Urgent letter to Government calling for immediate action to prevent Monkeypox (MPX) - sent Wednesday 3 August 2022.

Rt Hon Jacinda Ardern
Prime Minister of New Zealand
Wellington

CC: Hon Andrew Little, Hon Dr Ayesha Verrall, Fepulea’i Margie Apa, Riana Manuel, Dr Diana Sarfati, Dr Nick Jones, Dr Andrew Old, Dr Nick Chamberlain

3 August 2022

Tēnā koe Prime Minister,

We are calling for urgent Government action to prevent escalation of Monkeypox (MPX) cases in Aotearoa New Zealand.

The World Health Organisation (WHO) has declared Monkeypox (MPX) a Public Health Emergency of International Concern. MPX cases internationally have intensified into a crisis, particularly in Europe, with numbers rapidly increasing and overwhelming health systems.

We are calling for urgent Government action to prevent MPX endemicity in Aotearoa New Zealand. We still have a window of opportunity to act now and avoid the serious public health consequences of a large-scale MPX outbreak.

Summary

Urgent action is required to protect the health of New Zealanders in response to this public health emergency. MPX is a viral illness, with potentially severe morbidity associated with widespread transmission. Failure to contain MPX in Aotearoa will further overwhelm our already strained health system. The current global outbreaks are affecting gay, bisexual, and other men who have sex with men (GBM) at an extremely disproportionate rate, creating yet another inequity for these communities. We must act now to once again demonstrate that Aotearoa can be a global leader in infectious disease control. Early, evidence-based, and sensitive public health responses will protect the health of New Zealanders and ensure the populations most affected do not experience further health inequities due to inaction.

We call for the following actions:

• Leadership at the Government level that is implemented via an appropriately resourced MPX response team;
• Clear communication of accountabilities and responsibilities of key roles in the MPX response to the clinical sector and community organisations;
• Urgent procurement of vaccines for Aotearoa to use as pre-exposure prophylaxis;
• Development of a robust vaccine delivery plan that appropriately prioritises GBM at risk of MPX, contains comprehensive communication strategies, and ensures diverse delivery modes;
• Meaningful consultation and involvement of Takatāpui and Māori GBM to ensure equitable access to MPX prevention and equitable outcomes from MPX infection;
• Clear and consistent public health messaging to GBM created in collaboration with appropriately resourced community organisations;
• Support for training of contact tracing services in cultural sensitivities that affect GBM;
• Implementation of sensitive self-isolation policies that include comprehensive financial and social support packages, using COVID-19 support as a benchmark;
• Urgent funding to ensure sexual health and primary health services can provide MPX screening, assessment, treatment, care, and vaccination;
• A clear plan to redeploy clinical staff to sexual health when the outbreak grows in Aotearoa;
• Funding of free MPX evaluation in primary care to remove the financial barriers to early MPX diagnosis.

Introduction

MPX is a viral illness that is infectious through close physical contact and requires self-isolation for up to four weeks to prevent forward transmission. The current outbreaks are disproportionately affecting GBM. In Europe, over 99% of cases are occurring among males; ECDC reports that of cases where sexual behaviour data is available, 97.5% are among GBM [1]. This inequity is largely due to the dense nature of GBM sexual networks that facilitates rapid spread of infections in the absence of effective interventions, e.g., vaccination. It appears that the MPX virus may have found an ecological niche to sustain transmissions among this group via a sexual route. Preliminary research shows that the basic reproduction number (R0) for MPX within GBM sexual networks may be substantially greater than one [2], whereas for the general population R0 is typically less than one as evidenced by the lack of sustained spread and decaying chains of transmission.

The rapid spread of MPX indicates a failure of the public health strategies that were implemented early on overseas. As observed in other jurisdictions, interventions such as ring vaccination and contact tracing alone will not curb the spread of MPX in Aotearoa. We need urgent action now, including vaccine procurement for pre-exposure prophylaxis, planning, and resourcing to prepare for the inevitable arrival of more MPX cases in Aotearoa. This is crucial to ensuring we protect the health of our populations, avoid endemic MPX transmission locally, prevent bridging into the health workforce and other vulnerable communities such as reproductive-age Māori and Pacific communities, and prevent further exacerbation of health inequities faced by GBM.

MPX is a serious threat to public health

Case numbers of MPX are rapidly increasing overseas. The first case of MPX outside of Africa was identified on the 12 of May 2022. As of 22 July 2022, there were over 16,000 laboratory-confirmed cases in 75 countries [3].

While many MPX cases involve self-limited illness, data from the UK Health Security Agency shows that 10-15% of individuals diagnosed with MPX require further outpatient support or hospital admission for management of symptoms or complications [4]. Complications of MPX can include severe proctitis and rectal pain, tonsilitis, peritonsillar cellulitis, and secondary bacterial infection [4]. Delays in MPX diagnosis lead to onward transmission and increase the risk of harm to individual’s health. The high risk of late diagnosis of MPX in the current outbreaks is likely due to an unclear infectious period and many patients presenting with atypical symptoms and very limited or no prodromal illness.

Such issues involve significant morbidity for individual patients, while also creating a public health risk of overwhelming the already strained health system. Rapid escalation of cases due to slow delivery of effective interventions to currently affected populations can also lead to increased risk of spilling of MPX infections to the general population. This will, in turn, lead to even more harm and further burden on the health system considering that a substantial proportion of patients may require hospital-level care (currently 13% observed to date [5]). Overseas, MPX has especially destabilised sexual health services, disrupting access to PrEP which will threaten our HIV elimination efforts if repeated in Aotearoa. Delayed access to sexually transmitted infection (STI) testing and treatment risks forward transmission as well as increased antibiotic resistance. We are also concerned about a high proportion of people living with HIV among the cases: this was recently reported at 29.5% of cases where this information was available in the UK [4]. While the reasons for this remain unclear, we believe that Aotearoa has a duty to protect this population.

Clear leadership and coordination of MPX response is urgently needed

Observing the escalating crisis overseas, we call for urgent leadership at Government level to respond to this public health emergency. We must streamline coordination of our MPX response. Given the rapidly evolving nature of this crisis, we need transparent systems that ensure clinical staff and communities most affected are kept as up to date as possible. Patients need clear, sensitive pathways to build trust, ensure compliance with infection control measures, and ultimately curb this outbreak before MPX becomes endemic in at-risk populations.

Recent health system changes present additional challenges to our response and both the clinical sector and community health organisations must be well informed about accountabilities of different players both on national and regional levels. To ensure this, Aotearoa must establish a MPX response team that oversees national plans for testing, assessment, treatment, vaccination, and communication strategies.

This team will help ensure there are clear lines of accountability and responsibility that are critical for an effective public health approach.

Relevant community organisations must be involved in design, implementation, and ongoing review of the policies and communications that constitute the response to MPX. As demonstrated through decades of community-led HIV action, and more recently in COVID-19 management, engaging communities is critical to effective public health programming. To achieve this, community organisations must be appropriately resourced.

We call for:

• The establishment of an MPX response team that includes Government leadership, clinical experience, and community expertise. To be effective, this team must be appropriately resourced;
• Clear communication of accountabilities and responsibilities of key figures in the MPX response to clinicians and community organisations.

Vaccine procurement and advance rollout plans must be prioritised

Aotearoa will fail to contain MPX and prevent endemicity without urgent vaccine procurement and rollout of a pre-exposure prophylaxis vaccination programme to relevant populations. We must have a robust plan for vaccine rollout and prioritisation, ready for implementation as soon as we secure vaccines. This plan must include detail on vaccine quantities and procurement timelines, ensuring all eligible people receive the recommended two doses, 28 days apart.

Countries that earlier relied on ‘ring’ (post-exposure) vaccination methods are quickly moving to pre-exposure prophylaxis since the former was not sufficient to control MPX spread. We note that contact tracing and post-exposure vaccination are unlikely to be effective in identifying and therefore protecting contacts in the dense GBM networks.

As informed by the trajectory of the current global outbreak, GBM communities must be prioritised in vaccine roll-out. Community research expertise must be sought in developing sensitive, fit-for-purpose criteria that are able to be scaled depending on vaccine availability. The Australian Technical Advisory Group on Immunisation (ATAGI) has recently updated guidance on the use of MPX vaccines [6]. ATAGI offers a pragmatic prioritisation approach, including the use of pre-exposure prophylaxis among GBM at risk of MPX and post-exposure vaccination to close contacts. We agree that appropriate criteria can be used to manage distribution of limited vaccine supply and note that many of ATAGI recommendations would likely be fit-for-purpose in Aotearoa. Overseas, GBM living with HIV have been disproportionately affected by MPX and their access to the vaccine must be prioritised here as well if only limited stocks of the vaccine are available.

Sound health promotion and communication strategies developed in collaboration with communities will be crucial to ensuring optimal acceptability and uptake. There must be comprehensive resourcing to deliver vaccination at appropriate scale. Vaccine delivery modes should be diversified to include large scale vaccination distribution methods, delivery at sexual health clinics as trusted and established healthcare pathways for GBM, and distribution at non-clinical community venues. Initial vaccine delivery could begin within existing systems of PrEP and HIV care delivery to ensure those at highest risk have rapid, convenient access.

The Government must also consider its responsibilities under Te Tiriti o Waitangi to actively involve and meaningfully consult Takatāpui and Māori GBM at all levels of the MPX response, and especially around accessing effective prevention including vaccines. This is important to ensure vulnerable Māori have equitable access to MPX prevention measures and equitable outcomes from MPX infection. Tangata whenua health leaders must be appropriately resourced to deliver appropriate services and offer expertise.

We call for:

• Urgent procurement of vaccines for Aotearoa to use as pre-exposure prophylaxis;
• Development of a robust vaccine delivery plan that appropriately prioritises GBM at risk of MPX, contains comprehensive communication strategies, and ensures diverse delivery modes;
• Meaningful involvement and consultation with Takatāpui and Māori GBM to ensure equitable access to all MPX prevention measures, especially to vaccines, as well as equitable outcomes from MPX infection.

Need for effective and stigma-free communication within public health initiatives

Poor responsiveness to the MPX outbreak risks exacerbating existing health inequities for GBM. The language used in public communications must clearly, yet sensitively, convey to GBM the risks they face from MPX and consequently the personal and community benefits of engaging in public health responses. Inappropriate or stigmatising language and processes can fuel mistrust of health services that creates barriers for GBM to seek care, engage in testing, and cooperate with contact tracing, ultimately limiting the effectiveness of MPX control measures.

Contact tracing will be a useful adjunct to help limit the spread of MPX when used in conjunction with effective pre-exposure prophylaxis vaccination of at-risk GBM. To maximise the benefits of contact tracing, the processes involved must consider the sensitivities around disclosure of risk behaviour for GBM. Some GBM may participate in unique practices that carry a burden of social stigma in mainstream society, such as anonymous sex, chemsex, sex-on-site venues, and group sex events which make it difficult to identify close contacts. Stigmatisation of both GBM broadly and of these sexual subcultures specifically can increase reluctance to disclose participation in sexual networks linked to MPX transmission. There are additional challenges around this for straight-identifying men who have sex with men who participate in these events. Given these issues, it is vital to develop culturally safe messaging and policies around MPX. Community organisations are well positioned to help ensure sensitive design and delivery of these critical public health initiatives, provided they are appropriately resourced.

We need urgent action to:

• Develop clear, consistent, and stigma-free public health messaging to GBM;
• Support training of contract tracing services in sensitivities that affect GBM in particular.

Support for those self-isolating is urgently needed

Self-isolation for up to four weeks for confirmed cases presents a unique challenge to control the spread of MPX. Probable and confirmed cases will need financial and practical support to enable compliance with the requirement to isolate for such a long period of time. This includes support to meet food, medication, technology, and income needs. Further issues exist around potential loss of income and employment, especially for many who cannot work from home, given the limited sick leave available. These issues will affect low-income workers disproportionately.

Stigma around disclosing MPX infection to employers, other household members, and whānau complicates a person’s ability to self-isolate. There is a risk that fear of isolation requirements could limit people’s willingness to engage with health services which will delay diagnosis. If not specifically addressed, these issues may jeopardise the immediate health of those with MPX and hinder the ability of public health responses to act in a timely way and break chains of transmission.

We need urgent action to:

• Develop and implement sensitive self-isolation policies that include comprehensive financial, practical, and social support packages. This may involve repurposing of COVID-19 legislation to ensure direct support to those isolating, such as sick leave payments and direct forms of support delivered through community.

Lack of resources in health system

Sexual health services in Aotearoa New Zealand are already severely under-resourced and facing high demand. Primary care services are also in a precarious and exhausted state from the surge of COVID-19 cases and some of the worst rates of winter illnesses in recent times. Given this context, we cannot afford to wait for a widespread outbreak to justify a plan to address MPX.

MPX will create significant additional burden on these already strained systems with additional time required for assessing patients and ensuring infection control, including appropriate use of PPE. Our
health systems are at risk of failing to meet the demand of MPX management and vaccine delivery without additional funding and staffing support.

We strongly recommend:

• Urgent funding to ensure sexual health and primary health services can provide MPX screening, assessment, treatment, care, and vaccination;
• Developing a clear plan to redeploy clinical staff to sexual health if and when the outbreak grows in Aotearoa;
• Ensuring access to free MPX evaluation (including clinical assessment and appropriate testing) for priority populations in primary care to remove the financial barriers to early MPX diagnosis.

Conclusion

We are calling for urgent action to prepare for and prevent the escalation of MPX cases in Aotearoa New Zealand. These actions must include Government leadership and clear coordination of the MPX response; prioritisation of vaccine procurement and rollout planning; meaningful consultation with Takatāpui and Māori GBM; creation of sensitive, targeted messaging to GBM; training to ensure sensitivity of contact tracing services; facilitation of financial and social support for those who must self-isolate; and funding and redeployment plans for sexual health and primary health services to deliver MPX assessment and care. These actions will enable our health systems to respond early, appropriately, and safely to MPX and protect the health of our populations, while preventing MPX from becoming endemic in Aotearoa.

As with COVID-19, an effective response to MPX requires leadership, bold action, and comprehensive resourcing at a level commensurate with the threat of this novel global public health emergency. We still have a unique window of opportunity for sustained elimination of MPX in Aotearoa, but that window is closing and requires urgent action.

Thank you for considering our recommendations. Please do not hesitate to contact Dr Jacek Kolodziej, Burnett Foundation Aotearoa Policy and Science Manager, should you require clarification on any of the points made.

Ngā mihi,

Joe Rich

Chief Executive

Burnett Foundation Aotearoa

Dr Anne Robertson

President

NZ Sexual Health Society

Associate Professor Peter Saxton

Director of Gay Men's Sexual Health Research Group

University of Auckland

References:

1. European Centre for Disease Prevention and Control and World Health Organization, Joint ECDC-WHO Regional Office for Europe Monkeypox Surveillance Bulletin.
2. Endo, A., et al., Heavy-tailed sexual contact networks and the epidemiology of monkeypox outbreak in non-endemic regions, May 2022. 2022, Cold Spring Harbor Laboratory.
3. World Health Organization, Multi-country outbreak of monkeypox, External situation report #2 - 25 July 2022. 2022.
4. UK Health Security Agency. Investigation into monkeypox outbreak in England: technical briefing 3. 2022 22 July 2022 27 July 2022]; Available from: https://www.gov.uk/government/publications/monkeypox-outbreak-technical-briefings/investigation-into-monkeypox-outbreak-in-england-technical-briefing-3.
5. Thornhill, J.P., et al., Monkeypox Virus Infection in Humans across 16 Countries — April–June 2022. New England Journal of Medicine, 2022.
6. Australian Technical Advisory Group on Immunisation. Updated ATAGI clinical guidance on vaccination against Monkeypox. 2022; Available from: https://www.health.gov.au/resources/publications/atagi-clinical-guidance-on-vaccination-against-monkeypox.