Alaska Health Department Announces A Fatal Alaskapox Infection

 
#17,903

Three days ago in another blog on poxviruses (see A Newly Discovered Poxvirus Detected In Reindeer in Sweden & Norway) I mentioned a 2021 blog on  4 previous cases of Alaskapox, an emerging zoonotic Orthopoxvirus infection, first reported near Fairbanks in 2015. 

Yesterday, Alaska announced a 7th - and fatal - case in their State Epidemiology Bulletin. 

This latest case is unusual for several reasons.  

• First, because it occurred several hundred miles away from the previous 6 cases (all clustered around Fairbanks), appearing instead in the Kenai Peninsula.  
• Second, because all previous cases had been mild (skin lesions with fevers and swollen lymph nodes) that resolved on their own. 

The fatal case was in an elderly man with a a history of drug-induced immunosuppression secondary to cancer treatment.  He spent more than two months hospitalized - during which time he was treated with tecovirimat, intravenous vaccinia immunoglobulin (VIGIV), and oral brincidofovir - but succumbed in late January from acute renal failure and respiratory failure. 

Alaska's Health Department has released a brief new story, a FAQ, and a more detailed report in their  Epidemiological Bulletin.  First, the new release:

Alaskapox virus

Alaskapox virus is an orthopoxvirus that was first identified in a patient in Fairbanks, Alaska, in 2015. Orthopoxviruses are known infect mammals, including humans, and can lead to the development of skin lesions. Since 2015, six additional cases of Alaskapox virus have been reported in Alaska, five of which were in persons living in the Fairbanks North Star Borough and one person was living in the Kenai Peninsula Borough.

Current evidence indicates that Alaskapox virus primarily occurs in small mammals. The virus has been most commonly identified in red-backed voles and shrews, based on small mammal sampling in the Fairbanks North Star Borough. However, it is likely that the virus is more widespread in Alaska's small mammal populations, and infections in humans may have occurred in other patients but were not diagnosed. Domestic pets (cats and dogs) may also play a role in spreading the virus.

To date, no human-to-human transmission of Alaskapox virus has been documented. However, since certain orthopoxviruses can be transmitted through direct contact with skin lesions, we recommend that people with skin lesions possibly caused by Alaskapox keep the affected area covered with a bandage.

Symptoms of Alaskapox have included one or more skin lesions (bumps or pustules) and other symptoms like swollen lymph nodes and joint and/or muscle pain. Immunocompromised people might be at increased risk for more severe illness.

Healthcare providers who suspect Alaskapox virus infection and have not identified an alternative diagnosis should contact the Alaska Section of Epidemiology at 907-269-8000.

Due to its length, I've only posted some excerpts from the much longer Epidemiological Bulletin. Follow the link to read it in its entirety.  I'll have a brief postscript after the break.

Fatal Alaskapox Infection in a Southcentral Alaska Resident 

Bulletin No. 2 February 9, 2024 

Orthopoxviruses are double-stranded DNA viruses, and many are zoonotic, occurring in a range of mammalian taxa.1 Alaskapox virus (AKPV) is a recently discovered orthopoxvirus that was first identified in an adult living near Fairbanks in 2015.2

Seven AKPV infections to date have been reported to the Alaska Section of Epidemiology (SOE). Until December 2023, all reported infections occurred in residents of the Fairbanks area and involved self-limiting illness consisting of a localized rash and lymphadenopathy.3 Small mammal testing in the Fairbanks area identified evidence of current or prior AKPV infection in four different species (though mostly in red-backed voles).4

Evidence suggestive of prior AKPV infection has also been documented in at least one domestic pet linked to a patient. The extent of AKPV’s geographic distribution and animal reservoirs remain unknown. This Bulletin describes a recently reported fatal case of Alaskapox in a resident of the Kenai Peninsula. 

(SNIP)

Discussion

This is the first case of severe Alaskapox infection resulting in hospitalization and death. The patient’s immunocompromised status likely contributed to illness severity. Moreover, being the first case of Alaskapox identified outside of the Interior region, it indicates that AKPV appears to be more geographically widespread in Alaska’s small mammals than previously known and warrants increased statewide awareness among clinicians.

The route of exposure in this case remains unclear, although scratches from the stray cat represent a possible source of inoculation through fomite transmission. SOE is working with the University of Alaska Museum and CDC to test small mammals for AKPV outside of the Interior region.

Recommendations

1. Clinicians should become familiar with the clinical features of Alaskapox and consider testing for orthopoxvirus infection in patients with a clinically compatible illness.2-4

2. Promptly report suspected Alaskapox cases to SOE at 907-269-8000; SOE staff can help facilitate testing.

3. Advise outpatients with suspected Alaskapox to avoid touching lesions, keep lesions dry and covered, practice good hand hygiene, avoid sharing cloth that might have been in contact with lesions, and launder clothing and linens separately from other household items.5

4. Consider prescribing antiviral and VIGIV therapy for immunocompromised Alaskapox patients or those with progressive disease. SOE can assist in obtaining clinical consultations with CDC for access to therapeutics.

5. Hospitalized Alaskapox patients with immunosuppression should be placed under contact precautions. While humanto-human transmission of AKPV has not yet been observed, some orthopoxviruses can spread by direct contact with lesions (particularly broken skin contact with secretions).

6. Immunocompromised clinical staff with broken skin who have either had direct contact with Alaskapox lesions or handled soiled linen or dressings without proper use of personal protective equipment can be offered post-exposure prophylaxis with JYNNEOS™ vaccine.

7. Clinicians should photograph suspected poxvirus lesions to aid in clinical diagnosis; SOE staff and CDC poxvirus experts are available 24/7 to discuss suspected cases.

8. Alaskans should follow CDC guidelines for staying healthy around wildlife to prevent potential AKPV infections.6

9. Refer to the SOE Alaskapox website for more information: https://health.alaska.gov/dph/Epi/id/Pages/Alaskapox.aspx

Admittedly Alaskapox and reindeer pox are unlikely candidates for the next public health crisis, but they do remind us that there are a great many zoonotic viruses out there that we've yet to discover, or currently know very little about. 

In 2013's mBio: A Strategy To Estimate The Number Of Undiscovered Viruses researchers from Columbia University's Mailman School of Public Health, EcoHealth Alliance, the NIH, et al. estimated a `. . . minimum of 320,000 mammalian viruses awaiting discovery.'

More recent studies put that number more than twice that (see One Health, “Disease X” & the challenge of “Unknown” Unknowns). Most won't have pandemic potential, of course. But the reality is, it only takes one `Spanish Flu', or `COVID' virus to claim millions of lives and to disrupt the entire globe for years to come. 

Thirty months ago, in PNAS Research: Intensity and Frequency of Extreme Novel Epidemics, researchers suggested that the probability of novel disease outbreaks will likely grow three-fold in the next few decades.

Which suggests we may be a lot closer to the next global public health crisis than we think.