mer 2003, when it seemed to recede, severe acute respiratory syndrome (SARS) had sickened about 8,000 people across Asia, Europe, and North America and caused the deaths of nearly 800. SARS placed enormous strains on many public health agencies in the United States. The emergence of SARS and later monkeypox during the course of the smallpox vaccination program was a reminder of the importance of public health preparedness for a wide array of potential problems (the “all-hazards” approach used by other agencies). Naturally occurring diseases, from West Nile virus to monkeypox to SARS, require capabilities, resources, training, education, and communication channels similar to those needed to respond to deliberate attack with bioweapons and could therefore serve as proxy events. The committee has discussed the usefulness of proxy events in its sixth report (see Appendix G) and has recommended that CDC support a system to ensure the continuing collection, synthesis, and sharing of lessons learned and best practices public health response to proxy events.

A child in Wisconsin was identified as having the first case of monkeypox in the United States during this outbreak. The child had contracted the disease from a sick pet prairie dog. The disease was ultimately traced to a Gambian giant rat and other exotic rodents that infected a number of prairie dogs. Humans were infected by contact with pets; most of the patients had confirmed exposure to infected rodents and no cases of solely human-to-human transmission were reported. By the end of the outbreak, 71 cases in the six states had been reported to CDC; 35 cases were laboratory-confirmed, and 36 were suspect and probable. On June 12, 2003, CDC made a recommendation, on the basis of expert opinion and limited evidence that people exposed to monkeypox be given smallpox vaccine (CDC, 2003j). Thirty people received smallpox vaccine to prevent transmission of monkeypox; 7 were vaccinated before exposure and 23 after exposure, and no severe adverse events were reported among vaccinees (CDC, 2003l).

Although there has been little systematic study of the monkeypox experience, the anecdotal reports of federal, state, and local public health agencies suggest that smallpox preparedness activities had a favorable effect on the response to the monkeypox outbreak (McGlinchey, 2003b). Clinicians were familiarized with poxvirus diseases, and communication linkages between the health care and public health communities (for example, for reporting and surveillance) were strengthened. Trained vaccinators were available to vaccinate affected people with smallpox vaccine, and vaccine supplies were available regionally. Unfortunately, a dysfunction in the system was identified when the initial cases of monkeypox were not reported to CDC for 13 days; local experts apparently tried to identify the pathogen by using only their local and state resources (CDC, 2003i; Mitchell, 2003). In a smallpox outbreak, such a delay could be expensive and deadly.

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