During 3–12 May 2022, 2 sexual health clinics in Lisbon, Portugal were concerned to see a small number of patients presenting with unusual genital lesions, rashes and systemic symptoms including fever and swollen lymph nodes.
Dr Margarida Tavares is Director of the National Programme for Sexually Transmitted Infections and HIV Infection and an infectious diseases consultant at Centro Hospitalar Universitário de São João, in Porto and remembers how they were at a loss to explain the disease.
“At that time, it wasn’t clear what was causing these symptoms, but the correlation of having a number of similar cases within the same period of time made us question what was happening, and report them so that we could hopefully get some answers.”
Identification of monkeypox
Without being able to give a diagnosis, the National Reference Laboratory logged the unexplained cases on the EpiPulse online portal – a tool set up by the European Centre for Disease Prevention and Control (ECDC) through which European public health authorities and global partners can collect, analyse, share and monitor infectious disease data.
Three days later, the United Kingdom reported 4 laboratory-confirmed monkeypox infections, which allowed the Lisbon authorities to “join the dots” and get confirmation that they were also dealing with a monkeypox outbreak.
Responding to the outbreak and involving civil society
As soon as the first case was confirmed as monkeypox virus, a rapid response team was set up on 17 May, consisting of sub-teams responsible for key response pillars (including coordination, clinical management, laboratory analysis, vaccination, epidemiological surveillance and risk communication).
Right from the start, this team began a close dialogue with community-based organizations working with men who have sex with men (MSM), as it was in this group that the vast majority of cases were being found. The team also liaised with sexually transmitted infection (STI)/HIV testing and care centres, as well as venues, such as bars and sex-on-premises businesses, to consult them on key messages around monkeypox and the best approach for communicating them, particularly in the run-up to the upcoming Pride events Marcha do Orgulho on 18 June and Arraial Lisboa Pride on 25 June.
“Together, the Pride events attract up to 100 000 participants, and are the highlight of the city’s LGBTQI+ calendar. They offered us a perfect opportunity to identify feasible and clear messages, to spread the word about monkeypox to those at most risk from infection, and to provide information on the symptoms to look out for, ways to avoid it and what to do about it if you catch it,” explained Ricardo Fuertes, a psychologist working at the National Programme and liaison with the community.
At the same time that messages were being disseminated at Pride events, testing venues and hospitals readied to receive patients concerned about their symptoms in other parts of the city and the country.
Event organizers being part of the solution
Organizers of the two Pride events, together with Grupo de Ativistas em Tratamentos (GAT), a community-based organization that carries out counselling and testing for HIV and other STIs, were also involved in the design and distribution of informative materials, including a pocket-sized, bilingual guide (in Portuguese and English) that used images of a prickly gherkin to draw attention to the lesions and rashes characteristic of monkeypox. In addition, the organizers were provided with briefing information for staff, and were involved in the production of educational videos that were shown on large public screens at one of the events.
Rapid responses in coordination with the community
The health authorities in Portugal made the most of existing contacts and networks of community services and representatives – relationships developed in response to HIV and their work with MSM, migrants and sex workers – to respond quickly. Community representatives were consulted before announcements to the national media, and venues such as bars and saunas were engaged and encouraged to put up information posters.
“This alliance between health authorities, event organizers, community organizations and venues was crucial to our response,” says Dr Tavares. “And over time, this alliance has expanded as we realized we needed to include other subgroups, such as chemsex networks, and new geographic areas, such as Porto.”
GAT and the national health authority worked together to set up a monkeypox helpline to answer questions around disease infection, transmission and vaccination, as well as where to get tested in case of suspected infection.
Dr Tavares and Ricardo Fuertes believe that being pragmatic about the prevention measures being recommended and targeting the most at-risk groups, without stigmatizing or blaming have been important factors in getting people to take notice of their messages and in the success of their campaign. While Portugal continues to see monkeypox cases reported, the country was one of the first to show signs of stabilizing transmission. Now, the work is to focus on bringing case numbers down further, and stopping the outbreak entirely.
Preparing for a national vaccination programme
Similar steps to those described above are now being taken in preparation for the roll-out of a national preventive vaccination programme. Community partners and venue owners have once again been consulted on many of the practical considerations needed for this, including deciding on the appropriate eligibility criteria for vaccination, the location of vaccination points and the way that information will be communicated to reach those at most at risk.
GAT’s CheckpointLX, a screening centre for HIV and other STIs, is playing a key role in these plans and has already been designated as one of the 3 vaccination points for monkeypox in the Lisbon metropolitan area due to its close links to the most at risk MSM communities. With vaccines as a new tool in the response for Portugal, the continued engagement and involvement of the affected community in all its interventions will be the key to ending the outbreak in the country.