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• W4319656274 abstract "The discussion about MPOX (formerly called monkeypox)1 and its potential impact on transfusion medicine has received recent attention in the literature.2-5 Concurrently, public health authorities are urging a focus on communication and sharing knowledge about MPOX in a way that does not propagate stigma against equity-deserving groups.6 While MPOX infection is not limited to gay, bisexual, and other men who have sex with men (gbMSM), the outbreak has become an additional source of stigma and discrimination for them. As well, fear to contract MPOX has resulted in racial and xenophobic discrimination directed at people from affected and previously affected regions and countries.6 For those with intersecting identities of race/sexual orientation/gender, the stigma and discrimination are further compounded. This commentary attempts to open a discussion on how specific talking points presented by transfusion medicine professionals in literature and discourse can increase or decrease stigma and discrimination of equity-deserving groups that make up our community of donors, recipients, and colleagues. The purpose of this commentary is to reflect on how to address the topic of unconscious bias in transfusion medicine, using as a paradigm, the MPOX epidemic. Additionally, we provide suggestions for transfusion medicine colleagues on how to engage in discussion about MPOX. While transmission routes of infectious agents differ, we also believe that the observations below may be applicable to future epidemics that first impact equity-deserving groups of people. Implicit bias is unconscious, and everyone is susceptible to it, including the health care community.7 People can stigmatize others without even knowing they do it. As advised by the World Health Organization (WHO), addressing implicit bias starts by being open to learning and changing behavior, being reflective, seeking feedback, and noticing or calling out sources of stigma and discrimination.6 Stigma is defined as a negative view or association of a person or group of people. It can include labelling, stereotyping, separating, or segregating that results in loss of power for an individual or a group of people.8, 9 Stigma is an enabler of discrimination.9 Many conceptualize discrimination as overt or purposeful actions like name calling, violence, and hate crimes. This limited understanding of discrimination can cause people to incorrectly think that discrimination did not occur if it was not intentional, but often discrimination occurs without intent to do harm. Systemic or institutional discrimination is complex and refers to practices, policies, and discourse that seem neutral on their surface but have discriminatory impacts.9 Stigma and discrimination are known drivers of health disparities,8 so recognizing and correcting sources of stigma and discrimination in healthcare, including in transfusion medicine, is paramount. Words matter when communicating from a non-stigmatizing stance. The legacy of the term “gay-related immune deficiency” initially used to describe HIV, continues to stigmatize gbMSM and impacts their well-being to this day. The historical use of this term provides a cautionary lesson for MPOX and other infectious diseases outbreaks.10 Focusing entirely on one population when an infection is emerging can narrow the scope of an appropriate public health response and propagate stigma that outlives the outbreak. It also creates lost opportunities to adequately address the infection in all populations.11 The impacts of social stigma for racialized people or the intersectional impacts for racialized gbMSM is absent from recent transfusion medicine literature about MPOX. However, MPOX has become an additional source of racism for them.6 For people who whose race/sexual orientation/gender and other aspects of identity intersect, stigma and discrimination are further heightened. When talking about MPOX or any infection that may have originated in a specific country, it is important that words do not associate the infection with race or ethnicity. Using words such as “affected and newly affected countries” instead of “endemic and non-endemic countries” can help to address stigma.6 We see this recommendation in actionin a recent expert consensus of virologists and public health experts convened by the WHO. To mitigate stigma and discrimination for racialized people, the clades or variants of MPOX were re-named in August 2022 from the prior geographic titles to clade 1 and clade 2.12 Additionally, due to concerns about racist and stigmatizing language, following consultations with global experts, the WHO recommended an updated international re-classification of the name of the disease to MPOX.1 When speaking about impacts of policies on people, the term gbMSM is better than MSM.6 This term begins to recognize that epidemiological terms like MSM can undervalue or erase sexual identities.13 When talking about people who are impacted by policy, naming these groups of people specifically can help to reduce dehumanizing impacts.6 Various population descriptors other than sexual orientation are used in the transfusion medicine literature discussing MPOX. One paper uses the word “sexual preference”5 and another refers to “social practices”.3 Sexual orientation recognizes a person's physical, romantic and/or emotional attraction to other people and is the most inclusive term.6 “Sexual preference” can imply that everyone within a group experiences sex and sexual behaviors in the same way. Moreover, terms like “social practices” and “sexual preference” implies choice, although sexual orientation is not a choice. Describing the diversity of all who are susceptible to MPOX versus limiting it to specific equity-deserving groups is essential. The main population of focus in transfusion medicine literature regarding MPOX transmission has been gbMSM.2, 3, 5 One paper does acknowledge that MPOX is increasingly being diagnosed in people who are not gbMSM, however, their reflections and mitigation strategies focus entirely on gbMSM.4 Another paper describes that MPOX being confined to gbMSM is unlikely to continue.2 Indeed, recent Centers for Disease Control and Prevention (CDC) data supports that the virus is not limited to gbMSM. They found that in over 11,000 individuals where gender and recent sexual history data were available, approximately 25% did not report male-to-male sexual contact. Moreover, they noted a declining proportion of infections reporting male-to-male sexual contact over time.14 In contrast to most of the transfusion medicine literature, public health organizations around the world, including the WHO, Public Health Agency of Canada, and European Centre for Disease Prevention and Control (ECDC) clearly describe that anyone can become infected with MPOX. MPOX transmission occurs though direct close contact with infected individuals, by exposure to infected body fluids, or possibly through indirect contact via fomites in the environment.2, 5, 6, 15 The chance of infection is greatest for people who have a new sexual partner or multiple sexual partners regardless of gender and sexual orientation.6, 15, 16 Use of the testing assay's window period to detect newly acquired HIV infection as a rationale for identity-based deferrals for gbMSM has been described in transfusion medicine literature about MPOX.5 This approach seems to be outdated. New and recent behaviors, that anyone can engage in regardless of gender or sexuality, can lead to the presence of infections within the window period of testing assays.17 Gender neutral sexual behavior-based screening (GNSBBS) has already been implemented in the United Kingdom18 and in Canada19, 20 and is expected to be implemented by other blood operators. As blood operators move to evidence-informed sexual behavior-based screening instead of identity-based screening, the window period as justification of identity-based criteria is less defensible. GNSBBS is also designed to prevent window period infections. This type of screening can also reduce stigmatizing assumptions that everyone in a particular population has the same chance of HIV acquisition, as well as the false assumption that those outside the population all have limited to no risk of HIV acquisition. Transfusion transmission of MPOX has not been identified. The presence of the MPOX virus in blood components from infected but otherwise qualified donors, including surviving storage, and leukoreduction has not been studied.5 Most of the discussion in transfusion medicine literature about donor screening has focused on mitigation strategies only for gbMSM. The majority of papers suggest that because sexually active gbMSM are deferred in areas that use identity-based screening, this criterion mitigates risk for MPOX transmission through donation.2, 3, 5 Another paper recommends a reintroduction of identity-based deferrals for gbMSM who have not been vaccinated against MPOX.4 The suggestion that screening criteria and identity-based deferrals exclusively for gbMSM are a mitigation strategy for MPOX should be interrogated for accuracy, validity, and for the ability to propagate stigma. Focusing selectively on gbMSM can reinforce stigma about MPOX as being a disease that only impacts gbMSM and that any gbMSM is at risk of contracting MPOX regardless of their behaviors or health promoting practices. Deferring unvaccinated gbMSM from donation disregards current MPOX vaccine eligibility and availability policies.21 In many places, MPOX vaccine is not available to all sexually active gbMSM, including people in long-term monogamous relationships who are not at an increased risk of contracting MPOX. Therefore, reinstating an identity-based deferral for these donors would mean reinstating the deferral for all sexually active gbMSM. Some authors also recommended adding questions regarding MPOX exposure in jurisdictions that apply GNSBBS and thus do not defer all sexually active gbMSM.2, 5 Their premise cites a report from ECDC to support additional screening criteria for blood establishments that use GNSBBS.16 However, the ECDC report does not describe identity-based screening that defers all sexually active gbMSM from donation as a replacement for having donation criteria for MPOX, weakening the scientific premise of their recommendation and potentially reinforcing stigma.22 In the era of molecular medicine, determining viremia frequencies in donors and directly evaluating transmission risk seems to be the appropriate approach in assessing safety of our blood supply in relation to MPOX.23 Two papers also call into question the ability of gbMSM to be compliant with donation criteria3, 4 One of these papers describes that “exclusion for social practices cannot be expected to completely eliminate the threat of MPOX” due to perceived lack of adherence to the criteria on the part of gbMSM.3 This statement fuels stigma against gbMSM for both MPOX and donation eligibility for gbMSM in general. It reinforces the misconception that only gbMSM are susceptible to MPOX and also implies that gbMSM are dishonest and cannot be trusted to give honest answers during health screening. However, recent research demonstrates that non-compliance with criteria among gbMSM is low,24, 25 and anyone, regardless of sexuality or gender, can be non-compliant with donor screening criteria.26 As in any relationship, trust is an essential component, “the ideal relationship between donors and blood centers is based on mutual respect and understanding. Each party needs to have confidence the other is participating in good faith”.27 The evidence on compliance suggests that donors are trustworthy24-26 and using compliance concerns as a reason to justify exclusion of gbMSM propagates stigma. Given the evolving epidemiology of MPOX, a focus only on screening out gbMSM will provide false reassurance about risk mitigation while stigmatizing this population. Just like HIV, gbMSM also do not contract MPOX because they are gbMSM. They contract it the same way anyone else does, because of specific recent behaviors.6, 15, 16 Screening out gbMSM is a crude short-sighted strategy of donor screening and will not provide any opportunity to screen other populations that can also contract MPOX. Additionally, there has been significant work in many countries to transition to GNSBBS.18, 19 Focusing on the benefit of identity-based screening for MPOX mitigation might imply that a screening approach that excludes gbMSM is superior to behavior-based strategies. This is not only stigmatizing to gbMSM but also provides a false sense of reassurance to blood operators about risk mitigation. Although the current MPOX epidemic began by impacting gbMSM who engage in specific sexual behaviors, the MPOX epidemiology is changing. Indeed, recent trends from the current and historical outbreaks14 show that people of any sex and/or gender28 and any sexuality14 can contract MPOX. This further supports the need to communicate about MPOX from a non-stigmatized stance. GNSBBS can provide the nuanced understanding about sexual behaviors that increase the chance of MPOX acquisition in real time and as epidemiology changes. An identity-based criteria is inadequate to capture the changing epidemiology of the infection. Some authors also describe literature that highlights asymptomatic cases in gbMSM as a reason for vigilance.4, 5 An expanded view of this paper could help to reduce stigma for gbMSM. In the cited paper, the participants were gbMSM who also had multiple sexual partners, or who were living with someone taking antiretroviral therapy, or were taking pre-exposure prophylaxis (PrEP).29 These asymptomatic individuals quoted by the paper are unlikely to be eligible under GNSBBS. These data further highlight an important point, that MPOX is not sexual-orientation specific and that GNSBBS can be effective in being a minimally restrictive donor screening strategy, while maintaining the safety of the blood supply. Finally, when discussing outbreaks that disproportionately affect equity-deserving groups, context about why these differences exist will prevent inaccurate assumptions that being in an equity-deserving group is the cause for the observed disparities. Some authors described that there could be biases in “test seeking” contributing to higher reported cases among gbMSM.5 Test seeking is a stigmatizing term that undermines the message from the cited reference. The cited literature describes the diagnosis of MPOX in gbMSM in a health promoting, non-stigmatizing way. “Established links between persons receiving preexposure HIV prophylaxis and sexual health clinics and between persons living with HIV infection and HIV clinics could have led to a referral bias, especially given the potential for early care seeking in these groups.”30 In the cited paper, the authors describe the public health benefit of HIV prevention, treatment, and early care seeking in these groups. This means that people living with HIV and those at an increased chance of HIV acquisition are seeking care and treatment, maintaining their health, and reducing transmission of HIV and other infections. This observation should be described accurately and positively in transfusion medicine research. At present time, due to limitations in available data and concerns about testing assay accuracy, people who take PrEP are deferred from donation, and people living with HIV are unable to donate. However, PrEP and use of medications to maintain undetectable viral load in those living with HIV are important health promoting interventions that directly impact blood safety in a positive way by reducing HIV transmission in all, even if those taking the medications cannot currently donate. Speaking positively about health promoting behaviors is essential when communicating from a non-stigmatizing stance. In summary, the DEIA taskforce recommends that the transfusion medicine community approach discourse and suggested interventions that impact equity-deserving groups with scientific rigor and a humane perspective. This will prevent the implementation of well-intentioned but poorly conceived policies based on epidemiological associations that are conducive to systematic stigma. How we communicate about MPOX and other emerging infections that can first present in equity-deserving groups is critical for supporting people to take effective action and to avoid stigma and discrimination. None. The authors declare that they have no conflict of interest relevant to this manuscript submitted to TRANSFUSION." @default.
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• W4319656274 title "From <scp>MPOX</scp> to the next epidemic: Words matter when talking about equity‐deserving groups" @default.
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