Over the past several weeks, dozens of Americans might have been infected with monkeypox –- a close but less-deadly cousin of smallpox -- in its first outbreak in the Western Hemisphere. Doctors in Wisconsin saw the first patient May 22 when a 4-year-old girl developed a rash similar to that caused by smallpox, but the local health department and the Centers for Disease Control and Prevention in Atlanta were not notified until 13 days later.
The CDC, in turn, did not make the case known publicly until June 7, some three days after it learned of the case in Wisconsin. By that time, there were 19 suspected monkeypox cases in Wisconsin, Indiana and Illinois.
Despite the CDC's proclamations that the nation has improved its preparedness to respond to a bioterrorist attack and emerging infectious diseases, the monkeypox experience indicates there still is no rapid communication system to alert physicians and health agencies around the country, experts told United Press International.
"The biggest concern really is how quickly could we respond and how quickly are we able to distinguish between natural spread of disease vs. intentional introduction of a disease as a bioweapon," said Charles Pena, senior defense policy analyst at the Cato Institute, a think tank in Washington.
"Just how long it took for the events (surrounding the monkeypox cases) to transpire and deal with it demonstrates there's something wrong with the system," Pena said, noting a delay in responding to the first reports of smallpox cases could result in "a raging smallpox epidemic" that grows out of control.
"We're living in a sort of different world after Sept. 11 and more alarms need to be going off in people's heads," he said.
It now appears that quicker notification of the country's medical community might have been particularly prudent because monkeypox has spread, now infecting as many as 54 people in several additional states, including Texas, New Jersey, Pennsylvania and South Carolina. The outbreak has become such a concern the CDC is taking the unprecedented step of recommending experimental use of the smallpox vaccine –- which can have severe side effects, including death -- in infected people, healthcare workers and those who were exposed to sick prairie dogs, which appear to be the source of the monkeypox.
The concern about the delay in communicating information about the monkeypox cases is they could have been smallpox. It is quite easy to mistake monkeypox infection for smallpox. In fact, in a recent exercise to prepare for bioterrorism events, Boston Medical Center created a teaching case of a person coming into the emergency room with what appeared to be smallpox but actually turned out to be monkeypox. In addition, as reported by UPI, some bioterrorist experts have expressed concerns terrorists could try to use monkeypox itself as a bioweapon.
The physician who saw the first monkeypox case in Wisconsin, Dr. Kurt Reed of the Marshfield Clinic, said without the prairie dog connection he would have suspected smallpox.
If the event had been a smallpox attack instead of a spontaneous disease outbreak, it would have been critical to initiate a rapid response to identify those who might have been exposed and launch a vaccination campaign in order to curtail the disease before it became widespread.
The CDC did not return UPI's phone calls, but Dr. David Fleming, deputy director of the agency, in a recent news briefing, praised local and state health departments for their rapid response to the monkeypox cases. Later, however, he acknowledged the agency's concerns about the time it took to alert healthcare personnel. He said the CDC would examine the circumstances preceding the health department notification "to see whether or not there were delays in communicating that information."
From the first case, physicians knew the disease most likely originated from prairie dogs and thus they had no reason to suspect bioterrorism or smallpox. However, alerting local and state public health departments and the CDC rapidly still would have been beneficial.
Even if there was a strong link to the prairie dogs, any pox-like rash should be reported immediately to local and state health departments, Dr. William Bicknell of Boston University's School of Public Health told UPI.
"Until a couple of days ago, prairie dogs were a pretty unlikely source of monkeypox," said Bicknell, a former commissioner of public health in Massachusetts. "I'd like to see anything that looks like smallpox reported and not rely on prairie dogs as an explanation ... Let's not assume it's not smallpox."
Even if a report turns out to be a false alarm, Bicknell said, quick response remains a prudent strategy. "If it's really smallpox people are transmitting ... speed is of the utmost importance," he added. The delay between seeing the first case and notifying health departments should only be "a matter of hours."
One reason for the lengthy delay in reporting the monkeypox cases is the country still lacks an efficient communication system for this type of situation.
"In an era of bioterrorism, this type of scenario underscores the importance of rapid communication between the clinician community and the public health community," said Lew Radonovich, senior fellow at the Center for Civilian Biodefense Strategies at Johns Hopkins University in Baltimore.
"As a nation we need to build more efficient and standardized communication systems that will allow information to flow from the clinical community to the public health community and vice versa in a rapid fashion," Radonovich said. He is leading a project at Hopkins to develop a communications system called the Clinician's Biodefense Network that will provide physicians with information quickly about treating and recognizing symptoms caused by biological weapons such as smallpox, anthrax and botulism.
"As the system is set up right now, delays can occur at multiple levels," Radonovich explained. There can be delays between the clinician notifying the local public health department, the local health department informing the state health department and the state health department passing it on to the CDC. "Each one of the delays may not take a long time, but when you add them all up it can be days or weeks," he said.
Radonovich said there is a desperate need for a system to move information beyond the region in which the outbreak is occurring so healthcare personnel around the country can be alerted to developing situations. This could have proven useful in the monkeypox outbreak because it could have helped facilitate earlier diagnosis and treatment of cases in other states.
Even if a disease cannot be identified positively, the available information still should be distributed, Radonovich commented. "Some information is better than none and with bioterrorism or emerging infectious disease epidemics, small amounts of information can be valuable," he added.
Such a system would also be "of tremendous benefit" in outbreaks of emerging diseases in the future, such as severe acute respiratory syndrome. "Knowing that there is an outbreak of SARS on the West coast would be useful information for clinicians on the East coast even if the exact circumstances about the outbreak are still being gathered," he said.
Bicknell agreed there was a need for a better communications system, saying the delay in getting the word out "should make us a little nervous." He said he hoped the monkeypox experience would be "a nice wake up call for smallpox" preparation.
"At the present time, we are prepared for smallpox only in the sense that we have enough vaccine," he said. "But the systems for rapidly transmitting information (about an outbreak), gearing up to vaccinate and actually vaccinating - none of those are sufficient at the moment."
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