Possible Exposures Among Mpox Patients Without Reported Male-to-Male Sexual Contact

Six U.S. Jurisdictions, November 1-December 14, 2022

J. Danielle Sharpe, PhD; Kelly Charniga, PhD; Katrina M. Byrd, MD; Ruth Stefanos, MD; Linda Lewis, DVM; Jessica Watson, MD; Amanda Feldpausch, DVM; Jessica Pavlick, DrPH; Julie Hand, MSPH; Theresa Sokol, MPH; Emma Ortega, MPHTM; Preeti Pathela, DrPH; Robin R. Hennessy, MPH; Melissa Dulcey, DVM, PhD; Lisa McHugh, PhD; Michael Pietrowski, MPH; Dana Perella, MPH; Seema Shah, MD; Azarnoush Maroufi, MPH; Melanie Taylor, MD; Anna Cope, PhD; Ermias D. Belay, MD; Sascha Ellington, PhD; Andrea M. McCollum, PhD; Leah Zilversmit Pao, PhD; Sarah Anne J. Guagliardo, PhD; Patrick Dawson, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2023;72(35):944-948.

Abstract and Introduction

Abstract

The extent to which the 2022 mpox outbreak has affected persons without a recent history of male-to-male sexual contact (MMSC) is not well understood. During November 1–December 14, 2022, CDC partnered with six jurisdictional health departments to characterize possible exposures among mpox patients aged ≥18 years who did not report MMSC during the 3 weeks preceding symptom onset. Among 52 patients included in the analysis, 14 (27%) had a known exposure to a person with mpox, including sexual activity and other close intimate contact (eight) and household contact (six). Among 38 (73%) patients with no known exposure to a person with mpox, self-reported activities before illness onset included sexual activity and other close intimate contact (17; 45%), close face-to-face contact (14; 37%), attending large social gatherings (11; 29%), and being in occupational settings involving close skin-to-skin contact (10; 26%). These findings suggest that sexual activity remains an important route of mpox exposure among patients who do not report MMSC.

Introduction

During infectious disease outbreaks, there are often cases for which a source of infection cannot be identified. The 2022 mpox outbreak disproportionately affected adult gay, bisexual, and other men who have sex with men; however, approximately 30% of U.S. mpox patients did not report male-to-male sexual contact (MMSC)^†.^[1,2] During May–October 2022, increases in mpox cases among persons with missing exposure data or no reported MMSC highlighted a need to understand the extent to which the outbreak has affected other populations, as well as additional potential routes of Monkeypox virus (MPXV) transmission, to aid in the development and implementation of public health prevention guidance.^[1]

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Abstract and Introduction
Methods
Results
Discussion
References
Sidebar

^†MMSC is defined as cisgender male-to-cisgender male sexual (e.g., oral or anal sex) or intimate contact (e.g., cuddling, kissing, touching partner's genitals or anus, or sharing sex toys) within 3 weeks of symptom onset.

Table. Characteristics of patients aged ≥18 years with mpox who did not report male-to-male sexual contact, by known or unknown exposure to a person with suspected or confirmed mpox — United States, November 1–December 14, 2022
Characteristic (no. with available data)	No. (%)*
	All (N = 52)	Any known exposure to a person with suspected or confirmed mpox
	All (N = 52)	Yes (n = 14)	No (n = 38)
Median age, yrs (range)	36 (18–70)	37 (22–56)	36 (18–70)
Race and ethnicity (48)^†
American Indian or Alaska Native	0 (—)	0 (—)	0 (—)
Asian	2 (4.2)	1 (8.3)	1 (2.8)
Black or African American	24 (50.0)	7 (58.3)	17 (47.2)
Native Hawaiian or other Pacific Islander	0 (—)	0 (—)	0 (—)
White	5 (10.4)	1 (8.3)	4 (11.1)
Hispanic or Latino	16 (33.3)	3 (25.0)	13 (36.1)
Multiracial or other race or ethnicity	0 (—)	0 (—)	0 (—)
Prefer to not answer	1 (2.1)	0 (—)	1 (2.8)
Missing	4	2	2
Gender identity (52)
Cisgender man	32 (61.5)	5 (35.7)	27 (71.1)
Cisgender woman	15 (28.8)	6 (42.9)	9 (23.7)
Transgender man	0 (—)	0 (—)	0 (—)
Transgender woman	3 (5.8)	2 (14.3)	1 (2.6)
Another gender identity	1 (1.9)	0 (—)	1 (2.6)
Prefer not to answer	1 (1.9)	1 (7.1)	0 (—)
Missing	0	0	0
Sexual orientation (45)
Heterosexual	30 (66.7)	9 (75.0)	21 (63.6)
Lesbian or gay	7 (15.6)	1 (8.3)	6 (18.2)
Bisexual	6 (13.3)	2 (16.7)	4 (12.1)
Other	2 (4.4)	0 (—)	2 (6.1)
Missing	7	2	5
Occupation (42)
Employed	26 (61.9)	10 (76.9)	16 (55.2)
Unemployed	10 (23.8)	3 (23.1)	7 (24.1)
Retired	2 (4.8)	0 (—)	2 (6.9)
Living with a disability	3 (7.1)	0 (—)	3 (10.3)
Student	1 (2.4)	0 (—)	1 (3.4)
Missing	10	1	9
Housing (32)
Housing secure	28 (87.5)	7 (87.5)	21 (87.5)
Housing insecure^§	4 (12.5)	1 (12.5)	3 (12.5)
Missing	20	6	14
Rash during illness (49)
Yes	48 (98.0)	13 (100)	35 (97.2)
No	1 (2.0)	0 (—)	1 (2.8)
Missing	3	1	2
First location of rash ^¶
Genitals	21 (47.7)	6 (54.5)	15 (45.5)
Legs	15 (34.1)	3 (27.3)	12 (36.4)
Arms	14 (31.8)	4 (36.4)	10 (30.3)
Trunk	13 (29.5)	3 (27.3)	10 (30.3)
Hands	9 (20.5)	2 (18.2)	7 (21.2)
Face	9 (20.5)	0 (—)	9 (27.3)
Head	5 (11.4)	1 (9.1)	4 (12.1)
Perianal	4 (9.1)	2 (18.2)	2 (6.1)
Neck	3 (6.8)	1 (9.1)	2 (6.1)
Feet	3 (6.8)	1 (9.1)	2 (6.1)
Mouth	0 (—)	0 (—)	0 (—)
Lips or oral mucosa	0 (—)	0 (—)	0 (—)
Missing or not applicable	8	3	5
Received ≥1 dose of JYNNEOS vaccine (30)
Yes	3 (10.0)	1 (16.7)	2 (8.3)
No	27 (90.0)	5 (83.3)	22 (91.7)
Missing	22	8	14
Person with HIV by self-report (32)
Yes	8 (25.0)	1 (14.3)	7 (28.0)
No	24 (75.0)	6 (85.7)	18 (72.0)
Missing	20	7	13

*Percentages calculated using nonmissing data.
^†All racial groups listed are non-Hispanic; Hispanic or Latino persons could be of any race.
^§Housing insecurity was defined as being unhoused or living in a congregate setting (e.g., dormitory, shelter, or hotel or motel).
^¶First locations of rash are not mutually exclusive.