Thursday, September 20, 2018

Eurosurveillance Rapid Comms: Two cases of Monkeypox imported to the UK

Smallpox Vaccination - Credit CDC


We have a long, and remarkably detailed Rapid Communications published today in the ECDC journal Eurosurveillance on the two recently imported Monkeypox cases to the UK (see UK PHE Imports Smallpox Vaccine For HCWs Caring For Monkeypox Cases), which includes 2 case reports, and details on contact tracing of potentially exposed individuals.
Since Monkeypox had never been seen in the UK before, and because early symptoms are generally non-specific, Monkeypox was not immediately suspected.  As a result, a number of Health care workers were exposed before the patients were isolated.  
Additionally, both cases report being symptomatic prior to flying into the UK, which further increases the number of people who were potentially exposed in transit. 

While not easily transmitted between humans, today's report indicates nearly 250 people are currently being monitored either actively or passively (depending on their level of exposure risk), with more than 100 offered post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP) with the vaccinia vaccine.

This is a very long report, so I've only posted some excerpts.  You'll definitely want to follow the link to read it in its entirety. 

Rapid communication Open Access

Two cases of monkeypox imported to the United Kingdom, September 2018  

Aisling Vaughan1,15, Emma Aarons2, John Astbury3, Sooria Balasegaram3, Mike Beadsworth4,5, Charles R Beck3,14, Meera Chand6,7,8, Catherine O’Connor1, Jake Dunning6,9, Sam Ghebrehewet3, Nick Harper10, Ruth Howlett-Shipley11, Chikwe Ihekweazu12, Michael Jacobs9, Lukeki Kaindama13, Parisha Katwa13, Saye Khoo4,5, Lucy Lamb9,11, Sharon Mawdsley10, Dilys Morgan1, Ruth Palmer10, Nick Phin6, Katherine Russell1, Beng├╝ Said1, Andrew Simpson2, Roberto Vivancos3,15,16, Michael Wade3, Amanda Walsh1, Jennifer Wilburn1

Monkeypox is a rare viral zoonotic disease that occurs mostly in Central and West Africa. In this report, we detail the identification of two separately imported cases of monkeypox to the United Kingdom (UK) in September 2018 and the public health response. Each case was managed as a separate incident in the absence of epidemiological evidence linking them in the UK and the public health responses were conducted accordingly.
The first case, a Nigerian naval officer who was attending a training course at a naval base in Cornwall in the south-west of England, was notified to Public Health England (PHE) on 7 September. He arrived in London from Abuja, Nigeria on 2 September and travelled from London to the military base in Cornwall by train on the same day. 

The case presented to the general practitioner on the naval base on 3 September with fever, lymphadenopathy and a rash in the groin area that had developed the day before leaving Nigeria. The rash was initially thought to be due to a staphylococcal infection and was treated with antibiotics. On 6 September, the rash had spread to the torso, face and arms and after re-examination the patient was isolated in his quarters. Multiple samples including swabs of the lesions were sent for testing at the PHE Rare and Imported Pathogen Laboratory (RIPL). Monkeypox virus DNA was detected by multiple molecular assays and subsequently confirmed by sequencing analysis. The patient was then transported to the High Consequence Infectious Disease (HCID) Unit at the Royal Free Hospital in London. The clinical condition of the case is stable and he is improving.
On 10 September, PHE was notified of a second suspected case of monkeypox infection; the diagnosis was confirmed on 11 September. The individual is a UK resident who had returned from a 22-day holiday in Nigeria on 4 September on a flight via Paris, France. He presented to the Accident and Emergency department at Blackpool Teaching Hospitals on 6 September with fever, lymphadenopathy, a scrotal lump and an itchy maculopapular rash. The rash was reported to have started before departing Nigeria on the face and later spread to other areas including the palms of the hands and had become pustular.

The patient reported being unwell for approximately one week before presentation, following a different febrile illness that had been treated with antibiotics in Nigeria. On clinical examination the patient had crops of vesicles that were progressing and lesions on the mucosal surfaces of the mouth. The patient was isolated at Blackpool Teaching Hospitals from 7 September and multiple samples, including swabs from the lesions, sent to RIPL confirmed the presence of monkeypox DNA by multiple molecular assays. 

Although the patient was isolated, monkeypox was not initially suspected because the first lesions appeared in the groin, and the wearing of full personal protective equipment (a filtering face-piece with three indicating levels of protection (FFP3), eye protection, gloves and sterile disposable gown) was not implemented immediately. A number of healthcare workers (HCW) were potentially exposed as a consequence. The case was transferred to the HCID Unit at the Royal Liverpool University Hospital on 10 September where they remain in a stable condition. 

While the source of infection is not yet known, the patient reported contact with an individual with a monkeypox-like rash at a large family event and consumption of bush meat during his visit to a rural area of Nigeria. Since notification of the first case, no other cases have been identified.
Management of contacts in the United Kingdom
Contacts are being monitored actively or passively depending on their level of exposure risk.
Active surveillance is used for those classified as having a high- or intermediate-risk exposure to a case (direct contact in the South West), their body fluids or potentially infectious materials. This involves the designated PHE contact point contacting the individual every day throughout the 21-day follow-up period to check whether they develop any potential monkeypox prodromal symptoms such as fever, headache, muscle aches, backache, swollen lymph nodes, chills or exhaustion.
Passive surveillance is used for individuals identified as having a low-risk exposure to a case, their body fluids or potentially infectious material (Indirect contact in the South West). They will not be contacted daily during the follow-up period, but will be given a designated PHE contact point to phone if they feel unwell.
Currently 229 of 243 contacts are under investigation; 93 are under active surveillance and 136 are under passive surveillance. Efforts to contact the remainder are ongoing.
Following individual risk assessments (see above), 103 of 229 contacts were offered post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP) with vaccinia vaccine. Fifty-nine community and HCW contacts from the North West were offered PEP (46/59, uptake rate 78%) and 17 community and naval base contacts in the South West were offered PEP (5/17, uptake rate 29%).
In addition, 27 HCWs in the HCID units at the Royal Liverpool (Case 2) and the Royal Free hospital (Case 1) managing the patients were offered PrEP. Vaccinees with symptoms consistent with vaccination reactions [2] arising in the 48 h post-vaccination period would be monitored for a further 48 h to discount those in the prodromal phase of monkeypox infection. The individual is advised to discontinue working and self-isolate at home during this time.
Each individual identified as a contact was provided with an information sheet which describes what monkeypox is, how it is spread, and what the symptoms are. This information sheet provides the individual with a designated PHE contact point and telephone number to ring should they develop any symptoms. Contacts can continue to work with no restrictions on their duties if they are asymptomatic. Individuals who develop any symptoms were directed to phone their designated PHE contact point straight away and to stop working until they are assessed by the Imported Fever Service (IFS). Contacts who were planning to travel out of the UK were advised that they may continue with their plans during their 21 days follow-up period if they are asymptomatic. Any contacts under follow-up who are symptomatic are advised not to travel out of the UK.
        (Continue . . . .)