It could be because of a greater transmissibility of the virus, because today we have greater ease of transport and locomotion of people…”, points out Ana. The first records of this new variant came from Spain and gives Belgiumbut symptoms quickly popped up in countries like Portugal, the United Kingdom and the Americas.

One of the main obstacles to scale the reach of monkeypox in Brazil and in the world has been the variety of manifestations of the disease and underreporting. With the incubation period for the virus ranging from 5 to 21 days, the first symptoms usually include fever, sore throatin head and not body (which in some cases leads to a first suspicion of infection by some respiratory virus), in addition to swollen lymph nodes. A few days later, the skin lesionswith small rashes that can spread over the fingers, hands, arms, neck, back, chest, and legs.

The appearance of these sores in the genital and perineal regions (between the anus and the genital organ) has helped doctors to confuse monkeypox with other Sexually Transmitted Infections (STIs), such as syphilis and herpes. Patients heard by the report report that they were medicated with antibiotics and anti-inflammatories, in the first consultation after the first signs of the disease. With the persistence of symptoms, most of them were only retested after insisting on a new diagnosis or go to another hospital.

Sexual transmission?

The fact that monkeypox causes eruptions near the genitals and spreads so quickly among gay and bisexual men has raised the possibility that this form of the disease could be sexually transmitted. Preliminary studies in Italy and Germany found traces of the virus in the semen of patients, but the data are still too little to say whether the amount of viral load would be enough for an infection.

“The fact is that we have a disease transmitted from rodents to humans and taken to Europe, where it spread very intensively in casual sexual encounters, especially among men. The virus has found an epidemiological niche, which has the possibility of adequate transmission.” , explains Carlos Magno Castelo Branco Fortaleza, an infectious disease specialist and epidemiologist at the Universidade Estadual Paulista (Unesp).

For now, doctors and scientists say they can safely say that the main way monkeypox is transmitted is by direct contact with lesions or saliva of infected people, and not by sexual penetration, for example. In this sense, the use of a face mask is important, as is constant hand hygiene and keeping distance from those who have symptoms, especially the visible ones.

“Transmission is not through the sexual act, but it has presented a behavior that mimics these characteristics. We already have cases, for example, of someone who had the disease sexually and transmitted it to a second person in the same household in another way”, points out Fortaleza. “At the same time, ignoring that she has been behaving like an STI can make us not give the necessary guidance to a certain priority group.”

no past mistakes

This unique behavior by monkeypox and its association with the sexual act has fueled complaints from the LGBT+ community, which sees the specific warnings for “men who have relationships with men” as a way of renewing the stigma created decades ago on this same public since the emergence of HIV. Among the medical and scientific community, this same concern to reinforce stereotypes is “at the heart of the issue”, as epidemiologist Fábio Mesquita points out.

“We don’t want to make the same mistakes as HIV. At the time, our ignorance was very great. We only looked at the number of cases as if it was necessarily associated with a community”, observes he, who was once director of the then Department of Communicable Diseases. Sexual Health, AIDS and Viral Hepatitis from the Ministry of Health and is now based in Myanmar as a member of the WHO staff.

And what would be the correct way to alert the population at risk without falling into stigmatization or even blaming the community for the spread of the virus? “It is to say that, at this moment, the community needs to be attentive, because it is disseminating in an important way”, points out Mesquita. “But we also need to stress that there is no scientific evidence that monkeypox will be restricted to it (LGBT+ community).”

Who agrees with this view is David Uip, infectologist and secretary of Science, Research and Development in Health of the State of São Paulo. To Estadãohe said he believes that “clear, correct and scientific information” is the best way to circumvent prejudice and create the necessary awareness both in the risk group and in the general population, avoiding what he categorizes as “the catastrophe from the medical point of view , epidemiological and social” seen in coping with HIV.

“You have to protect yourself with what we have available information, without generating panic”, points out Uip, who was on the front lines of the fight against HIV when the disease exploded in Brazil, in 1980, and was initially named “gay plague “. “(the monkeypox) is not a lethal disease, at least at the moment, but people are very symptomatic and suffering a lot.”


Another parallel that Uip draws between monkeypox and HIV is the lack of specific and lasting vaccines for these diseases. In the United States and the United Kingdom, where immunization against monkeypox has already begun, doses initially developed for smallpox (smallpox) are used, distributed specifically for the MSM population and with stocks well short of necessary.

“I would take advantage of this moment and find more information about monkeypox. It’s been 40 years and we still haven’t found a vaccine for HIV. The treated patient has another life. What remains, for now, are medication and information”, he says.

For now, the acquisition of vaccines against monkeypox is not a reality for Brazil or for most countries where the disease has already been found. Questioned over the last few weeks, the Ministry of Health limited itself to saying that it has been in talks with the Ministry of Health since May. Pan American Health Organization (oops), who is responsible for the distribution of doses.

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