Experts debate mpox status as a sexually transmitted infection

News brief

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.

Some 'long-COVID' symptoms also occur after cold, flu, pneumonia

News brief

Some conditions considered long-COVID symptoms don't seem to occur more often than after other viral respiratory illnesses (VRIs), but heart palpitations, fatigue, chest pain, and shortness of breath were among the problems unique to SARS-CoV-2, finds a study published yesterday in Open Forum Infectious Diseases.

Researchers from the University of Missouri and the University of Minnesota analyzed electronic health record data from 17,487 adults who tested positive for COVID-19 at 122 US healthcare facilities before Apr 14, 2022. The patients were matched with those diagnosed as having the common cold, flu, or viral pneumonia from Mar 1, 2020, to Apr 1, 2021, and with uninfected controls.

For each studied outcome, COVID-19 was compared with a generic VRI by predicting diagnoses that occur 30 to 365 days after infection. Diagnoses of which SARS-CoV-2 was a significant positive predictor when compared with both VRI and control groups were considered unique to COVID-19.

Seven conditions specific to COVID

Compared with other VRIs, COVID-19 infection was a significant positive predictor of heart palpitations (odds ratio [OR], 1.32), hair loss (OR, 1.32), fatigue (OR, 1.13), chest pain (OR, 1.1), shortness of breath (OR, 1.09), joint pain (OR, 1.08), and obesity (OR, 1.08).

Shortness of breath and chest pain were the only lung-related conditions significantly elevated in both comparisons of COVID-19 versus VRI and COVID-19 versus controls. Pulmonary embolism (blood clots in the lungs), low oxygen levels, other respiratory failure, the need for oxygen, and pneumonia were significantly more common in SARS-CoV-2 than VRI patients but not compared with controls.

Abnormally rapid heart rhythm, anemia (low red blood cells), heart failure, high blood pressure, abnormal cholesterol levels, and type 1 diabetes were more common in COVID-19 than VRI patients but not compared with controls.

Relative to VRI patients, the average date of the last recorded fatigue and joint pain diagnoses was significantly earlier for COVID-19 patients, which the authors said suggests that symptom resolution may occur within 1 year. "The long-term clinical implications of SARS-CoV-2 infection are complex and will have on-going significant impact on quality of life and patient care," they wrote.

Trial results show superiority of shorter, all-oral treatment for drug-resistant TB

News brief

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.

This week's top reads