Download Executive Summary/Abstract

GIDSAS
Monkeypox:
Outbreak in the US
Rashid A. Chotani, MD, MPH
Assistant Professor, School of Medicine & Public Health
Center for International Emergency, Disaster & Refugee Studies
Director, Global Infectious Disease Surveillance & Alert System
Johns Hopkins School of Medicine & Public Health
410-614-8330
Chotani, 2003
GIDSAS
Monkeypox
Dr. Stephen Ostroff, deputy director of the
National Center for Infectious Diseases, Centers
for Disease Control and Prevention answers a
question during a teleconference at the CDC
headquarters in Atlanta Monday, June 9, 2003
Monkeypox is a virus that health officials say has
infected at least four people in the Midwest and
possibly dozens more.
Officials suspect they caught the illness from
exposure to pet prairie dogs.
The disease has never before been reported
in the Western Hemisphere. It is usually
found in remote villages in central and west
Africa.
Chotani, 2003
GIDSAS
Monkeypox: Background
The human monkeypox is caused by a
virus belonging to the genus
Orthopoxvirus
The virus was isolated from primate
tissues in 1958
In 1970, human monkeypox was identified
the Democratic Republic of Congo (DRC)
Zoonotic outbreaks were subsequently
observed in the US and Europe but
monkeypox was not considered a threat to
humans
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GIDSAS
Monkeypox: Background
Mass vaccination and then targeted
vaccination in conjunction with
surveillance resulted in the
elimination of smallpox in 1977
In 1980, after certification activates,
the World Health Organization (WHO),
declared smallpox eradicated.
By 1985, except military personnel
and laboratory workers exposed to
orthopox virus’s smallpox vaccine
was not administered to anyone
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GIDSAS
Monkeypox: Background
Monkeypox clinically causes a
smallpox-like disease (pustular rash,
fever, respiratory symptoms) except
for marked lymphadenopathy in
humans but varies biologically and
epidemiologically
Chotani, 2003
GIDSAS
Monkeypox: Background
Incubation period is between 7 to 17 days
and the disease is characterized by the
onset of a
prodrome of fever,
headache,
backache, and
fatigue.
The rash follows the four stage
progression of
vesiculation,
pustulation,
umbilication, and
encrustation evolving in the same stage over
14-21 days.
Chotani, 2003
GIDSAS
Monkeypox: Background
The pocks concentrate mainly on the
face, arms and legs.
The main source of disease
transmission are animal reservoirs
but person-to-person transmission
has been recorded.
Chotani, 2003
GIDSAS
Monkeypox: Background
The overall case-fatality in Africa has
been reported to be between 1%-10%,
with as high as 17% in the Democratic
Republic of Congo.
A majority of the cases appear in
children under the age of 15 years
and the mortality in this age group is
much higher
Chotani, 2003
GIDSAS
Monkeypox: Epidemiology
1970-80
1981-86
1996-97
2001
Total
No. of cases
47
338
344
23*
752
No. of deaths
8
33
5
5
51
Case-fatality-rate (%)
17
9.8
1.5
17
6.8
Secondary cases No. and (%)
4 (9)
93 (28)
268 (78)
Secondary attack-rate among
close susceptible contacts
(%)
3/40
(7.5)
9
23
Secondary attack-rate among
family members not
vaccinated (%)
4/123
(3.3)
9.3
26
189
(93)**
83
Cases in <15 years (%)
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40 (85)
GIDSAS
Monkeypox – the evolving
outbreak
June 15, 2003:
53 Total Suspected Cases
3 States Involved
12 cases confirmed
Monkeypox, a virus similar
to smallpox, apparently
jumped from possibly an
imported giant Gambian
rat, which is indigenous to
Africa, at a Chicago-area
pet distributor to pet
prairie dogs.
Chotani, 2003
GIDSAS
Monkeypox – the evolving
outbreak
June 15, 2003:
The total number of
suspected victims has risen
to 53
Three states involved in the
outbreak
Wisconsin (17 possible cases)
Indiana (25 possible cases)
Illinois (11 possible cases)
Chotani, 2003
GIDSAS
Monkeypox – the evolving
outbreak
June 15
Confirmed Cases = 12
Indiana 4
Wisconsin 4
Illinois 4
Chotani, 2003
GIDSAS
Chotani, 2003
GIDSAS
Monkeypox – the evolving
outbreak
Of the 53 cases,
29 (49%) cases were among males;
the median age was 26 years (range: 4
to 53 years).
Data were unavailable for sex and age
for 2 and 14 patients, respectively.
A total of 14 (26%) patients have been
hospitalized, including a child aged <10
years with encephalitis.
Chotani, 2003
GIDSAS
Monkeypox – the evolving
outbreak
Clinical information from 30 cases
reported in Illinois and Wisconsin
The earliest reported onset of illness was
on 15 May 2003.
73% (22) of the patients had a febrile
illness which either preceded or
accompanied the onset of a papular rash;
64% (16) had respiratory symptoms,
47% (14) had lymphadenopathy and
33% (10) had sore throat.
Chotani, 2003
GIDSAS
Chotani, 2003
Monkeypox: Clinical Features
in the US
Source: MMWR, CDC
GIDSAS
Monkeypox – the evolving
outbreak
The rash typically progressed through
stages of
vesiculation,
pustulation,
umbilication, and
encrustation.
Chotani, 2003
GIDSAS
Monkeypox – the evolving
outbreak
Early lesions became ulcerated in some
patients.
Rash distribution and lesions have occurred
on the
head,
trunk, and
extremities;
many patients had initial and satellite lesions
on
palms,
soles, and
extremities.
Rashes were generalized in some patients.
Chotani, 2003
GIDSAS
Negative strain
electron micrograph
of Monkeypox virus
identified in vesicle
fluid from an
infected patient
within the Wisconsin
2003 outbreak.
Morphologic
features of viruses in
clinical specimen are
often less distinct
than cell culture
isolate. Bar – 100nm.
Chotani, 2003
Source: CDC
GIDSAS
Chotani, 2003
US Outbreak: Epicurve
Source: MMWR, CDC
GIDSAS
Child: Secondary lesions 5/27/03, adjacent to
primary inoculation site on left hand
Source: Reed at el. Marshfield Clinic
Chotani, 2003
GIDSAS
Child, Marshfield Index Case: Primary inoculation site
right index finger, 5/27/03. 14 days after prairie dog
bites, 11 days post febrile illness, hospital day 5
Source: Reed at el. Marshfield Clinic
Chotani, 2003
GIDSAS
Child: Disseminated acral lesions 5/27/03
Source: Reed at el. Marshfield Clinic
Chotani, 2003
GIDSAS
Mother, 5/27/03, I day after vesicles & erythema at
site of cat scratch. Sweats, fever, and malaise the
night of 5/26/03. Had sore throat.
Source: Reed at el. Marshfield Clinic
Chotani, 2003
GIDSAS
Mother: 05/29/03, expansion of vesicles beyond
biopsy site of 05/27/03. Note satellite vesicles.
Source: Reed at el. Marshfield Clinic
Chotani, 2003
GIDSAS
Father, 06/05/03, after fevers, sweats,
malaise on 05/31-06/01/03. Feels well.
Source: Reed at el. Marshfield Clinic
Chotani, 2003
GIDSAS
Father, 06/05/03
Source: Reed at el. Marshfield Clinic
Chotani, 2003
GIDSAS
Monkeypox
Everyone who has caught it has been
in close contact with the animals.
The rest of the victims were in families
that purchased the animals.
One caught it from a rabbit that had
been in contact with a sick prairie dog.
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GIDSAS
A giant Gambian rat curls up in it's cage at Chicago's
Lincoln Park Zoo Monday, June 9, 2003. Federal health
officials are investigating four confirmed cases of
monkeypox which they say are likely linked to a
Gambian rat from Chicago-area pet distributor.
(AP Photo/Aynsley Floyd)
Chotani, 2003
GIDSAS
Monkeypox
Fear - that the virus will obtain a
permanent foothold in the United
States, much as West Nile virus did
after a case was identified in New York
City in 1999.
West Nile virus spread
from coast to coast,
infecting nearly 4200.
Chotani, 2003
GIDSAS
Monkeypox
The Centers for Disease Control and
Prevention (CDC) has issued interim
Guidance for Use of Smallpox Vaccine,
Cidofovir, and Vaccinia Immune Globulin
(VIG) for prevention and treatment in the
setting of outbreak of monkeypox.
They can be found at the following link:
http://www.cdc.gov/ncidod/monkeypox
/treatmentguidelines.htm
Chotani, 2003
GIDSAS
Monkeypox
The CDC and Food and Drug Administration (FDA)
has imposed embargo on export of all rodents from
Africa as well as prohibitions in terms of
transporting, sale, distribution or release in the
environment of prairie dogs as well as African
rodents including
tree squirrels (Heliosciurus sp.),
rope squirrels (Funisciurus sp.),
dormice (Graphiurus sp.),
Gambian giant pouched rats (Cricetomys sp.),
brush-tailed porcupines (Atherurus sp.), and
striped mice (Hybomys sp.).
Detailed guidelines are available at the following
links:
http://www.dhfs.state.wi.us/dph_bcd/monkeypox/Response.htm
http://www.idph.state.il.us/pdf/ExecutiveOrder14.pdf
Chotani, 2003
GIDSAS
Monkeypox
With the emergence of novel
pathogens like Nipahvirus,
Hantavirus, Ebola, Marburg, H5N1
(avian flu), SARS and now
monkeypox, at times in unlikely
geographic areas, serves a reminder
that scary pathogens continue to
emerge.
Chotani, 2003
GIDSAS
Monkeypox
Resources need to be allocated
for enhancing the global and
national infectious disease
surveillance capacity as well as
active research on emerging and
re-emerging infectious disease.
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GIDSAS
Selected reading on Monkeypox
Marennikova SS, Seluhina EM, Mal'ceva NN, Cimiskjan KL,
Macevic GR. Isolation and properties of the causal agent of
a new variola-like disease (monkeypox) in man. Bull World
Health Organ 1972;46:599-611.
Arita I, Jezek Z, Khodakevich L, Ruti K. Human monkeypox:
a newly emerged orthopoxvirus zoonosis in the tropical rain
forests of Africa. Am J Trop Med Hyg 1985;34:781-9.
Jezek Z, Fenner F. Human monkeypox. In: JL Melnick, editor.
Monographs in virology. Volume 17. Basel: Karger; 1988.
von Magnus P, Andersen EK, Petersen KB, Birch-Andersen
A. A pox-like disease in cynomolgus monkeys. Acta Pathol
Microbiol Scand 1959;46:156-76.
Khodakevich L, Jezek Z, Messinger D. Monkeypox virus:
ecology and public health significance. Bull World Health
Organ 1988;66:747-52.
Khodakevich L, Szczeniowski M, Manbu-ma-Disu, Jezek Z,
Marennikova S, Nakano J, et al. The role of squirrels in
sustaining monkeypox virus transmission. Trop Geogr Med
1987;39:115-22.
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Selected reading on Monkeypox
Fine PE, Jezek Z, Grab B, Dixon H. The transmission
potential of monkeypox virus in human populations. Int J
Epidemiol 1988;17:643-50.
Jezek Z, Grab B, Szczeniowski MV, Paluku KM, Mutombo
M. Human monkeypox: secondary attack rates. Bull World
Health Organ 1988;66:465-70.
Jezek Z, Arita I, Mutombo M, Dunn C, Nakano JH,
Szezeniowski M. Four generations of probable person-toperson transmission of human monkeypox. Am J
Epidemiol 1986;123:1004-12.
Mukinda VB, Mwema G, Kilundu M, Heymann DL, Khan
AS, Esposito JJ. Re-emergence of human monkeypox in
Zaire in 1996. Lancet 1997;349:1449-50.
Centers for Disease Control and Prevention. Human
monkeypox- Zaire, 1996-1997. MMWR Morb Mortal Wkly
Rep 1997;46:304-7.
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Selected reading on Monkeypox
Mills JN, Childs JE, Ksiazek TG, Peters CJ, Velleca
WM. Methods for trapping and sampling small
mammals for virologic testing. Atlanta: Centers for
Disease Control and Prevention; 1995.
Esposito JJ, Massung RF. Poxvirus infections in
humans. In: Murray PR, Tenover F, Baron EJ, Pfaller
MA, Yolken RH, editors. Manual of clinical
microbiology. 6th ed. Washington: ASM Press;1995. p.
1131-8.
Towbin H, Staehelin T, Gordon J. Electrophoretic
transfer of proteins from polyacrylamide gels to
nitrocellulose sheets: procedure and some
applications. Proc Natl Acad Sci U S A 1979;76:4350-4.
Loparev VN, Parsons JM, Knight JC, Panus JF, Ray CA,
Buller RM, et al. A third distinct tumor necrosis factor
receptor of orthopoxviruses. Proc Natl Acad Sci U S A
1998;95:3786-91.
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Selected reading on Monkeypox
Ropp SL, Esposito JJ, Loparev VN, Palumbo G.
Poxviruses infecting humans. In: Murray PR, Barron
CJ, Pfaller MA, Tenover FC, Yolken RH, editors. Manual
of clinical microbiology. 7th ed. Washington: ASM
Press; 1999. p. 1137-44.
Ropp SL, Jin Q, Knight JC, Massung RF, Esposito JJ.
PCR strategy for identification and differentiation of
smallpox and other orthopoxviruses. J Clin Microbiol
1995;33:2069-76.
Esposito JJ, Knight JC. Orthopoxvirus DNA: a
comparison of restriction profiles and maps. Virology
1985;143:230-51.
Jezek Z, Szczeniowski M, Paluku KM, Mutombo M,
Grab B. Human monkeypox: confusion with
chickenpox. Acta Trop 1988;45:297-307.
Centers for Disease Control and Prevention. Human
monkeypox--Kasai Oriental, Democratic Republic of
Congo, February 1996-October 1997. MMWR Morb
Mortal Wkly Rep 1997;46:1168-71.
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Selected reading on Monkeypox
Dean AG, Dean JA, Coulombier D, Burton AH, Brendel
KA, Smith DC. Epi Info, version 6: A word-processing,
database, and statistics program for public health on
IBM-compatible microcomputers. Atlanta: Centers for
Disease Control and Prevention; 1994.
Fenner F, Wittek R, Dumbell KR. The Orthopoxviruses.
San Diego: Academic Press; 1989. p. 162-5, 312-15.
Ziegler DW, Hutchinson HD, Koplan JP, Nakano JH.
Detection by radioimmunoassay of antibodies in human
smallpox patients and vaccinees. J Clin Microbiol
1975;1:311-7.
Cherry JD, McIntosh K, Connor JD, Benenson AS, Alling
DW, Rolfe UT, et al. Primary percutaneous vaccination. J
Infect Dis 1977;135:145-54.
McIntosh K, Cherry JD, Benenson AS, Connor JD, Alling
DW, Rolfe UT, et al. Clinical and serologic study of four
smallpox vaccines comparing variations of dose and
route of administration. Standard percutaneous
revaccination of children who receive primary
percutaneous vaccination. J Infect Dis 1977;135:155-66.
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