Continuing the conversation: Monkeypox — old disease, new fears

In late August, Boston University School of Public Health hosted a Public Health Conversation to discuss the current global outbreak of monkeypox virus (MPV), with a particular focus on how to build an effective public health response without increasing stigma and inequity. It brought together leaders in public health with experience in clinical management, virology, social epidemiology, health equity, and health policy.

A consistent theme among the series of presenters was the current public health response to the outbreak had not been rapid enough, nor sufficient. Due to pressure from activists, as well as the WHO and White House declaring the current MPV outbreak a public health emergency, the response has gathered momentum. However, the expert panel cautioned there remains a possibility it is too late to prevent MPV from becoming an endemic in the US.

Reflecting on the lessons learned from past outbreaks such as tuberculosis, HIV, and the more recent COVID-19 pandemic, there were certainly higher expectations for an effective response to monkeypox. Even more so, considering approved tests, vaccines, and treatments for this disease already existed. A rapid response should have been feasible in the US context.

There was a rich discussion on the health and social challenges that the public health community continues to face in tackling the current MPV outbreak. While it seemed clear that the effectiveness of the response will hinge on ready access to testing, vaccination, and treatment, there are several critical cross-cutting issues that need to be addressed if we are going to succeed in curtailing the current monkeypox outbreak. These include the following:

• Data: Despite MPV being first reported in the 1970s, there remain several significant gaps in our evidence and understanding of the current outbreak. While we know that close contact is a risk factor for transmission, the primary routes are unclear and potentially different from previous outbreaks. The optimal dose, best administration strategy, and durability of protection for the vaccine in the context of monkeypox require more evidence. This means that as we rapidly roll out services, we need to simultaneously gather data to adapt our current response and inform future strategies. Data also needs to be sufficiently granular to allow policymakers to identify and correct any inequities in accessing services.
• Messaging: There was recognition that accurately providing public health information on a disease that is disproportionately affecting marginalized and vulnerable populations is complex. Identity-based messaging (i.e., using geography, gender identity, sexual orientation, race, and ethnicity) can lead to stigma and discrimination as well as the exclusion of individuals who do not fall within that identity but are at elevated risk. Behavior-based messaging avoids this by focusing on the behaviors that are likely to confer risk irrespective of identity and can be used by individuals and communities to create behavior-based interventions.
• Equity: Successfully addressing the current outbreak requires a global response that provides access to all, irrespective of where they live and how they identify. The limited data available for the current MPV outbreak shows that, similar to the HIV and COVID response, those populations that are disproportionately affected are less likely to be accessing services. Despite recognizing this failing in our previous responses, we have not re-engineered our health system to address this. The inclusion of community organizations will be critical in rectifying this, especially as we start scaling a large vaccination program. Inequitable global access to testing, vaccination, and treatment for MPV has meant that for decades other countries have struggled with recurrent outbreaks.

The current monkeypox outbreak is a reminder that even with effective biomedical countermeasures available, our current public health systems and approach may not be adequate. To learn from the past and prepare for the future, we need to foster a health system that builds evidence, focuses on reducing inequitable access, and places people at the center, irrespective of how they identify.

Reflections were offered by moderator Dr. Lawrence Long, MCom, PhD, Research Assistant Professor in the Departments of Global Health at Boston University.

Watch the full Conversation here:

Monkeypox: Old Disease, New Fears from BU School of Public Health on Vimeo.