Friday, September 21, 2018

PRO/AH/EDR> Monkeypox - UK (03): ex Nigeria, additional details

MONKEYPOX - UK (03): ex NIGERIA, ADDITIONAL DETAILS
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Date: Thu 20 Sep 2018
Source: CIDRAP (Center for Infectious Disease Research & Policy) News
[edited]
<http://www.cidrap.umn.edu/news-perspective/2018/09/uk-monkeypox-case-exposed-health-workers-officials-say>


Because monkeypox was not immediately suspected in the most recent UK
monkeypox case, healthcare workers (HCWs) were not wearing adequate
personal protective equipment (PPE) and may have been exposed to the
virus, UK officials reported today in Eurosurveillance [see
<https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2018.23.38.1800509>].

They also noted that the patient -- the 2nd recently reported by
Public Health England (PHE), on 11 Sep [2018] -- had 2 potential
exposures. The patient had contact with a person who had a
"monkeypox-like rash," and he also ate bush meat while visiting
Nigeria. Nigeria has had 262 suspected and 113 confirmed monkeypox
cases since September 2017.

The officials also provide more details on the 1st case, which PHE
first reported on 8 Sep [2018]. The cases appear unrelated, PHE has
said.

Monkeypox is an orthopoxvirus infection and is related to smallpox.
The disease can also be confused with chickenpox, which is caused by
an unrelated virus.

The 1st monkeypox case involves a male Nigerian naval officer who was
attending a training course at a naval base in Cornwall in
southwestern England. PHE was notified of his case on [7 Sep 2018].

The officer arrived in London from Abuja, Nigeria, on [2 Sep 2018],
then took a train to the Cornwall base the same day. The next day,
however, he sought primary care on the naval base after he spiked a
fever and had swollen lymph nodes and a rash near his groin. Because
the rash was suspected to be caused by a _Staphylococcus_ infection,
the man was prescribed antibiotics.

By [6 Sep 2018], though, the rash had spread to the man's torso, face
and arms, and, after clinicians re-examined him they placed him in
isolation in his quarters. Multiple samples, including swabs of the
lesions, were sent to the PHE Rare and Imported Pathogen Laboratory
(RIPL), whose scientists confirmed monkeypox by sequencing analysis.

The man is now in stable condition and is improving, according to the
report.

Multiple exposures in 2nd case
------------------------------
The 2nd patient is a UK man of unknown age who returned to the country
from a 22-day vacation in Nigeria on [4 Sep 2018] via a flight from
Paris. He sought care at the Accident and Emergency Department at
Blackpool Teaching Hospitals on the northwest coast on [6 Sep 2018]
for fever, swollen lymph nodes, a scrotal lump, and an itchy
maculopapular rash, which is a flat, typically red area covered with
small, connected bumps.

The man said the rash first appeared in Nigeria before his trip back
to England and affected his face before spreading to other areas,
including the palms of his hands, and had become pustular. He has also
had a different febrile illness a week before coming to the Blackpool
hospital and had received antibiotics for that, the authors of the
report said.

On examination at the hospital, the man had "crops of vesicles that
were progressing and lesions on the mucosal surfaces of the mouth,"
the report said. He was isolated at the hospital, and the RIPL
confirmed monkeypox DNA by multiple molecular tests.

"Although the patient was isolated," the report said, "monkeypox was
not initially suspected because the 1st lesions appeared in the groin,
and the wearing of full personal protective equipment (a filtering
face-piece with three indicating levels of protection [FFP3], eye
protection, gloves, and sterile disposable gown) was not implemented
immediately."

A "number" of HCWs were potentially exposed because of the PPE lapse,
the authors wrote. The man was transferred to a specialized unit at
the Royal Liverpool University Hospital on 10 Sep [2018] and remains
in stable condition.

Although the ultimate source of the man's infection is unknown, he
reported contact with a person who had a monkeypox-like rash at a
large family gathering and ate bush meat during a visit to a rural
area in southern Nigeria.

Public health response
----------------------
"Although there was no evidence for an epidemiological link between
the 2 cases in the UK, both had travelled in southern Nigeria before
coming to the UK," the investigators said. "While it was difficult to
obtain clear travel histories from the patients, both cases had
visited areas in southern Nigeria (Lagos State, Federal Capital
Territory, Rivers State, and Delta State), where cases of monkeypox
have recently been reported."

The Nigeria Centre for Disease Control is conducting epidemiologic
investigations to identify contacts of the 2 cases and to determine
the source of infection, the authors noted.

In the UK, PHE is following up on 229 of 243 contacts; 93 of them are
under active surveillance, while 136 are under passive surveillance.
Officials are also seeking out the other 14 as-yet-unreached
contacts.

The report does not specify how many HCWs might have been exposed in
the 2nd case, but it says that 27 HCWs at the referral hospitals for
both patients (Royal Free and Royal Liverpool) were offered the
smallpox vaccine before being exposed to the patients.

In France, officials have contacted passengers who took the same
flight from Lagos to Paris with the 2nd case-patient.

The officials conclude the report, "The diagnosis of 2 unconnected
monkeypox cases within a short time frame in the UK is a highly
unusual occurrence and most probably reflects the ongoing monkeypox
transmission events in a number of African countries, including
Nigeria.

"This incident reinforces the importance of infectious disease
surveillance, clinical awareness, and early recognition and isolation,
as well as the need to obtain a full travel history for all patients.
This incident also highlights the importance of global health security
initiatives and the rapid sharing of information."

[Byline: Jim Wappes]

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[The report above, drawn from the Eurosurveillance published article,
provides some information about where in Nigeria these 2 cases might
have acquired their infections. Several possibilities are mentioned.
Nigeria has had many monkeypox cases in 2017-2018 in several states.
The most recent cases were in June 2018, in Plateau state. These cases
in Nigeria were caused by the West African clade of the monkeypox
virus, presumably the same clade of the virus as infected the 2 UK
cases. Previous monkeypox outbreaks indicate that monkeypox virus is
not readily transmitted directly from person-to-person. However,
contact tracing and surveillance and use of PPE by healthcare
personnel are prudent.

Non-human primates are not a monkeypox virus reservoir. The main
reservoirs of monkeypox virus are suspected to be rodents, including
rope squirrels (_Funisciurus_ spp; an arboreal rodent, and terrestrial
rodents in the genera _Cricetomys_ and _Graphiurus_). Some of these
rodents are consumed as bushmeat. - Mod.TY

HealthMap/ProMED maps available at:
United Kingdom: <http://healthmap.org/promed/p/40>
Nigeria: <http://healthmap.org/promed/p/62>]

[See Also:
Monkeypox - UK (02): ex Nigeria
http://promedmail.org/post/20180911.6023180
Monkeypox - UK: ex Nigeria
http://promedmail.org/post/20180908.6017005
Monkeypox - Africa (11): Nigeria (PL)
http://promedmail.org/post/20180608.5847036
Monkeypox - Africa (06): Nigeria
http://promedmail.org/post/20180405.5728330
Monkeypox - Africa (04) http://promedmail.org/post/20180327.5712702
Monkeypox - Africa: Nigeria
http://promedmail.org/post/20180120.5572204]
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