LAUSR

Hoffmann et al. described a large national outbreak of monkeypox virus (MPX) infection involving 546 men who had sex with men (MSM) in Germany [1]. Nearly half of the patients were living with HIV, but this did not affect the course of MPX infection, which was mild in most individuals. Nevertheless, as many as 4% of patients required hospitalization, mainly for treatment of painful proctitis lesions. A striking observation in this cohort was the high rate of other sexually transmitted diseases in the preceding months, which indicates a high-risk sexual behaviour in many of the affected people. Very similar results were reported from a Spanish cohort comprising 1256 individuals (1242 of whom were male). Out of 387 patients, who provided detailed information, 332 (85.8%) reported intimate and prolonged sexual contacts as a risk factor for the acquisition of MPX [2]. Thus, it has become very clear from these and other observations that MPX infection has to be regarded as a sexually transmitted disease. By the end of July 2022, MPX had affected more than 22 000 individuals in 79 countries worldwide [3]. The rapidly growing numbers and the wide geographical distribution of cases indicate that this infection will settle as a continuing epidemic. According to a recent modelling study, the growth of the epidemic is driven mainly by a relatively small proportion of individuals, who have disproportionately large numbers of sexual partners [4]. Therefore, it is crucial that prevention efforts focus on these most endangered groups with specifically tailored messages. This includes information on the MPX disease itself as well as on risk behaviour, transmission factors and risk reduction. Many individuals may have perceived MPX infection as a less severe disease that does not necessitate behavioural changes. Although the course is, indeed, mild in most cases, it is a novel disease with unpredictable evolution and with painful and eventually mutilating sequelae in some patients. Ideally, this outbreak should be terminated as soon as possible by using the whole armamentarium of containment measures we have at hand: prevention through vaccination of persons at risk, early diagnosis and treatment of infected patients, contact tracing, and, importantly, education campaigns to promote reduction of risk behaviour. Although we already have a specific vaccine, its limited availability will not allow rapid immunization of most people at risk. Treatment options are even more restricted by the low availability of tecovirimat, the only virostatic drug against MPX so far. Thus, educational programmes, directed predominantly at those people at risk, that provide knowledge on risk reduction will be a cornerstone in the containment of this emerging disease. Clearly, stigma and homophobia associated with MPX are real dangers that have to be meticulously addressed. This may best be achieved through accurate and open information on risks and on risk minimization while at the same time avoiding social judgment. [5]. Finally, this outbreak underlines the need for comprehensive and adequately funded services of sexual health that are easily accessible and able to cope with emerging challenges such as MPX infection.