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12 Big Questions You Have About Monkeypox,…

12 Big Questions You Have About Monkeypox,…

The COVID-19 pandemic illuminated longstanding global inequities that allow dangerous viruses to spread, targeting low-income and minority communities. Now, the monkeypox outbreak is once again showing how those inequities persist, and how health communications have yet to improve.

Monkeypox, an orthopoxvirus, was first identified in humans in 1970, according to the World Health Organization (WHO), and is endemic in 10 countries in West and Central Africa. Despite its continuous circulation, the current spread of the virus to non-endemic countries has raised the alarm of how officials communicate public health concerns.

In May 2022, the first monkeypox case outside of an endemic country was reported in the United Kingdom. Shortly after, the virus was found across the EU, with high case counts in Spain and Portugal. 

Despite early signs that the virus predominantly affected men who have sex with men (MSM) and was spread through close contact, public health officials around the world failed to ensure LGBTQ+ groups were properly informed, and missteps in providing vaccine doses left many at-risk people without protection.

“Not mentioning that most of the cases are happening among MSM is homophobic because it makes our communities and their suffering invisible,” Antón Castellanos-Usigli, a public health expert and founder and CEO of ACU Innovation and Consulting, told Global Citizen. “We must state the evidence: Monkeypox is transmitted through intimate physical contact, which includes sexual relationships, and most cases are currently happening among MSM.”

On the African continent, which has dealt with monkeypox cases across country borders for decades, vaccines are not available and testing capacity is limited.

COVID-19 has not ended, but the pandemic has shown the weaknesses in public health communication and how officials can better target vulnerable and low-income groups to end health inequities. 

The faulty communication, inequalities, and discrimination experienced during the current monkeypox outbreak prove that we have a much longer way to go.

In hopes of targeting miscommunication and shedding light on monkeypox, Global Citizen spoke to three public health experts to provide perspectives from the African continent, the United States, and Latin America, respectively. 

Here, they answer your biggest questions about monkeypox and share how you can keep yourself and others safe.

Dr. Ifeanyi M. Nsofor, MBBS

Image: Courtesy of Dr. Ifeanyi M. Nsofor, MBBS

Dr. Nsofor is a public health physician from Nigeria. He is currently the Director of Policy and Advocacy at Nigeria Health Watch and leads the organization’s advocacy interventions. Named a Senior New Voices Fellow at the Aspen Institute, Senior Atlantic Fellow for Health Equity at George Washington University, and a 2006 Ford Foundation International Fellow, Dr. Nsofor’s focus is on increasing advocacy for health equity and achieving universal health coverage in Nigeria.

1. How have people been affected by monkeypox?

Nsofor: This current monkeypox global health emergency disproportionately affects wealthy nations in the Global North. The US has the highest number of cases [more than 21,000 as of September 2022]; Spain, Germany, the UK, and France have reported more than 2,000 cases each. Ninety-eight percent of cases are among the [LGBTQ+] community. This is giving rise to stigma. 

Editor’s note: Current monkeypox data can be tracked using the US Centers for Disease Control’s (CDC) 2022 Monkeypox Outbreak Global Map.

2. What is the treatment for monkeypox once you’ve been infected? 

Monkeypox is self-limiting in most instances. That means it may not require treatment for recovery to happen. However, treatment is generally symptomatic — you treat symptoms that people present with. Symptoms may include fever, headache, muscle and backache, swollen lymph nodes, chills, tiredness, sore throat, cough, stuffy nose, and rashes.

3. What is the health response to monkeypox on the African continent, specifically concerning prevention and vaccination?

West and Central Africa are endemic for monkeypox and several countries have been reporting cases for decades. For instance, Nigeria’s first case of monkeypox was in 1972. Also, between Jan. 1 and July 31, 2022, Nigeria reported 152 monkeypox cases. Consequently, African countries have the experience of managing monkeypox cases. However, just like COVID-19, monkeypox vaccination has not begun on the African continent.

4. How can we improve global health equity when addressing viruses like monkeypox to prevent future global outbreaks?

We must view monkeypox and other infectious diseases as having capabilities of spreading beyond areas where they are endemic. The ease of international travels increases this risk. For decades, richer, Western nations ignored monkeypox cases being reported across Africa until it got to their domains. Even with this occurrence, there is still inequity in monkeypox vaccination and therapeutics.

The global health community must view infectious diseases as bushfires. One cannot assume that the fire will not get to their house because they live miles away. If the fire is not quenched at origin, it would consume everything in its path. 

Dr. Jessica Justman, MD

Image: Courtesy of Dr. Jessica Justman, MD

As an infectious disease specialist and epidemiologist, Dr. Justman has worked for over two decades to advance HIV prevention, care, and treatment and, more recently, to pioneer a precision approach to understanding the global HIV epidemic. She serves as an Associate Professor of Medicine in Epidemiology at the Columbia University Medical Center.

5. How does monkeypox spread?

Justman: Monkeypox is not a new virus, but the current outbreak has some new features. It appears to be spreading in the community predominantly through intimate, skin-to-skin contact and, so far, it has been mostly affecting gay, bisexual, and other MSM. This pattern in the US is also being described by other countries. While spreading through respiratory droplets and contaminated objects is possible, the pattern of the cases so far suggests those two routes of transmission are much less common.

6. What treatments are available?

Monkeypox can affect the skin in ways that can be extremely painful, such as through rash and sores, and the fever, aches, and exhaustion can be quite uncomfortable. Most cases of monkeypox, however, will get better with supportive measures such as drinking extra fluids, [taking] acetaminophen [and] ibuprofen, [using] calamine and other lotions for itching, and salt water rinses for sores in the mouth.

There is a specific antiviral treatment called tecovirimat that’s approved [by the US Food and Drug Administration (FDA)] for smallpox and is recommended for those with more severe monkeypox (for example, those who are hospitalized) or those at risk (for example, pregnancy, inflammatory bowel disease, or significant skin conditions such as psoriasis) for severe monkeypox. Your doctor will need to complete a specialized form under the non-research, expanded access investigational new drug protocol in order to obtain tecovirimat.

7. What vaccines are available?

There are two vaccines available. Both were developed for smallpox and both use a live [vaccinia] virus that is a cousin of the smallpox vaccine. One [known as ACAM2000] uses a virus that is capable of replicating, so it cannot be given to people with HIV or other immune conditions. The other one [known as JYNNEOS in the US, IMVANEX in Europe, and IMVAMUNE in Canada] consists of a virus that is not able to replicate, so it is safer for those with immune conditions. Supplies, however, are very limited at this stage.

Editor’s note: Monkeypox vaccination is found to be 85% effective in preventing monkeypox, according to the WHO. The ACAM2000 vaccine is licensed for use as a single dose in the US and is delivered percutaneously. The JYNNEOS vaccine is a two-dose vaccine, with each dose administered 28 days apart. The JYNNEOS vaccine can be administered through two routes — subcutaneously and intradermally — due to limited supply; according to the CDC, results from a clinical study showed that intradermal vaccination was immunologically non-inferior to subcutaneous vaccination.

Common side effects of monkeypox vaccination include pain and redness at the injection site, nausea, chills, headache, fatigue, and muscle pain. If you experience an allergic reaction after vaccination — such as hives, difficulty breathing, or extreme pain — consult a medical provider immediately.

8. What can people do to protect themselves?

Get vaccinated: In New York, vaccines are available for gay, bisexual, or other (MSM), and/or transgender, gender non-conforming, or gender non-binary people who are age 18 or older and who have had multiple or anonymous sex partners in the last 14 days. [New York City expanded eligibility to sex workers on Sept. 1.]

The CDC website also has an excellent guide to practice safer sex.

Editor’s note: Consult your national health authority to find out if you’re eligible for monkeypox vaccination, and where to find a vaccine site near you. 

Antón Castellanos-Usigli, MPH

Image: Courtesy of Antón Castellanos-Usigli, MPH

Antón Castellanos-Usigli is a Mexican public health expert and Founder and CEO of ACU Innovation and Consulting, a consulting firm that specializes in healthcare innovation and strategy. Since 2016, he sits on the Global Advisory Board for Sexual Health and Wellbeing (GAB). He has a Master of Public Health from Columbia University and is a Doctor of Public Health candidate at the Harvard T.H. Chan School of Public Health.

9. Despite originating in Africa, monkeypox has led to an influx of cases on other continents, with the epicenter of the outbreak now in the Americas. How are public health officials responding to monkeypox in Latin America?

Castellanos-Usigli: Public health officials in Latin America are not responding effectively to this outbreak because of institutional homophobia; in some cases, they seem to be completely ignoring it.

I was in Colombia during the summer and both the government and the media mentioned that monkeypox cases were concentrated among men, but they never mentioned explicitly “men who have sex with men” (MSM) in their messaging.

10. Has the response changed to ensure that at-risk groups and MSM are properly informed about monkeypox and can take the necessary precautions?

At this moment, the best responses to this outbreak are coming from the LGBTQ+ community. Recently, Gay Latino Network, the largest Latin American Network of gay leaders, which includes leaders of community-led health organizations, released a Declaration on Monkeypox

They call on governments in Latin America and the Caribbean to declare monkeypox as an emergency, to establish transparent epidemiological systems to track and report new cases, to recognize that most cases are happening among MSM, to scale up testing, and to urgently purchase and distribute vaccines.

11. Despite the fact that MSM is a majority at-risk group, monkeypox can and does pose risk to those outside of this demographic. How are public health officials in Latin America educating the public about the risks of monkeypox to everyone?

Discrimination and stigma have characterized this outbreak since the very beginning. However, it is important to note that this is not a “gay disease” — it can affect people of all ages, genders, and identities. We are also seeing cases among women, children, heterosexual people, trans people, etc.

This is very similar to what the world saw with HIV/AIDS decades ago; some people didn’t want to acknowledge the fact that [HIV/AIDS] was affecting predominantly MSM, while others were calling it a “gay disease” and avoided the fact that it can affect anyone.

12. How can public health officials globally improve communication relating to the monkeypox public health crisis?

Changing human behavior is extremely hard, so public health messages need to be clear and consistent for greater effectiveness. There was a missed opportunity to target MSM since the beginning with clear information on how monkeypox is affecting our communities, and for people to understand their own level of risk and the tools that can minimize risk, from reducing the number of sexual partners, to creating sex pods, to monitoring symptoms, getting vaccinated, using condoms, among others.

Public health officials should strive to communicate this information clearly. Messaging should be created with leaders from the LGBTQ+ community. We have amazing expertise in our community; leaders who have fought throughout the years for greater equity, access to healthcare, and for positive sexual health services. They should be at the forefront of developing these messages.

As of Sept. 7, 2022, the WHO has acknowledged a decline in monkeypox cases globally. While reported deaths of monkeypox are low, precautions should still be taken to prevent the spread of the virus. Until vulnerable populations, including in countries where monkeypox is endemic, are given access to treatments and vaccines, monkeypox is still a threat to the world.

Editor’s note: These responses have been lightly edited and condensed for clarity.

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