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Understanding sexual transmission dynamics and transmission contexts of monkeypox virus: a mixed-methods study of the early outbreak in Belgium (May–June 2022)
  1. Jef Vanhamel1,
  2. Valeska Laisnez2,3,
  3. Laurens Liesenborghs4,
  4. Isabel Brosius4,
  5. Nicole Berens-Riha4,
  6. Thibaut Vanbaelen4,
  7. Chris Kenyon4,
  8. Koen Vercauteren4,
  9. Marie Laga1,
  10. Naïma Hammami5,
  11. Oriane Lambricht6,
  12. Romain Mahieu7,
  13. Amaryl Lecompte2,
  14. Wim Vanden Berghe2,
  15. Bea Vuylsteke1
  1. 1Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
  2. 2Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
  3. 3ECDC Fellowship Programme, Field Epidemiology Path (EPIET), European Centre for Disease Prevention and Control, Solna, Sweden
  4. 4Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
  5. 5Department of Infectious Disease Prevention and Control, Agency for Care and Health, Flemish Region, Brussels, Belgium
  6. 6Agence pour une Vie de Qualité (AVIQ), Walloon Region, Charleroi, Belgium
  7. 7Department of Infectious Disease Prevention, Brussels Capital Region, Brussels, Belgium
  1. Correspondence to Jef Vanhamel, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; jvanhamel{at}itg.be

Abstract

Objective The available epidemiological and clinical evidence from the currently ongoing monkeypox (MPX) outbreak in non-endemic areas suggests an important factor of sexual transmission. However, limited information on the behaviour and experiences of individuals with an MPX infection has to date been provided. We aimed to describe the initial phase of the MPX outbreak in Belgium, and to provide a more in-depth description of sexual behaviour and transmission contexts.

Methods We used routine national surveillance data of 139 confirmed MPX cases with date of symptom onset until 19 June 2022, complemented with 12 semistructured interviews conducted with a subsample of these cases.

Results Sexualised environments, including large festivals and cruising venues for gay men, were the suspected exposure setting for the majority of the cases in the early outbreak phase. In-depth narratives of sexual behaviour support the hypothesis of MPX transmission through close physical contact during sex. Despite awareness of the ongoing MPX outbreak, low self-perceived risk of MPX acquisition and confusing initial signs and symptoms for other STIs or skin conditions delayed early detection of an MPX infection. In addition, we describe relevant contextual factors beyond individual behaviour, related to sexual networks, interpersonal interactions and health systems. Some of these factors may complicate early MPX detection and control efforts.

Conclusion Our results highlight the role of sexual contact and networks in the transmission of MPX during the early phase of the outbreak in Belgium. Risk communication messages should consistently and transparently state the predominant sexual transmission potential of MPX virus, and prevention and control measures must be adapted to reflect multilevel factors contributing to MPX transmission risk.

  • Sexual Behavior
  • QUALITATIVE RESEARCH
  • Epidemiology
  • Behavioral Sciences

Data availability statement

Data are available upon reasonable request. All relevant data supporting our findings are included in this published article. The complete dataset of conducted interviews is not made publicly available because they might contain information that could identify other persons, yet additional anonymised data are available from the corresponding author on reasonable request.

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Data availability statement

Data are available upon reasonable request. All relevant data supporting our findings are included in this published article. The complete dataset of conducted interviews is not made publicly available because they might contain information that could identify other persons, yet additional anonymised data are available from the corresponding author on reasonable request.

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Footnotes

  • JV and VL are joint first authors.

  • Handling editor Anna Maria Geretti

  • Twitter @JefVanhamel, @VLaisnez, @rommah

  • JV and VL contributed equally.

  • Contributors JV, VL, LL, IB, KV, AL, WVB and BV contributed to the conceptualisation of the study. LL, IB, NB-R, TV, CK and KV were involved in clinical management of the cases. JV, ML and BV designed the interview questionnaire. JV conducted the 12 interviews. NH, OL and RM interviewed cases as part of regional public health authorities. VL, AL and WVB analysed the routine surveillance data. JV and VL prepared the first draft of the manuscript. All authors were involved in the interpretation of the data and in writing and reviewing the final version of the manuscript. All authors approved of the final version. BV is the guarantor for this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The views and opinions expressed herein do not state or reflect those of the ECDC. The ECDC is not responsible for the data and information collation and analysis and cannot be held liable for conclusions or opinions drawn.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.