Time for a targeted campaign against monkeypox without stigma

Since May 2022 we have seen over 25,000 laboratory confirmed cases of monkeypox reported worldwide

The WHO has escalated this outbreak to a Public Health Emergency of International Concern (PHEIC) on 23 July 2022, and only last week the US declared it a national public health emergency.

Monkeypox is a virus from the same family of smallpox. It was first recognised in humans in 1970 and reported in several African countries. Outside Africa we had only seen one case in the US in 2003 and two cases in the UK in 2018 and 2019. The recent outbreak is not related to travel to endemic regions but linked to some social gatherings such as the Pride festivities in some countries.

The likelihood of transmission is highest with the skin-on-skin contact, but it can also be contracted through respiratory droplets in prolonged face-toface contact (kissing) and sharing various personal objects such as towels, bed linen, and clothing items The virus does not spread easily between humans and in the majority of cases, it’s been spread through prolonged skin-on skin contact and during sex. However, it is not an STI.

Most common symptoms reported have been fever, fatigue, muscle pains, chills and headache with a rash developing a few days after the onset of fever, but this may also happen before the onset of fever. Most people have mild symptoms but there have been several who have been hospitalised, and there have 3 deaths outside Africa reported so far.

In Malta there are at least 30 confirmed cases of monkeypox of which the demographic is expected to be similar to the global north with the majority of cases diagnosed among men who have sex with men (MSM). A recent case series found that over 98% of the people who contracted monkeypox were members of the MSM community. What this means is that we need a targeted public health campaign that speaks to the MSM community.

It's been suggested that having such a targeted campaign would fuel stigma against the gay, bi+ and other men who have sex with men who are disproportionately affected by the virus in the region. The problem is not a targeted campaign but a stigmatising language. HIV and AIDS were called the ‘gay disease’ in the early days of the pandemic, and that language has been proven to be stigmatising and counterproductive. The language we use shapes the narrative we want to give but saying that some members of the community are more disproportionately affected by a virus is not stigmatising, but a fact. We should be responding to the virus with all the tools we have and not stigmatizing or blaming the individuals at risk.

The monkeypox virus as is with other viruses doesn’t care about your sexuality or gender. It only cares about finding a host which would help it to populate. History shows us that outbreaks such as HIV, COVID19, measles, polio, and monkeypox, spread rapidly among self-associating communities such as the MSM community. LGBTI+ people may be at an increased risk due to our existing strong social connections and sexual networks within our community. However, these connections can be utilised to raise awareness rather than being a target of a stigmatizing campaign.

Many men who have sex with men tend to have more sexual partners over a shorter period of time. What we then need is a public health campaign that uses the right language that will inform both the dialogue and response around the infection. A targeted campaign means that the most affected groups get the correct information and are better equipped at making informed decision. Campaigns that treat all populations the same are not successful. They fail to reach those who would benefit from the information and tools that we have available the most.

As we have seen from previous campaigns in sexual health and infectious diseases, messages around abstaining alone are not effective. We need to have clear recommendations and a rapid vaccine roll-out instead of an outdated behavioural change approach.

We also need members of the MSM community to ask themselves first, how likely are you to be exposed to monkey pox and, second, if there is that exposure, how likely is it that you can get infected? But to make this assessment, affected communities need to be given all the information available. The relevant authorities need to be transparent about how many reported cases Malta has, the demographic of the people who have it, and how they plan to prevent onward transmission. Online campaigns are important but they are not enough. There are several at risk who may not have access to the internet or understand English or Maltese

There is also the question of when the vaccine Invanex/Jynneos is going to be made available in Malta. The vaccine is effective by it takes a little time to work (83% protection 28 days after 1 shot and 67% for people living with HIV) It offers protection against monkeypox and can also be used as PostExposure Prophylaxes (PEP). While the demand currently exceeds the supply, the relevant Maltese authorities must make public how many doses they have secured, when they will be made available and how they will be distributed. Other countries have managed to secure a stock and have started inoculating high risk populations. Why not Malta as well?

Monkeypox is not going to be the next COVID-19, but we need an informed public health campaign that targets at high-risk populations to stop the onward transmission of the virus. It is also necessary that a vaccine strategy is developed and shared with the public as soon as possible, and vaccines become immediately available. With Malta pride in a few weeks, there is not a minute to lose. We must share the available data and educate our community. But equally important we must vaccinate our community.

*If you think you may have monkeypox or have been exposed to someone with monkeypox contact your GP or the GU clinic on 25457494

“As we have seen from previous campaigns in sexual health and infectious diseases, messages around abstaining alone are not effective. We need to have clear recommendations and a rapid vaccine roll-out instead of an outdated behavioural change approach.”