Monkeypox

Monkeypox Data Collated from: ProMed 6/7, 6/10, 6/11, 6/12, 2003; CDC http://www.cdc.gov.ncidod/monkey.pox/factsheet.htm; Marshfield Clinic Web site; MMWR 2003;52:537; and Milwaukee Journal Sentinel 6/11/2003: History: Monkeypox was initially described as a poxvirus in monkeys in 1958, and it was first described as a human pathogen in 1970. Ground squirrels and rodents are the principle natural hosts. This virus may cause a mild disease in monkeys, but the name is now viewed as a misnomer. The disease in humans and the anima reservoir have been restricted to West and Central Africa until May 16, 2003 when the first case was noted in a three-year-old child in Wisconsin. This case was traced to a recently purchased prairie dog that apparently had acquired the infection from animals purchased from Ghana in April by a Texas importer who sold prairie dogs and Gambian giant rats to a distributor in Illinois. Through June 18, 2003, there were 93 cases of monkeypox in the US including Wisconsin (44 cases), Indiana (24), Illinois (19), Ohio (4), Kansas (1), Missouri (1), and New Jersey (1) (NY Times, 6/19/03). Analysis of the first 53 cases showed all 50 had contact with prairie dogs that were purchased from Phil’s Pocket Pets of Villa Park, Illinois. Records from this dealer indicate 200 prairie dogs were purchased, 63 were sold to identified customers, 70 were euthanized, and 67 are, as yet, not accounted for (Washington Post, 6/11/03). The implicated shipment to the Texas importer included 800 small mammals representing nine species (MMWR 2003;52:537). First Case: (Milwaukee Journal Sentinel, 6/10/03): On Mother’s Day (5/11/03) a 28-year-old woman from Wisconsin received two prairie dogs at a pet swap meet to add to her pet menagerie that included 13 cats, 7 horses, 4 goats, and 3 donkeys. On 5/13, one of the prairie dogs bit her daughter on a right finger and left palm. On 5/15, the prairie dog was sick with skin lesions and drainage from the nose and the eyes. On 5/16, the 3-year-old daughter developed fever and on 5/20, the bite sites were whitish, she had a cough and then developed a diffuse vesicula rash with ocular drainage. She was hospitalized on 5/22 and noted to have the above findings and an enlarged submandibular gland. On 5/27, the 28-year-old mother developed a vesicular lesion at a cat scratch site on the right hand and then developed disseminated lesions. On 5/31, the father developed sweats, multiple skin lesions, and axillary adenopathy. On June 5, the family was seen in the Marshfield Clinic and all were then well. Orthopoxvirus was seen on biopsy of the skin lesion in the mother, the submandibular gland in the daughter, and from necropsy specimens from the prairie dog; cultures from these specimens were also positive for an orthopoxvirus. In tracing the epidemiology, it appears that monkeypox-infected Gambian giant rats were imported in Texas, sold to an anima distributor in Illinois and distributed through 1 or 2 pet stores and pet swap meets in Wisconsin. Virus: Monkeypox is a member of the orthopoxvirus group that includes smallpox virus, vaccinia, and cowpox. As noted, it has been identified exclusively in Central and West Africa until these recent cases in the US. Clinical Features: Source: The usual source is a bite or direct contact with an infected mamma with transmission via blood, body fluid or lesions; less common is person-to-person (see below). Incubation period: The range is 7 to 17 days and the average is 12 days. Symptoms: The initial symptoms are fever, chills, sore throat, cough, headache, myalgias, blepharoconjunctivitis, and adenopathy. After 1 to 3 days, there is the onset of the rash that is often initially on the face and then becomes generalized, including involvement of palms and soles. The rash evolves like smallpox with papules, vesicles, pustules, and then scabs that evolve over 2–4 weeks. The disease is reportedly fatal in 1–10%, as encountered in Africa, and children seem to be at greatest risk for lethal outcome. Distinction from smallpox: The key elements are the animal contact and physical examination showing pronounced adenopathy. Transmission: The usual source is bite or contact with an infected animal via blood, body fluids, or lesions. The usual animal source is small mammals, especially prairie dogs or Gambian giant rats. There also appears to be person-to-person spread, although this is much less common and usually involves large respiratory droplets with prolonged face-to-face contact, or contact with lesions. Another potential source is contact with contaminated sources including bedding and clothes. Investigation of the first 53 US cases showed that 51 had contact with prairie dogs, one had contact with a Gambian giant rant, and one had contact with a rabbit that was sick after prior contact with a prairie dog. Two patients had contact with lesions or ocular drainage from other patients. At least one case involves a health care worker without animal contact (Baltimore Sun, Associated Press, 6/13/03). Diagnosis Clinical: The typical clinical features are fever, cough, headache, myalgias, the characteristic rash, and adenopathy with onset within three weeks of contact with an infected animal or patient source. Virologic diagnosis: Specimens are the same as those used to detect smallpox, or vaccinia (see http://www.bt.cdc.gov/agent/smallpox/lab-testing). The poxvirus may be detected by culture, PCR, serology, electron microscopy a by immunohistochemistry. Case Definition CDC (www.cdc.gov/ncidod/monkeypox/casedefinition.htm and Wisconsin Division of Public Health) Clinical description: Includes 1) fever; 2) other clinical features, including chills, sweats, headache, backache, adenopathy, sore throat, dyspnea, cough, and rash that is macular, papular, vesicular, or pustular; localized or diffused; discrete or confluent. Laboratory diagnosis: 1) Isolation of the virus in culture; 2) demonstration of monkeypox DNA by PCR; 3) demonstration of characteristic orthopox virus by EM without exposure to alternative orthopox virus; or 4) demonstration of orthopoxvirus by immunohistochemical test. Epidemiologic criteria (CDC): 1) Exposure to exotic or wild mammalian pet (prairie dog, Gambian giant rat or rope squirrel) obtained after 4/15/03 with clinical signs of illness (conjunctivitis, respiratory symptoms, rash); 2) exposure to wild mammalian pet that has been contact source of monkeypox in a mammalian pet or person; or 3) exposure (skin-to-skin or face-to-face) with suspected or confirmed case. Epidemiologic criteria (Wisconsin Division of Public Health): Contact with prairie dog or Gambian giant rat originally obtained on or after 4/1/03 from SK Exotics or Phil’s Pocket Pets, or contact with an animal housed with these animals at the designated sources or contact (skin-skin or face-face) with human case. Prevention Public health: Importation of all rodents from Africa is banned. Within the US, the sale, distribution or release of the following: is prohibited: prairie dogs, Gambian giant pouched rats, bush-tailed porcupines, striped mice, three squirrels, rope squirrels, and dormice. Public: Avoid contact with prairie dog or with Gambian giant rats that appear ill, especially with the characteristic clinical features of missing fur, visible rash, or nasal/eye drainage. Hand hygiene if contact occurs. Pet owners: Separate suspect animals from people, wear gloves and mask for any contact, and notify the health department. Contact a veterinarian for advice about transport. Clean surfaces with standard disinfectant. (See http://www.cdc.gov/ncidod/monkeypox). Infection control: Suspected cases should be managed with standard contact and airborne isolation meaning hand hygiene, gowns, and gloves with goggle for possible ocular exposure, N95 mask (if not available use surgical mask) and negative pressure room (or private room if negative pressure is not available). Contacts: 1) Surveillance for 21 days postexposure with concern for fever, rash, or respiratory symptoms; 2) may continue daily activities—work, school, etc.; 3) monitor temperatures bid. Smallpox vaccination: Prior studies show 385% protection with preexposure vaccination (Fine et al. Int J Epidemiol 1988;17:643). Smallpox vaccination is recommended by ACIP for laboratory and health care workers who are occupationally exposed to non-variola orthopoxyviruses (MMWR 1992;41:31). The efficacy of post-exposure smallpox vaccination is not known, but the experience with smallpox suggests efficacy. Caution needs to be advised based on the previous concerns with smallpox vaccination and its potential consequences noting that the mortality with monkeypox is substantially lower than with smallpox, 1–10% in prior reports from Africa and none in the 53 cases reported to date in the US. Smallpox Vaccination Recommendations (CDC) Persons investigating suspected human or animal monkeypox: Preference is for personnel with prior smallpox vaccinations, preferably within 1 to 3 years. Unvaccinated investigators should be vaccinated, preferably within 4 days of exposure. Health care workers: Preference is for HCW with prior smallpox vaccination; if not available, vaccinate prior to clinical care. If HCW is already caring for suspected or established case—vaccinate as soon as possible, after exposure vaccine, is recommended if given within 4 days of initial exposure and should be considered if within 2 weeks. Contacts: Persons with direct or close contact (≤3 feet for 3 hours with a sick prairie dog acquired after 4/15/03 should receive smallpox vaccination within 4 days of exposure; this vaccination should be considered if contact is up to 2 weeks previously. The standard contraindications to smallpox vaccination apply. (This includes HIV infection, but here, the CDC specifies those with a CD4 count <200/mm3). Treatment (CDC): Smallpox vaccination may presumably be given early in the course of monkeypox in a fashion analogous to its use in smallpox. Cidofovir is active in vitro, but there is no clinical experience to date with its use for prophylaxis or treatment. The same applies to VIG. Reporting: All established or suspected cases of monkeypox in people or pets should be reported to the state health department. SARS and Infection Control Dealing with SARS in a Hospital (Hosp Infect Control 2003;30:77): The hospital has been the major source for SARS in both patients and health care workers and the following summarizes the major points made from an audio conference “SARS What US Hospitals Must Learn From the Canadian Outbreak” that can be purchased at 800 688–2421. Case definition: The CDC case definition has changed three times; the most recent version is available at http://www.cdc.gov/ncidod/sars/casedefinition.htm. Isolation vs. quarantine: These must be distinguished. Isolation refers to sick people who are separated from others. Quarantine applies to healthy person who are believed to have been exposed to a communicable disease and have a requested restriction in interactions during the incubation period (during the Toronto outbreak, at least 10,000 persons were quarantined and in China, the total exceeds 30,000). Triage: The recommendation is to post signs in emergency departments and clinics asking persons with epidemiologic risks (travel to designated areas or close contact with cases) combined with fever, cough, or dyspnea to: 1) wear a surgical mask; 2) be evaluated in a room with negative pressure or HEPA filtration; and 3) use contact precautions. If negative pressure rooms and HEPA filtration are not available, there should be a private room for evaluation. Health care workers should use hand hygiene, follow CDC guidelines for tuberculosis with aerosol-generating procedures, use contact procedures, and use N-95 masks according to recommendations below. N-95 masks: There should be training and fit-testing to ensure adequate sealing (see http://www.osha.gov/SLTC/etools/respiratory. SARS is unlike tuberculosis wherein exposure is by contact with infected secretions, as well as by airborne route. Once worn in the presence of SARS, the outside should not be touched, and the device should be discarded followed by hand hygiene. Reuse may be considered if the device has not been obviously soiled or damaged. To increase safety with reuse, the following are recommended: consider wearing a surgical mask or face shield over the N95 respirator, consider labeling respirators for the user, and use hand hygiene after placing the respirator on the face. The recommended respiratory protective devices are particle filter efficiency of 95% (N-95) or greater (N-99 or N-100). An alternative is powered air-purifying respirator (PAPR). If none of these are available, a surgical mask should be worn since this will improve barrier protection with large droplets, but the disadvantage is substantial leakage. Contact isolation: Contact precautions include gloves, gown, and eye protection for all patient/environment contact. Visitors: Screen visitors who are suspect SARS patients themselves and educate visitors about avoiding public places if they have fever or a respiratory illness. Specifically, they should call the hospital before visiting to implement this screening. Management of exposed health care workers who were unprotected: Monitor for signs and symptoms of SARS for ten days postexposure. The recommendation is not to furlough an employee in the absence of symptoms. With symptoms, they should contact the health care facility by telephone, they should avoid interactions outside the home, they should not work, and they should implement infection-control precautions, including mask and hand hygiene. If symptoms do not progress in 72 hours, they may return for evaluation by health employee or infection control and then work if clear. Workers with suspected SARS should not return to work until 10 days after being afebrile and asymptomatic and cleared by infection control or health employee.

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