Correspondence

Discovery of Monkeypox in Sudan

N Engl J Med 2006; 355:962-963August 31, 2006

Article

To the Editor:

On November 4, 2005, the Poxvirus Program at the Centers for Disease Control and Prevention (CDC), a World Health Organization (WHO) Collaborating Center for Smallpox and other Poxvirus Infections, was contacted by a former volunteer with Médecins sans Frontières (MSF) with a request for information regarding a child with a generalized pustular rash illness in southern Sudan. On the basis of a review of a photograph of the child (Figure 1Figure 1Child with a Suspected Case of Monkeypox.), dated October 28, 2005, and limited clinical information describing a febrile period of disease, it was agreed that the findings were suggestive of a systemic orthopoxvirus infection. Orthopoxviruses include vaccinia, variola (smallpox), and monkeypox. Since monkeypox has been described in the Congo Basin and western Africa but has never been reported in southern Sudan, the potential emergence of orthopoxvirus infection in this region aroused concern. A rapid diagnosis was required to facilitate the appropriate public health response. An investigation by members of MSF found that small clusters of self-limited disease compatible with monkeypox had occurred that were not widely spread within the community. No deaths were reported among the patients with suspected cases.

On December 22, 2005, after approval by the Sudan National Laboratory, specimens from the WHO office in Khartoum that had been shipped through the U.S. Naval Medical Research Unit 3 in Cairo arrived at the CDC. The specimens were from a second patient (the mother of the child in Figure 1) and were dated November 6, 2005. Within 12 hours, preliminary data from real-time polymerase-chain-reaction assays showed that the samples contained nucleic acid signatures consistent with orthopoxvirus and that the signature of a specific monkeypox virus was present. Antiorthopoxvirus IgM was detected in the patient's serum. Subsequent sequencing of two genes revealed that they were most similar to those characterized as isolates of monkeypox virus obtained from the Congo Basin. This information was communicated to the WHO to permit coordination of the public health response. A follow-up investigation by the WHO found evidence of occasional, sporadic cases of monkeypox in southern Sudan, suggesting intermittent introductions from local, putative animal reservoirs.

The substantial delay between the identification of the suspected case of monkeypox infection and the confirmation of human monkeypox disease by the international reference laboratory at the WHO Collaborating Center illustrates the limitations of our ability to detect diseases globally. Programs should be enhanced to foster international public health collaboration and cooperation and expand the capacity of the network of international laboratories, with a particular focus on improving the shipping of clinical samples to reference laboratories for timely, effective efforts toward improving public health education and response.

Inger K. Damon, M.D., Ph.D.
Centers for Disease Control and Prevention, Atlanta, GA 30333
iad7@cdc.gov

Cathy E. Roth, M.B., B.Chir.
World Health Organization, 1211 Geneva, Switzerland

Vipul Chowdhary, M.D.
Médecins sans Frontières, 75011 Paris, France

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