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Monkeypox: learn from the past, be prepared, act quickly and lose the prejudice

The World Health Organization (WHO) has convened a meeting for 23 June to assess whether the monkeypox outbreak now affecting dozens of countries represents a Public Health Emergency of International Concern (PHEIC), the highest level of global alert.

This is a formal WHO declaration of “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response”, when a situation arises that is “serious, sudden, unusual, or unexpected”, and which “may require immediate international action”.

So far this year, more than 1,600 confirmed cases and almost 1,500 suspected cases of monkeypox have been reported to the WHO, from seven countries where the disease has been known for years, and from 32 newly-affected nations, according to UN News.

Dr Hans Kluge, the WHO’s Regional Director for Europe, told a briefing today that Europe remains the epicentre of this escalating outbreak and said its magnitude posed a real risk. The longer the virus circulates, the more it will extend its reach, and the stronger the disease’s foothold will get in non-endemic countries.

Kluge urged governments, health partners and civil society to act urgently, through enhanced surveillance, contact tracing and infection prevention and control, as well as effective communications to the general public and clinicians, and intensive community engagement.

In Europe, the majority of reported patients have been men who have sex with men. Kluge warned that stigmatising particular populations would undermine the public health response, as had been seen repeatedly, in contexts as diverse as HIV/AIDS, tuberculosis and COVID.

Meanwhile, Matthew Vaughan, Acting Director HIV & Sexual Health Division of ACON, writes below that preparations are being made for an increase of cases in Australia, and he stresses the importance of careful messaging and community engagement that does not contribute to fear and prejudice.


Matthew Vaughan writes:

As I write this, there have been more than 1,600 confirmed cases of MPXV – I prefer using this term to reduce stigma – around the world, with most in Europe, the United Kingdom and North America.

For now, Australia has only six cases, mostly among returned travellers, yet with the summer party season kicking off in the northern hemisphere, we are preparing for yet another viral outbreak.

Early media reports about MPXV cases highlighted the association with gay, bisexual and men who have sex with men. Particularly among those who had attended large dance parties or sex parties in Europe.

Anyone who lived through the early 1980s might recall similar headlines in the media about a previously unheard-of disease; ‘a rare cancer’, one we would later call the Human Immunodeficiency Virus (HIV).

There was so much we didn’t know about HIV in the early years. We didn’t know what caused it, we weren’t sure how it was transmitted, we didn’t know how to test for it, and sadly, we didn’t know how to treat it.

The multitude of unknowns caused immense fear and anxiety in the community. The media vilified those most affected by it, and conservative groups blamed it on immoral behaviours, claiming people’s suffering was a punishment from God. There were public calls to close bars, clubs and other venues frequented by gay men. At the height of the HIV epidemic, there were even moves to cancel the annual Sydney Mardi Gras celebrations.

As noted by leading Australian HIV researcher Edwina Wright from the Burnett Institute, in the absence of the known, we look for someone or something to blame. In the case of HIV, it was those people who were affected. This was even in the clinical name given by doctors when identifying the first cases: Gay-Related Immune Deficiency (GRID).

Some 40 years after the first cases of HIV were identified, people living with HIV still experience the stigma associated with the once life-threatening disease. A frightful campaign featuring the Grim Reaper rolled out on national television, telling people to be careful — because every one of us could be devastated by it.

We only need to turn to recent events to understand how blaming groups of people for virus outbreaks, especially those historically discriminated against, fuels stigma and impacts communities beyond the virus itself. At the start of the coronavirus pandemic, widespread racially motivated attacks on Asian-Australians increased dramatically and Asian-Australians had to simultaneously deal with the impact of the coronavirus and racial abuse.

Unfortunately, the arrival of MPXV in developed settings, and in networks of gay and bisexual men, poses similar threats to people’s dignity.

However, the circumstances are vastly different. Unlike the early years of HIV, we already know a lot about this virus; we have a reasonably good idea about how it is transmitted, we know how to test for it, there are treatment options available, and we have vaccines.

A very different situation entirely.

Matthew Vaughan

Prepare now

Nevertheless, we should not be complacent. We should, and we are, preparing for an increase in MPXV cases in Australia. We must learn from the past, be prepared and act quickly to contain future outbreaks when they occur.

We can achieve this by governments working alongside affected communities to inform targeted communications and pragmatic responses. Collaborative efforts between governments and affected communities builds trust, community engagement and prevents unintended consequences of fear and prejudice.

Importantly, we must recognise that the risk of MPXV is not limited to gay, bisexual and other men who have sex with men. Anyone sharing close contact with someone who is infectious is at risk, regardless of their gender or sexuality. Reporting cases of MPXV as a disease that only, or largely, affects gay and bisexual men prevents people who are experiencing symptoms from coming forward for testing.

Even in 2022, homophobia impacts the way people engage with health services. Homophobia doesn’t just affect gay and bisexual men, even if a person doesn’t identify as gay. Fear of being perceived or inaccurately labelled as gay in the media, or among family friends, prevents people accessing testing, and participating in important contact tracing efforts.

Critical key components of an early response to a viral outbreak are to isolate people who are sick, and for close contacts to quarantine. To do these effectively health departments employ vigorous contract tracing methods, allowing them to identify and notify potential cases and alert people self-isolate or monitor for symptoms.

For this to be effective, people need to be encouraged to note and remember their sexual partners and fully and openly disclose these to health authorities, without fear of backlash or moral judgement.

MPXV is not currently classified as a sexually transmissible infection. Whether it is transmitted through vaginal fluid, seminal fluid, and ejaculate is still unknown and requires more research. We know that it can be transmitted through close contact, which is inevitable during sex. Transmission can also occur from contact with clothing or bed linens of a person with MPXV.

So while not an STI, it does have the potential to spread through sexual networks, prompting organisations such as ACON (and many other LGBTQ organisations across the globe) to respond quickly with sensitive messaging for our communities.

At present, a large number of MPXV presentations appear to be among gay, bisexual and other men who have sex with men. One possible reason for this is the proactive health-seeking behaviours of these communities, particularly when it comes to looking after their own and each other’s sexual health.

Once again, we’re in another ‘unprecedented’ situation. However, we know that our communities are strong and resilient, and time and time again gay and bisexual men have responded and adapted our behaviour to protect ourselves, our partners, and our communities.

For reliable sources of information about MPXV, we recommend government sources like the NSW Health Factsheet or resources published by the Australian Department of Health.

• Matthew Vaughan is the Director for HIV Sexual Health, and ACON’s Principal campaign planner, where he leads the strategy and development of the multi award-winning campaign, Ending HIV, which seeks to end HIV transmissions in NSW.  Matthew has been working within the community services sector for the past 15 years working in a variety of roles within Government, Non-Government and Community-based organisations at state, national and international level.


Resources and reading

Related WHO updates
WHO publication: Clinical management and infection prevention and control for monkeypox: Interim rapid response guidance, 10 June 2022

From the United States, suggestions on messaging: Experts aim to thread needle on monkeypox messaging to MSM


See Croakey’s previous articles on monkeypox.