#16,070
On Friday evening, in CDC & Texas Confirm Monkeypox In US Traveler ex Nigeria, we looked at the first confirmed cases of Monkeypox in the United States since the multi-state outbreak in 2003. While endemic in west and central Africa, in recent years we've seen a spate of exported cases arrive in the UK, Singapore, Israel, and this week the United States.
While the risk of seeing a community outbreak of Monkeypox in the United States is probably very low - last summer, in WHO: Modelling Human-to-Human Transmission of Monkeypox, we looked at a WHO assessment which cautioned `. . . . with declining immunity to orthopoxvirus species, monkeypox can pose an ever-increasing threat for health security.'The UK is apparently still dealing with a limited household outbreak (see ECDC CDTR: 3rd Monkeypox Case In the UK), the 5th, 6th, and 7th case reported in the UK since 2018 (see here and here).
First the text from the HAN advisory, then I'll return with a postscript.
Potential Exposure to Person with Confirmed Human Monkeypox Infection — United States, 2021
Distributed via the CDC Health Alert Network
July 17, 2021, 5:00 PM ET
CDCHAN-00446
Summary
The Centers for Disease Control and Prevention (CDC), in collaboration with the Texas Department of State Health Services and Dallas County Health and Human Services, is investigating a single case of monkeypox virus infection in a U.S. citizen who resides in the United States and recently returned from travel to Nigeria. The patient traveled to Dallas from Lagos, Nigeria, via Atlanta on two separate flights during July 8-9, 2021. The patient presented to an emergency department in Dallas, Texas on July 13 for complaints of a rash that began on July 7, one day prior to travel. Testing at Dallas County and CDC confirmed the presence of monkeypox virus.
CDC is working with the airlines to share information with state and local health officials to contact airline passengers and others who may have been in contact with the patient during two flights: Lagos, Nigeria, to Atlanta on July 8, with arrival on July 9; and Atlanta to Dallas on July 9. CDC is issuing this health advisory to ask clinicians to consider a diagnosis of monkeypox in people who present with a febrile prodrome followed by rash and who may have had direct or indirect contact with the patient.
Background
Monkeypox is endemic to several Central and West African nations. Recent cases outside of Africa either reported recent travel to one of these countries or contact with a person with confirmed monkeypox.
Symptoms of monkeypox most often begin with a prodrome of fever and other non-specific symptoms such as malaise, headache, and muscle aches following an average incubation period of 5-13 days. After the prodrome, which lasts approximately one to three days, a generalized rash appears. Nearly all patients with monkeypox have had fever early in illness onset and prior to the rash onset. Although lesions often begin on the face before spreading to other parts of the body, there has been at least one report of lesions beginning in the groin region. Lesions progress through specific stages—macules, papules, vesicles, and pustules—before scabbing and falling off1. The rash appearance of monkeypox is very similar to that of smallpox, including a centrifugal distribution and lesions on the palms and soles. Monkeypox can occur concurrently with other rash illnesses, including varicella-zoster virus and herpes simplex virus infections. Case fatality ranges between 1 and 10%. Laboratory confirmation of monkeypox is performed using real-time polymerase chain reaction (PCR) on lesion material.
A person is considered infectious beginning five days prior to rash onset and is presumed to remain infectious until lesions have crusted, those crusts have separated, and a fresh layer of skin has formed underneath. Human-to-human transmission is thought to occur primarily through large respiratory droplets. Respiratory droplets generally cannot travel more than a few feet, so prolonged face-to-face contact is required. Transmission can also occur by direct contact with body fluids or lesion material. Indirect contact with lesion material through fomites has also been documented. Animal-to-human transmission may occur through a bite or scratch, preparation of wild game, and direct or indirect contact with body fluids or lesion material.
There is no specific treatment for monkeypox virus infection, although antivirals developed for use in patients with smallpox may prove beneficial2. Persons with direct contact (i.e., exposure to the skin, crusts, bodily fluids, or other materials) or indirect contact (e.g., presence within a 6-foot radius in the absence of an N95 or filtering respiratory for ≥ 3 hours) with a monkeypox patient should be monitored by health departments; some persons may be candidates for post-exposure prophylaxis with smallpox vaccine after consultation with public health authorities.
Recommendations for Clinicians
- If clinicians identify patients with a constellation of signs and symptoms that could be monkeypox, a travel history should be solicited. Monkeypox should be considered in patients with unexplained onset of fever, chills, new rash, or new lymphadenopathy, and a history of 1) air travel from Lagos Murtala Muhammed International Airport, Nigeria, to Hartsfield-Jackson Atlanta International Airport on July 8 with arrival on July 9, 2) air travel from Atlanta to Dallas Love Field Airport on July 9, or 3) presence in those airports on July 8-9.
- Patients with suspected monkeypox should be isolated in a negative pressure room, and all personnel should wear personal protective equipment (PPE) in accordance with recommendations for standard, contact, and airborne precautions3. All healthcare workers (e.g., clinical staff and environmental staff) caring for a patient with suspect or confirmed monkeypox should be communicated the importance of maintaining proper isolation precautions so that infection is not transmitted to them or others.
- Clinicians should consult their state health department or CDC’s monkeypox call center through the CDC Emergency Operations Center (770-488-7100) as soon as monkeypox is suspected.
Recommendations for Health DepartmentsIdeal specimens for laboratory testing include lesion fluid, lesion roof, scabs, and crusts. Serum and whole blood can also be collected. Best practices are to collect multiple specimens from different locations on the body. Detailed specimen submission instructions are available at CDC’s monkeypox website5.
- If monkeypox is suspected by the health department, then CDC should be consulted through the CDC Emergency Operations Center (770-488-7100).
- After consultation with CDC, samples can be sent to CDC or an appropriate Laboratory Response Network for confirmatory testing by PCR4.
- Send all specimens through the state/territorial public health department, unless authorized to send directly to CDC.
Recommendations for the Public
Individuals who have had contact with a suspect or confirmed monkeypox case should contact their health department for a risk assessment.
For More Information
Contact your local health department if you have any questions or suspect a patient may have monkeypox.
CDC
CDC-INFO or 1-800-232-4636
CDC 24/7 Emergency Operations Center (EOC): 770-488-7100
References
A recurrent theme in this blog is that most of the infectious disease threats humans face today are zoonotic (originate in animal hosts), and that the incidence of these diseases jumping species has increased markedly over the past 3 decades.
Seven years ago, in Emerging zoonotic viral diseases L.-F. Wang (1, 2) * & G. Crameri wrote:
The last 30 years have seen a rise in emerging infectious diseases in humans and of these over 70% are zoonotic (2, 3). Zoonotic infections are not new. They have always featured among the wide range of human diseases and most, e.g. anthrax, tuberculosis, plague, yellow fever and influenza, have come from domestic animals, poultry and livestock. However, with changes in the environment, human behaviour and habitat, increasingly these infections are emerging from wildlife species.
We explored some of the reasons behind this shift nearly a decade ago in The Third Epidemiological Transition - which focused on the work of anthropologist and researcher George Armelagos (May 22, 1936 - May 15, 2014) - of Emory University.
Emerging infectious diseases are considered such an important public health threat that the CDC maintains as special division – NCEZID (National Center for Emerging and Zoonotic Infectious Diseases) – to deal with them, and 26 years ago the CDC established the EID Journal dedicated to research on emerging infectious diseases.
And over the past 15 years we've followed dozens of EIDs, including MERS-CoV, H5N1, H7N9, H5N6, H10N8, EA H1N1 G4, Zika, Chikungunya, Ebola, Lyme Disease, SFTS, Nipah and Hendra, Hantavirus, The Heartland Virus, the Bourbon Virus, and many more.
While most of these emerging disease threats don't have serious pandemic potential, the sudden emergence of COVID-19 illustrates how quickly we can be blindsided by an obscure or unknown threat.
Even something with less than pandemic potential (like Zika, Ebola, Lyme Disease, and yes . . . even Monkeypox) can have profound impacts on public health, albeit most likely on a local or regional level.
Which is why we keep a such a close watch on the obscure, rare, or newly emerging infectious disease threats along with the more common ones.
