Monkeypox outbreak coming, says infectious diseases expert

“When congenital herpes is passed on from pregnant person to baby, no one stigmatises getting pregnant.”

An outbreak of monkeypox in New Zealand is “only a matter of when, not if,” and the Government must protect the LGBTQ+ community, says infectious diseases physician Massimo Giola.

As Queenstown’s Winter Pride event will bring LGBTQ+ people from around the country and overseas, Dr Giola says event organisers and officials have just weeks to prepare and protect the community.

While only two cases of the virus have been detected, widespread community transmission could be only weeks or even days away, he says.

WHO declared monkeypox a public health emergency of international concern last week, and the New Zealand Government must now ramp up action to stop the spread: “I’m worried it’s already here.”

While monkeypox is a viral disease and can affect everybody, the majority of the 17,000 global cases are gay, bisexual, and other men who have sex with men (MSM).

The Government must urgently collaborate with LGBTQ+ organisations to develop a public health strategy as soon as possible, says Dr Giola, who is also a sexual health physician and works for Te Whatu Ora – Health New Zealand in the Bay of Plenty and Lakes districts.

“There will be people who project stigma onto MSM because of their sexuality,” he says.

It’s not clear, he says, why the majority of cases have been found in MSM communities – all that is known is that that is the case, and it needs to be addressed.

The Government has a responsibility to care for MSM by communicating fair and scientific messaging to the public, and firmly dispelling homophobic myths, Dr Giola says.

There is no reason to discriminate against the gay community. “A healthy and fulfilling sex life is a basic human right, and we must work together to make it safe”.

“When congenital herpes is passed on from pregnant person to baby, no one stigmatises getting pregnant.”

The outbreak among MSM could have been as simple as a gay man travelling to Africa and bringing it to a pride festival, Dr Giola says.

“The same thing could have happened if someone contracted monkeypox and taken it to a rock concert.” No one would stigmatise the genre of music, he says.

The Ministry of Health website says the first symptoms of monkeypox are usually one or more of the following:

• headache
• acute onset of fever ( greater than 38C)
• chills
• swollen lymph nodes
• muscle and body aches
• backache, and
• tiredness.

After several days a rash usually appears on the place of infection and spreads to other parts of the body. It may also appear on the palms of hands and soles of the feet, inside the mouth, or on the genitalia.

The rash typically evolves in four stages – macular, papular, vesicular to pustular – followed by scabbing, with lesions progressing simultaneously on any part of the body. The symptoms usually resolve by themselves within a few weeks.

Dr Giola says a pre-exposure prophylaxis vaccination strategy will be most effective, as gay men generally have excellent uptake of public health advice.

“MSM overseas are queuing up to get this vaccine,” he says.

People living with HIV are more at risk of getting seriously ill from monkeypox, and the LGBTQ+ community is acutely aware of the impact of viral outbreaks.

The Government needs to urgently order at least 20,000 doses of the third-generation smallpox vaccine known as MVA (modified vaccinia Ankara) which is used against monkeypox, and be prepared to order more at a later date, say Dr Giola.

There are about 6000 people in Aotearoa New Zealand who are either living with HIV or taking pre-exposure prophylactic medication because of their heightened risk of encountering HIV; all of these people would need two doses of MVA.

Dr Giola suspects sexual health and urgent care doctors would also have good uptake of the vaccine because of their heightened risk of exposure to the monkeypox virus.

A second option would be to offer a post-exposure prophylaxis vaccination, but Dr Giola says this approach is “doomed for failure”.

Post-exposure vaccines would require contact tracing, which is exceedingly difficult and unrealistic in the case of sexually transmitted infections because of the stigma around sexual health.

Dr Giola says a health pathway for Auckland GPs is currently being developed to standardise the response to monkeypox across primary care.

GPs need to be on high alert for people returning from overseas, and MSM patients, even if they are not immediately presenting symptoms, he says.

Dr Giola urges the Government to collaborate with LGBTQ+ organisations to ensure they are best supporting the community.

The Burnett Foundation (formerly known as NZAIDS Foundation) is already beginning a public health and messaging campaign to educate the queer community about the risks of monkeypox, and collaborating with health officials.

“We have a few more weeks to act before Winter Pride,” Dr Giola says.

Running from 26 August to 4 September, the festival operates 24 events in Queenstown, which could provide an opportunity for monkeypox to spread.

Pride organisers should approach local health providers to establish a plan to prepare for community transmission, and what health messages will be most effective, Dr Giola says.

For example, condoms will not block skin-to-skin transmission of monkeypox, but could slow the spread through sexual transmission. Therefore, Dr Giola emphasises the importance of promoting safe-sex messaging throughout the event.

There have been many cases overseas where children and people with no connection to the MSM community have contracted monkeypox, Dr Giola says.

He reminds doctors and the public to keep a check on bias: “This is not ‘just’ a sexually transmitted infection, and it’s not ‘just’ men who have sex with men”.