Monkeypox stigma and risk communication; Understanding the dilemma

Abstract

Monkeypox (MPX) is a viral zoonotic disease that is endemic in Central and West African countries had affected countries in Asia, Europe, Africa, Australia, and South and North America. Some globally reported cases were linked to history of recent travel to endemic regions, however, official reports revealed homosexual practices among the majority of reported cases. In response to global increase MPX burden and number of cases, the WHO declared MPX a Public Health Emergency with International Concern (PHEIC) on July 23, 2022. The first MPX case in Saudi Arabia was a returning traveler from Europe to Riyadh on July 14, 2022. It is essential for policy makers to maintain neutral tone for health education messages and inform the public that MPX transmits via physical contact.

Introduction

Monkeypox (MPX) is a viral zoonotic disease that is endemic in Central and West African countries [1]. In 1970, the first case was reported in Democratic Republican of Congo (D.R.C) [2]. MPX is usually self-limiting and mild with a relatively low fatality rate. MPX could be transmitted from animal by direct contact with infected lesions, through contact with body fluid and/ or secretion, and through consumption of undercooked meat. Human-to-human transmission is evident and occurs through direct contact with body fluid of infected individuals including intimate contact, contaminated objects, or aerosol during extended face-to-face contact [2], [3].

Since May 2022, several MPX cases had been reported in non-endemic countries. The global outbreak had affected countries in Asia, Europe, Africa, Australia, and South and North America. Some globally reported cases were linked to history of recent travel to endemic regions, however, official reports revealed homosexual practices among the majority of reported cases [3], [4]. The World Health Organization (WHO) is closely monitoring the global epidemic status with countries, institutions, and technical and financial partners to strengthen early detection, preparedness, and response to enhance surveillance and mitigate disease transmission. The WHO-EMRO Regional Director had activated the incident management system for MPX to effectively coordinate and support preparedness, readiness, and response activities for the outbreak management at country and regional levels [1]. Member states established multi-sectoral coordination mechanisms for comprehensive response activities at local level. In response to global increase MPX burden and number of cases, WHO on July 23, 2022 declared MPX a Public Health Emergency with International Concern (PHEIC) [2]. MPX is a containable disease provided that there is effective contact tracing, early detection, and isolation of infected cases to disturb the transmission cycle. One-health surveillance is essential for monitoring MPX transmission and mitigation. As of November 23, 2022; the total number of reported cases globally was 80,634, among which 8 cases were identified in Saudi Arabia [5]. The first MPX case in Saudi Arabia was a returning traveler from Europe to Riyadh on July 14, 2022 [1]. Saudi Arabia had been closely monitoring the situation, pledging to handle any detected cases transparently, highlighting its readiness to deal with any development of the disease [1]. Saudi Arabia’s COVID-19 experience sets the foundation for MPX crisis management, Ministry of Health (MOH) in Saudi Arabia had called upon citizens and residents to adhere to health guidelines, especially during travel and to contact 937-call center for inquiries MPX disease.

Monkeypox stigma and risk communication

Zoonotic transmission had been reported in endemic countries, in contrary, transmission in non-endemic countries occurs primarily through physical human-to-human contact; including sexual/ intimate contact [1], [6]. MPX outbreak in non-endemic regions emphasized the issue of infodemic and conspiracy theories that go viral during population health crisis regarding infection emergence, transmission, and spread [7], [8]. Most reported MPX in non-endemic regions were mainly identified among men who have sex with men (MSM) [2], [9]. Identification of MPX cases occurs usually during routine visits to sexual health clinics or routine health services delivery at primary or secondary healthcare facilities with common observation lesbian, gay, bisexual, and queries (LGBTQ+), particularly MSM are the most involved [10], [11].

Recent COVID-19 pandemic experience presents rich materials to assess the impact of conspiracy theories and infodemic on public opinion manipulation and exacerbating the risk of stigma against population at risk and infected individuals. Although COVID-19 pandemic at its recovery phase, the public had not forgotten the burden of uncertainty, financial and emotional stresses, and loss of significant other or family members. COVID-19 pandemic presented political, economic, social, psychological, and health challenges for governments, scientific community, healthcare system, and the public. COVID-19 pandemic era created a conspiracy playbook that could serve as ingredients for any conspiracy theory that could be effectively and applied to other infectious diseases [12]. Conspiracy beliefs should receive a lot of attention and handled with caution and care in time of health crisis. Conspiracy beliefs were amplified by contradictory information that bad flooded social media outlets. During COVID-19 pandemic, social media platforms serve as a tabloid stuffed with rumors, misinformation, and scandals that manipulated the public opinion toward questioning the validity of scientific findings, and legitimacy of governmental policies which accentuates the status of uncertainty and public anxiety. Despite governmental efforts to contain the pandemic and disseminate accurate information, conspiracy beliefs tend to spread faster that evidence and truth. In May 2022, a multi-country MPX outbreak associated with human-to-human transmission began and spread globally [3], [4]. Human-to-human transmission occurs through close physical contact; including intimate/ sexual contact, contamination by or contact with body fluid, and/ or prolonged face-to-face contact via aerosol. However, recent MPX outbreak is predominantly linked to sexual contact, particularly among MSM. Occupation exposure to MPX is an issue of major concern for healthcare providers. Following WHO declaration of MPX a PHEIC, social media platforms flooded by scourge of misinformation appears with an evident crosspollination between different diverse conspiracy theories [7]. Social media outlets broadcasting of visible MPX disfigurement with heighten concerns further, and misinformation is likely to fuel public anxiety [10]. MPX had been misportrayed as a sexually-transmitted infection which may fail to recognize others at risk, interfere with implementation of precautionary measures, and access to healthcare services [10]. The current MPX outbreak pattern raises concern over individuals’ sexual orientation, similar to early HIV epidemic infection pattern and associated stigma [3], [13]. In order to avoid stigma associated with early AIDS global transmission, it is essential that MPX is not labeled as a “gay disease”. Sexual practices among MSM is the main MPX risk factor, in addition to unprotected sexual exposure with random, multiple, or anonymous partners. Thus, WHO advised MSM to limit their sexual partners to minimize their sexual partners to reduce the risk of transmission [14]. Despite proven MPX transmission via sexual activities, evidence concluded that not the only route of infection transmission. Close physical contact is not limited to LGBTQ+ , therefore, gender identity and sexual orientation is irresponsible for MPX infection. MPX is not classified a sexually transmitted infection despite transmission via sexual contact [3]. Current media broadcasting and social media clamor fulminate public perception of conspiracy theories and public anxiety. Considering the high level of conspiracy beliefs toward emerging infection is necessary to establish effective communication plan. Stigma may result in delays in seeking health care, reduced compliance to isolation and public health measures, and hinder contact tracing process.

Stigma is a societally created image used to discredit a subpopulation who possess a discrediting attribute [15]. Individuals experiencing stigmatized identities feel greater vulnerability, invisibility, and discrimination. Conspiracy beliefs through media and social media broadcasting feed stigmatization messages that imply that transmission is the responsibility of individuals for contracting infected despite adherence to preventive health measures. Furthermore, infected individuals will be labeled as LGBTQ+ regardless their sexual orientation. Stigma is often connected with negative health outcomes. Conspiracy beliefs emerged as an attempt to explain political, social, and health-related circumstances with claims to disclose undisclosed parents and the culprit behind the events by influences. People usually engage in conspiracy beliefs to satisfy their unfulfilled needs. Global alliance to fight emerging infectious diseases should accompany by efforts to combat infodemic in which falsehoods spread faster than truth and evidence.

Mass gatherings and Monkeypox stigma

Religious, entertainment, cultural, and sport mass gatherings in Saudi Arabia are receiving increased regional and global attention especially after successful COVID-19 pandemic management, cumulative experience gained from cultural events, and leading evidence-based management of Hajj and Umrah annually. Yet, disease transmission, mitigation, and containment present a challenge for health authorities and policy makers. Awareness language must be neutrals and address societal needs.

2022 FIFA World Cup in Qatar coincides with launching the seasonal festivals across Saudi Arabia, as a result, number of visitors to Saudi Arabia is expected to increase to attend cultural and entertainment events and/ or visiting the holy mosques. However, associated stigma with MPX may result in delayed in health-seeking, reduced compliance with isolation and other preventive measures, and reluctance to disclose contacts among infected individuals [10]. Addressing public fears and deep rooted stigma are not easy. Coordinated efforts between health authorities and civil society organizations is essential for public education and awareness. Successful COVID-19 pandemic containment in Saudi Arabia buys into population trust and sets the foundation to combat public health emergencies and associated infodemic and conspiracy theories. Manipulated public opinion presents a great risk in outbreak management. People usually engages in conspiracy theories when their social needs are not met. Infodemic spreads false and fabricated news in order program public opinion. Conspiracy theories and infodemic are often organized to exercise every effort to undermine societal stability. It is essentially important to highlight that MPX transmits via physical contact and/ or contact with body fluid or secretion. However, contradicting MPX is not necessarily associated with sexual practices or orientation. Risk communication messages should be neutral and must not activate stereotype. Anonymized testing and contact tracing should encourage suspected individuals to seek for medical care. During mass gatherings unavoidable physical contact may take place and infection transmission may occur. Crowd behavior presents political, social, psychological, and health challenges. The crowd usually communicates MPX stigma by talking about individual responsibility about contracting infection and warning others of suspected threat to community safety and stability. Stigma messages, hate speech, and associated violence increase with poor risk communication in health context. Stigma might be communicated through interpersonal communication, media, or healthcare settings [16], [17].

Saudi Arabia is becoming an icon for tolerance and acceptance. However, national security; including social and health security, is a priority. Interpersonal contact-based anti-stigma awareness programs are common and proven effective [16], [18], [19]. The risk of importing infectious diseases had always been lurking in the background and global outbreaks and attracted much media interest and generated public alarm especially after COVID-19 pandemic. Almost 19.30 million people are social media users where WhatsApp is the most popular social networking platform in Saudi Arabia, followed by Instagram, Twitter, and Snapchat [20], [21], [22]. Risk communication is a real-time exchange and dissemination of information, advice, and opinions between experts or officials and population at risk in order to maintain their survival and health, social, and economic wellbeing. Community engagement in risk communication develops a conceptual framework that outlines degrees of population engagement as an equal partner in the creation of emergency response solutions that are acceptable and workable to produce desirable impact [23]. Community engagement will empower confident participation in planning, and initiatives’ implementation in collaboration with policy-makers and governmental officials throughout the emergency response cycle. Thus, community leaders and social activists play a pivotal role to bring viewpoints into a common ground and protect social stability. The MPX outbreak reflects that communities will continue to face challenges arise from pathogen emergence which supports the need for international coordination and alliance to unify global efforts designed to combat public health threats and crisis [24]. Addressing public fears and deep rooted stigma will not be easy. WHO urges governments and media outlets to proactively reflecting and acting on tone of language, behavior, and intentions toward population. It is the responsibility of governmental and non-governmental agencies to reducing the harm caused by stigma and discrimination [24]. Targeted health messaging to population and high risk groups must be handled with sensitivity to avoid alienating population at risk [22], [23], [24]. Risk communication is Saudi Arabia should consider engagement of social media influences to utilize social media outlets to educate the public regarding any public health threats and crisis. MPX social and psychological impact on Saudi Arabia could be multifaceted. Properly designed risk communication messages for MPX can activate positive health behavior. Thus health authorities in collaboration with social media influences invest to promote public health awareness to soothe public prejudice. MPX risk communication is essential to encourage suspected individuals to seek-health care and disclose their close contacts in order for epidemiological investigation teams to conduct full, comprehensive assessment. Nevertheless, UNAIDS urges all media coverings to abide by regular updates issued by WHO and local health authorities [24]. In times of outbreak and pandemic, epidemiological assessment, active surveillance, and effective risk communication are corner stones in health disasters containment strategy. During mass gathering, carefully planned risk communication activities by public health authorities that engage relevant community leaders and social media influencers to deliver neutrally toned messages and encourage public compliance to preventive health measures.

Conclusion

Our health securities are all inter-winded with social, cultural and political parameters. Policy makers and public health authorities should be vigilant and take infodemic, conspiracy theories, and outbreak associated stigma seriously. MPX prevention is more effective than active treatment. Compliance with MPX preventive measures is linked to appropriate risk communication. homosexual practices might increase the risk for contracting the infection. However, MPX not a sexually transmitted disease and such stigma might lead to delayed access to care and affecting individuals whom diagnosed. It is essential for policy makers to maintain neutral tone for health education messages and inform the public that MPX transmits via physical contact.

CRediT authorship contribution statement

Both authors equally contributed to developing conceptual framework and writing this brief communication. WMB and MKA conducted literature search, summarized findings, and wrote and reviewed the manuscript.

Ethical approval

Not required.

Funding

No funding Sources.

Competing interests

None declared.