Investigation of Monkeypox cases in Pujehun and Kailahun Districts, Sierra Leone, 2018 – 2019

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Monkeypox is an emerging zoonotic viral disease clinically similar to smallpox with case fatality rates from 1-10%. In Sierra Leone, three cases were confirmed from 1970 to 2017. From 12th December 2018 to 2nd March 2019, Field Epidemiology Training Program trainees responded to notifications from the District health Management Teams and investigated the suspected cases in Pujehun and Kailahun districts to confirm the diagnosis, identify possible risk factors and additional cases, and institute control measures.
Case-patients and families were interviewed, medical records were reviewed, and samples from lesions and blood were obtained and analyzed at US Centers for Disease Control and Prevention. A case was define as any person from the respective communities who presented with fever 38.5 , generalized vesicopustular rash and lymphadenopathy, and having history of contact with animals or persons with similar symptoms. Information was collected on demographics and travel history. We conducted active case finding, contact tracing and risk communication among the communities.
Patients were a six-year old male from Pujehun district and a 38-year old female from Kailahun district. Both presented with generalized vesiculopustular rash, and lymphadenopathy preceded by a two-day history of fever. Sera from both tested positive for orthopox IgM and IgG, and lesion samples were positive by RT-PCR. One patient reported a contact with rodents and primates, and the other had history of contact with a sheep and a person exhibiting similar symptoms. The patients recovered, no additional cases were found, and none of 54 identified contacts developed symptoms during the 21-day follow-up.
This investigation identified a second case of monkeypox in Pujehun district within two years and the first case in Kailahun district. Because of evidence of widening distribution of monkeypox, its clinical similarity to vari- cella, and increasing proportion of the population not vaccinated for smallpox and, therefore, not protected against monkeypox, we recommend the following measures: 1) enhanced national surveillance for monkeypox by public health staff; 2) increased sensitization for clinical staff to include monkeypox in the differential diagnosis for rash illness; and 3) educational campaigns targeting the community to reduce the risk of animal-to-human transmission of monkeypox.

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