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Note: This draft is dated August 28, 2003.
Information about Monkeypox is changing rapidly. Make certain you have the
most current guidance.
Public Health Action
- Identify personnel to do field investigation of cases of monkeypox,
and protect employee health. Personnel must:
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Have documented immunity to smallpox
(successful vaccination within three years). If unvaccinated
personnel must be utilized in the response, they should have no
contraindications to the smallpox vaccine and ideally be vaccinated
prior to departure for fieldwork. If unvaccinated workers are
exposed, they should be vaccinated as soon as possible, ideally
within 4 days of exposure (vaccination should be considered up to 14
days after last exposure).
-
Use airborne (N-95 mask), contact
(gloves, gown), and standard precautions during direct
exposure to infected animals or humans, even if fully vaccinated.
-
Educate providers about diagnosis and urgent
reporting of suspect patients with monkeypox.
-
Educate veterinarians about diagnosis and
urgent reporting of suspect animals with monkeypox. IDEP should be
consulted immediately about control measures if suspect animal cases
are reported.
-
Educate providers to immediately isolate
patients suspected of having monkeypox, to include:
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Airborne precautions (negative pressure
isolation of the patient and use of an N-95 mask by the healthcare
worker);
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Contact precautions (gloves, gown);
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Standard precautions;
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Notification of the Infection Control
Practitioner; and
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Isolation must continue until all scabs
have fallen off
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Report suspect cases to IDEP immediately
(1-800-423-1271) and use "Form 1: Monkeypox case investigation
Form" to gather information on all cases. Laboratory confirmation
of suspect cases is critical. See ‘laboratory diagnosis.’ Consult
IDEP regarding the investigation.
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Advise cases not to donate blood, cells,
tissue, organs, breast milk or semen while ill or under symptom
surveillance.
- Monkeypox patients who do not require hospitalization for medical
indications may be isolated at home. Persons with extensive lesions
that cannot be easily covered (excluding facial lesions) or
draining/weeping lesions or respiratory symptoms (e.g., cough, sore
throat, or rhinorrhea) should be isolated in a room or area separate
from other family members when possible. For movement outside the
isolation area, a surgical mask should be worn if respiratory symptoms
are present. Educate the family about the following guidelines:
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Skin lesions should be covered to the
extent possible (e.g., long sleeves, long pants) to minimize risk of
contact with others.
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Family members who enter the room or area
should wear a surgical mask that fits snugly; disposable gloves
should be worn for direct contact with the patient.
-
Unexposed persons should not enter the
home. Health-care personnel and others who must enter the home to
provide patient-related services should wear an N95 respirator.
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Hand hygiene (i.e., hand washing with soap
and water or use of an alcohol-based hand rub) should be performed
by infected persons and household contacts frequently, and
particularly after touching body sites, clothing, linens, or
environmental surfaces that may have had contact with infectious
lesions.
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Laundry (e.g., bedding, towels, clothing)
may be washed in a standard washing machine with warm water and
detergent; bleach may be added but is not necessary. Care should be
used when handling soiled laundry to avoid direct contact with
contaminated material. Soiled laundry should not be shaken or
otherwise handled in a manner that may aerosolize infectious
particles.
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Dishes and other eating utensils should
not be shared but segregation of specific utensils for use by the
infected person is not necessary. Soiled dishes and eating utensils
should be washed with warm water and soap.
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Contaminated surfaces should be cleaned
and disinfected. Standard household cleaning/disinfectants may be
used in accordance with manufacturer’’s instructions. Dressing,
bandages, and other materials contaminated with lesion drainage
should be bagged and placed in another container for disposal with
other household waste.
- Identify and line list household contacts, close contacts and other
contacts (i.e. those that have contact with case’s clothing or
bedding) of humans or animals with confirmed monkeypox using the CDC
"Form 2: Monkeypox Contact/Site Worksheet". See form and
instructions following the protocol.
http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp
Close contact is defined as:
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> 3 hours direct exposure within 6
feet, or
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Intimate contact resulting in exposure to
body fluids or lesions of infected persons
Record locating and demographic information for each contact in the
spaces provided on Form 2. Use the priority codes according to the
criteria on Form 2 to prioritize contacts.
- For each contact:
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Prioritize contacts, using Form 2.
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Call, or preferably visit those contacts
in categories 1 and 2, and those contacts who have had intimate
contact with body fluids or lesions of infected persons or animals,
and:
- Educate regarding monkeypox and smallpox vaccine, including
contraindications to vaccination. Neither age nor pregnancy nor
history of eczema are contraindications to vaccination in persons
with close/intimate contact with a confirmed case of monkeypox.
IDEP is willing to help with difficult decisions regarding
risk-benefit of smallpox vaccination. Vaccination of persons with
life-threatening allergies to latex or smallpox vaccine components
and of persons with immunodeficiencies in T-cell function is
contraindicated, including:
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HIV-infected adults with CD4
lymphocyte count less than 200 (or age-appropriate equivalent
counts in children);
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Solid organ or bone marrow transplant
recipients or others currently receiving high dose
immunosuppressive therapy (i.e., 2 mg/kg body weight or a total
of 20 mg/day of prednisone or equivalent for persons whose
weight is > 10 Kg when administered for > 2 weeks)
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Persons with lymphosarcoma,
hematological malignancies, or primary T-cell congenital
immunodeficiencies.
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Make arrangements through BPH for
vaccination. Vaccine is available on emergency investigational new
drug (EIND) protocol for control of monkeypox. Vaccination should
be performed as soon as possible after a recognized exposure,
preferably within 4 days of last exposure, but not later than 2
weeks after exposure is broken.
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Place contacts under active surveillance
and document using CDC "Form 3: Monkeypox Contact
Surveillance Form". See form and instructions following the
protocol. During http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp
the surveillance period (21 days following last exposure to the
case):
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Call or visit the contact daily.
Continue to offer education and information.
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Contacts should take their temperature
twice daily.
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Contacts who develop a fever or rash
or suspect vaccine adverse event should be referred for medical
evaluation. The clinician, hospital or emergency room should be
notified prior to the patient’s arrival so that health care
workers can take appropriate precautions. Newly diagnosed cases
should be evaluated as above.
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Vaccination history and
"take" should be recorded on Form 3.
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Health care workers with unprotected
exposures should also be under active surveillance, with
temperature recorded prior to reporting for duty each day.
Hospital employees should be followed in collaboration with the
infection control practitioner or employee health nurse at the
hospital.
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Contacts should be advised not to
donate blood, cells, tissue, organs, breast milk or semen during
the 21 day surveillance period.
- Healthcare workers who care for patients with monkeypox while
adhering to the recommended infection control precautions (airborne
precautions with an N-95 mask and recent smallpox vaccination)
should be vigilant for fever and other symptoms. They should take
their temperature twice daily for the 21 days following last
exposure and should be contacted regularly by infection control,
employee health or other designated personnel to inquire about
symptoms.
- Prevent entry of monkeypox into West Virginia by
preventing importation and sale of exotic species in the state.
- Prevent transmission from a case of monkeypox by:
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Immediate isolation using airborne and
contact precautions for patients with monkeypox or
undifferentiated febrile vesicular/pustular rash illness.
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Appropriate vaccination of close and
intimate contacts and active surveillance of contacts.
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Investigation to identify the source and
elimination of any ongoing source of exposure.
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To detect human monkeypox
if it occurs in West Virginia.
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To detect monkeypox in animals if it
occurs in West Virginia.
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To characterize the occurrence of disease
in person, place and time.
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To characterize the risk factors for
disease in our state.
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To estimate attack rates and secondary
attack rates in our population.
Prior to May, 2003, human monkeypox had never been
identified within the Western Hemisphere. Monkeypox normally occurs in
central and west Africa. Usually, monkeypox cases are sporadic or may
occur in small clusters. However, African villages have experienced
outbreaks of monkeypox,. A well-documented African outbreak of monkeypox
occurred in 1996 and 1997 in the Democratic Republic of Congo. During this
outbreak, 88 cases were identified over a period of 12 months in 12
villages. The attack rate was approximately 2.2% and the mortality rate
was 3.7%. Environmental factors influencing this outbreak were not
identified. However, an increase in the susceptible population as a result
of the end of smallpox vaccination is thought to have played a role.
The World Health Organization considered reinstitution of smallpox
vaccination to prevent monkeypox in the region, but abandoned the idea
because the risk of adverse events was thought to be too high in a region
of the world where there is a high prevalence of undiagnosed HIV
infection.
At the end of May of 2003, human cases of monkeypox were identified in
the United States associated with direct or close contact with prairie
dogs, a Gambian giant rat, and a rabbit. Investigations identified a
common distributor where prairie dogs and Gambian giant rats were housed
together in Illinois. The Gambian giant rats had been imported from Ghana
in a shipment containing approximately 800 small mammals, and several of
these mammals have tested positive for the monkeypox virus indicating that
this shipment was the source of the 2003 United States monkeypox outbreak.
As of July 11, 2003, a total of 71 human cases of monkeypox have been
reported from Wisconsin (39), Indiana (16), Illinois (12), Missouri (2),
Kansas (1) and Ohio (1). Thirty-five of these cases are laboratory
confirmed and the rest are suspect and probable cases. All patients were
exposed prairie dogs or premises where prairie dogs were kept. There have
been no deaths related to this outbreak.
Monkeypox in the United States is of particular importance because of
its implications for the emergence of a new disease within the US. West
Nile has illustrated how quickly a new disease might spread across the
continent and become enzootic in our wildlife populations creating an
ongoing risk of infection for humans. Swift public health action is needed
to prevent further spread of monkeypox in both humans and animals within
the United States.
The most complete case series was published in
Journal of Infectious Diseases, 1987; 156:293. The clinical features in
282 cases in Zaire were similar to those of the discrete or semiconfluent
ordinary or modified type of smallpox.
Prodrome: During the preeruptive stage, patients reported fever,
which lasted in 80% of patients for one to three days before rash onset.
About 5% of patients developed fever the same day and the remaining 15%
had a febrile prodrome lasting more than 3 days before rash onset. Other
prodromal symptoms included severe headache, backache, general malaise and
prostration. In many patients, enlargement of lymph nodes was observed
prior to rash onset.
Eruptive phase: The skin eruption first appeared on the face, but
19% of patients first noted the rash on the forearms or some other part of
the body. In general, the lesions developed more of less simultaneously
and evolved in the same body region at the same rate through stages of
macules, papules, vesicles, and pustules before umbilicating, draining,
and desquamation. Most unvaccinated persons presented with a centrifugal
rash with lesions all in the same stage, and facial, palmar and plantar
pocks. Duration of illness was 2-4 weeks, with scabs falling off by day
22-24. Complications occurred in 43% of unvaccinated and 9% of vaccinated
persons, including secondary infection of skin lesions, pulmonary
distress, bronchopneumonia, vomiting diarrhea, corneal ulceration,
septicemia and encephalitis.
Previously vaccinated persons had less severe disease, including:
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a smaller number of lesions,
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less frequent finding of lesions of the
mucous membranes or face
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less occurrence of upper respiratory
symptoms, including sore throat and cough
In addition, there were no deaths among patients with a vaccination
scar, but death rate was 11% with all deaths occurring in children between
3 months and 8 years of age. The age-specific case-fatality rate was
highest in the youngest age group with a 15% case fatality rate in
children aged 0-4.
The major clinical feature differentiating smallpox and monkeypox is
lymphadenopathy, occurring in 84% of unvaccinated and 53% of vaccinated
persons with monkeypox.
Monkeypox virus (genus Orthopoxvirus)
Rodents, such as squirrels and rats are the most
likely reservoirs for Monkeypox. However, Monkeypox infects a wide range
of animal hosts including primates.
Monkeypox is usually transmitted to humans through
contact with respiratory droplets, skin, blood, other body fluids or
bedding of infected animals. However, the disease can also spread from
person to person via respiratory droplet or contact with body fluids,
bedding or clothes of an infected human. Person-to-person transmission is
relatively inefficient, and there is no evidence that person to person
transmission alone can sustain Monkeypox within a population.
7-17 days (CDC)
Unknown. Likely from the onset of symptoms until
scabs fall off.
As West Virginia has never had a case of Monkeypox,
one case is defined as an outbreak.
Case
Definition
(July 2, 2003)
Clinical Criteria:
Rash (macular, papular, vesicular, or pustular; generalized or
localized; discrete or confluent)
Fever (subjective or measured temperature $
99.3°F ($37.4°C))
Other signs and symptoms
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Chills and/ or sweats
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Headache
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Backache
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Lymphadenopathy
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Sore Throat
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Cough
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Shortness of breath
Epidemiolgical Criteria:
Exposure1 to an exotic or wild mammalian pet2
obtained on or after April 15, 2003, with clinical signs of illness
(e.g., conjunctivitis, respiratory symptoms, and/or rash)
Exposure1 to an exotic or wild mammalian pet2
with or without clinical signs of illness that has been in contact with
a case of monkeypox either in a mammalian pet3 or a human
Exposure4 to a suspect, probable or confirmed human case
1 Includes living
in a household, petting or handling, or visiting a pet holding facility
(e.g., pet store, veterinary clinic, pet distributor).
2 Includes prairie
dogs, Gambian giant rats, and rope squirrels. Exposure to other exotic
or non-exotic mammalian pets will be considered on a case-by-case basis;
assessment should include the likelihood of contact with a mammal with
monkeypox and the compatibility of clinical illness with monkeypox.
3 Includes living
in a household, or originating from the same pet holding facility as
another animal with monkeypox.
4 Includes
skin-to-skin or face to face contact
Laboratory Criteria:
Isolation of monkeypox virus in culture
Demonstration of monkeypox virus DNA by polymerase chain reaction
testing in a clinical specimen
Demonstration of virus morphologically consistent with an
orthopoxvirus by electron microscopy in the absence of exposure to
another orthopoxvirus
Demonstration of the presence of orthopoxvirus in tissue using
immunohistochemical testing methods in the absence of exposure to
another orthopoxvirus
Case Classification:
Suspect Case
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Meets one of the epidemiologic criteria, AND
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Fever OR unexplained rash AND two or more
other signs or symptoms with onset of first sign or symptom #21
days after last exposure meeting epidemiologic criteria
Probable Case
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Meets one of the epidemiologic criteria, AND
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Fever AND vesicular-pustular rash with onset
of first sign or symptom #21
days after last exposure meeting epidemiologic criteria
Confirmed Case
- Meets one of the laboratory criteria
Exclusion Criteria
A case may be excluded as a suspect or probable monkeypox case if:
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An alternative diagnosis can fully explain
the illness5 OR
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The case was reported on the basis of
primary or secondary exposure to an exotic or wild mammalian pet or a
human (see epidemiologic criteria) subsequently determined not to have
monkeypox, provided other possible epidemiologic exposure criteria are
not present OR
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The case was reported on the basis of
contact with an exotic mammalian pet with or without signs of illness
that had been in contact with an ill animal or human case that was
subsequently excluded as a case of monkeypox (e.g., another etiology
fully explains the illness) provided other possible epidemiologic
exposure criteria are not present OR
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A case without a rash does not develop a
rash within 10 days onset of clinical symptoms consistent with
monkeypox6 OR
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The case is determined to be negative for
non-variola generic orthopoxvirus by polymerase chain reaction testing
of a well sampled rash lesion by the approved Laboratory Response
Network (LRN) protocol.
5 Factors that might be
considered in assigning alternate diagnoses include the strength of the
epidemiologic exposure criteria for monkeypox, the specificity of the
diagnostic test, and the compatibility of the clinical presentation and
course of illness for the alternative diagnosis.
6 If possible, obtain convalescent-phase serum specimen from
these patients. See specimen collection guidelines for details on
collecting serum for convalescence evaluation.
Laboratory diagnosis is essential to confirm a case of monkeypox. Any
human or animal suspected of having monkeypox should have appropriate
specimens collected for testing. The specimens will need to be shipped to
the Centers for Disease Control in Atlanta. This must be done in
coordination with the West Virginia Office of Laboratory Services and the
Infectious Disease Epidemiology Program. Consult the CDC Guidelines for
the collection and transport of suspect monkeypox case specimens ( http://www.cdc.gov/ncidod/monkeypox/diagspecimens.htm)
prior to collecting specimens. Clinicians and public health practitioners
should collaborate to collect and store any of the following specimens on
persons suspected of having monkeypox:
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Vesicular or pustular tissue and fluid
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Scabs
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Biopsy tissues
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Autopsy specimens from major organs
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Throat swabs for viral culture
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Whole blood for viral culture
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Serum for serological tests
Label all tubes, vials, microscope slide and EM grid holders
with the following:
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Patient name,
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Date and time of collection
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Source of specimen (vesicle, pustule, or
scab)
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Date of birth of patient (for cross
referencing of specimens)
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Name or initials of person collecting
specimen
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If patient is hospitalized, include
hospital and identification numbers (e.g., medical record #,
surgical path #).
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State ID or CDC Monkeypox ID number
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Proportion of cases with
complete demographic information
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Proportion of suspect cases with
laboratory testing performed.
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Proportion of cases with complete clinical
and risk factor information
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Proportion of cases with identified
contacts.
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Number of contacts per case.
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Proportion of contacts with complete
follow-up information.
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Proportion of cases with complete
follow-up information.
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