Why officials have a balancing act in explaining virus risks

Public health messaging on both COVID and monkeypox has been too disjointed, confusing Americans on what steps they need to take to mitigate their risks.

Between the lines: Viruses often have multiple routes of transmission, and educating the public on the likeliest route to infection can be a balancing act for officials who want to cover all their bases and have to account for unknowns and public mistrust, several experts tell Axios.

Why it matters: The CDC and other public health agencies need to offer clear information on both potential and present risks that each outbreak poses and explain what they know — and don't know — before they lose more credibility.

• The CDC did not respond to queries before publication, but recently admitted it failed to meet expectations in its COVID response and is taking steps to restructure its operations.
• Julie Fischer, microbiologist and senior technical adviser for CRDF Global, says stumbles in global public health communications during COVID were "scarring" and monkeypox guidance now is still "incredibly frustrating."
• It's important to explain emerging and novel threats effectively to policymakers and individuals so each can make informed decisions on how to diminish the risks to the individual and to the community, Fischer says.

Context: It can take time to gather enough data to yield answers about how the majority of infections are happening, particularly when it's a novel pathogen, like Sars-CoV-2, which officials didn't immediately recognize as spreading asymptomatically — a fact that would have altered COVID guidance significantly.

• "Oftentimes, you get a list of ways [the virus] can transmit, but there's a difference between how you list it in the textbook versus what's actually driving transmission," says Amesh Adalja, senior scholar for Johns Hopkins University's Center for Health Security.
• "There may be some very, very small chance of getting it a certain way in a certain circumstance — but is that actually behind how people are getting infected?" Adalja asks. For example, monkeypox can be spread via surfaces, but "if we remove all the doorknobs from every door, will we still have a monkeypox problem? Yes."

Yes, but: The waiting period while data is gathered is a time when fear and misinformation can foment and people can start to take misguided actions. Misinformation about monkeypox appears to have spread faster than the virus itself.

• This was also seen with the COVID-19 pandemic, where "the message got lost" that public health officials didn't know everything at the start, says Sarah Bauerle Bass, director of Temple University's Risk Communication Laboratory.
• "The messages seemingly just kept changing, and then [public health officials] lost that trust in the public's eye," Bass says.
• "You have to rate [behaviors] from the most risky to the least risky. Because it is possible to contract [monkeypox] from a surface or shared clothing or bedding. ... But, is it as risky as having close sexual contact with someone where you are skin-to-skin? No," she adds.

Respiratory viruses are the most vexing because it's hard to determine if the virus is airborne and can hover or transmit over distances, or if it can spread via aerosols that remain in the air for shorter distances. Plus, something that could be shown in a lab with animals may not be happening in the real world.

• "You can infect a monkey with monkeypox in laboratory conditions by aerosol, but the epidemiology doesn't indicate that's how it's been primarily transmitted in the real world," says Angela Rasmussen, a virologist at the University of Saskatchewan's Vaccine and Infectious Disease Organization.
• Another factor is that there are a limited number of institutions that can safely study airborne transmission of a virus "in a way that is fast enough and efficient enough to satisfy demand when there's an emerging infectious disease," Fischer says.

The big picture: Three main ways to determine transmission are looking at "historical lines of evidence," "epidemiological evidence in the real world," and experimental evidence of potential avenues, Rasmussen says.

• "But there's also the need to explain that risk is not binary. It's not that you're either not at risk or you're almost certainly going to get monkeypox. Everything exists in a shade of gray in between those two extremes."

Zoom in: Read how monkeypox spreads and check out the interactive map by Axios' Erin Davis.