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With upcoming World Pride events in Sydney, now is the perfect time to raise awareness and encourage vaccination against mpox, write James MacGibbon and Vincent Cornelisse …
Mid-2022 saw a new global mpox (previously “monkeypox”) outbreak with distinct clinical and transmission characteristics. During August and September 2022, when Australia was in the early stages of implementing its mpox vaccination strategy, we surveyed 2287 gay, bisexual and queer men and non-binary people about their knowledge of mpox, willingness to make behavioural changes, and be vaccinated. In our recent pre-print article covering the key survey results, we argued that Australia is well placed to avoid a large-scale outbreak of mpox. Here, we summarise the implications of our research for medical practitioners, noting that the work is still under peer review. Continued community awareness campaigns and targeted vaccination of people at potential risk of acquiring mpox remain important, particularly ahead of the World Pride festival that commences in February in Sydney.
Background
Mpox is a viral zoonotic disease that has been endemic to Central and West African countries since it was first identified in humans in 1970. Human transmission occurs primarily through direct contact with infected skin, bodily fluids and large respiratory droplets. The primary symptoms are fever, myalgia, lymphadenopathy and progressive lesions (here). In May 2022, a global mpox outbreak emerged. More than 85 000 cases have been reported globally (here), of which more than 95% have been among gay, bisexual and other men who have sex with men (here and here). The current outbreak is distinct from the epidemiological characteristics of endemic mpox. For instance, most recent cases appear to have occurred through sexual transmission rather than social or household contact (here).
The number of confirmed incident mpox cases peaked globally in August 2022 at around 1000 cases per day and has since declined to around 50 cases daily (here). Australia recorded its first mpox cases in May 2022, and 144 cases by January 2023, most of which were acquired overseas. Australia’s mpox caseload also peaked in August, and notably, only four cases have been reported in Australia since the beginning of November 2022. The steep decline in cases has led some to speculate that it might be possible to eliminate new mpox virus infections in some high-income countries (eg in the UK and the US). Infection elimination is a tantalising prospect, but it is likely that low levels of the virus will circulate outside of endemic countries for the foreseeable future, leading to continued reintroductions into countries pursuing elimination strategies. Epidemic control measures will remain important, particularly increasing community awareness about mpox, targeted vaccination programs and surveillance.
To assist the Australian mpox response, our team at the Centre for Social Research in Health, the University of New South Wales Sydney partnered with researchers at the Kirby Institute and community organisations, the Australian Federation of AIDS Organisations and ACON (formerly “the AIDS Council of NSW”) to identify education and health promotion needs for people at risk of mpox. Our online survey went live at the end of August 2022 and attracted 2287 responses from gay, bisexual and queer-identifying men and non-binary people living in Australia. Most (71%) lived in New South Wales and Victoria, and a minority (14%) had already received the Modified Vaccinia Ankara (MVA) vaccine for mpox at the time of the survey.
Recognition of symptoms and transmission routes
Nearly all (99%) survey participants who had not been diagnosed with mpox had heard of it before the survey, although most (78%) rated their knowledge of mpox as relatively low (knowing a ‘small’ or ‘fair’ amount). Despite this, most undiagnosed participants identified skin lesions and rash as potential mpox symptoms (92% and 87%, respectively). This was an encouraging result, as early recognition of the most common clinical symptoms is important to ensure people who experience symptoms seek appropriate care. In relation to mpox virus transmission, most undiagnosed participants identified prolonged (94%) and brief (82%) skin-to-skin contact and contact with bodily fluids (75%) as potential ways to acquire mpox. Lastly, people who had higher numbers of sexual partners were more likely to recognise potential symptoms and transmission routes than those with fewer partners.
Acceptability of behavioural changes
Survey participants were generally more willing to make changes to their sexual rather than social practices to avoid mpox. For example, more participants were willing to reduce attendance at sex-on-premises venues and sex parties and to have fewer sexual partners in order to reduce their risk of exposure than to avoid kissing, avoid densely populated venues, or hug other people. These results are comforting given that prolonged skin-to-skin contact presents the greatest mpox virus transmission risk. Further, we believe any targeted messaging to gay, bisexual and queer men and non-binary people about behavioural changes, such as taking a break from sex or having fewer partners, should be carefully timed should there be an increase in local mpox virus transmission in Australia.
Willingness to be vaccinated
We found very high willingness to be vaccinated against mpox. Among the 1733 participants who had not yet been vaccinated, 84% were willing to receive the vaccine. Few factors differentiated vaccine willingness in our sample. In other words, there appeared to be high demand for vaccine regardless of participants’ demographic characteristics or sexual practices. That said, bisexual participants were less willing to be vaccinated than gay participants, and participants with greater numbers of recent male sexual partners (between 11 and 20) were more willing than participants with up to 10 recent male sexual partners.
Conclusion
Our data indicate that gay, bisexual and other men who have sex with men have generally good levels of awareness of mpox, including its clinical presentation. Most study participants appeared willing to be vaccinated, especially those men at highest risk of mpox. Bisexual participants appeared less willing to be vaccinated and might benefit from more education on the importance of vaccination. Australian governments have secured large quantities of MVA vaccine, and now is the perfect time to encourage eligible people to be vaccinated, in order to avoid a resurgent mpox outbreak in Australia during upcoming World Pride events in Sydney.
Mpox vaccine eligibility differs by jurisdiction, but in Sydney most sexually active men who have sex with men are now eligible. The MVA vaccine supply is being distributed by local health authorities, and GPs may need to refer patients to information about the vaccine and its availability.
The Emen8 website — an Australian Government funded website run by ACON and Thorne Harbour Health — has an interactive map with mpox vaccination clinic locations that can be passed on to patients.
James MacGibbon, PhD, MAPS (he/him) is a social and behavioural scientist researching HIV prevention and sexual health at the Centre for Social Research in Health, UNSW Sydney.
Vincent Cornelisse, MB BS, PhD, FAChSHM (he/him) is a sexual health physician with a PhD in sexual health epidemiology, who works for NSW Health, and is affiliated with The Kirby Institute, UNSW Sydney.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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