Monkeypox Outbreak Stokes Stigma and Vaccine Race
Child infected with monkeypox in Liberia – since smallpox vaccinations were discontinued children may be even more vulnerable

Fifteen non-endemic World Health Organisation(WHO) member states have reported 95 confirmed cases of monkeypox between 13-22 May – but the language and imagery used to report the outbreak has raised concerns over the reemergence of disease-related stigma against LGBTI and African members of society. 

Based on currently available information, the WHO said that cases have mainly but not exclusively been identified amongst men who have sex with men seeking care in primary care and sexual health clinics.

“While we’re seeing cases amongst men who have sex with men, this is not a gay disease, as some people on social media have attempted to label it. It is just not the case. Anybody can contract monkeypox through close contact,” said Andy Seale, Advisor at the WHO, in a live Q&A on Monday.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) also raised concerns over the portrayal of LGBTI and African members in the commentary and reportage being circulated in the media. 

UNAIDS said that such language and imagery can reinforce racist and homophobic stigma. “Experience shows that stigmatizing rhetoric can quickly disable evidence-based response by stoking cycles of fear, driving people away from health services, impeding efforts to identify cases, and encouraging ineffective, punitive measures,” said Dr Matthew Kavanagh, UNAIDS Deputy Executive Director. 

The current images used to portray monkeypox rashes belong to members of the African community based on the documentation over the last decades on cases in the African region where this disease is endemic. 

Seale re-emphasised that communities are the WHO’s main concern and it was working on getting more accurate information to better understand and manage the health risks of this disease.

“There’s a lot of stigma and discrimination that surrounds many diseases. And I think the key thing we need to look out for is WHO working with our partners in communities and elsewhere, to make sure that their messaging is correct.” 

The WHO expects more cases of monkeypox to be identified as surveillance expands in non-endemic countries. As per available evidence, those who have had close physical contact with someone with monkeypox symptoms are the most susceptible to contracting the disease which is endemic to West Africa. 

US orders freeze-dried smallpox vaccines 

As the reportage and awareness of the outbreak gains momentum in Europe and North America, US President Joe Biden said the current scale of the disease was something “everyone should be concerned about.” “It is a concern that if it were to spread, it would be consequential,” he said.

The US has exercised its options under an agreement with the Copenhagen-based Bavarian Nordic company to order a freeze-dried version of JYNNEOS® smallpox vaccine. According to the company, the first doses of this vaccine version will be manufactured in 2023 and 2024 and will cost US$119 million.  

Bavarian Nordic said that additional options on the contract, valued at US$180 million, would support the conversion of up to a total of approximately 13 million freeze-dried doses of the vaccine that are expected to be manufactured in 2024 and 2025. “The majority of the bulk vaccine for these doses has already been manufactured and invoiced,” the company’s press release said. 

A table showing the recent outbreak of WHO between 13-22 May in non-endemic countries.

According to the US Centers for Disease Control and Prevention, the smallpox vaccine is at least 85% effective against monkeypox. It also said that the U.S has licensed two vaccines to prevent smallpox, with one being authorized specifically for monkeypox.

Vaccine efficacy, and access

This 85% vaccine effectiveness is attributed to the older version of the vaccine, said Dr Maria van Kerkhove, WHO Technical Lead on COVID-19.

“We now have new vaccines. Although smallpox was eradicated, research has continued for the last 40 years… [because] these viruses are closely related to each other and now we have the benefit of all those years of research diagnostics and treatments in vaccines,” she said. 

However, she warned that since these are relatively newly discovered products, they are not yet widely available. “They are available to some Ministries of Health and National stockpiles, but they’re not yet widely available commercially.”

This highlights the US decision to exercise its options in light of the scarcity of vaccines in even regions where monkeypox is endemic. 

According to a paper published in February 2022, the cessation of the smallpox vaccine in 1980s caused a minimum of 10-fold increase in cases in 2010-19 compared to the 1970s. The smallpox vaccines provided some cross-protection against monkeypox. The paper had warned at its time of publication that monkeypox is gradually evolving to become of global relevance and surveillance and detection programs are essential tools for understanding the continuously changing epidemiology of this resurging disease.

How worried should one be about contracting monkeypox? 

“Monkeypox and COVID-19 are not the same disease,” said Dr Rosamund Lewis, head of the Smallpox Secretariat at the WHO Emergencies Programme.

“Monkeypox spreads through close physical contact, which includes touching the rashes developed in this disease,” she said. 

While COVID-19 and monkeypox are zoonotic viruses, the latter is transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials such as bedding. The disease has symptoms that are similar to those seen in smallpox patients, although the former is clinically less severe and has an incubation period of 6 to 13 days. 

Dr Van Kerkhove said that the WHO has been working with Ministries of Health in countries to expand surveillance in order to look for people who have a rash. This means broadening the radius of alertness to dermatology clinics, emergency departments, infectious disease clinics, and sexual health clinics to effectively understand the extent of infection.  

She brought to light that the current outbreak seen in non-endemic countries is “a containable situation” but warned that “we can’t take our eye off the ball on what’s happening in Africa as well as in endemic countries”.

“So this gives us an opportunity to talk about what monkeypox is and what it isn’t, so you can be very well informed,” she added.

All you need to know about monkeypox 

There are currently 12 monkeypox endemic countries in the WHO Regional Office for Africa: Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Ghana (identified in animals only), Ivory Coast, Liberia, Nigeria, the Republic of the Congo, Sierra Leone, and South Sudan. 

If you are in a non-endemic country, the symptoms to watch out for are an acute rash with the combination of one or more of the following: headache, acute onset of fever, swollen lymph nodes, muscle and body ache, back pain, and weakness.

Image Credits: US Centres for Disease Control , WHO.

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