Risk Communication and Community Engagement Approaches during the Monkeypox Outbreak in Europe, 2022

"Recent health emergencies...have reaffirmed the role of Risk Communication and Community Engagement (RCCE) as a core public health intervention contributing to emergency response."

This document is intended for health authorities designing risk communication and community engagement (RCCE) interventions in the context of the 2022 monkeypox outbreak in Europe. Jointly published by European Centre for Disease Prevention and Control (ECDC and the World Health Organization (WHO) Regional Office for Europe, it provides examples and approaches for RCCE, while building on experience from past outbreaks. These examples can be used to inspire countries in the European Region to develop community engagement approaches and risk communication strategies adapted to the national, regional, and/or local context and specific audiences in their response to the ongoing monkeypox outbreak.

Anyone can become infected with monkeypox, but the outbreak in Europe is affecting gay, bisexual, and other men who have sex with men (MSM) disproportionately. Therefore, ECDC and WHO encourage health authorities to ensure their RCCE is reaching MSM and that messages are non-stigmatising, credible, and actionable. Collaboration with civil society organisations active in these community groups and with organisers of events that the groups are likely to attend (e.g., Pride events) is recommended. Along these lines, representatives of the community should be consulted during the development phase of RCCE interventions: "The context they can provide on their communities - for example on perceptions, values, behaviour and trust - is key to crafting effective risk communication interventions."

This document presents insights from experiences from several of the countries affected by the outbreak (Belgium, Croatia, France, Ireland, Portugal, Spain, Sweden, and the United Kingdom, or UK) relating to the use of various approaches to reach MSM and other risk groups and to prevent stigmatisation, including:

• Trusted communicators: In the case of monkeypox, emphasis should be placed on communicators who are members of, leaders within, or individuals who have long-standing relationships with MSM groups and/or the lesbian, gay, bisexual and transgender/transsexual (LGBT+) community.
• Targeted channels: During the outbreak, and due to the large number of planned mass gathering events, use of social media channels should be exploited to the maximum to increase knowledge of the outbreak and provide credible and actionable information and advice to the groups most at risk. Among the examples provided: In preparation for the Glastonbury festival in the UK, key messages on sexual health and prevention of infectious disease were added to the festival website. Folded leaflets with condoms or lubricants, posters, and bracelets with QR codes were designed with civil society and public health professionals to provide advice on prevention of all sexually transmitted and infectious diseases. The messaging has remained transparent, but not solely focused on monkeypox, so as to not to stigmatise specific groups.
• Community engagement with civil society organisations: Activities for which public health authorities may work together with these organisations include: building an understanding of the perceptions and concerns of those affected and at risk in relation to the outbreak (through qualitative research, such as focus group discussions, intercept interviews, and social listening); facilitating the co-design and testing of risk communication interventions and messaging; providing advice on the appropriate language to use; amplifying public health advice through trusted community champions; monitoring rumours and misinformation, and helping to debunk them; and monitoring people's acceptance and adherence to protective measures.

A series of examples provides community engagement strategies used MSM and other priority groups during monkeypox and other outbreaks in Europe:

• MSM: For example, a coalition of civil society organisations active on sexual health issues, healthcare providers, and the UK Health Security Agency (HSA) have worked together to create actions such as jointly branded webcasts on monkeypox; a social media video clip of a UK HSA expert who is also a gay man talking about monkeypox and its symptoms; outreach in relation to monkeypox to the managers of saunas, clubs, and other venues frequented by MSM; and communication and outreach on social media, including on dating/hook-up apps (e.g., Grindr).
• Sex workers: Existing sex worker organisations and networks can facilitate access to this population and the implementation of appropriate prevention messaging and contact tracing strategies.
• Healthcare workers: Infection prevention and control guidance, and testing and management guidelines addressing healthcare professionals, have been developed by many public health authorities.
• Immunocompromised people, pregnant women, and children: For example, the European AIDS Clinical Society (EACS) and the British HIV Association have both issued statements about monkeypox to guide clinicians caring for and people living with HIV.

Strategies that can be used to prevent and counter stigmatisation include using respectful and inclusive language to stress that monkeypox is not a disease linked to sexual orientation, monitoring public perceptions of MSM (e.g., through social listening) to inform public health authorities on what mis or disinformation may need to be debunked, and concentrating most of the RCCE activities on channels and outreach activities that specifically hone in on the most affected community group (e.g., MSM).