September 23, 2022
2 min read
Can you catch monkeypox from a toilet seat, or by trying on clothes at a thrift store? Is the virus spreading through bodily fluids? Can you pass it to your pets?
Search for “monkeypox” on social media, and those are the kinds of questions you’ll find online.
Several months into an unprecedented outbreak of monkeypox, platforms like Instagram, Twitter and TikTok are rife with sensationalized posts about how this virus might transmit, stoking potential fears that people can catch it in their day-to-day lives, even as data overwhelmingly points to sexual contact between men as a primary driver of global transmission.
One analysis of monkeypox-related posts on Twitter, which was published in June as a letter to the editor in the Journal of Infection in Developing Countries, found more than half the posts contained misinformation or unverifiable details.
“There is a big difference between what is possible, and what is likely, and what is actually happening,” said Len Tooley, director of evaluation at the Community-Based Research Centre, a queer health policy organization, and one of the first people to catch monkeypox in Toronto.
“What we see actually happening is it is mostly gay and bi men who are getting monkeypox. Most of them are getting it sexually … so if you don’t fit into one of those two categories, you probably don’t have too much to worry about.”
While there are still key unanswered questions about the exact ways this virus spreads between hosts, data shows the bulk of infections remain among men who have sex with men — making it crucial, scientists say, to prioritize limited vaccines and supports to gay, bisexual and transgender individuals who are the highest risk of catching what’s often a painful, weekslong illness.
“We know that sexual transmission in men who have sex with men is an important mechanism of spread and is contributing significantly to the ongoing outbreak,” said physician and researcher Dr. Boghuma Titanji, an assistant professor at Emory University in Atlanta. “That being said, it is not the only method of transmission.”
So here’s what global researchers know — and don’t — about how this virus transmits.
Before this year’s global outbreak, scientists typically thought the monkeypox virus, or MPXV, primarily reached humans through contact with infected animals, leading to household transmission and limited outbreaks in regions of West and Central Africa where this pathogen is endemic.
But Titanji said there were hints MPXV was spreading through sexual networks as well, with Nigerian scientists ringing alarms during a countrywide outbreak in 2017 that largely impacted sexually active young men, often causing genital lesions.
“So it is possible that monkeypox has also been spreading through sexual contact and has kind of flown under the radar, and found its way into very densely connected sexual networks that allowed it to be amplified,” said Titanji.
In Canada, the disease is mostly reported among men who have sex with men, and 99 per cent of infected individuals identify as male, with a median age of 36.
Among U.S. monkeypox cases with available data, 99 per cent also occurred in men, including 94 per cent who reported recent male-to-male sexual or close intimate contact.
Broad European data also suggests cases remain primarily among men who have sex with men between the ages of 18 to 50. According to the latest European Centre for Disease Prevention and Control risk assessment, the likelihood of MPXV spreading further in networks of people with multiple sexual partners is “considered high,” while the chance of it spreading into the broader population is “assessed as very low.”
Understanding those transmission patterns is key to knowing where to direct limited supplies, including vaccines, said Angela Rasmussen, a virologist with the University of Saskatchewan’s Vaccine and Infectious Disease Organization.
“It makes the most sense to distribute that vaccine to the people who are at the highest risk,” she said. “People who are men who have sex with men, people who’ve had multiple partners, people who’ve had sex recently.”
When it comes to transmission through sex, what’s less clear is whether it’s primarily tied to skin-to-skin contact, or if bodily fluids are also playing a major role.
“One of the unknowns is to what extent — and for how long — can this be transmitted through semen,” said Toronto-based infectious diseases specialist Dr. Isaac Bogoch.
As Public Health Ontario noted in an August evidence brief, there’s not yet clear evidence of genital secretions as a “distinct route of transmission” alongside direct, intimate contact.
Several recent case studies analyzing human semen during active infections did report finding monkeypox DNA, which has been identified in other bodily fluids as well.
Other research suggests people can carry the virus without showing any obvious symptoms, such as telltale bodily or genital lesions. One recent study conducted in France, found 13 out of 200 individuals tested positive for MPXV at the time of an anal swab performed to find other potential infections — even though they were asymptomatic.
“Whether this indicates viral shedding that can lead to transmission is unknown,” the researchers wrote.
WATCH | What it’s like to recover from monkeypox:
Monkeypox does have a knack for lingering on contaminated items, like an infected individual’s clothes or bedding. But that doesn’t necessarily mean someone else will catch it.
In one study, investigators found live virus 15 days after a patient’s home was left unoccupied, the U.S. Centers for Disease Control and Prevention noted in mid-July.
Studies also show that other closely related viruses can survive in an environment similar to a household for weeks or months, the CDC statement continued, with porous objects, like bedding and clothing, potentially harbouring live virus for longer periods than non-porous surfaces, like glass or metal.
So, theoretically, this virus can be passed on by touching various objects, or through close, non-sexual contact.
There are concrete examples of household transmission to children and possibly pets, including one case study in France where two men who caught MPXV may have passed it to their dog, who slept in their bed.
But if this virus was easily spread through surface-based transmission, “we would have seen a much larger outbreak ages ago,” said Bogoch.
“I think it’s completely overblown that we should be concerned about touching an inanimate object, like a doorknob going into a place, or a scooter, or washing every item that we get from the grocery store,” he said. “I think that’s obviously premature.”
Dr. Zain Chagla, an infectious diseases specialist with McMaster University in Hamilton, agreed global data on cases during this monkeypox outbreak show infections typically aren’t just “showing up out of the blue.”
“And the few that are, are not really leading to sustained transmission,” he said.
Still, Chagla said there’s merit to taking certain precautions, primarily within health-care settings and households where a family member has an active infection.
If someone in a home has monkeypox, the CDC suggests cleaning and disinfecting the entire space, and putting all contaminated clothes and linens in the laundry — and if the person doing that job isn’t the one infected, they should wear, at a minimum, disposable medical gloves and a respirator or a well-fitting mask.
Like lots of other common viruses, including those that cause influenza and COVID-19, MPXV can spread through the air and infect other people — though many scientists don’t see evidence yet that it’s a major transmission route.
“You can still get transmission through droplets and aerosols,” said Titanji, referring to larger and smaller sizes of particles that people can breathe out or inhale.
“But the last two modes of transmission that I’ve just listed appear to be less frequent than the predominant mode of sexual transmission.”
The World Health Organization maintains that transmission through respiratory particles “usually requires prolonged face-to-face contact,” which puts health workers, household members and other close contacts of active cases at a greater risk of getting infected.
“If people were getting monkeypox … by inhaling it and breathing it in, then we would see a lot of people who are not men who have sex with men contracting monkeypox,” said Rasmussen.
As for misinformation circulating online, implying the general public can easily catch this virus, Tooley said some of it may come from a place of stigma or simply fear.
“I hope all those people who are afraid of getting monkeypox are advocating for services for those who do get monkeypox,” he said.
“Because if it does continue spreading into other populations, we want to make sure the health-care system is prepared.”
Every 22 minutes, a woman in Canada dies of a heart attack.
But the majority don’t have to, experts say, warning that more women will die unnecessarily if the medical community doesn’t tailor care to their needs.
“We have one of the best health-care systems in the world, and we’re not serving women,” said Dr. Paula Harvey, a cardiologist and head of the department of medicine at Women’s College Hospital in Toronto. “We have to do better.”
Heart disease is a top killer of women in Canada, and the push to change that is more urgent than ever. Harvey says more younger women are presenting with classic high risk factors for heart disease: high blood pressure, diabetes and obesity.
“There’s this trend to cardiovascular risk factors starting to be a problem at an earlier age, and I find that disturbing,” said Harvey. “I never used to see a woman in her 40s with high blood pressure. I’m starting to see that, and that’s going to mean that we’ll have more premature heart disease.”
Some studies have already found the heart attack rate among women aged 35-54 has gone up.
Lifestyle factors play a role in the trend, but the threat itself is broader — the majority of Canadian women have at least one risk factor for cardiovascular disease. Women with diabetes and those who come from certain racial or ethnic backgrounds are at higher risk, but fluctuating hormones can wreak havoc with any woman’s heart health, especially as they enter menopause and levels of the heart-protecting hormone, estrogen, start to drop.
That transition starts when women are in their 40s and can catch many off guard, Harvey said.
“I do think that a lot of that comes from the fact that women are still not being educated, they’re not being counselled, they don’t understand the impact of our changing biology with age that puts them at cardiovascular risk.”
According to the Canadian Women’s Heart Health Centre, at the University of Ottawa Heart Institute, 24,000 Canadian women die of heart disease every year. That’s nearly five times more deaths than from breast cancer.
Yet when it comes to heart health, experts say it’s still largely a man’s world: Women remain underdiagnosed, undertreated and unaware.
“It is a glass ceiling. It’s a glass ceiling for awareness, it’s a glass ceiling for research and for how we provide care,” said Karin Humphries, an associate professor at the University of British Columbia whose has researched gender and sex differences in the diagnosis, treatment and outcomes of patients with cardiovascular disease.
The basic medical model is still male-dominated and contributes to a general lack of awareness among women and health-care providers, Humphries said. And while awareness is growing, it’s not growing fast enough, she said.
“Everything in our culture emphasizes that cardiovascular disease is a man’s disease. I mean, think of Hollywood. Every time you see a heart attack, it’s on the male, right? You’re not watching a woman in a Hollywood movie having a heart attack.”
Part of the problem is that women’s symptoms can be different than those of men and can be attributed by both doctors and women themselves to stress and busy lives. For example, months before a heart attack, women may experience unusual fatigue, trouble sleeping, indigestion and anxiety.
Even during a heart attack, the symptoms can be subtle. Women are more likely to have chest discomfort, shortness of breath and even neck, jaw or back pain.
“I was still, you know, two months after my event, still reeling from that shock,” said Risa Mallory, who had a heart attack four years ago at age 61.
Mallory had been experiencing discomfort in her chest for several days, she said, but it came and went and didn’t seem so bad — until it suddenly was.
“On the fourth day, I experienced chest pain. It had changed. It was much more severe. I was feeling nauseous and I had this sense of fight or flight,” she recalled. “I remember sitting in the car, rocking, and saying, ‘We gotta go, we gotta go, we gotta go.'”
Mallory ended up in the emergency room and got help in time. But it was a close call. Heart disease runs in her family, she was aware of her own risk, but she still almost missed the warning signs.
That’s something that happens often, according to a 2018 Heart and Stroke Foundation report. The report found that early signs of a heart attack were missed in 78 per cent of women.
“What it tells us is that there are still a lot of inequalities and biases at the community level and the health-care provider level,” said Dr. Thais Coutinho, a cardiologist and chair of the Canadian Women’s Heart Health Centre at the University of Ottawa Heart Institute.
Many women are in the dark, Coutinho said, in large part because much of the medical community is too.
Even now, the majority of heart disease research is conducted on men — despite important physiological differences, she said. Women’s hearts and arteries are smaller, and plaque builds in different ways. Standard diagnostic tests like angiograms and stress tests are often not sensitive enough to detect heart disease in women.
“That assumption still permeates through the cardiovascular research community that women are small men,” Coutinho said. “I do a lot of sex- and gender-based research, or women-specific cardiovascular research, and it’s amazing the differences that you find if you look. All of the gaps that we know exist from awareness, diagnosis, treatment, care, rehabilitation, education, everything — it starts with knowledge.
“So if we don’t even know what the differences are, we don’t know how to manage them.”
Samia Janna was 48 when she first went to her doctor in 2018 because of shortness of breath. The Ottawa-area woman was prescribed anti-anxiety medication and told to take it easy. But the symptoms persisted.
Janna went back to her doctor twice more, only to be given the same advice.
“At that time, I said, ‘No, I know it’s not anxiety,'” Janna says. “I know myself. There’s something wrong with my heart.”
Blood tests didn’t flag anything, but Janna insisted on an ultrasound to check her heart. It revealed Janna’s heart was enlarged and causing damage to her heart valves. She ended up having two open heart surgeries.
Janna says it was hard to let go of her anger about the fact that her concerns were initially dismissed. She joined a cardiac rehabilitation program and says it helped her regain her physical and emotional strength. “If it wasn’t for them. I would have been in a different place now, in a very dark place.”
Research finds women are up to 50 per cent less likely than men to attend cardiac rehab programs, often because they don’t get referred to one or face other barriers to follow-up care, including a tendency to minimize their own needs.
It helps explain why women who have a heart attack are more likely to die or experience a second heart attack compared to men.
Harvey says research is beginning to uncover the biological, medical, and social reasons for this — and the hope is that new knowledge will lead to advances in tailoring prevention and treatment to women’s needs.
But she points out, 80 per cent of heart attacks can be prevented and women can decrease major risk factors by managing high blood pressure, not smoking and sticking to a healthy weight. Harvey says women should also urge their doctors to check their hearts.
“We need to be empowered,” she says. “Knowledge is power. Advocacy is power. And do what you can so that you are aware of cardiovascular risk.”
And though prevention is key, Humphries says women should not hesitate to get help if they feel something is wrong.
“Call 911 and ask for help. Don’t worry about, you know, taking up time for health-care providers. They’re there to help you. And if you find out there’s nothing wrong with you, that’s wonderful. But absolutely do not hesitate and call 911.”
The study by University of British Columbia researchers says that while reduced social interaction during the March-May 2020 lockdown worked to reduce HIV transmission, that may not have “outweighed” the increase caused by reduced access to services.
The study, published in Lancet Regional Health, found that fewer people started HIV antiretroviral therapy or undertook viral load testing under lockdown, while visits to overdose prevention services and safe consumption sites also decreased.
The overall number of new HIV diagnoses in B.C. continues a decades-long decline. But Dr. Jeffrey Joy, lead author of the report published on Friday, said he found a “surprising” spike in transmission among some drug users during lockdown.
Joy said transmission rates for such people had previously been fairly stable for about a decade.
“That’s because there’s been really good penetration of treatment and prevention services into those populations,” he said in an interview.
B.C. was a global leader in epidemic monitoring, which means the results are likely applicable elsewhere, Joy said.
“We are uniquely positioned to find these things,” he said. “The reason that I thought it was important to do this study and get it out there is (because) it’s probably happening everywhere, but other places don’t monitor their HIV epidemic in the same way that we do.”
Rachel Miller, a co-author of the report, said health authorities need to consider innovative solutions so the measures “put in place to address one health crisis don’t inadvertently exacerbate another.”
“These services are the front-line defence in the fight against HIV/AIDS. Many of them faced disruptions, closures, capacity limits and other challenges,” Miller said in a news release.
“Maintaining access and engagement with HIV services is absolutely essential to preventing regression in epidemic control and unnecessary harm.”
The Health Ministry did not immediately respond to requests for comment.
Researchers said the spike among “select groups” could be attributed to a combination of factors, including housing instability and diminished trust, increasing barriers for many people who normally receive HIV services.
British Columbia is set to become the first province in Canada to decriminalize the possession of small amounts of hard drugs in January, after receiving a temporary federal exemption in May.
Joy said this decision, alongside measures like safe supply and safe needle exchanges, will make a difference preventing similar issues in the future.
“The take-home message here is, in times of crisis and public health emergency or other crises, we need to support those really vulnerable populations more, not less,” he said.
“Minimally, we need to give them continuity and the access to their services that they depend on. Otherwise, it just leads to problems that can have long, long-term consequences.”
This report by The Canadian Press was first published Sept. 24, 2022.
© 2022 The Canadian Press
September 23, 2022
2 min read
One author reports receiving speaker and consultant fees from Bayer and Janssen for work unrelated to this study. Walli-Attaei and the other authors report no relevant financial disclosures.
The magnitude of associations with major CVD for most risk factors are similar in women and men, despite sex differences in risk factor levels, according to an analysis of the PURE study.
In a comprehensive overview of the prevalence of metabolic, behavioral and psychosocial risk factors for CVD in women and men globally, researchers also found that diet was more strongly associated with CVD in women than in men. However, high concentrations of non-HDL and related lipids and symptoms of depression were more strongly associated with risk for CVD in men than in women. Patterns remained consistent across countries regardless of income level.
“Existing studies, mostly from high-income countries, have reported that hypertension, diabetes, and smoking are more strongly associated with cardiovascular disease in women than in men,” Marjan Walli-Attaei, PhD, a research fellow at the Population Health Research Institute of McMaster University and Hamilton Health Sciences, and colleagues wrote in The Lancet. “Such findings would imply that women would benefit to a greater extent in reducing cardiovascular disease risk from control of these risk factors than would men. However, the burden of cardiovascular disease is greatest in low-income and middle-income countries, for which prospective data on the association of risk factors with cardiovascular disease are sparse, with a paucity of analysis by sex.”
Walli-Attaei and colleagues analyzed data from 155,724 adults aged 35 to 70 years at baseline without a history of CVD enrolled in the PURE study, which included participants from 21 high-, middle- and low-income countries, and followed them for approximately 10 years (58% women; mean baseline age, 50 years). Researchers recorded information on participants’ metabolic, behavioral and psychosocial risk factors; all participants had at least one follow-up visit. The primary outcome was a composite of major CV events, defined as CV death, MI, stroke and HF. Researchers reported the prevalence of each risk factor in women and men, HRs and population-attributable fractions associated with major CVD.
As of the data cutoff of Sept. 13, 2021, researchers observed 4,280 major CVD events in women (age-standardized incidence rate, 5 events per 1,000 person-years) and 4,911 in men (age-standardized incidence rate, 8.2 per 1,000 person-years).
Compared with men, women presented with a more favorable CV risk profile, especially at younger ages. HRs for metabolic risk factors were similar in women and men, except for non-HDL, for which high non-HDL was associated with an HR for major CVD of 1.11 in women (95% CI, 1.01-1.21) and 1.28 in men (95% CI, 1.19-1.39; P for interaction = .0037), with a consistent pattern for higher risk among men than women with other lipid markers.
Researchers also observed that maintaining a diet with a PURE score of 4 or lower (score range, 0-8) was more strongly associated with major CVD in women than in men, with HRs of 1.17 (95% CI, 1.08-1.26) and 1.07 (95% CI, 0.99-1.15; P for interaction = .0065), respectively.
In contrast, symptoms of depression were more strongly associated with CVD in men than in women, with the HRs for symptoms of depression being higher in men than in women (P for interaction = .0002). “The HRs of other behavioral and psychosocial risk factors, as well as grip strength and household air pollution, were similar among women and men,” the researchers wrote.
The total population-attributable fractions associated with behavioral and psychosocial risk factors were greater in men than in women (15.7% vs. 8.4%) mostly due to the larger contribution of smoking to population-attributable fractions in men (10.7%) vs. women (1.3%).
“Our results emphasize the importance of a similar strategy for the prevention of cardiovascular disease in both sexes,” the researchers wrote. “However, the increased risk of cardiovascular disease in men might be substantially attenuated with better reductions in tobacco use and lipid concentrations.”
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