Outside the Centre for Infectious Diseases in Riga, Latvia, snow lies on the ground and the temperature is well below freezing. Inside, though, a warm welcome is waiting. In the brightly lit foyer, volunteer Alex Ivanayev, his broad smile evident even behind his mask, greets people arriving for mpox (monkeypox) vaccination.
Alex caught mpox in the summer – an experience he describes as one of the worst of his life. His throat was extremely sore, and his lymph glands were so inflamed that he could not eat for 3 days. However, he did not seek medical help due to worries that he would be stigmatized based on misinformed stereotypes about men who have sex with men.
Alex now volunteers to guide others along a new pathway to vaccination that allows them to be referred not by their family doctors, but through the LGBT (lesbian, gay, bisexual and transgender) civil society organization Mozaika, of which he is a board member.
This smooth and judgement-free route to vaccination is part of a successful collaboration with the Latvian Ministry of Health that is increasing access to vaccines and information about the virus. It underscores the vital importance of risk communication and community engagement as components of responses to health emergencies.
A partnership for health
When the first cases of mpox were reported in Europe in May 2022, Mozaika staff began speaking with community members about how to avoid infection. During these conversations, Kaspars Zalitis, Director of Mozaika, heard that some were worried they would face stigma if they reported mpox symptoms to their family doctor or asked for a pre-exposure vaccine.
Kaspars identified these concerns as a barrier to health care and vaccine uptake, and reached out to the Ministry of Health, with whom his organization had long cooperated on HIV prevention and treatment.
“We had our first meeting quite quickly, not just with the Ministry of Health but with literally all possible stakeholders – the Centre for Disease Prevention and Control, the National Health Service, the Centre of Infectious Diseases, the reference laboratory. We’d just had one outbreak – COVID-19. We didn't need another. So, it was better to work together. Why not use the opportunity?”
This is exactly the approach that WHO/Europe recommends. Strong coordination among policy-makers, service providers and community-based organizations serving those at highest risk of exposure to mpox is essential for tailoring policies, interventions and communication.
Organizations such as Mozaika are trusted by people who self-identify as gay or bisexual and by other men who have sex with men, and are well positioned to collect and share the detailed insights necessary to understand barriers to and drivers of uptake of preventive measures.
“Our community is not homogenous. We are all very different, but we all need good health and the ability to prevent diseases,” says Inga Liepina, Senior Expert in the Environmental Health Division at the Latvian Ministry of Health. “We have these mpox vaccines and we need to use them. That’s the main task of vaccines – to be used, not to stay in the fridge!”
WHO’s interim guidance on vaccination for mpox recommends the priority groups who should receive primary preventive vaccination: those at high risk of exposure, including people who self-identify as gay or bisexual and other men who have sex with men.
Medical care without judgement
“The vast majority of mpox vaccination referrals are coming from Mozaika,” says Inga Ažiņa, Head of the Outpatient Department of the Latvian Centre of Infectious Diseases. “I feel really satisfied. It’s a great process.”
Irēna Anna Damberga, Vaccination Doctor at the Centre of Infectious Diseases, is also impressed with the new referral system: “Mozaika are very organized, very disciplined, decent people. That’s a very big advantage,” she says.
Irēna Anna greets everyone, no matter what vaccination they are receiving, in a friendly, jovial manner that makes her popular among her patients. Laughter fills the consulting room and people who arrive looking nervous eventually leave smiling and relaxed. “We treat everyone equally,” she emphasizes. “We cannot differentiate between people. No one who has studied medicine should do that.”
A creative solution
The written regulations of the Latvian Ministry of Health have been updated to prescribe the engagement of Mozaika in the vaccination referral process, legitimizing its involvement in the pathway and providing a clear blueprint for others to follow.
“As a result of this collaboration between the Ministry of Health and a community organization, there is improved access to vaccination for those most at risk,” says Uldis Mitenbergs, Head of the WHO Country Office in Latvia. “Avoiding discrimination, fighting stigma, serving the most vulnerable and engaging communities are essential to tackle this outbreak. It is a great example of how, by working together, we can arrive at an outcome which benefits everyone.”
WHO/Europe support for country responses to mpox
The WHO Country Office in Latvia has facilitated dialogue between the Ministry of Health and Mozaika. It continues to work closely with the Government and to develop strong professional relationships with community organizations.
Since the beginning of the outbreak, the Country Office has also been sharing technical guidance and best practices for tackling mpox with stakeholders. This has included a WHO/Europe mpox policy brief series that summarizes policy recommendations, knowledge and interim technical guidance on mpox as it relates to the WHO European Region.
The most recently published brief describes how to collect and integrate behavioural and cultural insights into the response and broader mpox control and elimination strategies in countries. As Latvia has shown, such an approach requires carefully tailored policies, interventions and communication, based on an understanding of the behaviours, perceptions and contexts of the populations at risk – which community organizations like Mozaika can provide.
Controlling and eliminating mpox in the Region
The number of cases of mpox has been declining in Europe in the past several months, bringing hope that this outbreak can be controlled and human-to-human transmission can eventually be interrupted. This will require strong surveillance systems, early case detection, contact tracing, tailored risk communication and engagement with communities.
Kaspars Zalitis believes mpox vaccination of at-risk groups is also a key long-term strategy: “Just because the numbers are declining in Europe doesn't mean mpox will disappear,” he says.
The popularity of Latvia’s new referral pathway is evidence that cooperation and communication with at-risk groups during disease outbreaks can result in strong partnerships for health. Although the 53 countries of the Region are disparate in their politics and practices, Kaspars has this advice: “I think one thing that other countries might take from Latvia is just to listen, listen, listen to what the community is saying, because sometimes this can be critical for ending an emergency.”