Mpox: “the stigma is as dangerous as the virus”. Historical, social, ethical issues and future forthcoming

Summary

Objectives

The authors aim to show the possibility of stigma that hits affected Mpox patients because of the statements of society involving their sexual sphere.

Introduction

23 July 2022, the Director-General of the WHO, Thedos Ghebreyesus, issued an international public health alert regarding cases of Mpox (formerly known as Monkeypox). Although Mpox has been present in an endemic form for years in some Central African countries, the spread of the disease outside Africa has aroused considerable alarm in populations already sorely afflicted by the COVID-19 pandemic. Aside from the data, what is striking is that Mpox, like other infectious diseases, seems to have become a problem only when it began to cross the borders of Africa. Some may justify this attitude simply by ascribing it to the fear of an epidemic outside the areas where the virus is endemic. However, in such cases, and especially after the COVID-19 experience, other factors are also involved: lack of information and, even more so, the human capacity to utilise diseases to reinforce arguments against the tendencies, inclinations, orientations and behaviours of some social groups. Such information, albeit basically correct, is nevertheless incomplete. Moreover, it tends to prompt a view of this disease that may give rise to highly dangerous and embarrassing situations, engendering the risk of repeating the error that was made about AIDS. Mpox is the latest in a series of epidemics that have struck humanity in the space of very few years.

Material and methods

Setting and partecipants: people and social groups who, due to sexual orientations and behaviours, are considered to be at risk of being infected with Mpox. Main outcomes measures: - outcomes directly related to mental health of Mpox patients: anxiety, fear and depression, emotional difficulties, feelings of loneliness and isolation; - well-being outcomes of people with Mpox; - risk of not being able to reduce the epidemic among those groups don’t feel as though they belong to LGBTQ and therefore do not implement any kind of prevention.

Results

Limit the contagion from Mpox through specific health and communication campaigns. Remove any stigma related to Mpox disease.

Conclusions

In the face of this disease, it is absolutely essential that we do not needlessly isolate groups of people by feeding stigma, prejudice and discrimination, which can have devastating effects not only on individuals but also on society as a whole. As the full inclusion of persons of LGBTQ community is probably still a long way off, we must surely wonder when we will be ready enough to achieve the important objective of equality for all.

Introduction

On 23 July 2022, the Director-General of the WHO, Thedos Adhanom Ghebreyesus, issued an international public health alert regarding cases of Mpox (MPX) [1]. He “declared that the multi-country outbreak of Mpox is a public health emergency of international concern (PHEIC)” [1].

According to the international health regulation, this declaration establishes the highest level of global alert for public health: in this way it ensures that there is better coordination of actions to be applied, greater cooperation and global solidarity.

In the majority of cases, the symptoms of Mpox, as skin infections, pneumonia, confusion and eye infections, disappear within a few weeks. However, in 3% to 6% of cases reported in countries where the disease is endemic, severe complications may ensue, leading even to death in immunodeficient subjects [2].

These data show that Mpox is in any case a serious disease that requires particular attention from the scientific community, governments and all citizens.

Background

Mpox is caused by a virus of the variola family that causes smallpox, now eradicated from World. Mpox is a zoonosis that, can also spread from animals to humans, and therefore from humans to other humans.

This disease has symptoms similar to those of human smallpox but milder and has an absolutely lower death rate. It has been clarified that Mpox is not related to chickenpox [3].

The most common symptomatology, recorded among those affected, is given by fever, headache, muscle aches, back pain, low energy and swollen Lymph nodes. These symptoms can be accompanied or followed by a characteristic rash that affects the face, palms, soles of the feet, groin, genital and/or anal regions. It may also be found in the mouth, throat, or on the eyes.

The number of such sores is extremely varied and changes from person to person. Sores on the skin begin flat, then fill with liquid before they crust over, dry up and fall off, with a new layer of skin forming below [4].

Usually, Mpox resolves positively and the symptoms just listed, including fever, disappear within a few weeks. However, in some individuals Mpox can have a much more severe course and in some cases can lead to death.

The period of infectiousness remains until all the sores have become encrusted, the crusts have fallen and a new layer of skin has formed below.

Origin and history of Mpox

The discovery of the virus that causes Mpox is rather young: it was recognized in 1958 when two outbreaks of a smallpox-like disease occurred in monkey colonies kept for research [5]. Hence the name “monkey smallpox”, although the source of the disease remains unknown. It is known that African rodents and non-human primates (such as monkeys) could host the virus and infect people.

The first known human case of monkey smallpox was recorded in 1970 in Zaire (now Democratic Republic of the Congo, DRC): it was a case of transmission of zoonotic MPV from animal to man in a 9-month-old child [6-9].

Prior to the Mpox outbreak detected in 2022, the disease rarely occurred outside the African continent, where over the years some cases have been reported in 11 African countries: Benin, Cameroon, Central African Republic, Democratic Republic of the Congo, Gabon, Ivory Coast, Liberia, Nigeria, Republic of the Congo, Sierra Leone and South Sudan [10].

When this happened, in most of the time it was linked to international trips to countries where the disease is endemic, such as Nigeria, where Mpox has re-emerged in the last decade after a 40-year break.

In other cases, the transmission is linked to the import of animals from Africa: a major outbreak – with 47 confirmed or probable cases – occurred in 2003 in the US following introduction to infected pet prairie dogs, which had got Mpox virus from infected exotic animals imported from Ghana [11-13].

During recent years, there have been various travel-associated cases of Mpox, all following exposures in Nigeria. There was one case in Israel in 2018, three in the UK (two in 2018, one in 2019, and one in Singapore in 2019 [14, 15]. There was also another case in 2018, in the UK, nevertheless it was the result of nosocomial transmission to a healthcare worker (Fig. 1) [16].

Fig. 1.

Number of confirmed, probable, and/or possible Mpox cases between 1970-2019 [11].

The WHO Bulletin reported over 6,200 and 9,400 confirmed and suspected cases in 2020 and 2021, respectively (probably underestimating data due to the lack of surveillance system in endemic regions) [17, 18].

Although Mpox has been present in an endemic form for years in some Central African countries, the spread of the disease outside Africa has aroused considerable alarm in populations already sorely afflicted by the COVID-19 pandemic.

With 92,167 total cases (data issued by the Centers for Disease Control and Prevention on December 1, 2023), 90195 of which in countries where Mpox had never been reported, the virus has now reached 117 nations, 110 of which for the first time. The dead due to the Mpox are 170: 149 in locations that have not historically reported Mpox, 21 in locations that have historically reported Mpox [19].

In recent times, the case fatality ratio has been around 3-6%, with a rate of 1 percent around the West African clade, found in cases in Europe and America [10].

One of the main and possible causes of the increasing number of cases of Mpox is the interruption of vaccinations against smallpox in the population following the eradication of smallpox in 1980 [20-22].

According to some scholars, including Zhilong Yang, the current epidemic of Mpox “is still very unusual, mainly for two reasons”, as most infected individuals have never traveled to areas where Mpox is endemic, and the epidemic is developing at the same time in different countries [23]. The latter suggests that there are multiple sources of introduction.

In Europe, noticeable data can be recorded, especially in countries such as Spain, France, United Kingdom and Germany (Fig. 2). There are 31,277 cases registered in USA (December 1, 2023), 1,496 in Canada and 4,071 in Mexico. On the same date, in South America, we report and highlight 10,967 cases in Brazil, 4,090 in Colombia, 3,812 in Peru, 1,531 in China. Only two cases in Russia [19].

Fig. 2.

Mpox Outbreak: cases reported in European countries as of December 1, 2023 [25].

Discussion

Current data suggests that Mpox may represent a long-term global threat. However, no particular attention we paid to this disease until July 2022 with the Public Health Emergency of international Concern (PHEIC).

We also add the public health conditions of African countries where the virus is endemic; they are developing countries, with little tools to monitor and report cases of Mpox and the clinical signs also have similarities with some other diseases that are widespread in the same countries, such as syphilis and chicken pox. This lack of rigorous and careful health surveillance can strengthen the spread of the epidemic.

Aside from the data, what is striking is that Mpox, like other infectious diseases, seems to have become a problem only when it began to cross the borders of Africa.

Some may justify this attitude simply by ascribing it to the fear of an epidemic outside the areas where the virus is endemic.

However, in such cases, and especially after the COVID-19 experience, other factors are also involved: lack of information and, even more so, the human capacity to utilise diseases to reinforce arguments against the tendencies, inclinations, orientations and habits of some social groups.

While outbreaks of Mpox in African countries have been limited to populations who eat the meat of wild animals – so-called “bushmeat” –, which enables the virus to spread, cases that by May 2022 have been identified and reported through sexual health or other health services in primary or secondary health-care facilities in countries other than African ones are instead caused by sexual transmission. They have been detected in men who have sex with other men [24]. As a result, the disease was immediately accompanied by a stigma.

And this, even though in the meantime it has been shown that the virus can also be transmitted through direct contact with infected sores, scabs or bodily fluids, or by sharing underwear or clothing [25-27].

A body of evidence shows that from February 2023 some individuals may spread the disease one to four days before the onset of symptoms [28]. This is a possibility that has important and serious repercussions during the epidemic.

It is essential to keep the focus on the transmission of the Mpox virus alive. We believe that the constant attention and international support are essential for greater surveillance and that the detection of cases of smallpox monkeys are necessary tools for the continuous understanding and to change the epidemiology of this emerging disease.

Ethical and social issues

Such information, albeit basically correct, is nevertheless incomplete. Moreover, it tends to prompt a view of this disease that may give rise to highly dangerous and embarrassing situations, engendering the risk of repeating the error that was made with regard to AIDS.

The current outbreak seems to be spreading mainly among men who have sex with other men a trend that has drawn parallels with the HIV/AIDS epidemic, which overly affected the LGBTQ community at its peak in the late 1980s and early ’90s. Scientists are not completely sure why the disease is spreading this way, but early outcomes suggest and record a wide spread within the LGBTQ community, where it can spread more than the general population.

On this point, blaming a particular social group for the spread of Mpox has two deleterious consequences; not only does it stigmatise the gay community, it also underestimates the risk to the rest of the population.

“It must be clear to people that everyone can acquire Mpox, regardless of gender identity or sexual orientation, or age” [29].

In this regard, the WHO recommendation that “men who have sex with men should consider limiting their sexual partners to lower their risk of infection and reduce the spread”, though based on good intentions, risks exacerbating the danger of stigma. And “The stigma and discrimination – as WHO chief Tedros Adhanom Ghebreyesus said – can be as dangerous as any virus and can fuel the outbreak” [30, 31].

In 1963, sociologist Erving Goffman, in his book Stigma. Notes on the Management of Spoiled Identity defined stigma as a social attribute that discredits an individual or group [32]. According to Goffman’s conceptualization, the term stigma refers to a series of signs - physical, such as certain malformations of the body, or character, such as dishonesty, an attitude to violence, inordinate passions, or cultural, tribal or religious affiliation - which, within a society, refer to a difference perceived as deviance from a norm [33].

Expanding on Goffman’s social interactionist definition of stigma, Link and Phelan [34] “conceptualize stigma as the co-occurrence of labelling, stereotyping, separating, status loss and discrimination. Their definition, with its focus on structural contexts in addition to relational contexts, has fostered stigma research in two additional areas: (a) the translation of stigmas into broader socio-cultural traditions and institutions, including social welfare policies and (b) the interaction of stigmas with other determinants of health advantage or disadvantage” [35-37].

People have always tended to blame outbreaks of disease on individuals who do not belong to their own social circle (“othering”), who are seen as intruders in their “walled garden”.

Because of fear, prejudice and discrimination against Mpox sufferers is growing, “prescribing an “otherness” to disease to feel protected and ascribing blame to justify prejudicial rhetoric. This stigma has recurred throughout history: Jewish persecution during the Black Death, LGBTQ communities during the rise of HIV, and people of west African descent during the Ebola outbreak” [38].

Thus, while we may regard “othering” as a defence strategy, we can in no way endorse it.

Indeed, history clearly demonstrates that blaming diseases or catastrophes on those who are different from us gives rise only to suffering and does not protect society against the incumbent evil [39].

For this reason, on September 27th CDC published “Reducing Stigma in Mpox Communication and Community Engagement” (updated October 18, 2022), with a series of recommendations to avoid stigma and give correct information, starting with the one according to which “Describe Mpox as a legitimate public health issue that is relevant to all people” [40].

On March 2, 2023, CDC reconsidered the issue of stigma in Mpox by publishing Mpox Equity and Anti-Stigma Toolkit. The document opens with this declaration of intents: “CDC is committed to health equity, which means everyone has fair and just opportunity to their highest level of health. For Mpox, this includes reliable access to accurate information and prevention education, as well as vaccine access” [41].

The ability to be properly informed and to have access to treatments and vaccines means that people can have all the necessary information and tools to prevent or treat the disease quickly, in their own and the community’s interests.

Extreme attention must therefore be paid to the implementation and dissemination of information messages, which must be transmitted by trusted messengers recognized by the community to which they are addressed. These messages must be realized through communicative codes recognizable and shared by the community itself. Only in this way will they be able to reach and be effective “on the populations at greater risk of Mpox through racial, ethnic, sexual, socio-economic and geographical backgrounds” [41].

For this reason, the WHO changed the name of the disease from Mpox to Mpox, as the term Mpox may appear discriminatory, stigmatizing and misleading. In fact, this occurred in the early months of the monkey smallpox epidemic, due to the particular naming but especially the mode of sexual transmission in gay individuals. This led the WHO to the determination to change the name of the disease to Mpox. Both names will be used simultaneously for one year while Mpox is gradually phased out [42].

Future forthcoming

The World Health Organization (WHO) declares that “It is fortunate that smallpox vaccines also provide solid protection against monkey smallpox, and the smallpox drug, TPOXX, is promising and probably effective for treating monkey smallpox” [24].

At least two vaccines approved by the US FDA can prevent Mpox. Similarly, it appears that other smallpox vaccines used in the era of smallpox should also be able to provide protection.

However, as monkey smallpox is spreading to many countries and affecting a significant number of people, further epidemiological studies are needed, “with particular reference to zoonotic hosts, transmission potential and severity of human cases”, and the study and development of a new generation of vaccines [21].

From a social point of view, we need to focus on our attention on a fundamental point: Mpox is the latest in a series of epidemics that have struck humanity in the space of very few years, with recrudescence also of important diseases that were considered to be in the process of being eradicated or under control, such as poliomyelitis [43, 44], measles [45] or cholera [46].

In the face of Mpox, it is essential that we do not needlessly isolate groups of people by feeding stigma, prejudice and discrimination, which can have devastating effects not only on individuals but also on society as a whole [47, 48].

As has happened with other diseases in the past, Mpox patients have also suffered stigma and discrimination, and this is not only unfair from an ethical point of view but can cause significant harm, delaying access to treatment in most cases.

Faced with such incidents, the response of the community must be unambiguous and respectful of human rights, with particular attention to the inclusion and dignity of all individuals, without exception [49].

However, the full inclusion of persons who are lesbian, gay, bisexual or transgender (LGBTQ) is probably still a long way off, we must surely wonder when we will be mature enough to achieve the important objective of equality for all [50].

For these reasons we therefore need to be extremely careful when we refer to Mpox disease and people affected by it.

The CDC suggestions covered in the Mpox messaging framework can be extremely valuable [40].

It is enough to use an inclusive language, such as ‘us’ and ‘we’ pronouns. At the same time, the media should avoid using sensational language and images: they do not serve and can hurt [51].

Instead, you should use simple language that is easy to understand [52, 53].

Finally, even considering that people are very afraid after the COVID-19 pandemic, it is useful to use a communication aimed at emphasizing the possibilities of prevention, the quick recognition of symptoms and especially the treatable condition of Mpox.

Funding

This research received no external funding.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Authors’ contributions

DO and MM: designed the study, conceived and drafted the manuscript; MLC and AMS: revised the manuscript; DO, MM and MS: performed a search of the literature; MLC, AMS: critically revised the manuscript; DO and MM: conceptualization, and methodology; MM, DO, MLC, AMS, MS: investigation and data curation; DO and MM: original draft preparation; MLC, AMS, MS, DO, MM: review; DO, MM, MLC: editing. All authors have read and approved the latest version of the paper for publication.