Last Smallpox Victim on Earth

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Last Smallpox Victim on Earth
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Little Nasty Things
Prions
Protozoa
Viruses
Bacteria
Amebae (dysentary) Plasmodium (malaria)
Mad Cow Disease Variant CJD
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Little Nasty Things
Prions
Protozoa
Viruses
Bacteria
E. coli B. anthracis (Anthrax) Y. pestis
(Plague)
Influenza Varicella (Chickenpox) Variola
(Smallpox)
Amebae (dysentary) Plasmodium (malaria)
Mad Cow Disease Variant CJD
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Little Nasty Things
Prions
Protozoa
Viruses
Bacteria
RNA Viruses
DNA Viruses
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Little Nasty Things
Prions
Protozoa
Viruses
Bacteria
RNA Viruses
DNA Viruses
(ortho)Pox Viruses
Other Pox Viruses
Many Other Viruses

• Variola (smallpox)
• Major Minor
• Vaccinia/Cowpox
• Monkeypox

• Molluscum
• ORF (parapox)
• Milkers nodules
• Tanapox, others

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An Orthopox Virus

• Variola (smallpox)
• major
• minor
• Vaccinia

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Variola minor, early 1900s
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Variola minor, early 1900s
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Variola minor, early 1900s
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Epidemiology

• Winter Early spring
• Like measles and chickenpox
• Virus killed by heat and humidity
• Age Distribution
• Historically affected younger children and
  unvaccinated persons
• Outbreak now would match age distribution of
  population since there is little immunity

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Transmission

• Person ? Person
• Primarily droplet, or aerosol
• No animal reservoir or vector
• Very contagious, but less than measles or
  chickenpox
• Less transmissible (lower 2 attack rates)
• Persons are very sick before contagious

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18th Century Native American Blankets
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Time Course of Infection

• Entry through Oropharynx or Lungs
• Virus Multiplies in Lymph Nodes
• Spreads through Bloodstream (1 viremia)
• Multiplies again in Lymph nodes, Spleen, Bone
  Marrow
• Spreads through Bloodstream (2 viremia)
• Prodrome Fever, Headache, Backache, SICK!
• Multiplies in mouth and Dermis (deep layer of
  skin) ? Rash

NOT Infectious (12-14 d )
NOT Infectious (2-4 d)
VERY Infectious
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Fever Curve of Typical Smallpox Case
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Last case of smallpox in Bengledesh (now
healthy)
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Early Chickenpox
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Chickenpox Varicella-Zoster Virus (VZV)
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Chickenpox Superficial Vesicles
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Chickenpox
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Smallpox 1 week into rash
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Chickenpox
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ChickenpoxDifferent sizes stages
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Smallpox
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Coxsackie A16Virus
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Smallpox
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Molluscum Contagiosum
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Molluscum Contagiosum
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Man Severely Ill with Smallpox
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• Smallpox Lesions
• Start on Face, (fore)Arms, Mouth
• Palms and Soles
• Deeply Embedded into Skin
• Similar Stage of Development
• Occur in Very Sick Persons

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Smallpox Complications

• Hemorrhagic-type Smallpox 1 in 20 cases
• More common in pregnant women
• Flat-type Smallpox 1 in 20 cases
• Encephalitis
• Variola major 1 in 500 cases
• Variola minor 1 in 2000 cases
• Ocular Infection
• Blindness in 1 of cases
• Infection transmitted to child in late pregnancy

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Case Presentation

• 20 y/o woman with Fever, Misery X 2 days
• Today, rash appeared on face arms
• Temp 103oF Blood Pressure106/78
  
• Pulse 116/minute Breathing Rate 18/minute
• Mentally sound, Lungs clear
• Scattered macules (spots) and vesicles noted
• Diagnosis Chicken pox (Varicella Zoster virus)
• Treatment oral Acyclovir, recheck in 2 days

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What if this wasnt Chickenpox?

• Patient had history of chickenpox as a child
• Unusually severe for atypical or second infection
• Need to Diagnose Smallpox ASAP
• Needle in a haystack

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What if this wasnt Chickenpox?

• Patient had history of chickenpox as a child
• Unusually severe for atypical or second infection
• Need to Diagnose Smallpox ASAP
• Match in a haystack

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Infection Control Nightmare(Yugoslavia 1972)

• 1 case ? Vaccination of 20,000,000

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Hospital Infection Control

• Respiratory Isolation Critical
• NOTIFY IMMEDIATELY
• Hospital Infection Control
• Local Health Department

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CDCs Interim Smallpox Response Plan

• Self-declared Work in Progress

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Smallpox Response Plan

• Surveillance
• Outbreak Investigation
• Outbreak Containment
• Vaccination
• Quarantine/Isolation
• Public/Media Communication

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Smallpox Response Plan

• Surveillance
• Outbreak Investigation
• Outbreak Containment
• Vaccination
• Quarantine/Isolation
• Public/Media Communication

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Smallpox Response Plan

• Surveillance
• Outbreak Investigation
• Outbreak Containment
• Vaccination
• Quarantine/Isolation
• Public/Media Communication

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Smallpox Response Plan

• Surveillance
• Outbreak Investigation
• Outbreak Containment
• Vaccination
• Isolation/Quarantine
• Public/Media Communication

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Smallpox Response Plan

• Surveillance
• Outbreak Investigation
• Outbreak Containment
• Vaccination
• Quarantine/Isolation
• Public/Media Communication

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Surveillance

• Pre-event (baseline) Rash Surveillance
• Notification for suspected smallpox case,
  outbreak, contamination or distribution
• Local Health Department
• State Health Department ? CDC
• Emergency Preparedness and Response Branch
• Bioterrorism Preparedness and Response Program
• Poxvirus Section, Division of Viral and
  Rickettsial Diseases
• Case Definitions and Clinical Appearance

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Surveillance Case Definition

• Major Criteria
• Fever 102F before rash onset
• Classical smallpox lesions
• Lesions at same stage of development
• Minor Criteria
• Patient is toxic or moribund
• Rash began on forarms, face, or mouth
• Rash includes palms and soles
• Centrifugal distribution (extremities trunk)
• Slow evolution of rash

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SurveillanceSmallpox Case Categories

• Low Probability
• No Fever
• Fever and no other major and
• Moderate Probability Fever
• 1 other major, or
• 4minor criteria
• High Probability all 3 major criteria

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Outbreak Investigation

• Active Surveillance for Smallpox
• Local, state, national, international
• Surveillance for Adverse Vaccine Reactions
• Epi Investigation of Cases
• Contact Tracing
• Specimen Collection Transportation
• Laboratory Confirmation (at CDC )
• Detecting Smallpox Directly in Tissues
• Viral Culture
• Molecular Fingerprinting using PCR

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Outbreak ContainmentVaccination Activities

• CDC vaccine deployment strategy
• Set up vaccination clinics
• Educate a pool of vaccinators
• Recognize vaccine take
• Recognize and treat adverse events
• Safe handling of vaccine
• MASS VS. TARGETED VACCINATION?

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Outbreak ContainmentRing Vaccination

• Strategy used for smallpox elimination
• Avoids recurring cost of mass vaccination
• Avoids unacceptably high, recurring risk of mass
  vaccination
• Strengthen public health surveillance
  infrastructure for ALL infectious diseases
• Smallpox vaccine prevents only smallpox

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Isolation of Smallpox Victim in Australia
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Outbreak ContainmentIsolation Categories

• Isolation Units (smallpox hospitals) contagious
  persons
• Observation Units (for persons with fever but no
  rash after smallpox contact) possibly contagious
  persons awaiting triage
• Home Fever Surveillance with travel restriction
  for exposed or vaccinated persons

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Outbreak ContainmentLevels of Quarantine

• Education/Notification
• Suspension of Gatherings
• Restriction on Travel
• Blockade (cordon sanitaire) and community-wide
  interventions

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Communication

• Training for Local/State Health Departments
• Webcasts
• Workshops
• Direct public education
• During an Event
• Contact Information
• Education of General Public
• Media Relations

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Other Critical Issues

• Infrastructure Development
• Inter-Agency Coordination

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Final Thoughts

• Smallpox can be recognized early in the course of
  an outbreak, incumbent on
• Provider and public awareness
• Public health surveillance capacity
• Outbreaks probably not avoidable, but could
  (theoretically) be contained
• Prodromal symptoms
• Rash identifiable
• Contagious persons unlikely to travel extensively

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Final Thoughts II

• Public health agencies will play a critical role
  in incident command (i.e., what do we do now?)
• Important but political
• Uncomfortable decisions
• Unprecedented (not yet available) public health
  surge capacity is crucial to early outbreak
  containment
• Dual-use infrastructure may become important
  method of efficiently using smallpox resources

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Questions Answers Smallpox plan available
athttp//www.bt.cdc.gov/DocumentsApp/Smallpox/
RPG/index.asp
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Summary III
Cancer
AIDS
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Summary IV
Cancer
AIDS
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Summary V
Bioterrorism
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Summary VI
Cancer
BT
AIDS
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Summary VII
Cancer
AIDS
BT
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Smallpox Vaccination Complications(a live virus
vaccine)

• Disseminated vaccinia
• Eczema vaccinatum

Pre-AIDS!

• Points
• For each 1 million vaccinated, there were 250
  complications
• Vaccine immune globulin (VIG) Rx is needed -
  short supply

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