Updates on Monkeypox Disease

Topic Outline

1. Risk Factors, Signs & Symptoms, and Transmission

2. Diagnosis and Treatment
3. Epidemiology, Case Definition, Global Situation, and Surveillance - Sample
Coordination
4. Sample Collection
5. PDITR Measures
6. Border Surveillance and Control
7. Immigration Reminders for Filipinos Traveling to Monkeypox Affected Countries
8. Monkeypox in Animal
Risk Factors, Signs & Symptoms, and
Transmission
DR. MARK PASAYAN
Philippine Society for Microbiology & Infectious Diseases (PSMID)
Diagnosis and Treatment
DR. ARTHUR DESSI ROMAN
Philippine Society for Microbiology & Infectious Diseases (PSMID)
Diagnosis
• Laboratory confirmation is necessary.
• Rule out other rash illnesses
• Chickenpox – Varicella IgM/IgG
• Measles – Measles IgM/IgG
• Bacterial skin infections – GS CS
• Scabies – characteristic ”burrows”
• Syphilis – palms and soles involvement, RPR/VDRL, TPPA
• Medication-associated allergies
Diagnosis: What specimens to
send?
• Vesicular or pustular fluid aspirate
• Crust or roof of skin lesion
• Skin or tissue
 What is the preferred test to
diagnose monkeypox infection?
PCR is the preferred test to indicate the
presence of the virus in the skin lesions
 Diagnostic Tests Used for Monkeypox
Polymerase Chain Reaction Viral Isolation by Cell Enzyme-linked
(PCR) assay Culture Immune Sorbent
Advantages • Preferred test Indicate the presence of • Detect exposure to the
• Indicate the presence of the virus the virus virus
• Can be used alone, or in • IgM-based serology to
combination with sequencing determine recent
• GeneXpert MPX/OPX assay is exposure
highly sensitive and specific • Paired sera analysis to
compared to real-time quantitative determine recent
MPX PCR assays (gold standard) infection

Disadvantages • No commercial PCR kits available • Limited to high-level • Cross-reactivity

• Cartridge, primers and probes not facilities with expertise between orthopoxvirus
• yet available locally and equipment (e.g. US species
CDC) • Not yet available locally
• Not yet available locally

https://www.who.int/news-room/fact-sheets/detail/monkeypox
Diagnostic Tests Used for Monkeypox
• Other diagnostic assays:
• Whole Genome Sequencing
• Electron microscopy: Brick-shaped poxvirus
• Histopathology: ballooning degeneration of
keratinocytes, prominent spongiosis, dermal edema, and
acute inflammation🡪 non-specific
Ancillary Diagnostic Tests
Ancillary test results are non-specific abnormalities (AST, ALT,
leukocytosis, mild thrombocytopenia, and hypoalbuminemia)

• Recommended: CBC, crea, AST, ALT

• If with significant GI losses: Na, K
• Other differentials: Varicella IgM/IgG, HSV PCR as needed
Treatment
• Supportive care – antipyretics, hydration if with losses
• Keep skin clean, dry with lesions covered with sterile wound
dressing.
• Change bed linens at regular intervals.
• Antibacterial treatment – if with superimposed bacterial infection
• Cloxacillin or clindamycin
 RITM Management Protocol for Monkeypox 23 May 2022
[DRAFT]

Use of Antivirals
• No proven antiviral therapy.
• Use of current Antivirals based on animal models and dose
studies in healthy humans
• Data not available on effectiveness of antivirals for human monkeypox
and its complications
• Can be used for control of outbreak or for severe cases
• Could only be used under Investigational New Drug (IND) or
Emergency Use Authorization (EUA) protocol
• Currently, no strong recommendation for use from any
international guidance.
 Antivirals against Monkeypox
Tecovirimat (US FDA, July 2018) Cidofovir Brincidofovir (US FDA June 2021) Vaccinia immune globulin
(VIG)
Potent inhibitor of an orthopoxvirus viral competitive inhibitor Analog of cidofovir, inhibits viral Provides passive immunity,
protein p37 required for the formation of an and an alternate DNA polymerase exact MOA not formally
infectious virus particle substrate for CMV DNA known
Treatment of choice in patients with severe polymerase
disease, With or without brincidofovir
Adult: 5 mg/kg weekly x 2 <10 kg: 6 mg/kg on Days 1 and 8 6000 U/kg IV
40 to <120 kg: 600 mg BID for 14 d weeks then 5 mg/kg (oral solution)
≥120 kg: Oral: 600 mg TID for 14 days every other week 10-48kg: 4 mg/kg on Days 1 and 8
(oral solution)
Pediatric: >= 48 kg: 200 mg on Days 1 and 8
13 to <25 kg: 200 mg twice daily for 14 d (solution and capsule)
25 to <40 kg: 400 mg twice daily for 14 d
40 to <120 kg: same as adult
≥120 kg: same as adult
Active in monkey models, likely effective in Active in vitro an in Limited published data, some Treatment of monkeypox
humans mouse models animal models show that it is likely under IND
an effective treatment of FDA-approved for treatment
orthopoxvirus infections of adverse reaction to
smallpox (vaccinia) vaccine
headache, nausea, and abdominal pain Dose dependent Inc AST, ALT. GI upset
proximal tubular injury Blackbox warning; increased
mortlity at higher, prolonged doses,
fetal harm, potential carcinogen
Epidemiology, Case Definition, Global Situation
and Surveillance - Sample Coordination
ALETHEA R. DE GUZMAN, MD, MCHM, PHSAE
Director IV
Epidemiology Bureau- DOH
Epidemiology: Monkeypox Outbreak
Monkeypox Cases from Endemic Countries reported to the WHO Monkeypox Cases from Non-Endemic Countries reported to the
(N=1,315) WHO (N=120)
(May 13 - 21, 2022)
No. of Confirmed No. of Confirmed No. of Suspect
Country No. of Deaths Country
Cases Cases Cases
Cameroon 25 <5 Australia 1-5 -
Central African 6 <5 Belgium 1-5 1-5
Republic
Canada 1-5 11-20
Democratic Republic 1238 57
of Congo France 1-5 1-5
Nigeria 46 0 Germany 1-5 -
Italy 1-5 -
Netherlands 1-5 -
Portugal 21-30 -
Spain 21-30 6-10
Sweden 1 -5 -

Reference: WHO (2022). Multi-country monkeypox outbreak in United Kingdom 21-30 -

non-endemic countries. United States 1 -5 -
https://www.who.int/emergencies/disease-outbreak-news/item/2022-
DON385#:~:text=During%20human%20monkeypox%20outbreaks%2 Total 92 28
C%20close,factor%20for%20monkeypox%20virus%20infection.
Multi-country Monkeypox Outbreak in Non-endemic Countries

● Previous cases in non-endemic areas are associated with travel

● From May 13 – 21, 2022, 92 laboratory confirmed and 28 suspect Monkeypox cases were
reported from 12 non-endemic countries to the WHO
● No death reported.
● Majority have been reported amongst men who have sex with men (MSM) seeking care in
primary care and sexual health clinics.
● All laboratory confirmed cases were detected with West African clade.
● No established travel links to an endemic area and have presented through primary care,
secondary care or sexual health services
● The identification of confirmed and suspect cases with no direct travel links to an endemic
area is atypical
WHO Risk Assessment
Actions taken:
● Ongoing epidemiologic investigation and genomic sequencing to confirm the particular monkeypox virus
clade(s)
● Vaccination, where available, provided to manage close contacts

WHO Risk assessment:

● Infection in non-endemic countries seems to have been locally acquired with circulation occurring amongst
MSM.
● The extent of local transmission is unclear at this stage and there is the high likelihood of identification of
further cases with unidentified chains of transmission.
● With three countries reporting cases of monkeypox in this population group within a few days, it is therefore
highly likely that other countries may find similar situations.

WHO Advice:
● Intensive public health measures should continue in countries reporting cases.
● Further spread in other Member States is likely, thus, any patient with suspected monkeypox should be
investigated and isolated during the presumed and known infectious periods, that is during the prodromal
and rash stages of the illness, respectively.
Aligning with the Four-Door Strategy
Aligning with the Four-Door Strategy
Case Definition: Monkeypox in Non-endemic Countries

A person of any age presenting with an unexplained acute rash

AND
One or more of the following signs or symptoms:
● Headache;
● Acute onset of fever (>38.5°C);
● Myalgia;
● Back pain;
Suspected ● Asthenia;
Case ● Lymphadenopathy; AND
For which the following common causes of acute rash do not explain the clinical picture: varicella zoster,
herpes zoster, measles, herpes simplex, bacterial skin infections, disseminated gonococcal infection, primary
or secondary syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, molluscum contagiosum,
allergic reaction (e.g., to plants); and any other locally relevant common causes of papular or vesicular rash.

As per WHO, it is not necessary to obtain negative laboratory results for listed common causes of
rash illness in order to classify a case as suspected.

World Health Organization. (21 May 2022). Multi-country monkeypox outbreak in non-endemic countries.
https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385
Case Definition: Monkeypox in Non-endemic Countries

A person meeting the case definition for a suspected case AND

One or more of the following:
● has an epidemiological link (face-to-face exposure, including health care workers without respiratory protection; direct
Probable Case physical contact with skin or skin lesions, including sexual contact; or contact with contaminated materials such as
clothing, bedding or utensils) to a probable or confirmed case of monkeypox in the 21 days before symptom onset;
● reported travel history to a monkeypox endemic country in the 21 days before symptom onset;
● has had multiple sexual partners in the 21 days before symptom onset.

A case meeting the definition of either a suspected or probable case and is laboratory confirmed for monkeypox virus by
Confirmed Case detection of unique sequences of viral DNA either by real-time polymerase chain reaction (PCR) and/or whole genome
sequencing (WGS).

A contact is defined as a person who, in the period beginning with the onset of the source case’s first symptoms, and
ending when all scabs have fallen off, has had one or more of the following exposures with a probable or confirmed case of
monkeypox:
Close Contact
● face-to-face exposure (including health care workers without appropriate PPE);
● direct physical contact, including sexual contact;
● contact with contaminated materials such as clothing or bedding.

A case meeting the definition of either a suspected or a probable case but tested negative for monkeypox virus through
Discarded Case
RT-PCR or WGS.

Monkeypox Case Investigation Form (CIF) (ICD 10 –CM Code: B04)

Guidelines for Public Health Surveillance
For Human ● Monkeypox shall be classified as a Notifiable Disease
● All primary care providers, clinicians, public health authorities, points of entry, and
institutions/offices shall notify the DOH of any suspect, probable, or confirmed case
within 24 hours of detection;
● Reporting of cases or contacts shall utilize the Case Investigation Form (CIF)
● Case investigation shall focus on:
i. Exposure investigation (back tracing) within 21 days prior to symptom
onset;
ii. Characterization of clinical presentation; and
iii. Tracing and profiling of identified contacts.
● Contacts shall be quarantined and closely monitored at least a period of 21 days
from the last contact with a patient or their contaminated materials during the
infectious period.

For Animals ● Shipments of rats and primates shall be strictly monitored by the Department of
Agriculture (DA), Department of Environment and Natural Resources (DENR),
and Bureau of Customs (BOC) for animals with monkeypox symptoms.
Laboratory Testing

● Laboratory confirmation of monkeypox shall be done through Reverse Transcription

Polymerase Chain Reaction (RT-PCR) and/or whole-genome sequencing of skin lesion
samples and other samples, as may be included in future policies.
a. Two samples shall be collected and shall need to have sufficient volume to be able to
accommodate parallel testing for differential diagnosis and whole-genome sequencing
(WGS);
b. Sample collection guidelines can be found in Annex C of the Department Memorandum
c. Samples for WGS must be coordinated with the EB through the Regional
Epidemiology and Surveillance Unit (RESU) for processing either at RITM or the
University of the Philippines-Philippine Genome Center (UP-PGC);
d. The second sample shall be sent to RITM for confirmatory testing through RT-PCR;
e. The RITM may opt to send out samples for PCR confirmation by its partner facility in
Australia.
Sample Collection
MS. GLAZEL NOROÑA
Science Research Specialist
Research Institute for Tropical Medicine (RITM)
WHO_MOOC_Monkeypox_Module2_Unit_B_EN-6.pdf
 BIOSAFETY MEASURES
• Use of adequate standard operating procedures (SOPs)
• Properly trained laboratory personnel
• All specimens collected for laboratory investigations
-potentially infectious
-handled with caution
• Minimize the risk of laboratory transmission based on risk
assessment
 Any individual meeting the
definition for a suspected case
should be offered testing
SPECIMEN COLLECTION

WHO_MOOC_Monkeypox_Module2_Unit_B_EN-6.p
df
WHO_MOOC_Monkeypox_Module2_Unit_B_EN-6.pdf
WHO_MOOC_Monkeypox_Module2_Unit_B_EN-6.pdf
WHO_MOOC_Monkeypox_Module2_Unit_B_EN-6.pdf
WHO_MOOC_Monkeypox_Module2_Unit_B_EN-6.pdf
WHO_MOOC_Monkeypox_Module2_Unit_B_EN-6.pdf
SPECIMEN PACKAGING

WHO_MOOC_Monkeypox_Module2_Unit_B_EN-6.pdf
 SAMPLE REFERRAL TO RITM
DETAILS NEEDED:

a. Date of Request
b. Region
c. Referring institution/ESU
d. Requesting physician/health worker
e. Outbreak details: Number of cases, location
f. Suspected pathogen
g. Test requested
h. Purpose (i.e. confirmatory testing for outbreak investigation)
i. Specimen type and total number sent
j. Expected date of arrival in testing laboratory
k. Courier (if applicable) including tracking number
l. Shipper’s name, signature, position, institution/agency and contact information
 DOCUMENTS REQUIRED
a. Completely filled-out
Case Investigation Form
(CIF)/ Case Report Form (CRF)
b. Linelist of referred samples
WHEN SENDING SHIPMENT TO RITM…

For Monkeypox Sample, address shipment to:

MS. JUNE C. CARANDANG

Surveillance and Response Unit
Research Institute for Tropical Medicine
9002 Research Drive Filinvest Corporate City Alabang Muntinlupa
SCHEDULES FOR PICKUP OF SAMPLES

Outbreak Samples/EREID Samples

Daily (Monday-Sunday)
Cut off: 3:00 PM PST
 Specimen Quality
(Non-Compliance with Specimen Requirements)
● Inappropriate specimen type for the requested test
● Insufficient quantity
● Leaking/broken container
● Suspicion of contamination or tampering
● Inappropriate transport or storage
● Unknown time delay
● Sample deterioration e.g. hemolysis for serologic samples; bacterial
overgrowth or contamination)
● Unlabeled or illegibly labeled specimen
 Specimen Information
(Non-Compliance with Document Requirements)

●Incomplete documents
●Missing information in documents
 Specimen Coordination
(Non-Compliance with communication/
Coordination Requirements)

●Testing laboratory is not notified of the shipment

●There is no documented acknowledgement by the testing
laboratory of acceptance of the specimen
RITM SURVEILLANCE AND RESPONSE UNIT

•RITM LANDLINE - (02) 8807-2631 local 412

•SMART – 0919-9279197
•GLOBE – 09153578603
LABORATORY TESTING

1. PCR Testing
2. Metagenomic Sequencing
PCR WORKFLOW IN SPL
RELEASING AND REPORTING OF RESULTS
RITM SRU

• shall forward the results to the RESU and EB as soon as

available.

• The RESU shall provide the result to the referring

institution.
 REFERENCES
1. World Health Organization (21 May 2022). Disease Outbreak News; Multi-country
monkeypox outbreak in non-endemic countries. Available at:
https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385
2. Monkeypox WHO factsheet. https://www.who.int/news-room/fact-sheets/detail/monkeypox
3. Monkeypox testing. https://cnphi.canada.ca/gts/reference-diagnostic-test/5030?labId=1021
4. WHO Online course on Monkeypox. https://openwho.org/courses/monkeypox-intermediate
5. Specimen collection procedures for monkeypox.
https://www.cdc.gov/smallpox/lab-personnel/specimen-collection/specimen-collection-proc
edures.html#tonsillar
6. Specimen transport procedures for monkeypox.
https://www.cdc.gov/smallpox/lab-personnel/specimen-collection/specimen-collection-tran
sport.html
7. Specimen submission procedures for monkeypox.
https://www.cdc.gov/laboratory/specimen-submission/detail.html?CDCTestCode=CDC-10515
PDITR Measures
DR. JOSE GERARD B. BELIMAC
Medical Officer V, Division Chief
Adult Health Division and
Evidence Generation and Management Division
Disease Prevention and Control Bureau- DOH
PDITR Measures
PREVENT DETECT ISOLATE TREAT REINTEGRATE

● Avoid contact with: Contact Tracing Infection Control: ● Supportive ● Observe infection
- animals that could Case-patients should be Hospital Management control
harbor the virus interviewed to elicit - Negative Air Pressure ● Antivirals ● Issuance of
- any materials, names and contact - Private Room
Clearance to work
such as bedding, information of all such - minimize exposure to
that has been in persons. Contacts should surrounding persons
● Constant
contact with a sick be notified within 24 implementation of
animal hours of identification Infection Control: Home the MPHS
● Isolate infected - Isolate in a room or
patients from others Testing area separate from
who could be at risk ● PCR Testing other family members
for infection ● Metagenomic - should not leave the
● Practice good hand Sequencing home except as
hygiene after contact ● Differential Testing required for follow-up
with infected animals medical care
or humans. Processing of specimen - Pets should be
● Use personal collected shall be through excluded from the ill
protective equipment RITM or Philippine person’s environment
(PPE) when caring for Genome Center (PGC)
patients
● Vaccination

https://www.cdc.gov/poxvirus/monkeypox/prevention.html
Border Surveillance and
Control
DR. CARLOS DELA REYNA, JR.
International Health Surveillance Division
Bureau of Quarantine
Border Surveillance and Border Control
BOQ’s OneHealthPass
• An online registration platform for arriving
traveler
• Electronic Health Declaration Checklist (eHDC)
• Prior to arrival, we are able to know:
• Passenger’s information
• Medical Status
• Travel History
• Declaration of possible exposure

www.onehealthpass.com.ph
Border Surveillance and Border Control
Heightened Alert at All Points-of-Entry
• Last May 20, 2022, DOH Sec.
Duque instructed BOQ Dir.
Salcedo to heighten the alert
level at POEs for Monkeypox.
• Dir. Salcedo ordered all BOQ
Stations to conduct stringent
screening for Monkeypox.
• BOQ issued guides to all
stations.
• Assessment of Risk of
Importation was conducted
through Flight Mapping.
Border Surveillance and Border Control
Immigration Reminders for Filipinos Traveling to
Monkeypox Affected Countries
MR. MARLON LIMJAP
Deputy for Operations NAIA Terminal 1
Bureau of Immigration
Reminders:
1. Refrain from traveling to the abovementioned affected countries if
possible;
2. If passenger cannot refrain from traveling to said affected countries,
then health protocols must be observed such as:
● Proper wearing of masks;
● Frequent handwashing; and
● Social Distancing;

3. Continuous coordination with Bureau of Quarantine and other

related government agencies.
• The Bureau of Immigration is an implementing agency of
DOH-IATF issuances. The Bureau adheres to IATF
Resolutions and issuances in crafting its policies during
this time of pandemic.
• The decision-making of the Bureau of Immigration in the
airport setting is guided by agencies such as the Bureau
of Quarantine (BOQ), who has expertise in the medical
field.
• Travel
protocol and policies are screened by BOQ before
Immigration assessment commences.
The Philippine Strategy on fight
against diseases
• The Bureau of Immigration shall incoporate in our present
policy the Department of Health (DOH) instructions on
monkeypox.
• At present, the Philippines has adopted a four-door strategy in
intensifying border control to prevent the entry of monkeypox
virus into the country.
• The Bureau of Immigration is the implementing arm which
provides travel restrictions and bans as a separate and
primary level of defense to supplement the currently
implemented health protocols.
Monkeypox in Animal
DR. FEDELINO MALBAS, JR.
Head, Veterinary Research Department
Research Institute for Tropical Medicine (RITM)
 Etiology
• Monkeypox is a pox diseases of nonhuman primates
similar to variola in man
• MP is a zoonotic disease
• Belongs to Genus Orthopoxvirus related to variola
(smallpox) vaccinia,cowpox,buffalo pox and camelpox
viruses .
• Old , new world monkeys and arthropod apes can be
affected

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 Etiology

• It was also isolated from wild squirrel

(Funisciurus anerythrus )Zaire/ Congo in 1986
• The natural reservoir of monkeypox remains
unknown;however,African rodents and
primates may harbor the virus and infect
people

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 Monkeypox

• 1959- the first known outbreak in monkeys

was reported at the Statens Seruminstitut
Copenhagen/Denmark
• 1976- additional outbreaks in captive
primates have occurred in Paris

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 Virus
• It is rectangular virus of typical pox virus
structure and of 200 to 250 nano meter size
• Resistant to ether and relatively resistant to
cold

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 • Monkeypox is endemic in the African tropical
rain forest particularly in Congo,Zaire ,West
and Central Africa
• The virus has repeatedly caused human
infections

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 Transmission
• The monkeypox virus can be transmitted to
humans in bites from animals ,aerosols or by
direct contact with lesions ,blood or body
fluids from an infected persons or animals .
• Most cases are zoonotic and occur after
contact with infected animal
• Can be spread on fomites

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 Transmission
• Aerogenous transmission is considered to be the main
route of transmission between nonhuman primates and
probably also to other species like man or as in one case in
ant eaters (Myrmecophaga tridactyla)
• The route of transmission in animals is less well
understood . The virus maybe transmitted through
aerosols through skin abrasions or by the ingestions of
infected tissues /meat

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 Pathogenicity
• Initial multiplication of the monkey pox virus
occurs in local cellular components ,most
probably in fixed or wandering connective
tissue cells
• In experimentally infected Macacca
fascicularis a constant viremia appeared
between the 23rd and 4th day P.I.

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 Clinical symptoms
NHP : Differences exist in the susceptibility of
the different host species. Anthropod apes are
usually more severely affected than monkeys ,
while cynomolgus monkeys suffer more than
rhesus monkeys.
• After an incubation period of usually 3 to 4
days a sharp temperature rise heralds the
onset of the disease .

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 Clinical symptoms
• Animals become anxious with older ones
• Aggressive
• Anorexia
• With behavioral abnormalities such:
- sucking on fingers
- inflammation of the lips

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 Clinical symptoms
As to development of the pocks (sores) two
types of lesions can be distinguished:
1st type of lesion
• Acute marked facial edema
• Ulceration in mucous membranes and
papule formation

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 Clinical symptoms

1st type of lesion

• General lymphadenopathy ,respiratory distress
• Death from asphyxia
• Arthropod apes are especially prone to such
severe infection (chimps,gorilla
orangutan,bonobo)

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 Clinical symptoms
2nd type of lesion
• Infection occurs as a benign cutaneous eruption
• 7-8 days after experimental infection itching and
vesicular exanthema are common
• Occasional coughing and mucopurulent nasal
discharge indicate the presence of early lesions in
the respiratory tract

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 Clinical symptoms
2nd type of lesion
• Ist typical pocks appears as papules of 1 to 4 mm.in
diameter
• Develop into pustules containing thick purulent
material
• Vesicles become umbilicated & covered by crusts or
scabs
• Desquamation of scabs or crusts within 7 to 10 days
& small scars remain

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 Clinical Symptoms
Most common sites of pocks/sore formation in monkeys
• Buttocks
• Hands
• Feet
• Mucous membrane of the tongue
• Oral cavity
• Pharynx ,larynx,trachea
• Spleen,tonsils, lymph nodes testes and ovaries

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 Infection in other Animals
Rabbits Rodents and Prarie Dogs initial signs
• Fever
• Conjunctivitis
• Nasal discharge
• Cough
• Lymphadenopathy
• Anorexia
• Lethargy

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 Infection …
Animals may then develop the following:
• Nodular rash
• Pustules
• Patchy alopecia
• Presence of pneumonia

The veterinarians should consider those signs.

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 Treatment
• Treatment is mainly supportive
• Antiretroviral drug cidofovir is effective in vitro
animal studies
• Prevention of secondary infection using
antibiotics in NHP
• Endangered animals can be protected/useful by
variola –vaccination

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 Way Forward
• Avoiding contact with infected animals ( dead or sick animals).
• Avoiding contact with bedding and other materials contaminated
with the virus.
• Washing your hands with soap and water after coming into
contact with an infected animal.
• Cook foods thoroughly that contains animal meat or parts .
• Avoid contact with people who may be infected with the virus.
• PPE when caring for people or animals infected with the virus.
• Shipment of rats and NHP shall be strictly monitored by
DA-BAI,DENR and BOC for animals with MP symptoms.

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 References
• Manfred Brack.Agents Transmissible from Simians to Man .Springer –Verlag Berlin
Heidelberg New York London Paris Tokyo;Spring 1987 pp.10-17
• Interim case definition for Animal Cases of Monkeypox . ‘’Centers for Disease Control
and Prevention (CDC)June 2003 ,30 June 2003
• Baskin, G.B. “Pathology of nonhuman primates.” Primate Info Net. Feb 2002 Wisconsin
Primate Research Center. 27 June 2003
<http://www.primate.wisc.edu/pin/pola6-99.html>
• Baxby, D. “Poxviruses.” In Medical Microbiology. 4 th ed.Edited by Samuel Baron .
New York; Churchill Livingstone, 1996. 27 June 2003
<http://www.gsbs.utmb.edu/microbook/ch069.htm>
• Schoeb, T.R. “Diseases of laboratory primates.” 27 June 2003
<http://netvet.wustl.edu/species/primates/primate1.txt>.

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Link to the Facebook Town Hall
Session
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