Monkeypox isn’t a new disease. There have been cases in the United States before, and there has been a standard medical diagnosis code to identify monekypox since before 2015 (first an ICD-9 and then an ICD-10). But most of the cases were largely imported and rarely resulted in domestic transmission. The one instance in which monkeypox did demonstrate domestic transmission, it was mostly zoonotic, and the transmission was not sustained.



What’s new is the fact that monkeypox is currently spreading from human-to-human in the United States. With cases present in Michigan, the Bureau of Infections Disease Prevention (BIDP) at the Michigan Department of Health and Human Services (MDHHS) is working diligently to drive the Michigan response. As the coordinating agency that helps measure the burden of over 100 infectious diseases in Michigan and works with partners to intervene to prevent infections, the Bureau of Infectious Disease Prevention is adept at using data to drive public health responses.

“A critical part of responding to any infectious disease outbreak is the time from detection to action,” says Joe Coyle, Bureau Director for the Bureau of Infectious Disease Prevention. “The faster we can find out about an infection, the better our response is in terms of preventing illness and keeping people healthy.”

And, in Michigan, time is on epidemiologists’ side. The data that identifies infectious disease flows automatically from labs and providers’ EHRs to MDHHS in near-real time thanks to Michigan’s advanced health data exchange infrastructure.

Rather than having to connect individually with the thousands of labs and providers in Michigan, MDHHS gets a single feed from Michigan’s statewide health information network, MiHIN. MiHIN, has worked closely with MDHHS for over a decade to ensure that the department can get critical public health data from across the state. This automatic data flow ensures that MDHHS can spend its time and energy analyzing, responding to, preventing, and ensuring the health and wellbeing of Michiganders rather than chasing down data. And it means providers can spend their time caring for patients instead of submitting paper forms.

“Before MiHIN’s infrastructure, this public health reporting happened via fax, phone call, paper forms, and manual entry into registries,” says Coyle. The fact that BIDP can get the data as soon as it’s reported means that they have the advantage of time—the most critical factor in successful public health responses. “The efficient transfer of data from point A to point B is the critical framework that allows us to protect health,” says Coyle.

Monkeypox and other communicable diseases like COVID-19 or viral hepatitis are considered “reportable diseases.” This means that the disease is identified by a lab result, and that that lab result must be sent to MDHHS’s Michigan Disease Surveillance System, the state’s communicable disease registry. This kind of passive surveillance—meaning that MDHHS doesn’t have to ask for data but can look at incoming data and identify trends—is foundational for public health responses.

For monkeypox, the first and only lab that could run the test was the State Public Health Laboratory, so getting data to MDHHS wasn’t an issue. But, since the beginning of the outbreak, other commercial labs have swiftly developed assays to test as well. “Rather than having to connect to each of these labs individually, because they are already connected to the statewide health data infrastructure, getting monkeypox lab results from them was as easy as the flip of a switch,” says Coyle.

For infectious diseases like monkeypox the reported lab result immediately triggers outreach response. Epidemiologists at the BIDP work together with case investigators employed by Michigan’s 45 local health departments.

Case investigators contact the infected person to learn about their illness, risk factors, who they may have been in contact with during their contagious period (contact tracing), and offer to help coordinate any support the individual may need. Outreach to contacts is that performed where those exposed to an infectious agent are notified and provided recommendations to protect their health – something public health has been doing for years and that’s now become a household term thanks to COVID-19. Public health is HIPAA-exempt, meaning that MDHHS is expressly allowed to receive and protect sensitive information that is critical for epidemiologists to understand disease risk and spread so that there can be population level benefit in terms of disease control.

This one-on-one outreach can be labor intensive and time consuming, but it enables the BIDP to gather information about disease spread and then focus their response. A team of epidemiologists analyzes all the gathered data from many different sources—the Michigan Disease Surveillance System, phone calls, wastewater surveillance, death records, hospitalization rates, emergency department visits, and even school closures to name a few—for trends, common factors, and communities that might be more adversely affected so that they can craft targeted containment and education response efforts.

For monkeypox, the lab data show that most cases are currently SE Michigan residents. The epidemiological data show that 99% of cases are in men and where data are available approximately 95% report having sex with other men. With this understanding, the BIDP can align its messaging and amplify that message among the impacted communities, working very carefully to ensure that communications are inclusive and non-stigmatizing, and determine allocation of medical counter measures (like vaccines and treatment) which have been in limited supply.

Coyle recognizes that monkeypox is in the news and that people want to know more about emerging infections, but he underscores that the risk to the general public in Michigan is low. That said, the course of any infectious disease can change rapidly. Monkeypox infections could conceivably happen in a jail or school or another location where many people have extended contact with one another. Should this happen, Michiganders can rest assured that MDHHS would know swiftly because of Michigan’s health information exchange infrastructure. “If the data changes, our response will change,” says Coyle. “Michiganders can have confidence that we’ll empower them with the right information at the right time to protect their health.”