Mpox virus infection in women and outbreak sex disparities: A Systematic Review and Meta-analysis

BACKGROUND Although the recent literature indicates that mpox (monkeypox) primarily affects men, there are also multiple reports in women. Estimates of the sex distribution of mpox patients and patterns will enable a better understanding of the ongoing mpox outbreak. METHODS In this systematic review and meta-analysis, seven databases were searched for studies published in English up to January 4$^{th}$, 2023. The proportion of women with mpox was the primary outcome. A random-effects model was fitted for the primary outcome, and a sensitivity analysis was performed to check possible outliers in the studies. RESULTS Here we screened 470 articles and included 60 studies for qualitative synthesis. 42 studies with 3125 women out of 47,407 confirmed cases were found suitable for meta-analysis. The pooled proportion of female patients is 17.22% (95% CI: 10.49-25.11; I$^{2}$ = 98.86%). Subgroup analyses reveal higher proportion before 2022 [44.09% (42.93-46.86] than 2022 onwards [2.40% (1.17-3.98)], and in endemic countries [43.13% (37.63-48.72)] than in nonendemic countries [6.15% (2.20-11.65)]. CONCLUSIONS There is considerable caseload (17.22%) amongst women, which must be seen in the context of a much higher proportion (44.09%) in studies prior to 2022 compared to 2.40% in the 2022 outbreak indicating an epidemiological shift. Data on disease characteristics among women with mpox disease are scarce. Further studies should focus on these aspects to better understand the disease in women and empower epidemiologists and clinicians to make evidence-based decisions for this vulnerable group.