Are mpox cases under-reported?

Owing to the study results, the protection offered by condoms against mpox virus would be open to debate. Representation pic

The outcome of a study conducted on used condoms in 16 countries including India has got the health experts concerned as monkeypox (mpox) virus was found in 32 of the 1,188 condoms that were tested in our country. After the study was published in the journal of Lancet Infectious Diseases in August, health experts are worried as the findings may be the tip of the iceberg. The two persons from India who have been confirmed to have mpox are being monitored in isolation.

Study covered 16 countries including India

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Dr Wiqar Shaikh

Dr Wiqar Shaikh, professor of medicine, Grant Medical College and Sir J J Group of Hospitals said that following the lifting of restrictions of pandemic and an increase in sexual interactions have fuelled the spread of the viral disease mpox beyond its known endemic regions. According to Dr Shaikh, the study by scientists from Japan, Thailand, Australia and Philippines concluded that the current global spread of mpox is marked by person-to-person transmission as well as sexual and non-sexual contact.

Study of used and discarded condoms

Dr Shaikh said that used and discarded condoms were collected by scavengers and sanitary workers from brothels and public spaces. A PCR test was done on the semen collected from each condom to determine the pathogens present. It was found that 262 condoms (1.3%) out of a total of 20,941 samples were found to be positive for mpox. Among the 16 countries that were part of the study, India has the highest rate, 2.7 per cent, of positive cases.

Dr Shaikh said that semen samples were also studied for other STDs particularly HIV (AIDS). Dr Shaikh questioned whether the condoms could have acted as a barrier to the spread of mpox and other STDs? He said it was difficult to say with certainty, but it could have.

Mpox and other STDs

Dr Shaikh said that the study also suggests that people have the potential to suffer from mpox along with other serious STDs such as HIV (AIDS). Dr Shaikh explained that the current spread of mpox Clade II variant shows that children and people with HIV (AIDS) are at increased risk of not only getting mpox, but are at increased risk for severe outcomes. Dr Shaikh said mpox has disproportionately affected homosexuals.

Dr Shaikh said, "According to WHO over 120 countries have confirmed more than 1,03,000 cases of mpox since the onset of the global outbreak in 2022. In 2024 alone, there were 25,237 suspected and confirmed cases and 723 deaths from different outbreaks in 14 countries of the African Region." This is based on the data from September 8 2024, he said.

Mpox as a sexually transmitted infection

Dr Subhash Hira

The correspondence letter titled "Community-based Mpox and sexually transmitted disease surveillance using discarded condoms in the global south" has been published in the journal, Lancet Infectious Diseases in its August 21, 2024 edition. Dr Subhash Hira, professor of global health at University of Washington who has critiqued the study said, "It is a good scientific study designed and conducted by a multi-disciplinary team of scientists, doctors, and researchers in 16 countries, including India with a credible participation of community NGOs and social groups of LGBT. The fact that the study identified mpox infection in semen of the used condoms, itself indicates that those persons were established cases of mpox." Dr Hira said that study successfully identified most bacterial and viral Sexually Transmitted Infections (STIs) through anonymous, passive surveillance methods.

"Incidentally, this study for mpox has also highlighted the importance of control of other STIs that have remained forgotten after the control of HIV/AIDS. The recent estimates are that over 100 million new cases of STIs occur in the world every year that cause avoidable morbidity and mortality. There is a global resurgence of syphilis and its adverse outcomes on pregnancy and children", said Dr Hira.

Protection by condoms is questionable

Dr Ketan Vagholkar

"Mpox is transmitted by both non-sexual and sexual routes. The study revealed a potential risk of co-transmission of mpox with wide range of other sexually transmitted diseases such as Neisseria gonorrhoeae, herpes simplex virus type 1 [HSV-1], herpes simplex virus type 2 [HSV-2], HIV, Chlamydia trachomatis, Gardnerella vaginalis, Haemophilus ducreyi, Mycoplasma genitalium, Mycoplasma hominis, Treponema pallidum, Trichomonas vaginalis, Ureaplasma urealyticum, human papillomavirus [HPV], hepatitis C virus [HCV], hepatitis B virus [HBV]). MPXV has disproportionately affected homosexuals, indicating amplified transmission through sexual networks. The protection offered by condoms against mpox virus continues to be a topic of debate taking into consideration the results of the recent study published in the journal of Lancet Infectious Disease," said Dr Ketan Vagholkar, professor of surgery at DY Patil Medical College, Navi Mumbai.

Expert view

Dr Jacob John

Dr Jacob John, renowned Virologist from Vellore, Tamil Nadu, raised serious concerns about the study published in Lancet. He said that this information by itself means that all people with Mpox are not getting diagnosed or reported or both. "India doesn't have a functional public health system like in other developed countries that could monitor every disease, ensure doctors diagnose and report all cases of infectious diseases and take measures to control all such diseases." He questioned our country's ability to control new diseases when we have failed to control tuberculosis, typhoid, malaria and cholera. Dr John even cited the recent outbreak of an unknown fever that claimed lives of people including children in Gujarat. "The reason why the public health system is not developed in India, is because doctors, hospitals, medical institutions, have to make more money and for that we need to have more diseases, which brings in patients," said Dr John.

First mpox vaccine approved

Meanwhile, On Friday evening, (WHO) approved Bavarian Nordic's manufactured vaccine known as Jynneos, the first vaccine against mpox to control the outbreak of the disease in Africa. WHO is in the process of reviewing a second vaccine to fight mpox called LC16 made by KM Biologics of Japan," said Dr Sahikh.

32
No. of +ve cases in India the study found out of 1,188 samples

16
Countries that were part of the study