Monkeypox: 3 mistakes made in past epidemics that can be avoided

Between May and June, 2,103 cases of monkeypox were confirmed in 42 different countries.

The disease, previously restricted to some regions of Africa, is spreading unexpectedly across Europe, the Americas, the Middle East and Oceania, according to the latest information from the World Health Organization (WHO).

The outbreak, which is still under investigation by the authorities, draws attention for bringing together three attributes that represent a risk of deepening stigma and prejudice – or, from another perspective, an “opportunity” to correct and avoid mistakes that were made in other crises. Sanitary.

In addition to the obvious effects on the health system, epidemics and pandemics also cause social transformations — and communication about them can lead to distorted notions that last for decades. This even jeopardizes the control of cases, hospitalizations and deaths related to that condition.

HIV and the coronavirus are examples of this phenomenon: the generic definition of “risk groups” made many people relax and not believe in the possibility of an infection. This, in turn, created new chains of transmission in the community and allowed pathogens to spread silently without attracting attention.

Next, experts heard by BBC News Brazil list three mistakes made in past epidemics that can be avoided now, in the monkeypox outbreak, and in other future crises.

Xenophobia

For decades, the classification system for new viruses, variants or even diseases took into account the location where they were first detected or reported.

Zika, for example, is a Ugandan rainforest where the pathogen of the same name was first found in 1947.

In 1918, the disease that caused one of the deadliest pandemics in history became known as the “Spanish flu”—although the virus most likely originated in US military camps (it had only been reported before by newspapers in Spain).

“And until today we name the new strains of the influenza virus, the one that causes the flu, according to the city in which they were detected”, adds infectious disease specialist Raquel Stucchi, a professor at the State University of Campinas (Unicamp).

Let’s take a practical example of this: the versions of the pathogen that most circulated in Brazil in recent months were H1N1 Victoria and H3N2 Darwin.

Victoria and Darwin are cities in southern and northern Australia, respectively.

Such a system brings many problems. The first is that the place where a virus, variant or disease was first described is not always the birthplace of that pathogen or that condition.

The discovery could only mean that that city (or that country) has an excellent surveillance system, which has detected cases imported from another region of the planet.

And, even if the place was the “birthplace” of the infectious agent or disease, it doesn’t seem to make much sense to use the name of a neighborhood, a forest, a city or a country to describe that new situation.

This custom only creates an unnecessary incentive for xenophobia — the adopted name can lead to misinterpretations, as if the problem lies with the people who live in the original epicenter of the outbreak, epidemic or pandemic.

The WHO realized this risk and has already changed things since Covid-19 appeared.

The last coronavirus to come to attention before the current pandemic was Mers-CoV in 2012, first detected in Saudi Arabia. The name Mers is an acronym for Middle East Respiratory Syndrome.

In the current health crisis, this trend has been corrected. The name of the causative virus is Sars-CoV-2 (Sars is an acronym for Severe Acute Respiratory Syndrome) and the disease became known as Covid-19 (something like “coronavirus disease 2019” in the literal translation of the acronym in English).

More neutral terms were also adopted with the coronavirus variants. When they first emerged, they were called “UK”, “South African” or “Manausian” lineages.

But this was quickly corrected, and the variants of concern were pegged to the Greek letters — such as alpha, beta, gamma, delta, and omicron.

And the WHO seems to show the same concern now about monkeypox. The entity took a stand after more than 30 scientists signed a letter in which they highlighted “the urgent need to seek names that are not discriminatory or stigmatizing”.

Stucchi, who is also a member of the Brazilian Society of Infectious Diseases, considers this discussion “prudent”.

“This is something that must be very well thought out so that we do not encourage constraints or prejudices”, he evaluates.

“But it is curious that this worldwide concern with the name only appears now that the disease has left Africa and started to reach the Americas and Europe”, he observes.

Stigmatization of social groups

The emergence of a new infectious disease always prompts the same question: who is most likely to be affected?

On the one hand, defining the so-called “risk groups” is important from a public health point of view.

“In no disease is the risk of illness or death homogeneous in the population”, explains epidemiologist Alexandre Grangeiro, from the Department of Preventive Medicine at the Faculty of Medicine of the University of São Paulo (USP).

“So by determining who is most likely to be affected, you target public policy properly and don’t increase inequalities.”

“This not only guarantees care for patients at the right time, but also helps to interrupt the chain of transmission of the virus”, he adds.

The problem is when this definition of risk groups is hasty, messy or takes into account only the first cases.

And that’s exactly what happened (and still happens) in some of the epidemics of the last few decades.

In the 1980s, when AIDS became a global problem, the first information released was that only men who had sex with men were at risk – at the time, the term “gay plague” was used pejoratively to talk about HIV infection. .

More recently, in the current Covid-19 pandemic, some content released by the press and on social media said that only the elderly and individuals with compromised immune systems developed complications.

In both cases, these early messages confirmed the notion that other people who did not fit into such “risk groups” were free from any threat.

And the result of this we saw in practice: the viruses spread and seriously affected people who, supposedly, according to this wrong information, would not need to worry about AIDS or Covid, such as heterosexual women and young adults, for example.

Grangeiro believes that the problem begins when risk definitions are very generic and based only on the first cases detected, which are usually more serious and end up being referred to specialized services.

“In principle, some information about risk groups is not wrong, but it can lead to public health strategies that, in practice, even have a negative impact”, points out the expert.

“In the case of AIDS, for example, it was defined that the risk was greater among men who have sex with men. Is this wrong? No, the risk was in fact 10 to 11 times greater in this public”, he calculates.

“The mistake is in taking into account only this single observation in health policies. Because those who were at greater risk were individuals with extensive and unprotected sexual networks, including heterosexuals”, he says.

Now with monkeypox, there’s a chance this same pattern will repeat itself. According to a report published by the UK Health Safety Agency, the vast majority of cases have been identified in individuals who consider themselves to be gay, bisexual or men who have sex with men.

The study followed 152 patients with confirmed infection. Of these, 151 claimed to be part of one of the three characteristics listed above.

But, as past experiences tell us, it is dangerous to close such generic risk groups too soon and say that the rest of the population can relax.

“Every new disease brings anxiety, insecurity and fear. And these initial concepts end up being very strong and are marked”, points out Grangeiro.

“In HIV itself, even with decades of work, we still see a lot of prejudice against the homosexual and trans population.”

“We cannot repeat this mistake again”, concludes the epidemiologist.

threats to nature

To close the list, it is not possible to ignore the fact that the choice of name and the information disclosed about the disease bring danger to some animals.

Brazil had a classic example of this between 2016 and 2017, when some states registered an outbreak of yellow fever.

In this context, the big problem was that the virus, transmitted by some wild mosquitoes, affects humans and monkeys, such as howler monkeys.

“And we had regrettable records of episodes of aggression and violent deaths of some primates during this period”, recalls veterinary doctor Paula Rodrigues de Almeida, a professor at Feevale University in Rio Grande do Sul.

This was because some people interpreted the apes as the culprit or even transmitting the virus — when in fact they were victims like humans.

“They are even more susceptible than we are”, corrects Almeida.

“And as these howler monkeys die faster, they serve as a sentinel and alert us to the possible increase in cases in a given region”, he adds.

In the case of monkeypox — as the name suggests, by the way — this risk is repeated to animals because of a mistaken interpretation of the facts.

“And, once again, the monkeys are victims of this story. They are infected, but the reservoirs of these viruses in nature are some rodents”, explains Almeida.

This gives even more strength to an eventual change of name of the virus or disease.

“We cannot reinforce or encourage stigmas, whether against humans or animals”, concludes the expert.

This text was originally published here