The arrival of Mpox in Venezuela: Why so few cases?

Dear Editor:

Although Latin America has improved its ability to face new epidemic threats following the COVID-19 pandemic [1], the region has already confirmed at least 27,706 cases of Mpox as of 31 May 2023 [2]. The current epidemic has mainly affected MSM with multiple partners. Additionally, 24–47% of individuals diagnosed with Mpox infection are living with HIV, and a majority of those without HIV are on pre-exposure prophylaxis [3]. In Venezuela, the first Mpox case was reported on 12 June 2022, in a 32-year-old man who had returned from Barcelona, Spain on 6 June 2022. Swabs from the lesions and nasal region were collected and sent to the “Rafael Rangel” National Institute of Hygiene in Venezuela, resulting in a positive MPXV viral DNA qPCR test [4]. Despite Venezuela's improved infrastructure for molecular epidemiological surveillance after the pandemic, detection of probable and suspected Mpox cases remains limited. To date, only 12 Mpox cases have been reported in Venezuela, and information on Mpox cases in the country is scarce. Here, we present sociodemographic, behavioural, and clinical data from four confirmed Mpox cases, which represent the first case series to our knowledge in Venezuela.

We recorded the demographic, clinical, and paraclinical profiles of four Mpox cases among men living with HIV, which are summarised in Table 1 . The patients had a mean age of 26 years and were identified as MSM. All patients were diagnosed with HIV and were receiving ART with undetectable viral loads, except for one patient who was simultaneously diagnosed with HIV infection and Mpox. All patients presented with mucocutaneous lesions, most commonly on the genitals (n = 3), body extremities (n = 3), and perianal area (n = 3) (Fig. 1 ). The most common systemic symptoms were pruritus (n = 4), lymphadenopathy (n = 3), fever (n = 3), and fatigue (n = 2). One patient reported rectal pain, and his anoscopy showed proctitis. None of the patients had sore throat, penile oedema, or oral lesions. All cases were managed with strict outpatient isolation and symptomatic treatment (for pruritus and pain). No antiviral therapy was administered, and no superinfections occurred. Lesions resolved within a mean of 12 days, but one patient developed a penile ulcer. All patients fully recovered.

Table 1.

Demographic, clinical, and paraclinical profiles of four patients confirmed with MPXV in Venezuela.

	Patient 1	Patient 2	Patient 3	Patient 4
Demographics
Age, years	26	25	32	20
Clinics
No. of sexual partners in the last month	0	2	2	7
Maximum number of concurrent lesions	10–50	10–50	51–100	10–50
CD4 count	N/A	N/A	N/A	577
HIV viral load, copies/mL	Undetectable	161,000	Undetectable	Undetectable
Smallpox vaccination history	No	No	No	No
Lesion morphology	Vesicular	Vesicular	Vesicular	Vesicular
Lesion resolution time, days	10	14	12	13
Complication	None	Proctitis	None	Penile ulcer
Outcome	Full recovery	Full recovery	Full recovery	Full recovery
Paraclinics
White blood cells, × 103/mL	N/A	7.9	N/A	5.5
Neutrophils, × 103/mL	N/A	5.21	N/A	2.86
Lymphocytes, × 103/mL	N/A	2.21	N/A	1.27

N/A: not available.

Fig. 1.

Lesions observed in the four confirmed cases of human MPXV infection. Image A shows lesions on the chest and abdomen, image B shows lesions on the deltoid, images C and D show lesions on the left arm and right elbow crease, respectively. Image E shows an inguinal lesion, image F shows perianal lesions, and image G shows proctitis diagnosed by anoscopy.

All Mpox cases occurred in young PLHIV and presented with systemic symptoms such as fever, lymphadenopathy, and pruritus, along with mucocutaneous lesions, most commonly anogenital, which is consistent with the previously described clinical presentation [3]. None of the cases had received smallpox vaccination, which had been mandatory in Venezuela until 1971. Following the identification of the first Mpox case in the country, the Venezuelan National Academy of Medicine recommended that the government declare a public health emergency to mobilise resources and take action to strengthen diagnostic and molecular surveillance capabilities, develop surveillance programs for at-risk populations, and initiate steps to ensure access to Mpox vaccines [5]. However, no specific measures were taken in response to the epidemic in the country. In fact, a study conducted among at-risk individuals, including PLHIV and MSM, by a leading NGO in Venezuela showed that only 32.6% of respondents believed that the Venezuelan Ministry of Health would be able to support prevention and care efforts, and the majority (75.8%) of the at-risk population evaluated public health services as not being prepared to treat them in a dignified and non-discriminatory manner [6].

The first Mpox case in Latin America was confirmed in Mexico on 13 May 2022 [7], and subsequent cases were reported in Brazil, Colombia, and Venezuela on 9, 12, and 23 June 2022, respectively [4]. To date, only 12 Mpox cases have been reported in Venezuela, which is in stark contrast to neighbouring countries such as Brazil and Colombia, where 10,948 and 4,090 cases have been reported, respectively, as of 31 May 2023 [2]. Several factors may contribute to this significant disparity. First, molecular diagnosis of Mpox is centralised and mainly performed at the “Rafael Rangel” National Institute of Hygiene, limiting diagnostic capacity outside the capital city. Second, there is no active case-finding strategy, even for at-risk populations, and no institutions have the necessary materials for sampling. Third, pre-existing air-traffic restrictions have limited the number of imported cases. Fourth, a lack of knowledge about Mpox among patients and physicians in Venezuela may contribute to a low rate of Mpox suspicion in the presence of skin lesions. Finally, fear of discrimination and lack of dignified treatment may deter at-risk individuals from seeking care at public health centres in Venezuela.

To increase diagnostic suspicion of Mpox in Venezuela, education campaigns targeting both patients and physicians could be implemented. Active case finding strategies could also be useful in identifying at-risk populations such as MSM and PLHIV. However, significant challenges remain, including stigmatisation, inequitable access to vaccines, diagnostic barriers, and the need for complete isolation. Multicentre studies are necessary to gain a better understanding of the clinical characteristics of Mpox in Venezuela and to develop effective public health interventions.

Consent for publication

All patients —or patient's legal guardian, as appropriate— included in this study signed a consent form authorising the use of their medical records for the purpose of this publication. A copy of each patient's written consent is available for review by the Chief Editor of this journal.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare no conflicts of interest.

List of abbreviations

COVID-19

coronavirus disease 2019

MSM

men who have sex with men

HIV

human immunodeficiency virus

MPXV

Mpox virus

DNA

deoxyribonucleic acid

qPCR

quantitative polymerase chain reaction

ART

antiretroviral treatment

PLHIV

people living with HIV

NGO

non-governmental organisation