Outbreak & Emerging Diseases

There currently is a global outbreak of mpox affecting multiple countries in which the disease is not endemic, including the U.S. Mpox is a rare disease that is caused by infection with the mpox virus, which belongs to the Orthopoxvirus genus in the family Poxviridae. The Orthopoxvirus genus also includes variola virus (which causes smallpox), vaccinia virus (used in the smallpox vaccine) and cowpox virus.

Mpox is considered an immediately reportable disease in the State of Missouri. To report a suspected case, hospitals and clinics should contact their local public health agency or the Missouri Department of Health and Senior Services’ Bureau of Communicable Disease Control and Prevention at 573-751-6113 or 800-392-0272 (24/7).

The Missouri State Public Health Laboratory will perform an orthopox test, and if it is confirmed positive, specimens will be submitted to the CDC for testing. Instructions for submitting specimens for testing are available.

Situational Awareness

• CDC Mpox Health Advisory
• CDC Mpox in the United States and Around the World: Current Situation
• Travel Notice – Level 2-Practice Enhanced Precautions
• WHO Mpox Outbreak Information

A High Consequence Infectious Disease (HCID) is a contagious illness that poses significant risks to public health and requires a heightened, specialized response. HCIDs generally share several key characteristics: 

• High Case-Fatality Rate: They often lead to a high percentage of deaths among those infected. 
• Limited or No Effective Medical Countermeasures: There may be no readily available vaccines, effective treatments, or prophylaxis. 
• Difficulty in Rapid Recognition and Detection: Initial symptoms can be non-specific, making quick identification challenging. 
• Potential for Widespread Transmission: They are easily transmissible from person to person, both in the community and within healthcare settings. 
• Significant Public Health Impact: They have the potential to cause widespread illness, death, social disruption, and economic consequences. 
• Requirement for Enhanced Response: Managing HCIDs necessitates an elevated individual, population, and system response, including strict infection control measures and specialized personal protective equipment (PPE). 

Examples of diseases commonly categorized as HCIDs include Ebola Virus Disease (EVD), Marburg Virus Disease and Lassa Fever. 

All HCIDs are considered an immediately reportable disease in the State of Missouri. To report a suspected case, hospitals and clinics should contact their local public health agency or the Missouri Department of Health and Senior Services’ Bureau of Communicable Disease Control and Prevention at 573-751-6113 or 800-392-0272 (24/7). 

All potential patients with a possible HCID should be managed through the Identify – Isolate – Inform methodology. 

Identify - Screen all patients and ask about signs and symptoms  that might indicate an infection: fever, headache, body aches, etc.  If screened positive (S+S), ask the patient to don a mask. Then, ask the patient about travel/exposure history. 

Isolate - Place the patient in an AIIR room. If AIIR is unavailable, place the patient in a private room or area. Limit contact with other patients, visitors, and healthcare workers.  Don appropriate transmission-based PPE before entering the patient room. 

Inform - Keep the patient informed about their care. Acknowledge their questions or concerns. Inform appropriate leadership in the department and facility. Notify the provider and work with Infection Prevention to determine the next steps, including if the patient meets case criteria and notification of public health or DHSS. 

Ebola Virus Disease (EVD), commonly known as Ebola, is a rare yet severe and often fatal illness in humans, stemming from viruses within the Ebolavirus genus of the Filoviridae family. The disease is primarily caused by several species of Ebolavirus, with Ebola virus (EBOV), Sudan virus (SUDV), and Bundibugyo virus (BDBV) being the most common during outbreaks. EVD was first identified in 1976, near the Ebola River in the Democratic Republic of the Congo, lending its name to the virus. 

Transmission: Ebola is primarily transmitted through direct contact with the blood, body fluids (such as urine, feces, saliva, vomit, sweat, semen, and breast milk), or organs of an infected person or animal. This can occur through broken skin or mucous membranes in the eyes, nose, or mouth. Individuals with Ebola are only contagious once they begin to show symptoms. The virus can also spread through contact with objects or surfaces contaminated with these infectious bodily fluids. Globally, unsafe burial practices that involve direct contact with the body of someone who has died from Ebola can facilitate transmission. Fruit bats are believed to be the natural reservoir for the virus, and spillover events can occur from other infected animals.  

Symptoms: The incubation period (time from infection to symptom onset) ranges from 2 to 21 days, with an average of 8 to 10 days. Early symptoms are often flu-like and can be non-specific, often mimicking Malaria making early diagnosis challenging. These "dry" symptoms include:  

• Sudden onset of fever 
• Severe headache 
• Muscle pain 
• Weakness and fatigue 
• Sore throat 

As the disease progresses, "wet" symptoms typically appear, including:  

• Vomiting 
• Diarrhea (often severe and watery) 
• Abdominal pain 
• Rash 
• Impaired kidney and liver function 
• In some cases, internal and external bleeding (though bleeding is not always present and may occur later in the disease). 

Severity: Ebola is a severe illness with a high case-fatality rate, which can range from 25% to 90% depending on the specific virus species and outbreak. Fatal cases often involve multi-organ failure and septic shock. 

Treatment and Prevention:  

• Treatment: While historically challenging to treat, there are now FDA-approved treatments for Ebola virus disease caused by the Zaire ebolavirus species, which utilize monoclonal antibodies ( Inmazeb and Ebanga). Supportive care is crucial, including fluid rehydration, managing symptoms, and addressing complications like organ failure. 
• Vaccination: An FDA-approved vaccine (Ervebo) is available for the prevention of Ebola virus disease caused by Zaire ebolavirus in individuals aged 18 and older who are at high risk of exposure  such as healthcare workers in outbreak areas). 

Highly Pathogenic Avian Influenza (HPAI, Avian Flu, H5N1) remains a concern that is closely being monitored at the state, regional and national levels. With continued mutation, this virus could become transmissible from human to human, causing a large outbreak. A vaccine has already been developed but is not currently available.

Presently, this virus is rapidly spreading throughout both domestic and wild animal populations, including a variety of mammals. The greatest impacts can be seen in dairy cattle and poultry flocks. This disease is fatal to poultry flocks and requires the culling of infected and exposed animals to prevent the spread. While multiple outbreaks among dairy cows have been noted, and at least one worker infected, confidence remains in the pasteurization process of dairy products. The gastric environment may protect against this virus. The FDA and CDC warn against the use of raw milk.

This virus is difficult to detect in humans as it mimics other viral illnesses, and to date, the symptoms have not been severe. The course of action recommended at this time is the familiar Identify – Isolate – Inform strategy.

• Identify – Does the patient show signs of viral illness and spend significant time around commercial animal endeavors or has backyard poultry flocks that are also not well?
• Isolate – Use appropriate PPE, as with all potential patients with viral illness, and obtain appropriate lab tests.
• Inform – If the patient comes back negative for common RVI or viral illness panels, notify local public health or DHSS 24/7 about the possible need for additional testing.

Additional HPAI information, including ongoing situational awareness and clinical information on testing and treatment, is available from the CDC.