The 2022 monkeypox outbreak: considerations for public policy and social science research

• Mpox

Social science questions related to Monkeypox can be addressed through both the synthesis of contextually relevant knowledge, as well as the conducting of new, primary research.  In order to facilitate a discussion and to encourage future work to be useful for policymakers, the International Public Policy Observatory, in collaboration with the Economic and Social Research Council, convened an online roundtable on the 10th August 2022, and conducted 1-2-1 interviews with experts in the field.

Participants came from both within and outside the social sciences.  They included epidemiologists and behavioural scientists who are working directly on the Monkeypox outbreak, academics from other disciplines including biology, culture, and development studies, representatives of the third sector, and a voice of lived experience.  The roundtable and interviews built on work being conducted by the UK Health Security Agency and set out in their Technical Briefing 5 on the outbreak, helping to flesh out identified research gaps requiring primary and/or synthesis of existing research.

Social science research gaps

In simple terms, these UK research gaps represent the things that we know we don’t know about Monkeypox from a social science perspective and set an agenda for social science or interdisciplinary research to conduct to inform future policymaking.  Work to fill some research gaps is currently being undertaken through Health Protection Research Units in the UK, including on risk perception and the efficacy of different kinds of messaging through the Health Protection Research Unit on Emergency Preparedness and Response at Kings College London and Behavioural Science and Evaluation at the University of Bristol. Using quantitative and qualitative methods the study focuses on both the general population, as well as gay, bisexual, and other men who have sex with men (MSM)    Another HPRU study, also at the University of Bristol, is undertaking an impact and cost-effectiveness analysis of different Monkeypox vaccination strategies to help guide broader vaccination policy. Social scientists and other experts are also self-organising to confront questions other relevant questions raised by the outbreak, such as whether Monkeypox is a sexually transmitted infection.

Effective public policy responses to Monkeypox should be guided by a conviction that lessons from Covid, previous outbreaks, and other epidemics be implemented.  One such learning includes the importance of a multidisciplinary response to such incidents, including governments and other stakeholders working with social scientists.  This is particularly relevant given that the current outbreak raises numerous questions relevant to the social and behavioural sciences.

Prioritisation of future social science research

When prioritising areas for future social science research, we suggest that particular attention and resource is focused on the following topics:

• Communication, including
  • Synthesis of existing research on reaching at-risk and underserved communities and application to Monkeypox context
  • Primary research on application and efficacy of government communications strategies related to Monkeypox, including reasons for application or otherwise of lessons learned from previous outbreaks/epidemics
  • Primary research on self-organisation of MSM community and lessons learned for future top-down and horizontal communication
• Vaccination and supply chains, in particular
  • Synthesis of existing lessons learned from the Covid and previous pandemics including Ebola on vaccination procurement, production, and distribution
  • Primary research on current vaccine shortage and supply chain issues, including reasons for the application or otherwise of lessons learned from previous outbreaks/epidemics

The remainder of this report sets out in more detail the themes, gaps, and research questions related to the current outbreak.  As with the areas of prioritisation above, we recommend that research be designed specifically with the aim of helping enable governments and other stakeholders to take informed decisions when responding to this and future outbreaks.

Risk perception: how does perceived risk relate to communications and messaging?

The relationship between messaging about Monkeypox and public perception of the risk of exposure to the disease and its severity warrants investigation.  There is a tension between the extent to which Monkeypox is perceived as a disease affecting this minority community and the communications strategies being deployed by different governments to speak to their populations as a whole.  Concerns have been raised that broad-based public health communications have focused excessively on the general reassurance of the population, at the expense of providing clear information to the group particularly at risk of transmission.  Third sector organisations and those with lived experience of the disease have emphasised the importance of narrow-casting key information on risk and protection directly to the MSM community.

We suggest that primary research continue to be undertaken on the following research questions:

• How are the public and affected groups perceiving the risk from monkeypox?
• What is the public understanding of the disease and what actions they need to take?

We further suggest synthesis of existing learnings from Covid and more generally on risk perception for reaching under-researched groups and communities and increasing access to information and education.  We therefore recommend the following as priority primary research areas related to communication:

• Synthesis of existing research on reaching at risk and underserved communities and application to Monkeypox context
• Primary research on application and efficacy of government communications strategies related to Monkeypox, including reasons for application or otherwise of lessons learned from previous outbreaks/epidemics

Seeking care: what encourages and discourages care-seeking behaviours?

While the exact proportion of symptomatic cases seeking care is difficult to estimate, it is hoped that as awareness of the disease increases, so too will the amount of people who do seek care.  Nevertheless, factors that may discourage care-seeking behaviour amongst those aware of Monkeypox include stigmatisation and perceived inadequate resourcing for services like sexual health clinics.  We suggest primary research on the following research question:

• Which factors influence symptomatic cases to seek care?

Care-seeking behaviours are likely to be discouraged in jurisdictions where sexual activity between men is socially stigmatised or illegal, contexts that also pose challenges for accurately tracking the level and progress of the outbreak.  Similarly, communities who mistrust government and the advice it provides may also be less likely to seek care or to pursue vaccination where available.  Adequate resourcing of existing care structures including clinics, together with partnering to provide information with trusted community leaders and existing networks used by MSM, are ways in which barriers to seeking care could be overcome.  We therefore suggest synthesis of existing research on the following question:

• What factors are associated with effective symptom recognition and help-seeking when symptoms develop?

Isolation and other control measures: what influences compliance?

Questions around what influences adherence to isolation remain open to further investigation.  Adherence, together with vaccination and increased awareness, are likely related to the plateauing of cases of Monkeypox being experienced in late August 2022 in jurisdictions like the UK.  Nevertheless, the relationship between adherence and economic support for those isolating – in particular, those in low paid or insecure roles, or in professions like sex work – is an area for further research.  We suggest primary research on the following question:

• What are current levels of adherence to self-isolation?

Questions have also been asked around the length of the isolation period for Monkeypox, the hardships associated with it, and its relationship with proportionality and risk.  One suggestion is for isolation guidance to vary at different stages of the infection proportionate to the level of risk.  For example, walking to the store to buy essential supplies could be permitted towards the end of the isolation period.  We suggest synthesis of existing research on the following questions:

• What factors are associated with poor adherence or successful adherence to self-isolation?
• Is length of self-isolation a deterrent to help seeking?

Adherence to other control measures, including voluntary ones, also remains an avenue for investigation.  Debates are ongoing on the appropriateness of messaging to the MSM community around refraining from some types of sexual activity as opposed to giving clear information so informed decisions can be made.  These discussions take place against a backdrop of collective societal exhaustion from the significant behavioural interventions made during the Covid pandemic.  We suggest synthesis of existing research on the following questions:

• What factors are associated with compliance with other control measures?

Community responses: how are MSM self-organising?

Informal networks in the MSM community have been proactive in information sharing, particularly on social media and through formats such as memes, as well as in mobilising existing networks including community groups and health resources.  Nevertheless, those outside this organised and connected milieu may be left relying more on government/official or news media-led sources of information.

Views on the efficacy of official information provision vary by jurisdiction.  In the UK, there has been some perception that informal networks among MSM filled a gap when there was lack of knowledge about the disease early on, including initially in some sexual health services.  Further work could be undertaken to understand and support the MSM community in self-organising to provide knowledge, as well as outreach using channels and venues frequented by under-researched  members of the community.  As a priority, we recommend:

• Primary research on self-organisation of MSM community and lessons learned for top-down and horizontal communication

We further suggest primary research to answer the following questions, with reference to under-researched  communities including those where MSM are stigmatised, and including the specificities of different contexts:

• How has media coverage of this as a sexual health problem affecting gay, bisexual, and other men who have sex with men (MSM) in particular affected public responses, including health seeking behaviours?
• How do MSM communities wish to self-organise monkeypox transmission prevention and control?

Contact-tracing and transmission: how can we get accurate information?

The prevalence of Monkeypox in the MSM community and possible prevalence of transmission in sexual encounters with multiple individuals present simultaneously leads to issues around contact-tracing, particularly where the participants in encounters may not all be known to each other.

Challenges also exist in jurisdictions where homosexuality is illegal and/or stigmatised for gaining an accurate picture of transmission, and thus developing effective strategies to contain the disease.  Issues of asymptomatic transmission, particularly in jurisdictions without a formal reporting mechanism, also provide obstacles to ascertaining how much transmission is occurring “under the radar”.  We suggest cross-disciplinary primary research together with synthesis of research of existing knowledge on the following research question:

• How effective is contact tracing?

Misinformation and stigmatisation: what can be done?

Issues of potential stigmatisation of the main risk group remain, with knock-on potential risks for care- and vaccine-seeking behaviours.   Although Monkeypox is not strictly a sexually transmitted infection, most infections occur in situations with sexual contact.  Nevertheless, further work could be undertaken on risks from potential other venues of transmission where individuals are in close proximity.

A balance also remains to be stuck in ensuring clear communication at a risk group does not bleed into more homophobic discourse.  The risk of stigmatisation also demonstrates the difficulty of having a nuanced and mature conversation around sex, one avoiding sensationalism, judgement, or moral panic about lifestyles and practices.

While learning the lessons of previous outbreaks and pandemics is important, care should be taken in using Covid or HIV/AIDS as a framing tool when talking about the Monkeypox outbreak.  While the public are more aware of epidemiological issues and terminology as a result of information campaigns during Covid, the disease’s current concentration in MSM communities means it an uneasy fit for simply repeating Covid narratives.  Similarly, references to HIV/AIDS should also be made carefully, particularly given issues of stigmatisation of those with HIV, together with the collective trauma and devastating impact of the AIDS crisis in the MSM community.

We suggest primary research specific to Monkeypox misinformation and harm, and synthesis of research on countermeasures on the following research questions:

• What characterises monkeypox misinformation and what are the scalable countermeasures?
• What are the potential harms from stigmatising monkeypox communications attached to specific risk groups?

Vaccination: overview of current wider issues

The existence of an already-approved Smallpox vaccine that is effective against Monkeypox means that, in comparison to Covid and the need to develop from scratch, vaccination strategies begin from a head start.  Nevertheless, there remains, as of late August 2022, a shortage of vaccines in many countries, with not all who wish to be vaccinated able to do so in a timely manner.

Frustrations have been expressed on lack of vaccine preparedness given the possibility of a Monkeypox outbreak in the west, with case numbers where the virus is endemic in West Africa increasing in the previous decade, and a 2003 outbreak in the US affecting nearly 50 people.  Likewise, swift roll-out of Covid vaccinations in many parts of the world can be contrasted with a perceived global vaccine policy response on Monkeypox characterised as reactive rather than proactive.

Disappointment has been expressed at broader equity issues which are not limited to the Monkeypox vaccine.  These include the inability to produce the vaccine where it is needed most in areas such as West Africa, as well as frustrations around lack of knowledge-sharing, infrastructural investment, and access to therapeutics.  It is possible that existing vaccines which expired could have been used in countries where Monkeypox is endemic in previous years.  However, the situation is complicated in some of these countries by the illegal status of homosexuality and associated stigma.

Vaccine supply chain issues: why is there a shortage and what can be done?

The current vaccination against Monkeypox is manufactured by Bavarian Nordic, a relatively small company who lack the capacity to produce enough vaccine for current global demand.  While vaccine production is not easily transferable, the current impasse – with many jurisdictions initially ordering insufficient doses and a lack of coordinated plan to scale up production – has been characterised as a collective failure of political will by the international community.

The evolution of the production of the Ebola vaccine, whose production was quickly scaled up after intervention by the international community, provides a useful case study in how to solve the current bottleneck.  As with other issues relating to the outbreak, the experience of Covid demonstrates the possibility of resolving complex production and supply chain issues where there is the requisite will and resource to do so. The current HPRU impact analysis on different Monkeypox vaccination strategies does not cover supply chain issues and we suggest these are a potential area for urgent priority research, including:

• Synthesis of existing lessons learned from the Covid and previous pandemics such including Ebola on vaccination procurement, production, and distribution
• Primary research on current vaccine shortage and supply chain issues, including reasons for the application or otherwise of lessons learned from previous situations/epidemics

Trigger points: lessons for the future and the need for knowledge

A further lesson of the Covid pandemic relates to the desirability or necessity of trigger points for government intervention.  While the responses of governments to the Monkeypox outbreak have varied, frustration has been expressed that the recent experience of Covid did not always trigger concerted action earlier in the outbreak, including on messaging and vaccine supply.  The institution of such trigger points, together with strategies to increase the level of epidemiological knowledge for decision-makers and policymakers, is a further area where the lessons of the current outbreak could potentially be applied to improve future decision-making.

Participants

The following participants took part in the roundtable:

Prof. Richard Amlôt UKHSA / HPRU in Emergency Preparedness & Response, Kings

Richard Angell Campaigns Director, Terrence Higgins Trust

Carolina Arevalo Interim Deputy Director, Research Management & Knowledge

Danny Asogun Pandora / Professor of Public Health, Irrua Teaching Hospital

Brendan Collins Head of Health Economics, Welsh Government

Dr. Claire Dewsnap President, British Association of Sexual Health & HIV

Prof. Nigel Field Professor of Infectious Disease Epidemiology, UCL / NATSAL

Dr. Najmul Haider Post Doc Researcher, Royal Veterinary College

Prof. Jeremy Horwood Professor of Social Sciences & Applied Health Research, University of Bristol

Dr. Jaime Garcia Iglesias Centre for Biomedicine, Self and Society, University of Edinburgh

Monkeypox Jake Anonymous – Lived Experience

Hayley MacGregor Research Fellow, Institute for Development Studies

Dr. Siobhan McAndrew Senior Lecturer in Politics, Philosophy & Economics, Sheffield University

Erin McReadie  Health Protection Team, Scottish Government

Prof. Brigitte Nerlich Emeritus Professor of Science, Language & Society, University of Nottingham

Dr. Howard Njoo Deputy Chief Public Health Officer, Public Health Agency of Canada

Prof. Eskild Petersen European Society for Clinical Microbiology and Infectious Diseases

Prof. Damien Ridge Professor of Health Studies, University of Westminster

Dr. Louise Smith Research Fellow, Emergency Preparedness and Response HPRU

Prof. Dr. Oyewale Tomori WHO Virologist & Advisor and Professor of Virology, Redeemer’s University, Nigeria

Prof. Shaun Treweek Chair in Health Services Research, University of Aberdeen

Ursula Wells Head of Research Liaison, Department for Health & Social Care, UK

Prof. Lucy Yardley Professor of Psychologial Science, Bristol University / Behavioural Science & Evaluation HPRU

IPPO also conducted 1-2-1 interviews with:

Prof. Tony Barnett Professor of Social Sciences, Royal Veterinary College

Prof. John Edmunds Professor of Epidemiology, London School of Hygiene and Tropical Medicine

Prof. Martin Dempster Professor of Psychology, Queens University Belfast

Dr. Jamie Hakim Lecturer in Culture, Media & Creative Industries, King’s College London

Prof. Jason Mercer Professor of Virus Cell Biology, University of Birmingham

Prof. Martyn Pickersgill Professor of the Sociology of Science & Medicine, University of Edinburgh

Dr. Boghuma Titanji Assistant Professor of Medicine, Emory University