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1 MARCH Stan Deresinski, Section Editor In the Literature

Monkeypox Makes This surveillance study identified 760 transmission as household members be- a Comeback: a Downside of cases of laboratory confirmed cases of come increasingly vaccine naı¨ve. Discontinuation of monkeypox in humans from November Since it is highly unlikely that smallpox 2005 to November 2007. The annual vaccination will be reinstituted, the best Rimoin AW, Mulembakani PM, Johston crude incidence rate in these zones was chance for control of monkeypox lies in SC, et al. Major increase in human mon- 5.53 per 10,000 population. The mean age improvements in public and social. Ac-

kypox incidence 30 years after smallpox of cases was 11.9 years (range, 5 days to 70 tive case surveillance can help control Downloaded from https://academic.oup.com/cid/article/52/5/iii/386902 by guest on 30 September 2021 vaccination campaigns cease in the years), with 92.1% having been born after human-to-human spread and educa- Democratic Republic of Congo. Proc the mass smallpox vaccination campaigns tional activities may help reduce contact Natl Acad Sci 2010; 107:16262–7. ended in 1980. A scar suggesting prior with infected animals, as well as allowing smallpox vaccination was detected in only early detection of human disease. The 2010 marks the 30th anniversary of the 3.8% of individuals with monkeypox, ultimate solution will, however, involve global eradication of smallpox, an event while this was present in 26.4% of the resolution of civil strife and of poverty. predicted by Thomas Jefferson in a letter overall population. In one health zone in Thus, the problem of monkeypox in the to Edward Jenner written in 1806 [1]. The which comparable surveillance had pre- DRC and other areas will almost certainly success of the global smallpox eradication viously been performed, the incidence of persist for a long time. campaign led to the discontinuation of human monkeypox increased approxi- vaccination, with the last doses given in mately 20-fold relative to cases in 1981- References the Democratic Republic of Congo 1986. Individuals who had received 1. Poland GA, Henderson D. Thirty years after (DRC) in 1980. Concern had, however, smallpox: celebration and sobering thoughts. been raised that discontinuation of vac- smallpox vaccination (24.5% of the local Vaccine 2010; 28:4013–4. cination would lead to the emergence of population) had an approximately 5-fold increased numbers of cases of human lower risk of monkeypox than those who Nice and Dengue with related and antigenically were unvaccinated. Evidence indicates that the cross immunity provided by cross-reactive zoonotic , La Ruche G, Souare`sY,etal.Firsttwo smallpox vaccination persists for at least such as monkeypox . The Global authochtonous 25 years. Commission for the Certification of in metropolitan France, September The animal reservoirs for monkeypox Smallpox Eradication, nonetheless de- 2010. Euro Surveill 2010; 15(39):pii5 virus include, in addition to non-human cided that this risk did not justify contin- 19676. http://www.eurosurveillance.org/ primates, the African squirrel, rats, mice, uation of smallpox vaccination in areas ViewArticle.aspx?ArticleId519676 endemic for monkeypox. A program of shrews and the dormouse (and, in the active surveillance for monkyepox in- recent US outbreak, pairie dogs). The The first autochtnonous cases of den- fection in humans in Africa between 1981 name is itself a misnomer arising from the gue in Europe since an epidemic in Greece and 1986 led to the conclusion that the fact that the first isolation of the virus was in 1927–1928 (with the exception of virus was unlikely to represent a public from laboratory monkeys since a nosocomial case transmitted by a nee- health threat, despite the fact that smallpox appear to be the major vector trans- dlestick injury) were identified in the vaccination had provided 85% protection mitting the infection to humans. Mon- south of France in the summer of 2010. A against human monkeypox. Rimoin keypox cases are almost totally limited to male resident of Nice, France developed and colleagues have now reexamined this rural villages in or near tropical rain- and myalgia on 23 August 2010. His issue at a time when the proportion of the forest. Because of worsening civil war and illmess resolved without complication, at risk population that had been vacci- poverty, residents have increasingly relied except for transient thrombocytopenia. nated was markedly diminished. They re- on for food, resulting in in- Serological and antigen tests results were instituting an active surveillance program creased risk of exposure. At the same consistent with acute dengue virus in- within 9 health zones in DRC in which the time, there is concern regarding an in- fection, which proved to be due to a se- virus was known to be present. creased potential for human-to-human rotype 1 virus. The patient had no recent

IN THE LITERATURE d CID 2011:52 (1 March) d iii history of international travel or of having The US has recently had its own expe- mid-Atlantic, upper midwest, and Pa- received a blood transfusion, but he had rience with autochthonous dengue as the cific northwest states), Europe, China, had friends from the French West Indies result of identification of cases in Key Siberia and Korea [1] – almost all areas staying with him since April 2010. West, Florida [1]. Although dengue virus with nasty winter weather. A. phag- Because this case was apparently au- infection has been acquired in Hawaii, ocytophilum is transmitted by Ixodes tochthonous in origin, active control the Key West cases were the first such persulcatus group ticks, including I. ri- measures were implemented, including cases identified in the continental US cinus in Europe, I. pesulcatus in Asia, I. vector control activities within a 200 meter (with the exception of some cases along pacificus in the western US, and I. scap- perimeter of the patient’s home, active case the Texas-Mexico border) since 1945. ularis in the eastern US [1]. Since this finding in his neighborhood, and public Aedes aegypti is present throughout the bacterial organism is not transmitted and professional education. Six patients southern US and Aedes albopictus transovarially, it faces the necessity of with confirmed imported dengue were throughout the southeastern US, thus surviving winter within the tissue of identified by routine laboratory network giving reason for concern regarding the these ticks. surveillance in Nice between 24 July and 23 potential reemergence of dengue in these Neelakanta and colleagues investi- Downloaded from https://academic.oup.com/cid/article/52/5/iii/386902 by guest on 30 September 2021 August, one of whom had acquired the areas. gated the means by which this mutual infection in Martinique and lived ap- survival of tick and is possible. References proximately 200 meters from the index They have demonstrated that A. phag- 1. CDC. Locally acquired dengue — Key West, case. Active case finding identified a sec- Florida, 2009-2010. MMWR 2010; 59:577–81. ocytophilum infection of I. scapularis ond confirmed case of authochthonous 2. Angelini R, Finarelli AC, Angelini P, et al. enhances the ability of the tick to survive dengue in an 18 year old man who lived 70 in north-eastern Italy: a sum- temperatures as low as -20°Candcold ming up of the outbreak. Euro Surveill 2007; meters from the with symptom 12(47). pii: 3313. Available from: http:// tolerance increased with increased onset on 11 September 2010. His illness www.eurosurveillance.org/ViewArticle.aspx? Anaplasma burden. This was associated ArticleId53313 was also uncomplicated except for tran- 3. Tsetsarkin KA, Vanlandingham DL, McGee with the production by the tick of sient thrombocytopenia. CE, Higgs S. A single mutation in chikungunya a glycoprotein with antifreeze proper- virus affects vector specificity and epidemic The outbreak of chikungunya in Italy in potential. PLOS 2007; 3:e201. ties, I. scapularis antifreeze glycoprotein 2007 raised awareness of the potential for Available at http://pathogens.plosjournals (IAFGP), resulting from upregulated .org/perlserv/?request5get-document&doi5 non-endemic to establish a foot- 10.1371/journal.ppat.0030201 transcription of the relevant gene, iafgp. hold in Europe [2] and led to some of the This effect was not observed with ongoing surveillance activities that quickly Anaplasma and Ixodes: infection of I. scapularis by Babesia recognized the importance of the cases of Keeping warm with Snuggling microti, indicating that this was not dengue in Nice. That surveillance is ‘‘en- and Antifreeze a non-specific effect of intracellular hanced’’ from May to December in French parasitism. departments, such as Alpes-Maritimes, Neelakanta G, Sultana H, Fish D, et al. Thus, A. phagocytophilum enhances which contains Nice, where Aedes albo- Anaplasma phagocytophilum induces Ix- winter survival of its vector by upregu- pictus has become established. While Aedes odes scapularis ticks to express an anti- lating expression of a glycoprotein with aegyptus is a more efficient vector than Ae. freeze glycoprotein gene that enhances antifreeze properties – an example of albopictus, the latter has been involved in their survival in the cold. J Clin Invest mutually beneficial coevolution. a number of large dengue outbreaks. The 2010; 120:3179-90. recent Indian Ocean epidemic of chi- The Ixodes ticks and the pathogens References kungunya appears to have resulted, at least they transmit, such as the etiologic agents 1. Dumler JS, Madigan JE, Pusterla N, Bakken JS. in part, from a viral mutation that resulted of Lyme disease, anaplasmosis, ehrli- Ehrlichioses in humans: epidemiology, clinical presentation, diagnosis, and treatment. Clin in its increased transmissibility to and fit- chiosis, and babesiosis, often must sur- Infect Dis 2007; 45(Suppl 1);S45–51. ness in Ae. albopictus [3]. It can be hoped vive harsh winters. Areas of endemicity of Published by Oxford University Press on behalf of the that a similar event will not occur with Anaplasma phagocytophilum include, in Infectious Diseases Society of America 2011. regard to dengue virus. addition to parts of the US northeastern, DOI: 10.1093/cid/ciq222

iv d CID 2011:52 (1 March) d IN THE LITERATURE