No health issue stands alone in Eastern Europe: Monkeypox emergence amidst socioeconomic and political crises
The 2022 monkeypox outbreak (MPX) had spread to Eastern Europe by July 2022. As of October 6, 2022, the CDC has reported 195 cases in Poland, 78 in Hungary, 68 in the Czech Republic, 40 in Romania, 14 in Slovakia, and 2 in Moldova.1 Although the number of confirmed cases remains limited in comparison to reporting from much of western Europe, there is likely to be significant under-counting due to limited public health and surveillance systems and inadequate real-time reporting. Thus, there can easily be uncontrolled transmission due to a conundrum of social, political, and financial circumstances in the region.
Eastern European countries typically have weaker economies than their western counterparts. Historically, this has put a strain on the capacity of the national healthcare systems and public health agencies.2 The second wave of the COVID-19 pandemic took a toll on the weaknesses of healthcare systems in eastern Europe, with lower health education levels among local populations leading to risky attitudes and subsequently adverse health outcomes. Since February 2022, the invasion of the armed forces of the Russian Federation in Ukraine has resulted in a humanitarian crisis with millions of refugees displaced within Ukraine, or fleeing to neighboring eastern European countries,3 and concerns about their inability to access healthcare.4 This fragile status quo emphasizes the need for high-quality real-time reporting to understand the scale of monkeypox transmission, allowing interventions that can mitigate the spread of MPX in the region.
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MPX can be easily spread in displaced populations such as those within Ukraine. Approximately 50 000 people are crossing the border daily. More than half of them are returning to Ukraine.5 Displaced populations within Ukraine, and perhaps to a lesser extent people who fled the country, may be at higher risk of contracting MPX. Asymptomatic cases might further increase the dissemination of the disease, especially due to the high number of individuals who are forced to travel due to the ongoing war.
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Hospitals in the entire region and notably in Ukraine and in border areas have limited capacity to isolate and treat MPX cases. The transportation of 1000 Ukrainian patients to western European hospitals in early August 2022 indicates the pressure on healthcare facilities in Ukraine and neighboring eastern European countries.6 Although the rate of inpatient transmission is lower for MPX than in COVID-19, the need to transfer patients between different healthcare facilities might accelerate the spread of the virus to high-risk hospitalized patients.
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There are limited resources for population-wide preventive measures. The availability of personal protective equipment (PPE) is likely to be limited. The European Union and the United Nations are attempting to procure the necessary amount of PPE and other life-saving consumables to war-torn regions.7 Vaccination against smallpox or monkeypox can also be challenging. High vaccine wastage rates have been reported in the region due to the disruption of supply chains and the destruction of critical facilities.8 There are also global shortages of the necessary immunizations, with vaccine equity again being raised in public discussions.9
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The risk for vulnerable populations is maximized due to the general limitations towards access to all aspects of healthcare. Pregnant women and their neonates/children are particularly at risk, both by the lack of access to antenatal care, and by physiological immune suppression of the pregnancy.
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Stigmatization of the LBGTQ+ community is thought to be highly prevalent in Eastern Europe, where political, legal, and cultural norms can create hostility towards the LGBTQ+ community.10 This hostility is unlikely to support widespread and appropriate public health messaging, nor will it encourage those with monkeypox-like symptoms to come forward for clinical examination and treatment.
Overall, the risk of MPX transmission in eastern Europe is disproportionately higher than the capacity to control the disease and its socioeconomic sequelae. In a “One World, One Health” frame, it is evident that community transmission of MPX in eastern Europe, alongside significant international population movement, can result in MPX outbreaks in other regions. Countries with fragile healthcare systems in the global south can hence also be disproportionately affected.
The best way to make progress entails a combination of individual and institutional initiatives. Healthcare practitioners in the region need to be alert for MPX, when examining patients with symptoms such as fever, or skin lesions. Healthcare systems and individual practitioners need to be educated about the prevention, infection control, and management of MPX. Their sustained engagement with communities about the disease and its manifestations can help to debunk inappropriate narratives and reduce stigma. Similarly, the public needs access to trustworthy information about symptoms, isolation, and self-care practices. Healthcare facilities should have sufficient preventive measures and updated infection control strategies such as awareness campaigns, and access to PPE and vaccines.
Given the urgency of the situation and the scarcity of resources in several eastern European countries, international aid is essential for this cause. The European COVID-19 recovery strategy, the European Union for Health Programme (EU4Health), that provides funding toward epidemiological surveillance and infection control, can serve as a starting point. This infrastructure can help channel international aid to facilities and stakeholders in need.11 Whilst sufficient resources are being collected and distributed, public health education of the healthcare workers and the public should be prioritized.
There is evidence that sustained and positive health promotion can result in behavior change, and thus reduction in risk of exposure to MPX.12 Measures ensuring that patients can be diagnosed, isolated and treated with adequate resources and non-judgmental attitude is pivotal. In this regard, helplines with social and psychological support in a range of languages need to be more widely rolled out.
The emergence of MPX in eastern Europe sets a reminder that no health issue stands alone. Integrating the geopolitical and socioeconomic coordinates of the region to the management of the health crisis is essential to increase understanding of MPX, and to ensure the outbreak is under control across the Eastern European region and globally.
AUTHOR CONTRIBUTIONS
All authors made substantial contribution to the paper.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
Open Research
DATA AVAILABILITY STATEMENT
Data Availability Statement is not available.
