written by Chandana Balasubramanian
Hot on the heels of the COVID-19 virus and its variants, another infectious virus recently landed in the United States. On July 9th, 2021, a passenger with monkeypox flew from Lagos in Nigeria to the United States, ultimately landing in Dallas, Texas. The Centers for Disease Control and Prevention, CDC confirmed the case of Monkeypox on July 15th – the first case of monkeypox in the United States in almost 20 years. While rare, the Monkeypox virus is contagious and kills one in ten people that it infects.
“…we are only a plane ride away from any global infectious disease.”
– Dr. Philip Huang, Director of the Dallas County Health and Human Services.
A few fortunate events prevented a Monkeypox outbreak in the United States this time around.
- Symptoms Presented Early: Symptoms of monkeypox are similar to those of smallpox and can take anywhere from 7 to 14 days to appear after getting infected (incubation period). Luckily, symptoms presented earlier, and the patient visited a hospital within four days of entry into the country.
- Early Detection by Frontline Clinicians: The symptoms of monkeypox include fever, headache, backache, swollen lymph nodes, chills, and fatigue. Within three days of the onset of fever, a rash appears on the face and spreads to other parts of the body. Doctors and healthcare workers at the Dallas hospital were able to identify and diagnose monkeypox quickly, so the infected patient was isolated early.
- Mask Mandates and Social Distancing: Monkeypox can spread from person to person through respiratory droplets and body fluids. In this instance, a huge silver lining is that due to COVID-19 mandates, everyone, including the patient, other passengers, airline and airport staff, and others wore masks. This helped prevent the spread.
Monkeypox is transmitted to humans through infected animals or other humans. Animals can share it through bites, scratches, or direct contact with body fluids. Human transmission is mostly through respiratory droplets and body fluids but also contact with contaminated clothes.
While there was no outbreak this time, there have been a few in prior years.
In the case of monkeypox, there have been notable outbreaks in the past. In 2003, 81 people in the United States were infected with monkeypox through contact with prairie dogs. These animals acquired the virus from rodents imported from Ghana.
In 2018-2019, five cases of monkeypox were reported in Israel, Singapore, and London. The UK also had one additional case in May 2021. Worldwide, Monkeypox cases are on the rise. In 2020, almost 4,500 cases of monkeypox were reported in the Democratic Republic of Congo in just nine months.
According to the GIDEON (Global Infectious Diseases and Epidemiology Network) country note on Monkeypox in Nigeria, there were six cross-border events of monkeypox from Nigeria to other countries and two notable outbreaks. In the latest one from 2017-2021, 446 people in Nigeria were infected with Monkeypox.
Diagnosing Monkeypox Accurately
Monkeypox has specific symptoms that distinguish it from other diseases. Swollen lymph nodes and a telltale rash help diagnose it more accurately, but misdiagnosis is possible.
Let’s look at the illustration below. When we add patient travel history from Nigeria and the symptoms of monkeypox like fever, headache, generalized lymphadenopathy, skin lesions or rash, and others into the GIDEON infectious disease diagnostic probability engine, Varicella is also a strong contender. But the presence of ‘severe illness’ and the type of rash signifies a greater probability of Monkeypox.
GIDEON’S side-by-side comparison of the clinical features of Monkeypox and Varicella helps narrow down and confirm the Monkeypox diagnosis based on patient presentation.
As Monkeypox has no cure, saving lives relies on early detection and control of spread. Although there is some evidence that vaccination against smallpox may also prevent monkeypox, the Smallpox vaccine is no longer used. Another outbreak could happen anywhere, anytime.
Are we prepared to detect the next infectious disease that crosses our shores early?
Detecting Foreign Infectious Diseases Early
Regarding the July 2021 Monkeypox case in Dallas, Dr. Philip Huang, the Director of the Dallas County Health and Human Services, stated, “This is another demonstration of the importance of maintaining a strong public health infrastructure, as we are only a plane ride away from any global infectious disease.”
Indeed, as the COVID-19 pandemic demonstrated, it is easy for emerging infectious diseases to spread rapidly worldwide. As seen in the Texas Monkeypox case, if patient travel history is considered at first presentation and symptoms are detected early, we can stop the spread of a disease-causing pathogen.
Healthcare providers are our first line of defense against infectious diseases. Unfortunately, clinicians, nurses, emergency room workers, paramedics, and ambulance drivers in clinics and hospitals are also some of the first casualties from infection. The World Health Organization (WHO) recently reported that 115,000 healthcare workers have died from COVID-19. With the Delta variant on the loose, the pandemic is very much underway, and this number may rise. Protecting our borders and healthcare workers from emerging infectious diseases requires better access to advanced diagnostic tools with epidemiological data.
When frontline clinicians have doubts about their initial assessment, they can conduct a differential diagnosis by comparing a patient’s symptoms with other diseases or consult infectious disease specialists. However, if they do not, or cannot, refer to a specialist or use an infectious disease platform for differential diagnosis (DDx), the disease-causing virus or bacteria may be misidentified and spread unchecked.
The best way to catch emerging infectious diseases early is to equip frontline clinicians with comprehensive data on all reported infectious diseases, including:
- a list of symptoms,
- the ability to compare conditions with similar presentations, and
- a history of global outbreaks and documented cases,
- country-specific notes on disease outbreaks.
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