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Mpox (previously known as monkeypox) is a viral infectious disease, first discovered in humans in the 1970s and up until 2022 was almost entirely situated in areas of central and western Africa. In July 2022 the World Health Organisation (WHO) designated a public health emergency of international concern (PHEIC), related to growing incidences of Mpox transmission in regions across the world, mostly in communities of gay and bisexual men, and other men who have sex with men (GBmsm) (WHO, 2022). The PHEIC was declared over in May 2023, and while there is continued ongoing transmission worldwide, cases have significantly reduced. This commentary aims to reflect on the experience of the Mpox PHEIC and note a number of learning points for nurses to consider for future PHEIC preparedness and a more equitable approach to healthcare. Mpox is a zoonotic disease, meaning that it transmits between animals and humans. The first reported cases in animals go back to 1958, while the disease was reported in humans in the 1970s. Mpox is transmitted from person to person through direct bodily contact with infected lesions and bodily fluids, but transmission through respiratory droplets and via contact with surfaces or materials exposed might also occur. The virus itself is related to smallpox (eradicated since 1980), although much milder in severity. Early stages of infection manifest in similar ways to flu-like conditions with fever muscle ache and lethargy, leading in later phases to a distinctive rash with the development of painful lesions which can occur anywhere on the body. The clinical manifestations of monkeypox can vary, and healthcare providers rely on a combination of clinical examination, laboratory tests and a patient's history to make an accurate diagnosis. While Mpox usually isn't fatal, the symptoms can cause significant discomfort, and while usually self-limiting, symptoms can persist for upwards of a month. Given the risk of onward transmissibility, it is important to gain an accurate diagnosis and engage in infection, prevention and control measures as soon as possible. A Public Health Emergency of International Concern is a formal declaration made by the WHO to signify a public health issue that poses a risk to multiple countries and requires a coordinated international response. There have been a number of PHEICs declared over the past decades, the most recent prior to Mpox was COVID-19, with other PHEICs including, Zika Virus, Ebola and H1N1 Swine Flu. Unlike some of the other diseases declared as PHEIC, Mpox was not a novel virus, there had been cases noted in humans for more than 50 years. This should possibly have meant a clear strategy for managing the disease in infected individuals, and containing onward transmission; but despite Mpox being a known infection, there was very little evidence around the treatment or management of this disease. Another unique element of the Mpox PHEIC was that the impact of this outbreak was overwhelmingly disproportionate in communities of gay, bisexual and other men who have sex with men. While modes of transmission are not uniquely linked to sexual behaviour, and this link was not made prior to this current outbreak; the link to sexual activity brings another layer of specificity to this outbreak and the corresponding response. When a PHEIC is declared, it triggers a coordinated international response involving the WHO, affected countries and international partners. The declaration allows for the mobilization of resources, technical expertise and support to address the public health emergency effectively. While there was a clear coordinated global response to the new transmissions of Mpox, there remained little focus on the regions where Mpox was already endemic. Initial debates ensued on whether Mpox could be classified solely as a sexually transmitted infection (STI). However during this outbreak, given its prevalent occurrence within gbMSM communities, in most cases sexual health services took a lead in the clinical management of those presenting with symptoms. Consequently, there was an urgent need for services and clinics to swiftly adapt their triage, assessment, treatment and management pathways to accommodate the influx of Mpox cases. The classification of Mpox as a high-consequence infectious disease (HCID) mandated stringent infection prevention measures, not usually adopted in sexual health. These included the mandatory use of Personal Protective Equipment during Mpox assessments, separate processing of samples and intensive decontamination of clinical spaces following suspected cases. This added significant logistical complexity to managing Mpox along with regular STI testing, treatment and vaccination services (ECDC, 2022). This posed significant challenges to clinical staff, compounded by the similarity of presentation to other infections common in this population, such as syphilis, lymphogranuloma venereum and herpes. As the PHEIC progressed, the availability of vaccines and expanded treatment options allowed clinicians to transition from the emergency phase of Mpox to integrating it into routine clinical activities. Although case numbers have significantly diminished, the experience of the PHEIC means that sexual health services have now adopted the vigilance, assessment and surveillance of Mpox as a routine part of sexual health service provision. While sexual health nurses have always played a significant role in the psychological and emotional support of presenting patients, the prolonged infectious period demonstrated in Mpox meant that follow-up and monitoring of Mpox-positive patients had added practice implications. The management of Mpox, on both an individual and population level, is complicated by the stigmatization of various social features demonstrated in this outbreak. Carmen Logie (2022) eloquently distilled these features into indicators of three 'stigma archetypes: the "foreign" other, the "immoral" other and the "visibly" unwell' that is often seen when infectious diseases are stigmatized. The foreign archetype can be seen when specific communities who are different from the majority in a society, usually in terms of either ethnic or sexual identity, are blamed for the spread of a disease. Since Mpox had previously mostly circulated in West Africa, and recently spread through the Global North primarily through communities GBmsm, this archetype could be seen in racist and homophobic commentary about the outbreak in the public sphere and was a challenge for public health officials faced with the dilemma of using targeted or universal messaging. When moral judgement is cast on specific communities or practices—as is often the case with any form of queer sex—the immoral other archetype is being drawn upon. Since it became clear that this outbreak of Mpox mostly involved sexual transmission, examples of the stigmatization of sex between men have surfaced and been reinforced by public health messaging urging GBmsm to change their sexual behaviour. The visibly unwell archetype captures the ways in which being unable to conceal characteristics that have become stereotypically associated with a disease exposes one to stigma and discrimination. The skin lesions that Mpox can cause became a well-known and aversive signifier of the disease and for some patients, an unconcealable one. More broadly, simply being openly gay or bisexual could also be construed as an unconcealable association with the Mpox outbreak. It is vital for nurses to be aware of these different types of stigma that are associated with Mpox so that they can avoid perpetuating stigma, challenge the perpetuation of stigma by others and show compassion and allyship to those who may be anticipating or experiencing stigma. This is important for helping patients to cope with the experience of Mpox and to reduce the avoidance of testing and healthcare. While the high prevalence of Mpox within communities of GBmsm posed challenges around dealing with stigma, it meant that interventions and health promotion campaigns could be targeted to those most at risk. In many jurisdictions, outbreaks led to engagement and partnership with community and grassroots organizations to ensure effective and culturally appropriate public health measures. These kinds of collaborative efforts offered a strengths-based approach to community engagement, which led to rapid and high uptake of vaccination when delivered in partnership with community organizations and in community spaces. This shift in health service delivery, taking healthcare and health promotion initiatives into the community, rather than asking community members to attend established clinics, proved effective in engaging and empowering GBmsm to make informed decisions regarding sexual and healthcare behaviours (WHO, 2023). While the specificities of this outbreak are important to note, the delivery of vaccination programmes and health advice at music festivals, community celebrations, nighttime and sex-on-premises venues may have potential applicability to other aspects of healthcare delivery and should be considered. The rapid action and designation of this Mpox outbreak as a PHEIC demonstrates a clear inequity in global health responses to the disease. For over 40 years Mpox was a burden to health systems mostly in the African region, with little focus, investment or innovation in treatment or prevention for the disease. Ogunkola et al. (2023) give the analogy of fighting a war without a weapon, describing while there was a rapid response in vaccine procurement, health protection initiatives and resources in the West to manage Mpox, the regions with the highest prevalence remained largely ignored (Ogunkola et al., 2023). Once it became apparent that Jynneos vaccination may be effective in preventing the disease, high-income nations successfully acquired significant quantities of Mpox vaccines, whereas low- and middle-income countries faced challenges in autonomously accessing substantial vaccine supplies. Instead, they had to depend on vaccine donations from affluent nations, echoing the dynamics observed during the COVID-19 pandemic. The global impact of COVID-19 and subsequently this Mpox PHEIC have shown that no outbreak of a transmissible disease should be ignored, as the risk of pervasiveness to the whole world cannot be predetermined. The abrupt impact of Mpox globally and need the to declare a PHEIC was precisely because Mpox had been largely ignored prior to this. As long as health systems in the global south remain underfunded and global health responses to communicable diseases are not maintained, there remains an ongoing risk for future avoidable PHEICs. There is a universal need for justice and continuing advocacy from the international nurses' community for equal access to the best medical resources and care for all individuals requiring help regardless of the region and region's financial status. All human beings should be afforded equal rights, so surveillance, support, collaboration and fair practices must be strengthened to control Mpox and other communicable diseases. This will not only spare lives but also prevent another future global outbreak. The Mpox PHEIC brought to light crucial lessons for nurses and the global healthcare community. This particular outbreak emphasized the need for comprehensive and equitable responses to public and global health issues and infectious diseases, particularly when they disproportionately affect marginalized communities. Nurses continue to play a leading role in adapting clinical management strategies, enhancing health systems change and navigating the complexities of stigma associated with Mpox and other stigmatizing diseases. The unique features of the Mpox PHEIC, including its impact on GBmsm, highlight the importance of culturally sensitive responses and community participation. Collaborative efforts with grassroots organizations proved effective in engaging at-risk populations and delivering health interventions in community spaces. Additionally, the global response revealed stark disparities in healthcare resource distribution, echoing the need for global justice in addressing communicable diseases. As frontline advocates and healthcare leaders, nurses should champion equal access to healthcare resources and advocate for just responses to public health crises. The Mpox experience serves as a poignant case for enhancing readiness, fostering community engagement and mitigating the impact of stigma in future outbreaks. In the pursuit of global health equity, nurses, as the largest healthcare workforce, stand at the forefront, driving positive change and ensuring a more just and inclusive response to public health challenges. No acknowledgements to declare. Open access funding provided by IReL. No conflicts of interest to declare. Not applicable.
Gilmore et al. (Wed,) studied this question.