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Last Smallpox Victim on Earth

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					Last Smallpox
  Victim on
    Earth
               Little Nasty Things

Protozoa         Bacteria   Viruses         Prions




Amebae
 (dysentary)
                                      Mad Cow Disease
Plasmodium
                                      Variant CJD
 (malaria)
               Little Nasty Things

Protozoa          Bacteria    Viruses          Prions



               E. coli         Influenza
               B. anthracis    Varicella
                (Anthrax)       (Chickenpox)
               Y. pestis       Variola
                 (Plague)       (Smallpox)
Amebae
 (dysentary)
                                        Mad Cow Disease
Plasmodium
                                        Variant CJD
 (malaria)
           Little Nasty Things

Protozoa     Bacteria    Viruses       Prions


               DNA Viruses     RNA Viruses
              Little Nasty Things

 Protozoa          Bacteria     Viruses        Prions


                      DNA Viruses      RNA Viruses

(ortho)Pox Viruses      Other Pox Viruses     Many
                                              Other
                                              Viruses
•Variola (smallpox)    •Molluscum
  -Major & Minor       •ORF (parapox)
•Vaccinia/Cowpox       •Milker’s nodules
•Monkeypox             • Tanapox, others
  An
  Orthopox
  Virus



•Variola (smallpox)
  -major
  -minor
•Vaccinia
Variola minor, early 1900’s
Variola minor, early 1900’s
Variola minor, early 1900’s
             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
             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
18th Century: Native American Blankets
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
Fever Curve of Typical Smallpox Case
 Last case of
 smallpox in
 Bengledesh
(now healthy)
Early Chickenpox
        Chickenpox:
Varicella-Zoster Virus (VZV)
Chickenpox: Superficial Vesicles
Chickenpox
Smallpox:
~1 week
into rash
Chickenpox
Chickenpox
Different sizes & stages
Smallpox
Coxsackie A16Virus
Smallpox
Molluscum Contagiosum
Molluscum Contagiosum
Man Severely Ill with Smallpox
Smallpox Lesions:
Start on Face, (fore)Arms, Mouth
Palms and Soles
Deeply Embedded into Skin
Similar Stage of Development
Occur in Very Sick Persons
       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
           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
 What if this wasn’t 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”
 What if this wasn’t 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”
  Infection Control Nightmare
       (Yugoslavia 1972)


1 case  Vaccination of 20,000,000
Hospital Infection Control


  •Respiratory Isolation Critical


  •NOTIFY IMMEDIATELY
    –Hospital Infection Control
    –Local Health Department
CDC’s Interim Smallpox
   Response Plan


Self-declared “Work in Progress”
Smallpox Response Plan
• Surveillance
• Outbreak Investigation
• Outbreak Containment
  –Vaccination
  –Quarantine/Isolation
• Public/Media Communication
Smallpox Response Plan
• Surveillance
• Outbreak Investigation
• Outbreak Containment
  –Vaccination
  –Quarantine/Isolation
• Public/Media Communication
Smallpox Response Plan
• Surveillance
• Outbreak Investigation
• Outbreak Containment
  –Vaccination
  –Quarantine/Isolation
• Public/Media Communication
Smallpox Response Plan
• Surveillance
• Outbreak Investigation
• Outbreak Containment
  –Vaccination
  –Isolation/Quarantine
• Public/Media Communication
Smallpox Response Plan
• Surveillance
• Outbreak Investigation
• Outbreak Containment
  –Vaccination
  –Quarantine/Isolation
• Public/Media Communication
                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
            Surveillance:
           Case Definition
• Major Criteria
  – Fever > 102°F 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
      Surveillance:
Smallpox Case Categories
• Low Probability
  – No Fever
  – Fever and no other major and <4 minor criteria

• Moderate Probability: Fever +
  – 1 other major, or
  – > 4minor criteria

• High Probability: all 3 major criteria
    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
Outbreak Containment:
 Vaccination 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?
 Outbreak Containment:
   Ring 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
Isolation of Smallpox Victim in Australia
 Outbreak Containment:
  Isolation 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
 Outbreak Containment:
  Levels of Quarantine
• Education/Notification
• Suspension of Gatherings
• Restriction on Travel
• Blockade (“cordon sanitaire”) and community-
  wide interventions
      Communication
• Training for Local/State Health Departments
  – Webcasts
  – Workshops

• Direct public education

• During an Event:
  – Contact Information
  – Education of General Public
  – Media Relations
 Other Critical Issues

• Infrastructure Development

• Inter-Agency Coordination
         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
         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
 Questions & Answers

     Smallpox plan available at:
http://www.bt.cdc.gov/DocumentsApp
       /Smallpox/RPG/index.asp
Summary III



          Cancer

   AIDS
Summary IV



          Cancer

   AIDS
Summary V




  Bioterrorism
Summary VI



          Cancer

   AIDS            BT
Summary VII



        Cancer
AIDS
       BT
 Smallpox Vaccination Complications
                 (a live virus vaccine)
          Pre-AIDS!

• Disseminated vaccinia




• Eczema vaccinatum

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

				
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posted:10/25/2011
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