A Case of Monkeypox in a Returned Traveler
By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: The arrival of a traveler from Nigeria to the United States with monkeypox infection, which was quickly recognized, led to a massive public health response investigating exposed individuals, but no secondary cases were detected.
SOURCE: Rao AK, Schulte J, Chen TH, et al. Monkeypox in a traveler returning from Nigeria — Dallas, Texas, July 2021. MMWR Morb Mortal Wkly Rep 2022;71:509-516.
On June 30, 2021, five days after having arrived in Nigeria, where he stayed only in urban centers, a man had onset of cough, fever, diarrhea, and vomiting. Then, on July 8, he developed a purulent skin eruption. (See Figure 1.) The following day, he flew to Dallas, with a brief stopover in Atlanta, followed by a ride-share to his home. On July 13, he was driven to the hospital by a friend after worsening of the rash, which had become visible on his face.
The man was immediately placed into airborne isolation and managed with contact isolation and eye protection. The emergency department doctor reviewed the information for Nigeria at the Centers for Disease Control and Prevention (CDC) Traveler’s Health website, which led him to suspect monkeypox and to immediately notify public health authorities. The diagnosis of monkeypox was confirmed the following day, and subsequent testing identified the virus as belonging to the West African clade. The patient was treated with tecovirimat and was discharged after 32 days, at which time monkeypox virus deoxyribonucleic acid (DNA) could no longer be detected in residual skin lesions.
Figure 1: Time Line of Patient Activities and Potential Exposures to Monkeypox Virus from Patient’s Arrival in Lagos, Nigeria to Completion of Monitoring for the Last Exposed Known Contact — Dallas, Texas, June–September 2021 |
ED: emergency department Source: Rao AK, Schulte J, Chen TH, et al. Monkeypox in a traveler returning from Nigeria — Dallas, Texas, July 2021. MMWR Morb Mortal Wkly Rep 2022;71:509-516. |
Potential exposures of others were determined by patient report, flight seating arrangements, and airport video surveillance. Public notifications were made. It was determined that the labels of disinfectants used on planes between flights indicated that they inactivated monkeypox virus. Multiple relevant surfaces, including those in the patient’s home, were disinfected.
Of the 223 contacts identified, 85% were considered to be at “low/uncertain risk.” Thirty-four patients were believed to be at an intermediate level of risk, including 21 seated within six feet of the patient during the flight from Lagos to Atlanta. When defined as, e.g., direct contact with body fluids or exposure during an aerosol-generating procedure, there were no high-risk contacts. No secondary cases were identified.
COMMENTARY
The immediate response to this case in the emergency department of a Dallas hospital was stellar, with the physician immediately checking the CDC resource to confirm his/her suspicion. This prevented exposures within the healthcare setting and led to treatment of the patient with tecovirimat, a drug active against poxviruses, and ultimately to successful patient discharge.
Before this occurrence, six cases of monkeypox in travelers from Nigeria were found in non-endemic countries. This was the first case imported by a traveler to the United States — but not the last. Four months after this case, another traveler from Nigeria to the United States was found to have monkeypox virus infection.
Monkeypox is a virus whose African reservoir is believed to be a rodent or other small mammal. The case described by the CDC illustrates that the disease may be acquired in urban as well as forested areas that were identified previously. As appropriate for someone of his age, this patient had never received smallpox vaccine.
Paradoxically, the use of face masks in response to the COVID-19 pandemic may have played an important role in the prevention of secondary cases during this event.
The arrival of a traveler from Nigeria to the United States with monkeypox infection, which was quickly recognized, led to a massive public health response investigating exposed individuals, but no secondary cases were detected.
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