Overview

The purpose of this document is to provide public health advice to host governments, public health authorities, national or international organizers, and professional staff involved in the planning and delivery of gatherings, including people organizing smaller gatherings or attending gatherings of any type and size. 

During gatherings, the likely high density and mobility of attendees (crowding) represents a conducive environment for close, prolonged and frequent interactions between people. Furthermore, it may also be associated with the widespread adoption of risky behaviours and unsafe practices, including unsafe sexual practice, therefore playing a role in the spread of the monkeypox virus.

WHO recommends that the decision-making process related to gatherings of any size and type should rely on a risk-based approach, tailored to the characteristics of the event under consideration and be repeated at regular intervals. In the context of the current outbreak, monkeypox-associated risks should be considered and factored in when planning an event.  Postponing or cancelling gatherings in areas where monkeypox cases have been detected is not required as a default measure, and gatherings should be used as opportunities for information outreach and community engagement.

Background

The unexpected appearance of monkeypox in several WHO regions in the initial absence of epidemiological links to areas that have historically reported monkeypox suggests that there may have been undetected transmission for some time. Epidemiological investigations are ongoing. Most reported monkeypox cases have presented through sexual health or other health services in primary or secondary healthcare facilities.

The identification of confirmed and suspected cases of monkeypox with no direct travel links to previously affected areas is atypical, and even a single case of monkeypox in a newly affected country is considered an outbreak. For the latest information on transmission, signs and symptoms please refer to Clinical management and infection prevention and control for monkeypox: Interim rapid response guidance.

Scope

Gatherings are events characterized by the concentration of people at a specific location for a specific purpose over a set period of time, and may be public or private, planned or spontaneous, recurrent or one-off, and also of varying size, duration and visibility. They can be of different nature, including, although not limited to, sports, religious, cultural, entertainment, political, business and health-campaign events.

During gatherings, the likely high density and mobility of attendees (crowding) represents a conducive environment for close, prolonged and frequent interactions between people. Some gatherings may lead to attendees socially interacting with people previously unknown to them. For some, these new interactions could lead to sexual activity which can play a role in the spread of the monkeypox virus.

Risk-based approach for gatherings
Principles
WHO recommends that the decision-making process related to holding, modifying, postponing or cancelling gatherings of any size and type should rely on a risk-based approach, tailored to the characteristics of the event under consideration and be repeated at regular intervals.
The risk-based approach entails three steps:

1. Risk evaluation: identification and quantification of the baseline risks based on the characteristics of the event and the context in which it takes place;
2. Risk mitigation: application of a package of precautionary measures aimed at decreasing the baseline risk;
3. Risk communication: proactive dissemination of information on the measures adopted, their rationale and purpose, and on how the relevant decisions were taken.
   
   In the context of the current outbreak, monkeypox associated risks should be considered and factored in when planning a gathering event.
   
   Postponing or cancelling gatherings in areas where monkeypox cases have been detected is not required as a default measure.

Monkeypox-associated risks during the current outbreak

In the context of the current monkeypox outbreak, cases have been primarily identified among some gay, bisexual and other men who have sex with men including those who have reported recent sex with a new partner or multiple partners. Key transmission routes include skin-to-skin, mouth-to mouth and mouth-to-skin contact during sexual activity.

Transmission can also occur through skin-to-skin contact not related to sexual practices, face-to-face contact via respiratory droplets and from contaminated surfaces or material; it is still unclear if infected people with no symptoms can transmit the monkeypox virus, making it important for anyone attending gatherings to exert additional care.

Public health advice for decision-makers (authorities and event organizers)

The following precautionary measures can be considered to decrease risk of monkeypox transmission associated with gathering events:

• Health authorities are invited to:
  – identify those events in their jurisdiction that are most likely to be associated with risk of monkeypox virus transmission, based on the prevailing modes of transmission and the likely profile of the attendees;
  – ensure that monkeypox is included among the diseases regularly reported through routine surveillance; WHO has published guidance on surveillance, case investigation and contact tracing for monkeypox;
  – make provision to ensure prompt isolation and adequate clinical management of identified cases; WHO has published guidance in this regard;
  – keep the general population and event organizers informed on the evolution of the outbreak, and adequately monitor and address rumours and misinformation about monkeypox.
• Event organizers should establish a liaison with the relevant health authorities and be aware of the epidemiology of monkeypox in the host area.
• Gatherings should be used as opportunities for information outreach and for risk communication and community engagement (RCCE) activities; these should also target individual behaviours associated with side gatherings, unplanned congregation, and unstructured socialization in public or private spaces.
• Health authorities and event organizers should facilitate the adoption of appropriate public health and social measures, including those aimed at infection prevention and control, to decrease the risk of transmission of monkeypox virus in conjunction with the event.
• Staff responsible for dealing with people who fall ill at the event should be provided with information on how to identify and manage people with signs and symptoms consistent with monkeypox, and with the relevant personal protective equipment.
• RCCE activities including the development of communication materials for travellers on signs and symptoms consistent with monkeypox, on infection prevention and control measures, and on how to seek medical care in countries where monkeypox cases have been reported, should be considered at points of entry.

Public health advice for people organizing smaller gatherings or attending gatherings of any size and type

• People with signs and symptoms consistent with monkeypox should refrain from close contact with any other individual, should avoid attending gatherings, and should follow advice issued by relevant health authorities.
• Close contact, including sexual contact, with someone who has signs and symptoms consistent with monkeypox should be avoided.
• Anyone who feels they may have been exposed to monkeypox should exercise additional care. Information specifically designed for communities of gay, bisexual and other men who have sex with men is now available, including updated public health advice.
  
  Gatherings attendees should always be reminded to apply individual-level responsibility to their decisions and actions, with the aim of preserving their health, that of the people they interact with, and ultimately that of their community.

© World Health Organization 2022 (DOWNLOAD PDF FILE)

• World Health Organization (WHO) declares Monkeypox a public health emergency
• Monkeypox Endemic News: What is monkeypox?, Symptoms and Preventive Measures