Monkeypox Is Not a Sexually Transmitted Disease: A Public Health Concern and Avoidance of Myths

Following the disastrous and life-threatening consequences of coronavirus disease 2019 (COVID-19), the World Health Organization (WHO) declared another public health emergency, Monkeypox (MPX), on July 23, 2022. According to the Centers for Disease Control and Prevention (CDC) Worldwide statistics, more than 19 000 cases have been recorded in 76 countries, including 18 800 in 70 nations that haven’t previously reported monkeypox cases. The public health care professionals claimed that the true number of this infection is likely far greater than the published numbers. The world may witness a rapid increase in monkeypox cases if testing capability has been improved, resulting in the burden on countries’ populations and also the health care sector. ¹ The CDC reported that 73 deaths resulted from the monkeypox virus (MPXV) infection globally. ² Monkeypox is a disease that is similar to smallpox, and it is caused by an orthopoxvirus called Monkeypox virus, with symptoms that include fever, tiredness, headache, lymphadenopathy, muscle aches, and a rash, which is more predominant on the face and extremities instead of the trunk, with the risk of complications such as superimposed illnesses, sepsis, keratitis, encephalitis, and bronchopneumonia. The first human case of monkeypox was documented in the Democratic Republic of the Congo in 1970. ³ The monkeypox virus has 2 strains: the African strain and the Congo Basin strain. The West African variant of the virus, which is spreading internationally, has a case fatality rate of roughly 1%, making it milder than the Congo Basin clade, which is growing in some regions of Africa. ¹ Vaccination against the now-extinct smallpox virus protects against monkeypox in 85% of cases. The WHO advises post-exposure prophylaxis (PEP) with a vaccine provided to contacts of patients within 4 days of initial exposure in a new WHO interim advice on vaccine usage for MPX. ⁴ This vaccination program should be prioritized among individuals who are at higher risk of a monkeypox infection, like men who have sex with men (MSM). Moreover, as the most vulnerable group, health care personnel should be fully equipped with the required personal protective equipment (PPE), especially in light of the global shortage witnessed during the COVID-19 pandemic. ^5,6

According to the WHO, the majority of MPX cases recorded internationally, as well as their abrupt increase, were caused by MSM, hence various fallacies about monkeypox as a sexually transmitted disease (STD) such as herpes, gonorrhea, and human immunodeficiency virus (HIV) are spreading. The WHO has identified sexual contact or several or multiple sexual partners in the 21 days preceding symptom onset as one of the risk factors. In addition to recognizing MPXV symptoms, newly described manifestations of the disease indicate a sexual transmission method. Deep-seated and well-circumscribed lesions were discovered on the genital organs. ⁷ In real-time PCR, samples acquired from vaginal and anal lesions had similar findings to those derived from the skin, feces, seminal fluid, nasopharynx, serum, and plasma in MPXV DNA. Another critical factor to consider is the possibility of MPXV and other sexually transmitted infections (STIs) co-infection. The instances detected in this community of concern were among MSM with STIs. For example, all MSM with MPXV had a history of STIs, hepatitis C, syphilis, and HIV. ⁷ The notion of MPXV as a sexually transmitted disease is reinforced by laboratory findings in Germany and other countries of positive MPXV qPCR in MSM seminal fluid. ⁸ Furthermore, research from London, UK, supports sexual contact transmission since 54 MSM individuals tested positive for the MPXV test. Furthermore, they had clinical features such as genital and perianal lesions as well as sexual transmission. ⁹

Sexually transmitted disorders, on the other hand, are conditions induced by sexual contact in which bacteria, viruses, and parasites are spread from person to person by blood, sperm, vaginal fluid, and other bodily fluids. Meanwhile, the majority of monkeypox cases documented in the Western world among men who have sex with men are due to close skin-to-skin contact; the virus is not transferred through seminal or vaginal fluid, and hence cannot be categorized as a sexually transmitted disease. The monkeypox virus has no known biological feature that boosts its susceptibility to infecting MSM. Because anybody may get or spread monkeypox through close personal contact with lesions, fomites such as infected clothes and other items, and respiratory droplets, misconceptions about it being an STD and blaming MSM should be avoided. Monkeypox being classified as an STD may be due to its disproportionate diagnosis among homosexual, bisexual, and other MSM, which may be due to ascertainment bias. Because many of the early cases were detected in MSM, sex health clinicians and the MSM communities they serve were acutely aware of monkeypox and its clinical manifestation. This early vigilance may have enhanced the likelihood of cases being diagnosed among MSM as compared to other populations where clinician and patient awareness is not as strong. ¹⁰

STDs are those conditions in which intimate sexual contact is important to transmission, and sexual contact is the transmission center. However, monkeypox is one of those conditions when only intimate touch, not sexual activity, is involved. The recent monkeypox outbreak is similar to the meningitis outbreak among the LGBT population that was reported a few years ago. ¹¹ To summarize, monkeypox is a disease that is spread from person to person by intimate skin contact; it is more common among MSM, but it cannot be classified as an STD because it is not transmitted through seminal or vaginal fluid. Furthermore, the disease may be halted from spreading by following the CDC and WHO recommendations and implementing a widespread immunization campaign.