Today in Clinical Infectious Diseases two opposing commentaries debate whether or not mpox should be considered a sexually transmitted infection (STI).

While the 2022 global outbreak has largely been defined by sexual transmission among men who have sex with men (MSM), the disease has historically been defined via household contact, or animal-to-human contact via the ingestion of bushmeat.

Three requirements fulfilled

In the first article, physicians from Brigham & Women's Hospital in Boston and from California use epidemiologic factors to demonstrate causality. They suggest that, because the virus can be isolated from sexual fluids and because of the temporal association between sexual activity and subsequent infection, mpox should be considered an STI.

"The association between Mpox and sexual transmission thus far fulfills three important requisites: strong association, consistency across time and geographic location, and temporality," they write.

The authors said this definition should certainly be adopted in Europe and North America, but sexual transmission is not the dominant transmission mode in Africa, so designating the virus as an STI in that region may be unhelpful.

The association between Mpox and sexual transmission thus far fulfills three important requisites: strong association, consistency across time and geographic location, and temporality

Need for historical context

The second commentary says that labeling mpox as an STI ignores the historical impact of the disease in Central and West Africa. "The majority of historical outbreaks have been localized with little to no sexual transmission noted, significantly differing from what is seen currently," the authors write.

By labeling the virus an STI, less attention could be given to pediatric cases or tracking the disease in other vulnerable groups who are more commonly affected in Africa, add the authors, Aniruddha Hazra, MD, of University of Chicago Medicine, and Joseph N Cherabie, MD, of Washington University School of Medicine in St. Louis.

The majority of historical outbreaks have been localized with little to no sexual transmission noted, significantly differing from what is seen currently

In September, CIDRAP published a commentary by H. Hunter Handsfield, MD, stating that mpox is certainly an STI, as sexual activity has been implicated in 95% of US cases, and MSM must be properly educated on the risks of contracting the virus.

Clinical trial results published today in the New England Journal of Medicine show that a shorter, all-oral treatment regimen for drug-resistant tuberculosis (TB) is more effective and safer than standard care.

The phase 2/3 TB-PRACTECAL trial, the results of which were initially presented in October 2021 at a conference prior to peer review, compared outcomes and adverse events in rifampicin-resistant TB patients who were randomly assigned to receive the 6-month BPaLM (bedaquiline, pretomanid, linezolid, and moxifloxacin) regimen or the 9- to 20-month standard-care regimen. Patients 15 years or older at seven sites in Belarus, South Africa, and Uzbekistan were enrolled.

The primary outcome was an unfavorable status (a composite of death, treatment failure, treatment discontinuation, loss to follow-up, or TB recurrence) at 72 weeks at randomization. The noninferiority margin was 12 percentage points.

The trial enrolled 552 patients, 301 of whom were included in the final analysis. In the modified intention-to-treat analysis, 7 of 62 patients (11%) in the BPaLM group had an unfavorable status at 72 weeks, compared with 32 of 66 patients (48%) in the standard-care group. With an unadjusted risk difference of –37 percentage points, the BPaLM regimen was both noninferior and superior to the standard-care treatment. The incidence of adverse events of grade 3 or higher or serious adverse events was significantly lower in the BPaLM group than in the standard-care group (19% vs 59%). 

BPaLM is one of two shorter, all-oral regimens that were recently recommended by the World Health Organization for treating patients who have multidrug-resistant or rifampicin-resistant TB, based on data from TB-PRACTECAL and other trials.

"This publication will provide deeper evidence to policymakers and treatment providers deciding to use the TB PRACTECAL regimen," chief trial investigator Bern-Thomas Nyang'wa, medical director for trial sponsor Doctors Without Borders/Medecins Sans Frontieres (MSF), said in a press release. "Now it is essential that the new treatment is made available to everyone who needs it."

MSF says five countries have begun implementing the BPaLM regimen, and eight are set to implement it next year.