Introduction by Croakey: The World Health Organization announced this week that following consultations with global experts, a new name for monkeypox virus is recommended. The new preferred term is mpox – WHO advise that both names will be used for the next year while “monkeypox” is phased out.
According to the WHO, “when the outbreak of monkeypox expanded earlier this year, racist and stigmatising language online, in other settings and in some communities was observed and reported to WHO.”
For the report below, freelance health and science journalist Felicity Nelson spoke to health professionals about Australia’s response to mpox, highlighting that the LGBTIQ+ community rapidly mobilised after the first Australian case was reported in May.
As we mark World AIDS Day on 1 December, Nelson reports that forty years of advocacy and action in HIV and AIDS meant the community were prepared.
Felicity Nelson writes:
AIDS Councils quickly formed in each state and territory to share information and to fight stigma and discrimination. In 1985, the Councils came together to form a national advocacy body – the Australian Federation of AIDS Organisations (AFAO).
It is no surprise to those working at these organisations today that mpox has been dealt with in such a swift and targeted way.
The LGBTIQ+ community has been preparing for this for forty years.
Mpox in Australia
The first case of mpox was diagnosed in Australia in May 2022.
Since then, we’ve had a total of 143 cases of mpox nationally (as of 24 November), including 70 in Victoria, 56 in NSW, seven in Western Australia, five in Queensland, three in the Australian Capital Territory, and two in South Australia.
People with mpox are only infectious for up to four weeks, so most of these cases have now resolved.
“As I understand it, we don’t have any active cases, which is remarkable,” says Heath Paynter, the deputy CEO at AFAO.
“So, I’m calling monkeypox ‘contained’ because that suggests that situation is fluid. So, we could have an outbreak at any moment.”
In September, Victorian Chief Health Officer Professor Brett Sutton declared a win, tweeting: “Victoria has had no MPX [mpox] cases for a few weeks now, having had significantly early growth in cases… Well done!”
Sutton offered “particular thanks” to the men who have sex with men and the gay and bisexual male communities “as this has turned around because of their responsiveness and engagement”.
“With over 60,000 cases globally the risk will continue for some time, so MPX vaccination will be really important to manage risk now and into the future,” he said.
Credit the LGBTIQ+ community
When Paynter first heard reports of mpox spreading among men who have sex with men in Europe back in May, his organisation immediately sprang into action.
Not much was known about the disease and its transmission pathways at that time because mpox had rarely been seen outside of Africa, he said.
“It was a steep learning curve, because it was effectively a new transmission pathway for an existing disease,” he said.
The steps that AFAO took immediately were to establish a taskforce with fortnightly meetings, along with a clinical and a community subcommittee.
AFAO also met with The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM), who represent sexual health physicians.
The organisation rapidly engaged its membership by producing social media material.
And it started working closely with pre-existing contacts at state, territory, and federal health departments to ensure that mpox communications were sensitive to communities.
AFAO produced mpox factsheets, which were published on its Monkeypox Information Hub online. It hosted a virtual community forum in October, which provided an update on the situation from key community leaders.
“There’s been a lot of activity. We’ve sought to engage with communities and develop their capacity to make informed decisions around the risk of monkeypox,” Paynter said.
In Australia and other developed nations, mpox is almost entirely concentrated among gay and bisexual men, and men who have sex with men. So, it’s been possible to leverage all the existing HIV infrastructure and expertise to raise awareness, he said.
“The vast majority of our success today is due to the vigilance of gay men who have very high sexual health literacy based on having to navigate HIV for four decades,” Paynter said.
“In a nutshell, we’ve pushed monkeypox through the prism of the HIV response. We have basically just done what we did with HIV for monkeypox,” he said.
Origins of mpox
Mpox was originally identified in monkeys in a lab setting in Denmark in 1958. The first human infection was diagnosed in a nine-month-old boy from the Democratic Republic of Congo in 1970.
Mpox is caused by the mpox virus, which is a member of the Orthopoxvirus genus in the family Poxviridae. It is part of the same family as the smallpox, vaccinia and cowpox viruses – the smallpox vaccine provides some protection against mpox.
The mpox virus is endemic to tropical rainforest areas of central and west Africa but it has rarely been seen on other continents before the 2022 outbreak.
There are two genetic clades of the mpox virus: one is found in the Congo Basin, which is more severe and more transmissible, and the other is found in west Africa.
The first mpox outbreak outside of Africa occurred in the United States in 2003, when 70 people were infected after contact with pet prairie dogs, which had been housed with Gambian pouched rats and dormice imported from Ghana.
Within days, there was a family cluster of mpox diagnosed in the UK, which was not related to travel or exposure to the first case.
Reports emerged from Portugal of an unidentified illness causing a rash, which was later confirmed to be mpox.
“These events marked the start of a multi-country outbreak of monkeypox and suggested there had been undetected spread,” the WHO said.
Between January and June 2022, over 2,000 cases of mpox were reported to WHO from 42 countries. Most of the cases were in Europe in May-June.
By July-August, the Americas were carrying the highest burden of mpox cases, with a steady decrease through October.
Yet-to-be-peer-reviewed research has suggested that mutations in the mpox genome may be responsible for the global outbreak, but we still don’t know for sure what caused this crisis.
Stigma and sensitivity
There is a real risk of stigma when infectious diseases affect a single, marginalised community.
“This was a big concern and continues to be a big concern because we need gay and bisexual men to be talking about this virus to their peers but also to doctors,” Paynter said.
“If you have stigma, what we know from HIV is that it shuts down communication because people feel as though they’re going to be exposing themselves to the risk of judgment.”
There has overall been a “pretty good response” from the media and government, but there was the “very obvious exception of Kyle Sandilands” who was widely criticised for comments about mpox that he made on Sydney public radio in August, Paynter said.
“We responded very quickly condemning it, as did other news agencies,” he said. “The response to that made it very clear that joking about monkeypox stigmatised affected communities and perpetuated harmful and inaccurate stereotypes about gay men. In effect, this conduct risked undermining efforts to build community awareness of this health threat.”
Access to third-generation vaccines
One of the first things that AFAO did was to strongly advocate for immediate access to third generation mpox vaccines, which are now available in Australia.
Australia has a stockpile of smallpox vaccines that were last routinely given to people in the 1970s and provide some protection against mpox.
However, smallpox vaccines are difficult to administer, leave a scar, can have side effects and can’t be used in people who are immunocompromised because they contain a live vaccinia virus, which is similar to smallpox but less harmful.
“The smallpox vaccine may not have been popular, and people may not have volunteered to get the vaccine like they have with the third-generation vaccine,” said Paynter.
“So, to the government’s credit, they went in hard and early and purchased a big order of this new vaccine. And there are next to no side effects and it’s much more effective at protecting people from infection.”
There is only one global manufacturer of the third generation mpox vaccine – the Danish company Bavarian Nordic – and its factory had been closed for a year until August 2022 due to a planned expansion.
Despite the global shortages, the Australia government managed to secure an order of the Jynneos mpox vaccine. The first shipment arrived in August and was immediately made available to high risk groups in areas where mpox was transmitting.
In early November, a second shipment of almost 40,000 vials of Jynneos was due to be delivered.
“The government’s order of vaccines means there will be enough third generation vaccines for all eligible populations in Australia to receive the recommended two doses,” Paynter said.
“It’s important as it allays concerns in the community that there is insufficient supply of the vaccine, which is an issue in most of countries of the world,” he said.
New Zealand, for instance, will not have a supply of Jynneos available until at least December.
A federally funded advertising campaign has been timed to launch just as more vaccines became available in November.
The ‘Prick – Pause – Play’ campaign was developed by an online sexual health and wellbeing initiative called Emen8, which is led by two government-funded LGBTIQ+ advocacy organisations, Victoria’s Thorne Harbour Health and NSW’s ACON.
“We’ve been developing this campaign since August and we were just waiting to go live,” says Matthew Vaughan, the director of the HIV and sexual health division at ACON.
The campaign includes a series of six light-hearted videos featuring diverse talent from the gay and bisexual community.
In one video, a drag queen dressed in a white, pearl-studded dress applies lipstick while a voiceover reads: “It’s been a long, long winter for Charisma and there’s no way monkeypox is going to ruin her hot girl summer. She was first in line for the shot because, ‘Honey, it ain’t pretty’. Prick – Pause – Play.”
In another video, a man dressed in tight-fitting, black latex rolls around the floor wincing in pain as the voiceover reads: “There’s a simpler way to protect yourself, big guy. Monkeypox is transmitting through sexual contact. But the vax is free and available now. Prick – Pause – Play.”
“We’ve gone for something that is short and snappy, but we hope very relatable to people in our communities,” Vaughan said. “We’re really hoping that this will be the slip – slop – slap equivalent for preventing monkeypox.”
The videos will be disseminated out to men who have sex with men through social media, such as TikTok, Facebook, Grindr, as well as other channels through which these LGBTIQ+ organisations connect with the communities they represent.
It’s the deep relationships and trust that HIV groups have built over time with state and federal governments, the community and sexual health providers that is the key to rapidly mobilising in response to a public health threat, Vaughan said.
ACON was founded in 1985 as the NSW response to the HIV/AIDS epidemic. Today, the organisation is largely funded by NSW Health to deliver social marketing campaigns to its communities on a variety of sexual health issues.
Emen8 specialises in ‘stealth’ health communications that are packaged inside content that people are more likely to want to read, with headlines such as ’10 tips for turning date one into date two’ or ‘Things to back before going overseas’.
Emen8’s social media content and website get strong engagement that is above industry levels, and the website recently celebrated its millionth pageview, which is a big milestone, says Vaughan.
The priority for ACON back in May was to make sure people were educated about mpox signs and symptoms, transmission pathways, prevention measures and how to seek help.
This took the form of social media communications, press releases and engaging with external media, and liaising with NSW Health for clinical review to ensure accuracy.
“It wasn’t necessarily broad messaging about monkeypox like we saw with COVID because it was really trying to keep the message very focused,” Vaughan said.
“NSW Health are very good with their strategy and engage with the right people that need to be brought in. For example, one of the things that ACON was most aware of was the potential stigmatising language that could come from monkeypox.”
If messaging around infectious diseases appears to target one group, it can enhance or create stigma. So, ACON made sure its external communications spoke broadly about how mpox could affect anybody and that it just seems to be passing through sexual networks, while targeting this message to the highest risk groups using social media and other channels.
“[This campaign] shows the faith and the collaboration between ACON and the health department,” Vaughan said.
Two vaccination hubs have been operating in NSW since the first mpox vaccines became available, one in Surry Hills and another in Camperdown. There were no vaccine clinics in rural or regional areas because mpox infections were focused on metropolitan areas at this time.
While the messaging to GPs and the setup of these facilities was done through NSW Health, ACON organised for peers – gay or bisexual volunteers – to greet men at the door of these clinics and help guide them through the process, which helped create a welcoming, non-judgemental environment.
Vaccines were quickly deployed to the highest risk groups, including those traveling overseas, people with multiple sexual partners, sex workers, people with compromised immune systems and First Nations people.
The high-risk groups were nominated through a consultative process – NSW Health called for expressions of interest from anyone seeking a mpox vaccine and then categorised them into different groups.
Vaughan is feeling “cautiously optimistic” about mpox prevention in Australia. “What I’ve been really encouraged by is how gay and bisexual men have come forward for the vaccine rollout,” he said.
“We’ve seen gay and bisexual men continuing to take steps to protect themselves and their partners, like they do with HIV and STIs.”
Aboriginal health sector response
A spokesperson from National Aboriginal Community Controlled Health Organisation (NACCHO) said they have been involved in the mpox response from the earliest stages, including participation in the National MPX Taskforce and through the Blood Borne Viruses and Sexually Transmissible Infections Standing Committee.
“As part of our work supporting the ACCHO sector we have shared updates and information with member services, delivered a monkeypox webinar for member services and produced monkeypox resources for ACCHOs to use in their clinics and with communities,” they said.
“Monkeypox remains rare in Australia and there has been only a very small number (less than five) of cases among Aboriginal and Torres Strait Islander people.”
What is mpox?
Mpox is a zoonotic disease transmitted to humans from animals or between humans through contact with lesions, body fluids, respiratory droplets, or contaminated materials such as bedding.
In developing nations, mpox is almost exclusively transmitted between men who have sex with men.
A study published in The New England Journal of Medicine examining over 500 mpox cases across 16 countries found that 98 percent of transmissions had occurred between men who have sex with men.
A study of over 26,000 people in the United States with mpox found that 70 percent had recently had male-to-male sexual conduct.
Despite this, mpox is not considered a sexually transmitted infection and could potentially spread through other forms of close contact.
Another recent study in the British Medical Journal suggested that mpox is often transmitted before the onset of symptoms.
The mpox virus usually causes symptoms lasting between two and four weeks. During the first five days of infection, people usually experience a fever, an intense headache, swelling of the lymph nodes, back pain, muscle aches and lack of energy.
Around one to three days after the appearance of a fever, the skin starts to erupt into rashes that are concentrated on the face, palms of the hands and soles of the feet, as well as the genitalia.
The rashes evolve from lesions with a flat base to lesions that are raised and contain clear and then yellow fluid. They eventually dry up and fall off.
The infection is deadly in around one to three percent of cases.
Primary care response
Community health providers, such as Access Health and Community, have responded to mpox by raising awareness among patients and educating staff.
Access Health and Community is a primary healthcare service with around 360 staff and 200 volunteers. It operates GP clinics, dental care, and mental health services at 18 sites in east Melbourne. It’s one of dozens of similar community health providers in Victoria.
It focuses specifically on vulnerable communities, including people who are experiencing or at risk of homelessness, people living with a disability, cultural and linguistically diverse communities and people with mental health and substance use disorders.
David Towl, the Executive Lead of Community Impact at Access Health and Community, says the organisation responded to the mpox threat by revising its infection control strategies, running Q&As with staff and providing information and referrals for high-risk individuals to get vaccinated.
Towl says the main group that may not have been reached by other public health campaigns are those men who have sex with men but do not identify as part of the LGBTIQ+ community or who live a closeted lifestyle.
“They may be just as health literate and just as aware of their sexual health status, but they’ve got this self-imposed barrier in place which can prevent them from accessing health services from queer specific health agencies,” he said.
• Felicity Nelson is a freelance health and science journalist based in Sydney.
Croakey thanks and acknowledges donors to our public interest journalism funding pool who have helped support this article.
See Croakey’s archive of articles on mpox.