Monkeypox is hardly a new viral infection. It has been endemic to countries in Central and Western Africa for decades, even before 1970 when it was first identified in the Democratic Republic of the Congo. What is new is an outbreak in 82 newly affected countries globally that began several months ago and is challenging our ability to effectively communicate about health and science to the public.
In the Monkeypox outbreak in newly affected countries, like the U.S., about 95% of the reported cases have occurred among men who have sex with men (MSM). Epidemiological trends confirm that most of these cases often occurred in MSM with multiple partners. It might seem logical, then, that public health communications should be directed mainly to the community most affected by monkeypox.
However, such a strategy raises at least two problems for public health communicators. First, we know from the HIV epidemic how easy it is to stigmatize sexual minority communities by targeting only them with health information. We don’t want to make the mistake of facilitating anyone falsely labeling monkeypox a “gay disease” as happened with HIV. The pain and suffering this caused members of the MSM community is still incalculable.
Second, monkeypox is biologically capable of infecting anyone who comes in close physical contact with an infected person or animal, regardless of their sexual orientation. In previously affected African countries where monkeypox has caused outbreaks for years, more common modes of exposure to the virus and possibly transmission are either from animal bites—the monkeypox virus is found in a variety of animals including rodents—or from preparing animal products intended for human consumption . This is not a “gay disease,” but rather an infectious outbreak that is currently affecting the MSM communities and social networks the hardest.
Reluctant Public Health Messengers
Because of understandable skittishness around how best to walk these fine lines, public health communicators began by seemingly not trying too hard to communicate about monkeypox at all. It took time, for example, for the World Health Organization (WHO) to advise the MSM community to limit sexual contacts, especially anonymous ones, and consider keeping covered during intimate encounters. The U.S. Centers for Disease Control and Prevention (CDC) took even longer to issue that guidance, not offering direct advice to the MSM community until August 5, a week after the WHO. Furthermore, Fenit Nirappil commented in the Washington Post that “The CDC did not widely promote its new guidance after rereleasing it online…A tweet and accompanying video linking to the changes did not mention the new recommendations to reduce exposure, including limiting partners.”
Predictably, misinformation and disinformation have flourished on the internet and social media platforms. Our colleagues at the University of Pennsylvania’s Annenberg Public Policy Center found in a survey that there is widespread misunderstanding about monkeypox among the U.S. respondents. For example, two-thirds of people were either not sure or did not believe there is a vaccine for monkeypox (there are two, see below) and 12% believe it is probably or definitely true that the monkeypox virus was bioengineered in a lab. In its most egregious form, a Twitter post identified by the Annenberg team alleged that parents should keep their children away from gay caretakers for fear of spreading monkeypox to them, a totally baseless claim. That tweet has since been taken down.
In a critique of the CDC’s handling of the monkeypox outbreak last month in the New York Times, columnist Ross Douthat wrote:
And then along with these failures came an absurd ideological spectacle, in which health officials agonized about how to state the obvious — that monkeypox at present is primarily a threat to men who have sex with men — and whether to do anything to publicly discourage certain Dionysian festivities associated with Pride Month. As the suffer-no-fools writer Josh Barro has exhaustively chronicled, public-health communication around monkeypox has been an orgy of euphemism and wokespeak, misleading and baffling if you don’t understand what isn’t being said.
Douthat’s critique here may be excessively harsh; we empathize with the dilemma CDC faced under these circumstances. But he is right that communication about monkeypox specifically to the MSM community and to the broader public was slow, confusing, and generally inadequate. CDC is an outstanding agency for the detection of infectious agents, but is repeatedly falling short in communicating appropriate guidance to the public.
A Bit About the Monkeypox Virus
Monkeypox is caused by a virus in the orthopoxvirus genus and belongs to the same group as its more lethal close relative, variola, the causal agent of smallpox. There are two main strains of the virus, now called Clade I and Clade II. Clade II, formerly known as the West African clade, has been detected in cases from the ongoing outbreak in newly affected countries. It causes less severe disease (2-3% mortality) than Clade I, which is endemic to Central Africa’s Congo Basin, and has a mortality rate of as high as 10%.
People who get monkeypox experience a variety of flu-like symptoms like swollen lymph glands, fever, and muscle aches, but the hallmark of monkeypox is the large, crusted, lesions that form on the skin where the virus concentrates. In the current outbreak in newly affected countries, atypical presentations with a predominance of painful in oral, genital, and anal lesions have been noted, likely a reflection of transmission through close intimate contacts facilitated by sex playing a key role in new infections in the current outbreak
The hallmark of monkeypox is typical pox-like skin lesions in which the virus concentrates. Close and prolonged contact with these lesions is the main mode of transmitting the virus from one person to another (image: Shutterstock).
The most common mode of transmission is clearly via close and extended physical contact with active pox lesions. Other modes of transmission like prolonged contact with contaminated objects such as bedding or clothing and droplets/aerosol are possible but not considered to be the primary modes of transmission. Although monkeypox virus has been isolated from seminal fluid, it is not officially described as a “sexually-transmitted infection” because actual transmission by exchange of semen has not been definitively documented. Similarly, although monkeypox virus can be found in large respiratory droplets like those that originate from a cough or sneeze, it is not clear how much if any transmissions occur by inhalation of infectious droplets. Household transmission appears uncommon, and the risk of transmission by aerosolized respiratory droplets in a manner similar to the Covid-19 virus is considered very low. Hence, it is not likely that one can become infected with monkeypox simply by being in the same room as someone who has it; close and sustained contact with the actual lesions appears to be by far the most common mode of transmission.
Vaccines and Medication Are Available
Prevention of monkeypox begins of course with limiting physical contact with people already infected. Two vaccines are authorized for monkeypox prevention in the U.S. One is a smallpox vaccine called ACAM2000, which contains a less virulent orthopoxvirus (vaccinia virus) that is capable of replication. It can cause adverse side effects in people who receive it, especially in immunocompromised people for which it is contraindicated , including people with HIV who are not on antiretroviral treatment . There is also the Jynneos vaccine, which contains a modified vaccinia virus that does not replicate. It is manufactured in Denmark, has fewer adverse side effects, and can be used in immunocompromised individuals but is in short supply. To expand the supply, the CDC recently recommended giving it in lower doses and using a different injection method than originally authorized. Finally, the antiviral drug Typoxx, also in short supply, can be used to treat monkeypox.
Equitable Treatment is Lacking
We have stressed that monkeypox is not a new illness to highlight that once again a virus has only gotten attention only when it affects high-income countries. As Critica Chief Scientific Advisor B.K. Titanji, an infectious disease specialist at Emory University, recently Tweeted: “Mixed emotions again vaccinating and protecting folks and their communities amidst a global outbreak…Knowing fully well it could be years before communities in Africa, S. America, and Asia are able to do the same. We need EQUITY in Global Health.”
Even in the U.S. there are clear inequities in infection rates and treatment, with Black MSM in certain southern states having higher rates than white men and having more difficulty accessing preventative services and treatment.
So there are two imperatives for controlling monkeypox. One is to pay immediate attention to the disease in Africa by getting vaccines and other preventative and treatment measures to people who have been dealing with monkeypox for decades. Similarly, we need to get vaccines and treatments to people at high-risk for monkeypox in non-endemic countries, especially MSM from minority communities. Equitable attention and access to treatment globally and within the U.S. are clear moral and medical imperatives.
The other imperative is to learn from our science communication mistakes once again, as we have been forced to do with the Covid-19 pandemic. It should not be so difficult for public health agencies to figure out early messaging that can deal with difficult situations, like that presented by monkeypox. We need to ensure that the community most affected by monkeypox gets reliable information, and that means communicating directly with the MSM community with facts and options. Guidance should not be hedged but must be explicit in explaining what kinds of contacts are most likely to spread disease and what preventative measures most likely to offer protection. At the same time, it must be made clear to the general population that monkeypox is not a “gay disease,” but rather one that can affect anyone. The aim here is not to generate public hysteria; it is unlikely that monkeypox will spread through the U.S. population the way Covid-19 has. Rather, it is to make clear that everyone must take monkeypox seriously and care about those most likely to be affected. More than anything else, it is a plea to public health agencies like CDC to develop better policies and practices around public communication, making them more rapid, relevant to specific communities, and effective in shaping health-promoting behaviors.