A little over three weeks ago, in Nigerian CDC: Suspected Monkeypox Outbreak in Baylesa State, we saw the first report of suspected cases of Monkeypox in the West African nation of Nigeria in nearly 40 years. Initially suspected in an 11 year old male patient in Bayelsa State, within days 11 other suspect cases were identified.
Unable to test for the virus locally, samples were sent to the WHO Regional Laboratory in Dakar, Senegal - where - after 11 days (Oct 16th), we learned that 3 cases had tested positive for the virus, while 12 others were negative.The CDC also reported `a total of 43 other SUSPECTED cases have been reported from eight other States (Akwa Ibom, Cross River, Ekiti, Lagos, Enugu, Nasarawa, Rivers, and FCT)'. Four cases from Lagos State had already tested negative, and the CDC expected that many of these cases would test negative as well.
Despite this reassurance - and the fact that no deaths had been reported - the level of panic and the number of conspiracy theories in the local press and on social media continued to rise.
Eleven days after confirming the first three cases, yesterday the Nigerian CDC announced 6 more positive cases, detected across 4 additional Nigerian states.What accounts for this sudden appearance of a rare zoonotic virus across 5 different Nigerian states is a bit of mystery, as thus far no epidemiological links have been disclosed between these cases.
Meanwhile - according to yesterday's report - the number of suspected cases across the country continues to rise:
As at the 25th of October 2017, a total of 94 suspected cases have been reported from 11 States (Akwa Ibom, Bayelsa, Cross River, Delta, Ekiti, Enugu, Imo, Lagos, Nasarawa, Niger, Rivers) and the Federal Capital Territory (FCT).Unlike previous reports, this latest update doesn't mention any negative tests, only the number of positive cases. First the full statement from the Nigerian CDC, after which I'll return with a bit more on the Monkeypox (MPXV) virus.
Friday, October 27, 2017
27 October 2017 | Abuja – MONKEYPOX: SIX MORE CASES CONFIRMED - Minister of State for Health Calls For Calm.
The Honourable Minister of State for Health, Dr. Osagie Ehanire has announced laboratory confirmation of six additional cases among the suspected cases for Monkeypox. These include two cases each in Bayelsa and Akwa Ibom States, one in Enugu State and one in the Federal Capital Territory. With this, there are nine confirmed cases of Monkeypox in Nigeria.
Announcing this in his office today, Dr. Ehanire noted that investigations are on-going to see if any of the new cases has a link with the Bayelsa cluster, where the outbreak started. He called for calm among members of the public, as the Nigeria Centre for Disease Control (NCDC) is working with all affected States to ensure case finding and adequate management.
He added that as frightening as the manifestation of the ailment may seem, no fatality has been recorded to date. As at the 25th of October 2017, a total of 94 suspected cases have been reported from 11 States (Akwa Ibom, Bayelsa, Cross River, Delta, Ekiti, Enugu, Imo, Lagos, Nasarawa, Niger, Rivers) and the Federal Capital Territory (FCT).
He noted that the newly confirmed cases are patients already being managed by public health authorities and have been receiving appropriate clinical care since onset of the illness.
The Federal Ministry of Health, through the NCDC, is in close contact with all State Epidemiology Teams, as well as the health facilities providing clinical care to both suspected and confirmed cases. State Commissioners of Health have been advised to place all health care facilities and Disease Surveillance and Notification Officers on alert, to ensure early case detection, reporting and effective treatment.
A National-level Emergency Operations Centre (EOC) led by the NCDC with support from our development partners, is coordinating outbreak investigation and response across affected States. The EOC includes the Federal Ministry of Agriculture and Rural Development, as well as experts from partner agencies. The EOC provides daily support to State Ministries of Health in active case finding, epidemiological investigation, contact tracing, case management, psychosocial support and risk communication.
The NCDC has also deployed Rapid Response Teams to the four States with confirmed cases. Measures have been put in place to ensure proper investigation of all reported cases, effective sample collection and testing, as well as case management of all suspected and confirmed cases. Risk communication activities have been heightened to advise the public as well as healthcare workers on preventive measures. A nationwide communications campaign has begun, to inform Nigerians of key preventive measures to take to curtail the further spread of monkeypox.
The NCDC has been working with poxvirus experts from the World Health Organization and the U.S. Centers for Disease Control and Prevention to ensure that every available step is taken to trace how this outbreak may be spreading, and in understanding the links between case clusters, in order to prevent further spread.
An Interim National Guideline for Monkeypox has been developed and disseminated to all States for coordination of response activities. This is also available via http://ncdc.gov.ng/themes/common/docs/protocols/50_1508912430.pdf.
Monkeypox is a largely self-limiting disease i.e. a disease that resolves itself. Generalised vesicular skin rashes, fever, and painful jaw swelling are characteristic symptoms associated with an infection. Although there is no specific medicine to treat the disease, when intensive supportive care is provided virtually all patients recover fully, as we have seen with the current outbreak.
It is thought that people could get Monkeypox if they are bitten or scratched by an animal, or contact animal blood in preparing bushmeat or have contact with an infected animal’s body fluids or sores. Monkeypox may also be spread between people through prolonged face-to-face contact, or through contact with body fluids or sores of an infected person, or items that have been contaminated with fluids or sores (clothing, bedding, etc.), Ehanire said.
Measures that can be taken to prevent infection with Monkeypox virus include avoiding contact with animals that could carry the virus such as rodents and bushmeat, especially animals that appear sick or were found dead in areas where Monkeypox occurs.
The public is advised to always wash hands with soap and water after contact with animals or, when caring for sick relatives, or managing soiled beddings.
Nigerians are once again advised to remain calm and supportive of public health authorities, avoid self-medication and report to the nearest health facility if feeling unwell or notice any of the above symptoms in anyone around you. It is important to reiterate that supportive care can be provided and full recovery is mostly the case.
Health care workers are strongly advised to take prescribed universal precautions while handling patients and/or body fluids at all times. They are also urged to be alert, be familiar with the symptoms and maintain a high index of suspicion. They are urged to adhere to guidelines stated in the Interim National Guideline for Monkeypox, and to report all suspected cases to the Local Government Area or State Disease Surveillance and Notification Officers (DSNOs).
To call the Emergency Operations Centre: +2348148216538, Email: email@example.com.According to the CDC:There are two distinct genetic groups (clades) of monkeypox virus—Central African and West African. West African monkeypox is associated with milder disease, fewer deaths, and limited human-to-human transmission.
Dr. Osagie Ehanire,
Honourable Minister of State for Health,
The more severe form of Monkeypox is most commonly found in the Central Africa countries of the DRC and the CAR - where outbreaks have been on the rise for years - presumably because smallpox vaccinations (which provided up to 85% protection) were halted in the late 1970s.As the percentage of vaccinated members of the community dwindles, the risks of outbreaks is only expected to increase (see 2010 PNAS study Major increase in human monkeypox incidence 30 years after smallpox vaccination campaigns cease in the Democratic Republic of Congo).
Like all viruses, Monkeypox continues to evolve and diversify, as discussed in the 2014 EID Journal article Genomic Variability of Monkeypox Virus among Humans, Democratic Republic of the Congo, where the authors cautioned:
Small genetic changes could favor adaptation to a human host, and this potential is greatest for pathogens with moderate transmission rates (such as MPXV) (40). The ability to spread rapidly and efficiently from human to human could enhance spread by travelers to new regions.
Therefore, active disease surveillance should continue to be used monitor MPXV for changes that are consistent with increasing adaptation to humans. Continued active surveillance of the Sankuru District, and expansion to all other regions where the virus is known or predicted to circulate, would help determine the true geographic range of this virus.
Given the apparent rapid evolution of this virus, when suspected or confirmed cases in humans are observed, health authorities in presently unaffected areas should become vigilant and actively prepare to take immediate action.While this outbreak remains small, the concurrent appearance of MPXV after four decades across (at least) 5 different Nigerian states is unusual enough to warrant our close attention.