Monkeypox spreads as US public-health system plays catch-up.

At the time of going to press, 81 cases (32 laboratory-confirmed) of monkeypox had been reported in the USA, a Figure that is likely to increase, according to Michael Osterholm (University of Minnesota, Minneapolis, MN, USA). Unless all animal reservoirs are identified and efforts made to “contain monkeypox and, hopefully, eradicate it”, he emphasises, “there is no reason why an agent like that could not become an endemic viral infection of rodents in the United States, which would be absolutely horrible”.

Figure

A Gambian giant rat

Indeed, on July 3, the US Centers for Disease Control and Prevention (CDC) confirmed the presence of monkeypox virus in one Gambian giant rat, three dormice, and two rope squirrels that were part of an African rodent shipment from Ghana to the USA (http://www.cdc.gov/od/oc/media/pressrel/r030702.htm). The shipment is said to be the source of the US outbreak, which started with a little girl who presented at the Marshfield Clinic (Marshfield, WI, USA). “The whole thing was a big surprise. It was difficult with the few cases we had here to recognise that something was happening that involved multiple cities in multiple states”, says Kurt Reed, director of Marshfield's clinical research centre. Days went by as Reed and his colleagues tried to identify the source of the girl's antibiotic-resistant infection, taking cultures and, after her mother also showed signs of illness, doing biopsies and electronic microscopy.

“On June 3, we had the first indication that this was an orthopox virus. Then we heard about the Gambian rat, and things got very bizarre. That's when we finally considered that this could be an old-world virus that had somehow got into the USA”, recalls Reed. “Things moved quickly from there, but it could have been figured out a lot faster if everyone had all the information up front. But we didn't. If we had known when we saw we had pox virus that there were other cases from similar exposures elsewhere, that would have prompted a public-health response.”

And therein lies the rub, says Osterholm. “This is a big-picture issue now. It's not the initial hit of monkeypox or West Nile or whatever—it's the spread throughout the country”, he asserts. “It's not just being able to respond initially to an outbreak, it's surveying and being sure we get it all. Monkeypox is like West Nile because we never did control it right at the beginning and now look what's happened.”

The US public-health system—even with limited resources and near “burnout” as a result of the threats of bioterrorism—needs to embrace a new mindset, continues Osterholm. “We have been basing our public-health practices on the concept that the developed world dealt with the developed world, and the less developed world was just there. Now we have to think that any disease there can occur not just in travellers, but here. It's like the deer in the headlights—you're going to hit it. It's a matter now of whether you just forget about it or let it come through the windshield.”