Monkeypox

Historical Perspective and O

verview

2006

One Medicine Symposium

December 6-7, 2006

Research Triangle Park

C. Gregory Smith, MD, MPH

General Communicable Disease Control Branch

Epidem

iology Section

North Carolina Division of Public Health

Human M

onkeypox

African Rodents

Prairie Dogs

Black-footed

Ferrets

Poxviruses by G

enus

•Orthopoxvirus

–Cowpox, Monkeypox, Vaccinia, Variola (Smallpox), Camelpox

•Yatapoxvirus

–Tanapox, Yatapox (non-human primates, humans incidentally)

•Parapoxvirus

–Orf, Pseudocowpox, Bovine Papular Stomatitis, Sealpox

•Molluscipoxvirus

–Molluscipox (Molluscum contagiosum) human &

nh primates

•Avipoxvirus

(Fowlpox-birds)

•Capripoxvirus(Sheep pox-sheep, goats, cows)

•Leporipoxvirus(M

yxoma-squirrels, rodents, rabbits)

•Suipoxvirus(Swinep

ox)

Orthopoxviruses

Yes

Direct contact,

Respiratory

droplets

US, Russia

(laboratories)

Eradicated

1980 W

HO

Humans

No known

anim

al

reservoirs

Humans

Variola

Smallpox

(SPXV)

Direct contact

Direct contact,

Respiratory

droplets

Direct contact

Direct contact

Mode of

Transm

ission

Probably

Africa, Asia

Camels

Camels,

? H

umans

Camelpox

(CMPV)

Yes

Central and

West Africa

Rodents

Humans,

monkeys,

rodents

Monkeypox

(MPXV)

Yes

Europe,

Africa, Asia

Rodents

Humans,

cats, cattle

rodents

Cowpox

(CPV)

?? Indian

Subcontinent

Buffulopoxvirus

Unknown

Humans

Vaccinia

(? Extinct

horsepoxvirus)

Protection

by Vaccinia

Vaccination

Geographic

Region

Primary

Reservoir

Host

Species

Monkeypox Virus (M

PXV)

FamilyPoxviridae

Subfamily Chrodopoxvirinae

Genus Orthopoxvirus

MPX

Pat

ient-Ele

ctro

nm

icro

gra

ph o

f Skin

Bio

psy

-Mar

shfiel

d C

linic

, M

arsh

fiel

d,W

I

Hum

an M

PX

-Lib

eria

1971

CDC -1971

MPX

His

torica

l N

ote

s

•1958-Initial discovery

-Den

mark-O

utbreak in laboratory primates

•1970-First human case identified in Zaire

9 m

o child who had not been vaccinated against SPX

•1970-1994: Following eradication of SPX in sub-

Saharan Africa, about 400 cases of MPX were

reported from the tropical-forested countries of

West and Central Africa

–95% of these were recorded in Zaire following intense

surveillance from 1982-1986

–Epidem

iologic and laboratory studies during this period

provided the foundation of our knowledge about MPX in the

natural setting.

Epid

emio

logy o

f M

PX

in A

fric

a•

Sporadic viral zoonosis confined to equatorial rain forests of West

and Central Africa

•Natural history is not clear

•Monkeys, other primates, including humans, are susceptible but

are unlikely reservoir hosts

•Antibody evidence indicates that wild rodents (African tree

squirrels, Gambian giant rats, elephant shrews, etc) serve as

primary viral reservoirs

•Routes of exposure and transm

ission have not been clearly

delineated but butchering m

onkeys and contact with sick

primates and rodents are thought to be the primary sources of

exposure

•Increased trade in bush m

eat is one possible risk factor for

outbreaks of human M

PX in enzootic areas

•Cases of MPX ten

d to occur singly or in small clusters.

Human-to-human transm

ission occurs infrequently

•2005

Updat

ed fro

m F

rien

d. M

PX

-A

Les

son N

ot Y

et L

earn

ed…

; U

SG

S C

ircu

lar1

285; 2006 p

170.

MPX

-susp

ecte

d w

ildlife

res

ervoirs

Source: Friend M

. Monkeypox-A

Lesson Not Yet Learned. In: Disease Emergence and

Resurgence: The W

ildlife H

uman Connection. USGS Circular 1285; 2006.

MPX

Clinic

al Illnes

s

•Incubation period: like SPX--12 days (R

ange 7-17 days)

•Signs and symptoms also sim

ilar to smallpox:

•Fever, HA, myalgias, backache, swollen lymph nodes,

general feeling of discomfort and exhaustion,

generalized pustular rash

•Rash resembles the ordinary or modified form

s of SPX

macules papules vesicles pustules

umbilication scabbing desquamation

Differen

ces Compared to SPX

•Lymphadenopathy tends to be more prominent than in

SPX and occurs early in the disease.

•Routes/mechanisms of p-t-p transm

ission are sim

ilar to

those for SPX but secondary transm

ission in M

PX is

lower, about 8%.

Sim

ilarities Compared to SPX

MPX

Clinic

al Illnes

s

Sim

ilarities Compared to SPX

•Illn

ess la

sts 2 to 4

wee

ks

Differences Compared to SPX

•Cas

e fa

tality

rat

io for M

PX

is le

ss c

om

par

ed to S

PX

–Among unvaccinated populations in W

est Africa, the

CFR varies between 1%-10%.

–It m

ay be higher in children

–For comparison CFR for SPX is 20-50%

Lym

phad

enopat

hy is th

e princi

pal

clinic

al fin

din

g

that

hel

ps to

distinguish m

onkey

pox fro

m sm

allp

ox.

Photos from Nalca et al. ClinInfectious Dis, 2005:41 (15 Dec) 1767.

Differential Diagnosis R

are

Common

Common

Lesions on

palm

s/soles

6-14 days

14-21 days

14-21 days

Tim

e to

desquamation

Heterogeneous rash

Homogenous

Homogenous

Lesion Stage

Centripetal

Centrifugal

Centrifugal (m

ainly)

Lesion

Distribution

Superficial (2-4 m

m)

Unilocular

Deep (4-6 m

m)

Multilocu

lar

Superficial to Deep

(4-6 m

m) M

ultilocular

Lesion Depth

None

None

Moderate to severe

Lymphadenopathy

Mild

Severe

Moderate

Headache, severity

Mild

Moderate

Moderate

Malaise, severity

Mild or None

Severe

Moderate

Fever, severity

0-2 days

2-4 days

1-4 days

Prodrome Pd

12-14 days

7-17 days

7-17 days

Incubation Pd

Chickenpox

Smallpox

Monkeypox

Is M

PX likely to become endemic

in the human population?

•MPX virus genome lacks some of the

immunomodulatory genes possessed by the

SPX virus genome.

•This suggests that MPX is unlikely to

become endem

ic in the human population.

Prevention

•Due to genetic sim

ilarities between smallpox and

monkeypox, vaccination with Vaccinia

virus

protects against both diseases.

Fam

ous W

ord

s

“Ther

e is

no e

vid

ence

that

monkey

pox

will bec

om

e a

public

hea

lth thre

at

outsid

e of en

zootic

area

s.”

Control of Com

munic

able

Disea

ses M

anual

APH

A, c.

2000

A funny thin

g h

appen

ed o

n the

way

to the:

•??

Foru

m—

No

•??

Mar

ket

—N

o

•??

Pet

sto

re—

Yes

Illu

stra

tion b

y John E

van

s

MPX H

uman Cases

WI 39

IN 16

IL 12

MO 2

KS 1

OH 1

50 G

ambia

n G

iant Rat

s

510 D

orm

ice

53 R

ope

Squirre

ls

47 T

ree

Squirre

ls

100 S

trip

ed M

ice

2 B

rush

tailed

porc

upin

es

Imported from

Accra, Ghana to US

April 9, 2003

West African Rodents

Illustration Source:

Friend M

. USGS 2006

2003 M

PX

Outb

reak

in U

S•

First h

um

an c

ases

dia

gnose

d in m

id a

nd lat

e M

ay in

Wisco

nsin a

nd Illin

ois

•By July

71 c

ases

in six

Mid

wes

tern

had

bee

n

reported

to C

DC

–W

isco

nsin 39 India

na

16 Illinois 1

2

–M

isso

uri 2

Kan

sas 1

Ohio

1

•Cla

ssific

atio

n

–35 L

abora

tory

confirm

ed

–36 S

usp

ect or pro

bab

le

Sourc

e: N

alca

et al

. Clinic

al Infe

ctio

us D

isea

ses V

ol 41 D

ec 1

5,2005

Sym

pto

m h

ighlights to the

right ad

ded

.

Rash

Fever

Chills

Adenopathy

Monkeypox: Signs and Symptoms 2003 US O

utbreak-34 Patients

Headache

Sore throat

Myalgias

Sweats

Cough

Sourc

e: N

alca

et al

. Clinic

al Infe

ctio

us D

isea

ses 2005:4

1 (15 D

ec),1767.

Monkeypox Rash in M

idwestern US O

utbreak Cases

Sourc

e: N

alca

et al

. Clinic

al Infe

ctio

us D

isea

ses 2005:4

1 (15 D

ec),1749.

Hosp

ital

ized

10 Y

ear O

ld G

irl w

ith M

PX

Ret

rophar

yngea

l A

bsc

ess, T

rach

eal Im

pin

gem

ent, a

nd C

ervic

al L

ym

phad

enopat

hy

Hum

an M

onkey

pox C

ase

Def

initio

n

Updat

ed inte

rim

def

initio

n Jan

uar

y 2

004

•Clinical Criteria

–Rash (macu

lar, papular, vesicular, or pustular; generalized or

localized; discrete or confluent)

–Fever (subjective or measured tem

p of >99.3 F (37.4C)

–Other signs and symptoms

•Chills and/or sw

eats

•Headache

•Back

ache

•Lymphadenopathy

•Sore Throat

•Cough

•Shortness of Breath

Hum

an M

onkey

pox C

ase

Def

initio

n

Updat

ed inte

rim

def

initio

n Jan

uar

y 2

004

•Epidem

iologic Criteria

–Exposure to an exotic or wild m

ammalian pet

obtained on or after April 15, 2003, with clinical signs

of illness (e.g., conjunctivitis, respiratory symptoms,

and/or rash)

–Exposure to an exotic or wild m

ammalian pet with or

without clinical signs of illness that has been in

contact with either a m

ammalian pet or a human with

monkeypox

–Exposure to a suspect, probable, or confirm

ed case of

monkeypox

Hum

an M

onkey

pox C

ase

Def

initio

n

Updat

ed inte

rim

def

initio

n Jan

uar

y 2

004

•Laboratory Criteria

–Isolation of monkeypox virus in culture

–Demonstration of monkeypox virus DNA by

polymerase chain reaction testing of a clinical

specim

en

–Demonstration of virus morp

hologically consistent

with an orthopoxvirus by electron m

icroscopy in the

absence of exposure to another orthopoxvirus

–Demonstration of presence of orthopoxvirus in tissue

using immunohistochem

ical testing m

ethods in the

absence of exposure to another orthopoxvirus

Hum

an M

onkey

pox C

ase

Cla

ssific

atio

n

•Suspect Case

–Meets one of the epidem

iologic criteria AND

–Fever or unexplained rash ANDtw

o or more other signs or symptoms with

onset of first sign or symptom <21 days after last exposure m

eeting

epidem

iologic criteria

•Probable Case

–Meets one of the epidem

iologic criteria AND

–Fever AND

–Vesicular-pustular rash with onset of first sign or symptom <21 days after

last exposure m

eeting epidem

iologic criteria

OR If rash is present but the type is not described, dem

onstrates elevated

levels of IgM antibodies reactive with

orthopox virus between at least days 7 to 56 after rash onset

•Confirm

ed Case

–Meets one of the laboratory criteria

Hum

an M

onkey

pox C

ase

Excl

usion C

rite

ria

•A case m

ay be excluded as a suspect or probable

monkeypox case if:

–An alternative diagnosis can fully explain the illness, O

R

–The case was reported on the basis of primary or secondary

exposure to an exotic or wild m

ammalian pet or a human (see

epidem

iologic criteria) subsequently determined not to have

monkeypox, provided other possible epidem

iologic criteria are

not present, O

R

–A case without a rash does not develop a rash within 10 days of

onset of clinical symptoms consistent with m

onkeypox

–The case is determined to be negative for non-variola generic

orthopoxvirus by polymerase chain reaction testing of a well

sampled rash lesion by the approved Laboratory Response

Network

(LRN) protocol.

–The case is determined to have undetectable levels of IgM

antibody during the period of 7-56 days after rash onset.

NC

Res

ponse

•A

ctiv

e su

rvei

llan

ce-feb

rile

ras

h illnes

s

•V

eter

inar

y P

ublic

Hea

lth

–Loca

l H

ealth D

epar

tmen

ts

–N

C D

epar

tmen

t of A

gricu

lture

-reg

ula

tes Pet

Sto

res

–Lic

ense

d V

eter

inar

ians

–Loca

l Pet

Sto

res-

public

hea

lth iss

ues

–In

div

idual

s w

ith P

ets

Prairie Dog with Owner

Take to

veterinarian

Animal is

sick Veterinarian examines

animal, history, physical &

maintains full records

Animal is healthy

or doesn’t appear

to have MPX

Return

animal to

owner

Animal is sick &

appears to have MPX

DVM notifies LH Dept

and NCDA&CS

immediately: Does DVM

allow owner to keep?

Euthanize animal:

Incinerate or freeze according

to instructions by LHD or

NCDA

Animal is

healthy

Animal

remains at

hom

e of

owner

Owner seeks

permission from

NCDA/LHDept

to give to

refuge

Order given to

euthanize

animal

Give to refuge, refuge keeps animal on

premises, maintains full records,

notifies LHD or NCDA if animal sickens,

dies, escapes

•Refuge space

available

Refuge space

available and

Perm

ission given

Refuge space not

available

Or

Perm

ission not given

Prairie Dogs: Most Social Mem

bers of the Squirrel Family

Genus Cynomys-5 Species

Bla

ck-tai

led (C ludovicianus)*

dry

pla

ins ce

ntral

TX

to C

anad

a

White-

tailed

(C leucurus)-w

este

rn U

S, CO

, U

T, W

Y, M

T

Gunnison’s

(C gunnisoni)-Four co

rner

s 5000-1

1,0

00 ft

Uta

h (C parvidens)-s

mal

lest, ESA

: th

reat

ened

Mex

ican

(C mexicanus)-ESA

: en

dan

ger

ed

In 1900, a prairie dog settlem

ent on the high

plains of TX extended 100 by 250 m

iles with

an estim

ated population of 400 m

illion.

Predators:Hawks, owls, eagles, ravens, coyotes,

badgers, ferrets, snakes, andhumans

* Sold in pets stores

in US and abroad

Public Health Risks:

•Plague from fleas

•Tularemia (Japan)

•Salm

onellosis

Photos: US Fish &

Wildlife Service

Anim

als In

fect

ed w

ith M

PX

V

13 lin

ed g

round squirre

l

Pra

irie

dog

Adapted from : Friend M

. Circu

lar Monkeypox-A

Lesson Not Yet Learned. In:

Disease Emergen

ce and Resurgen

ce: The Wildlife H

uman Connection. USGS 1285; 2006.

Black-footed Ferret -im

portant predator of prairie dogs-PDsexterm

inated

Thought extinct until sm

all colony discovered in 1981 near Meeteetse, Wyoming

Mustela nigripes

.

Photos: US Fish and W

ildlife Service

North American Black-footed Ferret

One of three ferrets in the world:

European ferret (European polecat) (Mustela putorius)

Domesticated (Mustela putorius furo)

Pets

Led to Discovery of Influenza Virus

Anim

al Model for Influen

za

North American black-footed ferret (Mustela nigripes)

Fossil evidence indicates it is descended from the Siberian

ferret which crossed into NA during the Pleistocene Period

Siberian ferret (Steppe polecat) (Mustela eversmannii)

closest relative of BFF

Black-footed Ferret Facts

•1967 Listed as federally endangered species, thought to be extinct

•1981 Small population discovered by a rancher near Meeteetse, WY

•1984 Estim

ated population of 129 crashed due to canine distemper-no

immunity

•1985 Six ferrets in the Meeteetse population were captured and m

oved to

captive breeding facilities at the WY G

ame and Fish Department’sSybille

Research Facility-all died from canine distemper

•1987 Rem

aining 18 ferrets captured -Initial breeding efforts unsuccessful

•1988 Breeding success

•1992 Reintroduction to the wild

•1998 SSP captive breeding facilities 425 born with 321 kits surviving

•2006 W

ild population now approx 700-850 in five western states

–BFF live in Prairie Dog burrows 90 %

BFF diet is PD

–Single ferret family requires 100 acres of PD colony for sustenance

Threats to wild BFF population:

–Loss of prairie dog habitat

–Predators

–Disease (canine distemper, plague**, influenza)

–MPX if captive prairie dogs infected with M

PX were released into

wild

Threats to captive BFF population (VA, KY, WY, AZ, CO, Canada):

–Disease as above and M

PX if M

PX-infected prairie dogs were fed to ferrets

What good are G

ambian giant rats, anyway?

Excellent, cheap, replaceable

detectors for land m

ines.

Wines M. For Sniffing O

ut Land M

ines, A Platoon of Twitching Noses. The New York

Times M

ay 18, 2004.

http://www.acs.appstate.edu/~kms/classes/psy3202/RatsLandMines.htm

www.taipeitimes.com

www.thaiclinic.com

Ref

eren

ces

•Control of Communicable Diseases Manual. James Chin, MD, MPH,

Editor, 17thEdition 2000, American Public Health Association,

Washington D.C. pp 458-459.

•Landyl ID

, Ziegler P, Kim

a A. A human infection caused by m

onkeypox

virus in Basankusu Territory, Dem

ocratic Republic of the Congo (DRC).

Bull W

HO 1972;46:593-7.

•Breman JG. Monkeypox: an emerging infection for humans? In: Scheld

WM, Craig W

A, Hughes JM, eds. Emerging Infections 4. Washington,

DC: ASM Press, 2000:45-76.

•Shchelkunov SN, Totm

enin AV, Babkin IV, et al. H

uman m

onkeypox and

smallpox viruses: genomic comparison. FEBS Lett 2001;509:66-70.

•Shchelkunov SN, Totm

enin AV, Safronov PF, et al. Analysis of the

monkeypox genome. Virol 2002;297:172-94.

•World H

ealth O

rganization. Technical Advisory G

roup on H

uman

Monkeypox: report of a W

HO m

eeting. Geneva, Switzerland, January

11-

-12, 1999.

•Jezek ZM, Scczeniowski KM, Paluku M

, Putombo M

, Grab B. Human

monkeypox: clinical features of 282 patients. J Infect Dis 1987;156:293--8.

Ref

eren

ces-

continued

•Hutin YJF, Williams RJ, Malfait P, et al. O

utbreak of human m

onkeypox,

Democratic Republic of Congo, 1996-1997. Emerg Infect Dis 2001;7:434-8.

•Khodakevich L, Jezek Z, Kinzana K

. 1986 Isolation of monkeypox from a wild

squirrel. Lancet 1986;1:98-9.

•State of Wisconsin, Departm

ent of Health and Family Services. Emergency order.

Available at http://www.dhfs.state.wi.us/dph_bcd/m

onkeypox/Response.htm

.

•State of Illinois. Executive order in response to orthopox outbreak. Available at

http://www.idph.state.il.us/pdf/ExecutiveOrder14.pdf.

•CDC/FDA: Joint CDC/FDA Interim

Final Rule

http://www.fda.gov/ohrms/dockets/98cfr/03-27557.htm

•Reed K

D, Melski JW, Graham M

B, Kazm

ierczak JJ, et al. The detection of

monkeypox in humans in the W

estern H

emisphere. N Engl J M

ed 2004Jan 22;

350(4):342-50. Comment/author reply 2004 (Apr 22:350(17):1790-1.

•Guarner J, Johnson BJ, Paddock CD. Monkeypox transm

ission and pathogenesis in

prairie dogs. Emerg Infect Dis. 2004 (Mar;10(3):426-31.

•Langohr IM, Stevenson G

W, Thacker H

L, et al. Extensive lesions of monkeypox in a

prairie dog. Vet Pathol. 2004 Nov; 41(6):702-7.

•Huhn G

D, Bauer AM, Yorita K

et al. Clinical characteristics of human m

onkeypox

and risk factors for severe disease. CID

2005; 41 (15 December):1742-51.

•Nalca A, Rim

oin A, Bavari S et al. Reemergence of monkeypox: prevalence,

diagnostics, and countermeasures. CID

2005; 41 (15 December): 1765-71.

•Friend M

. M

onkeypox-a lesson not yet learned. In: Disease Emergence and

Resurgence: The W

ildlife-H

uman Connection: USGS Circular 1285; 2006 168-171.

Accessed 11/13/2006http://wildlifedisease.nbii.gov/documents/pg%20168-

170%20Monkeypox.pdf

Ref

eren

ces-

continued

•CDC. Human m

onkeypox-K

asai Orien

tal, Zaire, 1996-O

ctober 1997. M

MWR Dec 12, 1997; 46

(49);1168-71.http://www.cdc.gov/m

mwr/preview/m

mwrhtm

l/00050245.htm

•CDC. Human m

onkeypox-K

asai Orien

tal, Zaire, 1996-1997. M

MWR Apr 11, 1997; 46(14);304-7.

http://w

ww.cdc.gov/m

mwr/preview/m

mwrhtm

l/00048673.htm

•CDC. Multistate outbreak of monkeypox—Illinois, Indiana, and W

isconsin, MMWR June 13,

2003; 52(23) 537-40.http://w

ww.cdc.gov/m

mwr/preview/m

mwrhtm

l/mm5223a1.htm

•CDC. Update m

ultistate outbreak of monkeypox—Illinois, Indiana, Kansas, M

issouri, Ohio, and

Wisconsin, MMWR June 20, 2003; 52(24) 562-4.

http://w

ww.cdc.gov/m

mwr/preview/m

mwrhtm

l/mm5224a1.htm

•CDC. Update m

ultistate outbreak of monkeypox—Illinois, Indiana, Kansas, M

issouri, Ohio, and

Wisconsin M

MW

R June 27, 2003; 52(25) 589-90.

http://w

ww.cdc.gov/m

mwr/preview/m

mwrhtm

l/mm5225a4.htm

•CDC. Update m

ultistate outbreak of monkeypox—Illinois, Indiana, Kansas, M

issouri, Ohio, and

Wisconsin M

MW

R July 4, 2003; 52(26) 616-8.

http://w

ww.cdc.gov/m

mwr/preview/m

mwrhtm

l/mm5226a5.htm

•CDC. Update m

ultistate outbreak of monkeypox—Illinois, Indiana, Kansas, M

issouri, Ohio, and

Wisconsin, 2003. MMWR. July 11, 2003; 52(27) 642-6.

http://w

ww.cdc.gov/m

mwr/preview/m

mwrhtm

l/mm5227a5.htm

Ref

eren

ces-

continued

•CDC: Information on m

onkeypox:

http://w

ww.cdc.gov/ncidod/m

onkeypox/index.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/clinicians.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/vet.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/factsheet.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/qa.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/anim

als.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/smallpoxvaccine_mpox.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/vaccineqa.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/casedefinition.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/treatm

entguidelines.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/anim

alguidance.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/anim

alcasedefinition.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/anim

alhandlers.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/diagspecim

ens.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/autopsy.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/labbiosafetyguide.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/specim

enguide.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/specim

entrackingform.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/infectioncontrol.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/embargoqa.htm

•http://edocket.access.gpo.gov/2003/03-27557.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/law.htm

•http://w

ww.cdc.gov/ncidod/m

onkeypox/pet.htm