Mpox

The 2022 mpox outbreak has taught public health authorities a lot about the value of working with communities on important areas like testing, vaccination, and risk communication. Lessons that can be applied to other disease outbreaks.

Mpox is back in the news; there are sporadic clusters of cases in our region, and, in Central and West Africa, two strains of the virus continue to cause suffering and death. 

In this episode, we speak to Rosamund Lewis, Emergency Manager & Technical Lead for the global mpox response at WHO Headquarters, about the current situation. Cristiana Salvi, who leads the Risk Communication and Community Engagement unit for WHO regional Office for Europe explains the importance of community insights in the mpox response. We also hear from epidemiologist Mateo Prochaska Nunez on the combination of factors that brought the outbreak under control and the measures needed to keep the virus in check.

Transcript

Not if, but when podcast- episode 3

Throughout history, pandemics have swept around the world, leaving devastation in their wake. What are we doing to prepare for the next one? Hello. I'm your host, Alice Allan. And in this series, I'll be going behind the scenes at who, and some of the European regions, major public health institutions to understand what the most likely causes of future pandemics could be. And what strategies are in place to avert them? I'll talk to the experts, applying the lessons of previous pandemics and focus in on the systems in place to spot threats and reduce their impact.  I'll speak to the legion of public health experts, quietly working away. Getting on with the not very glamorous, but incredibly important work of emergency preparedness. Experts in surveillance, genomic sequencing. Epidemiology and more. The people who are containing outbreaks and laying the groundwork to mitigate the effects of pandemics. Not if, but when they occur.

Episode 3: Mpox

For decades, mpox – formerly called monkeypox – was a disease largely confined to swathes of sub-Saharan Africa. 

Affected countries there had long called for the disease to be taken seriously, for more research, for better vaccines. But for much of the world, including the global health community, it was largely ‘out of sight, out of mind.’

But then, in 2022 – amid the COVID-19 pandemic – flared a different kind of mpox outbreak, one that surfaced initially in the European Region and then spread around the world. And this time, much of the world took notice –although not immediately.

As the global mpox outbreak of 2022 accelerated, it was obvious that those predominantly affected were communities of men who have sex with men, particularly those with multiple partners. Individuals and communities that – even in the 21st century – remain widely stigmatized and discriminated against, just as they were in the early years of AIDS.

However, just as they had done decades ago in the face of HIV, those same communities mobilized quickly – sharing information, getting vaccinated wherever mpox vaccine was available, changing behaviours – ultimately helping to contain the mpox outbreak. 

Mateo: So, what actually we did as communities, but also as a sector, is say, there is this new threat, this is how it looks like, this is what you can do to minimize your risk. And people took that information, shared it with other people, and made adjustments. This is what we're doing. So I think it was a really good example of fantastic community organization towards sustained behavioral change that supported the control of the transmission.

Alice: That was Mateo Prochazka, a medical doctor and epidemiologist working for WHO. We’ll hear more from him later.

The 2022 mpox outbreak has taught public health authorities a lot about the value of working with communities on important areas like testing, vaccination, and risk communication. Lessons that can be applied to other disease outbreaks.

Recently, Mpox hasn't been in the headlines so much, but it certainly hasn't gone away; there are sporadic clusters of cases in our region, and, in Central and West Africa, two strains of the virus continue to cause suffering and death. 

Dr Rosamund Lewis, Emergency Manager & Technical Lead for the global mpox response at WHO Headquarters gave me some background and helped me catch up with the current situation.

Rosamund: An orthopox virus is a family of viruses which lead to different diseases, characterized principally by skin lesions. So, the classic one, of course, was smallpox, which was eradicated in 1980, and now what we have in many countries in the world is mpox, formerly known as monkeypox. There are others.  There are other pox viruses of different sorts of animals, rabbit pox, camel pox. So it remains primarily a virus that can spill from animals to humans in a forest setting, but also very much now from person to person, as we've seen.

Alice: While the virus continues to be referred to as monkeypox, in 2022, WHO changed the name of the disease resulting from the virus to mpox, to reduce stigma. There are two clades of the virus, clade 1, most often found in Central Africa, and clade II, most frequently seen in West Africa. It was a variant called clade II b that was responsible for the global outbreak of mpox that spread across the world in 2022. Although clade II can cause severe illness, and occasionally death, clade I is has a much higher mortality rate. 

Rosamund: It still seems to be the case that where mpox occurs in Central Africa, for example, the case fatality rate can approach even above 10 percent in the youngest children, for example, whereas in the global outbreak, there was less than 1 percent fatality for the cases of mpox that occurred globally since 2022 

 Alice: In terms of the global outbreak that began in 2022, what was unusual about it in terms of epidemiology or symptoms?

Rosamund: It was unusual because the mode of transmission, which is sexual through sexual contact, had not previously been recognized.

Mpox had always been known as a disease that transmits through close contact, and that could be face to face contact, which includes exposure to respiratory secretions, for example, but also skin to skin contact. You can contract it simply by touching another person and then touching your own face, for example.

You can contract it through contaminated towels or sheets.  Bedding, things like that that can be heavily contaminated with virus. What had not previously been described was infection through sexual contact. 

 Alice: Globally, what's the situation with mpox now? 

Rosamund: The global data that we have is among laboratory confirmed cases over 95, 000 cases in 117 countries and with almost 200 deaths documented. 

It was quite stunning when you consider that only a few thousand cases that ever been reported before globally, and then suddenly we're approaching 100, 000 cases. So it is significant because it happened now and it can also happen again, which is what we are now trying to avert. Of course, at the same time, there is the, as you mentioned earlier, the clade I central African clade of the monkeypox virus, which is continuing to cause outbreaks in central Africa, particularly in the Democratic Republic of the Congo, the number of cases has been rising over decades since it was first discovered there in 1970. In 2023, the country reported a record number of cases of over 12, 000 cases, and these are clinically compatible cases. Not all of them are laboratory confirmed because many of them occur in remote rural areas where it can take weeks or maybe more than a month to secure a skin sample and transport it to the central laboratory at the national level. There's no such thing as a rapid test yet for mpox.

 Alice: Rosamund told me that in 2024, around 10% of cases are laboratory confirmed and 300 deaths have already been recorded.  

And can you tell me if the virus has undergone any mutations recently?

Rosamund: So there are specific outbreaks, particularly in Eastern Congo right now in South Kivu province. There's an outbreak with a strain that's a new strain that does have mutations and deletions that have not previously been documented.

So these mutations in the virus suggest that in fact it has only been transmitting through human-to-human transmission. And secondly, that some of the deletions lead to the fact that it may not be picked up easily by the laboratory test that we currently have. So there's a capacity to evade diagnosis. It's possible that that if one is not aware of the mutations in that strain, that even if you have a classic case of mpox in front of you, during the diagnostic test it may still lead to a negative test.

 Alice: WHO is supporting researchers to document this new strain which is currently circulating in a highly populous mining area. One third of the cases are being seen in sex workers, and there is evidence that mpox infections during pregnancy can have a severe impact on unborn babies. 

Alice: Is there a risk that this new mutation may lead to more transmissibility and spread globally? 

Rosamund: Yes, that risk is clearly there. We've seen it before, so we know that it's possible. We've seen it with clade IIb.  And now we're seeing clade I being transmitted from person to person through sexual contact in highly densely populated areas with a lot of population movements across national boundaries, national borders. And so we are supporting countries to be on alert in those areas, We're supporting countries to put in place vigilance, surveillance, early detection, laboratory capacity, communication for people at risk, and eventually, of course, working towards introducing vaccines in those countries

Alice: Do we have that capacity within Europe to be doing the surveillance for those new strains of mpox?

Rosamund: Yes. So the surveillance is primarily, first of all, a disease-based surveillance. So countries in Europe are reporting through the European Centers for Disease Control and through the European region of the World Health Organization who work together and together have a surveillance mechanism through which countries report to ECDC and WHO. And then that information is transferred to us at headquarters where we can put together a global database so that disease surveillance is ongoing. There's less appetite than there was before to continue that surveillance, which in itself represents a risk. And in addition to that, then there, of course, there's a laboratory network of scientists and laboratory practitioners who work together both within countries and throughout the region, to continue sequencing the genome of the virus.

 Alice: So just to return to the global outbreak, of clade IIb there's been a number of   clustered cases in Europe quite recently and it's been reported that some of those are amongst double vaccinated individuals. Is there waning immunity from vaccination and if so, what are WHO's current guidance? 

Rosamund: So these are very good questions since WHO has just updated recommendations on use of Mpox vaccines during an outbreak and also use preventive use of vaccines for people at risk. So, considering the context that we're still in, in an outbreak, although at a much lower level than in the past, , it is still recommended for those who have not yet been vaccinated or who are not fully vaccinated because some vaccines require two doses to complete the course of vaccination.

We don't yet know enough about the duration of immunity of the mpox vaccines that are currently in use so because of that, we don't yet have a booster dose recommendation. The vaccine is not 100 percent protective against mpox. That does mean that there will be breakthrough cases.

In addition, even in those breakthrough cases, there is some immune response. There's some immunity remaining, and therefore the person may also be protected against severe disease. 

 Alice: WHO has recently published a new strategic framework on mpox, to guide health authorities, communities and other stakeholders in preventing and controlling mpox outbreaks, eliminating human-to-human transmission of the disease, and reducing spillover of the virus from animals to humans. I asked Rosamund Lewis whether we are likely to see another large outbreak of mpox in Europe.

Rosamund: Well, we've learned a lot, which means when we start seeing cases, we should be able to respond very quickly and effectively.

I have every hope that we would not see the same scale of outbreak, but orthopox viruses, like any other virus, are generally unpredictable. We didn't know that the first outbreak would happen and manifest through sexual transmission, so we don't know how the next one is going to occur either, but I hope we've learned and gained capacity to respond to this particular family of viruses, 

So it's about ability to detect cases, but it's also about ability of people to feel comfortable coming forward. So this is another lesson learned that where there's stigma about any particular disease or infection, which includes any that affects the skin, no matter who you are that people will be reluctant to come forward and look for care.

So 1 other really important lesson is, is that offering stigma free access to care, including early detection and treatment where available should be front and center of any infectious disease outbreak. 

Alice: What did you personally learn during the global impacts outbreak?

Rosamund: Well, I think what we learned is that there will always be more surprises when it comes to infectious diseases, right? So, in other words, expect the unexpected would always be, in public health and infectious disease control, always be a dictum. That you need to be open to all possibilities because really, honestly, anything, anything can happen. But in that case, you can also prepare for the different eventualities.

 So, for example, in the global outbreak, what was absolutely critical was the communications response and the engagement with affected communities. So the most affected communities stepped right up. Figuring out what was the best way for them to engage in in their own health and preventing ongoing spread of the disease.

There was quite a lot of engagement, awareness, communication of risks, understanding which behavior change may reduce one's risk at an individual level, at a community level. So this concept of communicating risks so that people can understand enough to manage their own risk, to change their own behaviour, to protect themselves and to protect their families and the people they love.

Alice: Cristiana Salvi leads the WHO Regional Office for Europe team that deals with Risk Communication, Community Engagement and infodemic management (RCCE-IM). When the global outbreak of mpox began, the team worked closely with affected communities, to understand their needs and co-create messages on the virus. 

Cristiana: There were a couple of clear and initial steps that we took. The first one that was setting up a social listening system because we needed to understand what conversations were there and how the community was represented and the disease was being acknowledged and whether there were any information voids that we had to address.

The most important thing we needed to do was to engage the affected communities in order to make sure that everything we do is relevant to their needs and their perception.

Also the type of language that we needed to use, which would resonate with them and would be culturally appropriate.  There was a big risk of stigma towards these communities. And we needed to do everything in our power to avoid and to mitigate this stigma.

 We started with engaging civil society organizations in the context of the networks that had been established in the context of HIV and sexually transmitted diseases. And then we continued working with them throughout the response. And there was an evolution of the outbreak and evolution also of the people, the community that we saw affected. For instance, in 2023, we started to see that there were sex workers and refugees and trans community that were affected. And we got advice from the communities we were engaging with that we needed to also address them. And this is what we did in the second part of the response. I think this was one of the most important collaborations with the civil organizations that we have ever had in terms of emergency response.

I think the most important thing was the insights that we would get from these community actors and we established an informal working group engaging about 30 of these civil society organization with whom  we worked throughout the response and they were advising us based on what would be the evolution of the situation and what would  be the evolution of the perception and what would be needed at that point in time.

So, there were a number of things that we did following their advice. For instance, at the very busy beginning, they advised us to make clear to the target group, to the affected community what would be the symptoms. So, what would be the signs of the disease in a way that this would resonate with them.

An imagery that would make sense to them. And so we started using photos of rashes and lesions on the body so that they could actually recognize them. 

 Alice: Another element that the team worked on was developing health information and advice for mass gathering events like pride festivals. At the time, some voices were calling for these events to be cancelled, 

Cristiana: Another important advice that we got was that cancelling public mass gathering, like it was discussed at some point would be extremely counterproductive.

And actually that mass gatherings could be that opportunity for us to provide this public health advice and to engage the civil society organization to do. And we followed that advice and we were pretty bold in recommending that mass gatherings would be organized, of course in a safe way. So I think that this continued insight gathering, but also the co-development and co- delivery of the materials and interventions.

Alice: What learnings from mpox can be applied to other emergencies?

Cristiana: So, I think that the main learning of the mpox outbreak response is really the communities at the core. We want to achieve real protection engaging with communities and through interventions that are tuned to their unique risks and needs. It's not just about dropping off supplies like tests or vaccines or implementing measures like contact tracing. It's about making sure they are accepted and utilized effectively.

And ultimately, it's about enabling and empowering the communities to leverage their capacity, knowledge, culture, assets, and strength, and be resilient for the future. 

Alice: Let’s return to Mateo Prochaska, the  medical doctor and epidemiologist, we heard from earlier. 

Mateo: I think I never thought about going into sexual health as a specialty, but I think I tended to gravitate towards it because of my own lived experience.

Being someone who is a gay man, I'm from Latin America, I needed to use prevention services throughout my life, and I had lots of access barriers to it. And when I migrated from Latin America to Europe, I really quickly realized that there are services that can be set up to meet the needs of people like myself.

So, sexual health seemed like an area that I could contribute to more because of my individual lived experience. I'm interested in sexual health specifically from a social and behavioral perspective as well, and a human rights perspective, and not just from the scientific part that I find interesting across all infectious diseases.

In May 2022, when the first cases of the global mpox outbreak were detected, Mateo was working as an epidemiologist for the UK Health Security Agency, monitoring outbreaks of sexually transmitted infections. 

 So there was a lot of uncertainty. There was a lot of questions about whether this virus has changed, whether we're looking at increased severity. And I did think that stigma could play a huge role because the cases that were arising were sexual and gender minorities that usually face stigma and discrimination. So I was concerned that there was going to be backlash against the community. 

A lot of people were coming to me with questions. I had lots of conversations with people who were scared. Who were asking me if they should change their behavior or asking me, how does this look like? What should I do? And a lot of people who were just concerned about the way we were communicating and a lot of discussions on whether we should be singling out some communities for being affected, or whether we should not be talking about it because it could reinforce stigma.

Mateo: Mateo produced communications for affected communities in which he answered the questions and concerns he was hearing. 

Mateo: I think the fact that I was part of the affected communities myself and I started with that really created an element of trust. And of certainty that I was not coming with a stigmatizing view, and I think I had good nuance insights on why I was communicating the things the way I was doing that and that was well received.

Alice: What impact does stigma have on people's health seeking behaviors?

Mateo: I think it has a huge, huge impact because stigma is a removal of social value. It can be experienced in yourself without anyone else contributing to that. And you may feel shame, but you can also feel fear of being discriminated against, but it can also happen as overt discrimination of you being kicked out by your family from your house or, or, or having consequences in your job or not being well-treated in a health facility.

Right, so overall, the whole experience of stigma can make someone not want to hear a diagnosis that they feel can stigmatize them may make them not want to engage with information or click on links because they are ashamed you may make them not go to a health facility to get a diagnostic test or even a vaccination because of what being in the queue says about them.

But it can also make it so that they don't talk to their partners or their family members about something that they're going through. And that can make it so that they don't go to a health facility when a complication arises or they don't ask someone to give them a lift to the hospital if something's going on with them.

So it can really impact someone's health, not just the mental health, but also like the physical health. And it can lead to people not seeking care and dying eventually. So we often underestimate the impact of stigma. Sometimes it comes as an afterthought, but it's such a core experience of having any infection, any infection. 

Alice:  What role did affected communities play in containing the outbreak?

 Mateo: So in Europe, we had a really interesting epidemiological trend for the outbreak. In 2022, we saw a rapid increase in cases between May and July and a bit of a plateau throughout August and a rapid decline from September onwards. And that decline has been sustained. And the interesting thing is that when we think about what dynamics, what infectious diseases dynamics can bring an outbreak like this down so fast, it's either behavioural change, vaccination, or immunity acquired through natural infection.

So people getting mpox to the point in which herd immunity is reached and interestingly, vaccination came too late for it to be the explanation. For the rapid drop in cases, it can have, it may have contributed especially to the sustained decrease that we have seen thus far, but the initial declining cases is either from infection acquired immunity or from changes in behavior.

So, in order to answer these questions, actually, we conducted a study looking at behavioral changes during the outbreak in Europe, but also in the Americas, in Latin America and the north of North America as well. We used dating apps for gay men, for trans people.

And we had around 17, 000 people who had completed the survey, completed the survey fully. And that's what we analyzed. And around 50 percent of people said they changed their behavior. And of those that changed their behavior, one third of them did lasting behavioral change almost a year into the outbreak, saying that we're reducing the number of new sexual partners, avoiding context of high transmission, like group sex or sex clubs.

So there was a lot of behavioral adaptation, which definitely contributed. But we also know when we look at how many people actually got mpox per country, that in almost every country, the prevalence of mpox got to like 2 percent or 3 percent So that means that a part of the sexual networks, probably the part of the sexual network where people are the most intertwined, having the most number of contacts, was exposed to mpox very quickly during the outbreak.

And that immunity that we built there just by some level of spread at the beginning of the outbreak really helped contain the outbreak later on. So, it's a mixture between this infection-acquired immunity and behavioral change, but most of the behavioral change that happened, happened through the exchange of information.

Alice: Now that cases have decreased in the region, is there still a role for communities in moving towards elimination of mpox?

Mateo: I think definitely there's a role for communities. There we have built awareness and people know what to do if transmission increases, but a sustained decrease in transmission and or even elimination cannot be reliant on sustained behavioral change because we need to find a balance between freedom from infection and freedom of choice for people to do what they want.

So it's with vaccination. We have effective vaccines that can help us contain the outbreak and these vaccination strategies that we had at the beginning for the outbreak need to turn into vaccination programmes. 

Alice: For anyone worried about mpox, Mateo’s advice is to pick one trusted source of information and follow it. WHO's international and regional websites have lots of resources on mpox, both for individuals and health authorities.