GIDSAS Monkeypox Outbreak in the US Rashid A

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 Chotani, 2003

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 Chotani, 2003

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 (%) Chotani, 2003 40 (85)

June 15, 2003: GIDSAS Monkeypox – the evolving 53 Total Suspected Cases outbreak 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 – 100 nm. 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. Chotani, 2003

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/Executive. Order 14. pdf Chotani, 2003

GIDSAS Monkeypox With the emergence of novel pathogens like Nipahvirus, Hantavirus, Ebola, Marburg, H 5 N 1 (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. Chotani, 2003

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. Chotani, 2003

GIDSAS 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. Chotani, 2003

GIDSAS 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. 6 th 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. Chotani, 2003

GIDSAS 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. 7 th 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. Chotani, 2003

GIDSAS Chotani, 2003 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, Mc. Intosh K, Connor JD, Benenson AS, Alling DW, Rolfe UT, et al. Primary percutaneous vaccination. J Infect Dis 1977; 135: 145 -54. Mc. Intosh 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.