Monkeypox and COVID: Public Health Has to Increase Trust

Monica Gandhi, MD, MPH


June 28, 2022

As a long-standing HIV doctor (where we use harm reduction messaging as a matter of course), I have watched with interest the excellent messaging by the Centers for Disease Control and Prevention (CDC) on monkeypox and contrasted that with the "abstinence only" messaging that occurred with COVID-19. Harm reduction messaging — which incorporates the needs of individuals while working to minimize the impact of a pathogen — increases trust in public health. At this point, however, trust in public health is at a historic low in the US , with just one third of Americans stating that they have trust in the CDC. Polarization around COVID-19 policies is at an all-time high. Divisiveness around mask mandates, vaccine and booster mandates, vaccine passports, enforced quarantines for COVID-19 exposures, and the continued use of mass asymptomatic testing for COVID-19 despite the availability of vaccines for more than a year, runs rampant in the US at this stage of the pandemic.

Distrust in public health can have disastrous consequences, and trust can be difficult to earn back. Despite the recent approval by the FDA of the COVID-19 vaccine for those under 5 years old, only 18% of US parents are willing to vaccinate their children right away. And only 29% of 5- to 11-year-old children in the US have been vaccinated for COVID-19. In addition, recent data show that influenza vaccine and measles vaccine uptake has decreased in the US, with distrust of the public health system playing a role.

This distrust could be the result of messaging by public health in the US around COVID-19 that has tended to not be nuanced (eg, "wear a mask; save lives"); has not always acknowledged the age-gradient of risk since the start of the pandemic (eg, older people are much more likely than children to have severe disease); and led to prolonged school closures and then school disruptions in the US, which contrasted sharply with what happened in the UK and Europe (where public health officials generally opened schools much earlier).

The messaging from public health on the recent monkeypox outbreak in nonendemic countries, however, is full of nuance and helpful guidance, from the CDC to the World Health Organization (WHO). Since the majority of the cases in this worldwide outbreak are in men who have sex with men, and close skin-to-skin and close prolonged respiratory contact are risk factors, public health is full of "sex positive" messaging that both acknowledges the sexual needs of individuals involved and advises on how to avoid the pathogen.

This concept of "harm reduction" in infectious diseases stems from the HIV epidemic and involves public health recommendations that both minimize the impact of a pathogen and take into account other needs of the individuals and the society involved. Harm reduction is the substratum of how we message about HIV risk and is profoundly important in the field of addiction and substance use; but it was not used during the COVID-19 pandemic response as much as expected.

At this stage of the COVID-19 pandemic, where rates of COVID-19 deaths worldwide are at their lowest since March 2020, the WHO, the European CDC, and US public health officials have all indicated that that the "emergency phase" of the pandemic may be receding and that the phase of ongoing management and control has started. We have already laid out a 10-point plan to manage COVID-19 during this phase of the pandemic which includes:

  1. Stopping resource-intensive asymptomatic testing (especially in schools where populations are low-risk), contact tracing, and quarantines, but maintaining surveillance of COVID-19 cases via targeted testing and wastewater surveillance;

  2. Continuing with the 5-day isolation period for COVID, but also enacting a "stay home when sick" model with accompanying paid sick leave policies, which allows for protection of the population from other respiratory pathogens as well;

  3. Investing in the White House's test-to-treat initiative to ensure that vulnerable adults have rapid access to effective antiviral therapies through community-based pharmacies and health centers;

  4. Acknowledging natural immunity in our vaccine recommendations but still recommending one dose of the vaccine after natural infection to acquire stronger "hybrid immunity";

  5. Enhancing the safety of our vaccines by spacing the doses of the primary series 8 weeks apart for young men ages 12-39, thereby significantly lowering the risk for myocarditis;

  6. Counting an infection as a "booster dose" in colleges since a breakthrough infection with Omicron after vaccination leads to broad immune responses against variants;

  7. Expanding our vaccine arsenal with Novavax and Covaxin;

  8. Reassuring the public that long-haul COVID can be minimized through vaccination by publicizing well-controlled studies suggesting that vaccination reduces the risk of long COVID significantly;

  9. Expanding ventilation in indoor spaces as announced by the White House; and

  10. Retiring mask mandates, while continuing to recommend fitted and filtered masks for vulnerable individuals indoors, since evidence is lacking that mask mandates at the population level (including in schools) have had a significant impact on slowing COVID transmission or hospitalizations.

Harm reduction is a tried-and-true principle of how to manage infectious diseases and is being used admirably by the public health establishment around this unprecedented monkeypox outbreak in nonendemic countries. Incorporating harm reduction principles into our messaging around COVID-19 will help ease divisiveness and polarization and increase trust in our public health establishment in 2022.

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About Dr Monica Gandhi
Monica Gandhi, MD, MPH, is an infectious diseases doctor, professor of medicine, and associate chief in the Division of HIV, Infectious Diseases, and Global Medicine at the University of California, San Francisco (UCSF). She is also director of the UCSF Center for AIDS Research (CFAR) and medical director of the HIV Clinic ("Ward 86") at San Francisco General Hospital. Her research focuses on HIV and women; adherence measurement in HIV treatment and prevention; and, most recently, on how to mitigate the COVID-19 pandemic.

Connect with her on Twitter: @MonicaGandhi9


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