Experts aim to thread needle on monkeypox messaging to MSM

Pride parade
Pride parade

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Yesterday the US Centers for Disease Control and Prevention (CDC) released new guidance called "Social gatherings, safer sex, and monkeypox," highlighting the risks of transmission in higher-risk situations.

"Enclosed spaces, such as back rooms, saunas, or sex clubs, where there is minimal or no clothing and where intimate sexual contact occurs, have a higher likelihood of spreading monkeypox," the guidance reads. "A rave, party, or club where there is minimal clothing and where there is direct, personal, often skin-to-skin contact, has some risk. Avoid any rashes or sores you see on others and consider minimizing skin-to-skin contact when possible."

While it is still unknown if monkeypox can be transmitted through semen or vaginal fluids, the presenting genital rash suggests intimate contact is a key to transmission. The CDC's site is also clear that the question of asymptomatic transmission is still unknown.

Because most, but not all, cases of monkeypox in the current outbreak have been in men who have sex with men (MSM), public health agencies face their first significant challenge in the post-COVID era: How to communicate risk to MSM without stigmatizing?

Don't hold back from warning people

Jeff Duchin, MD, health officer for Public Health Seattle–King County, said the CDC is doing a good job toeing the line between alerting MSM groups about the real risks of monkeypox and avoiding stigmatization.

Duchin said in the wake of the COVID-19 pandemic, public health officials have been extremely careful to admit what they don't know about a virus or to attempt to predict how it will act.

"COVID-19 has shown the importance of acknowledging areas of uncertainty when describing what is known, and in making predictions about, newly emerging pathogens," Duchin said. 

"Monkeypox, on the other hand, is not newly discovered, and there is considerable existing knowledge with it, but it's probably good to keep an open mind regarding the extent to which the current outbreak may indicate differences in how the virus behaves compared to the past."

Though monkeypox was first described in humans in the Democratic Republic of the Congo in 1970, infection outside of West and Central Africa has been extremely rare until last month. And cases in endemic countries in Africa are usually linked to eating contaminated bushmeat, or in households. The sexual transmission component of the current outbreak is novel.

Duchin said in Seattle one confirmed case has been closely monitored, with close contacts under surveillance. So far, monkeypox in the area has been limited to a single resident. In King County, the information website on monkeypox is called "Monkeypox in men who have sex with men," which Duchin said was a deliberate choice.

"We don't let people hold us back from warning people, and providing them with the best information to protect their health,” Duchin said. "Right from the get go, we have been clear about the risk to MSM."

Be clear, don't 'pussyfoot'

Being clear about that risk is one of the most important messages about monkeypox, according to New Jersey–based risk communication expert Peter Sandman, PhD.

"In the current outbreak, most patients so far are catching it from MSM. But it will almost inevitably spread from MSM, to others who have close contact (especially sexual contact) with MSM, to still others who have close contact (especially sexual contact) with those others," Sandman said in an email. 

"I would urge risk communicators to say all this—and I'd specifically urge them not to let fear of stigmatization deter them from doing so. Fear of stigmatization is an unacceptable reason to withhold or even to soft-pedal this information.

"Stigmatization of MSM is still a real social evil—but candid monkeypox risk communication won't exacerbate that evil, and pussyfooting won't ameliorate that evil. I think what's masquerading as a fear of stigmatization is really a fear of being accused of stigmatization—and that's an unacceptable reason for suppressing or downplaying important health information."

Global total tops 1,100

The CDC said the United States now has 40 cases of monkeypox.

The European Centre for Disease Prevention and Control (ECDC) today posted an epidemiological update on monkeypox, citing the global total as 1,176 confirmed cases from 24 countries as of Jun 8.

The ECDC said, "The EU outbreak sequences are a part of a distinct cluster from 2022 within the West African clade. There are two 2022 sequences from the US that are not part of this cluster, but still belong to the West African clade."

The outbreak is concentrated in Europe, where 704 cases have been reported in 18 countries, mainly in the United Kingdom, Spain, and Portugal.

So far there have been no deaths, and most cases are occurring in young MSM.

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