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SMALLPOX SMALLPOX Stevan Cordas DO MPH Clinical

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SMALLPOX SMALLPOX Stevan Cordas DO MPH Clinical Powered By Docstoc
					            SMALLPOX


       Stevan Cordas DO MPH
Clinical Assistant Professor UNTHSC

      Smallpox - Stevan Cordas DO MPH   1
           History
First indicated in Egypt 1500 BC.
Rameses V died of smallpox in 1154 BC.
China first recorded 4th century AD.
622 AD Ahrun of Alexandria first
describes smallpox.
India 7th century AD.


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           History
Early 16th century – smallpox epidemics
in Africa.
1507 –introduced into the Caribbean.
1520 to 1555 – introduced into Mexico
and south America.
1617 severe outbreak in Massachusetts.
1763 used against Indians by Amherst.
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              History
1721 Boston cotton Mather obtained services
of Zabeil Boylston. 285 patients inoculated. 6
died. (2%) of 5579 cases not inoculated 844
died (about 15%). Smallpox lesions were
utilized. Variolation.
1774 Benjamin Jesty, a farmer, introduced
cowpox vaccination. Never given credit.
1794 Edward Jenner legitimized and refined
cowpox vaccination for smallpox
immunization. Vacca means cow in Latin.
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           History
1777 Washington orders variolation of
American army.
Early 19th century pandemics among
Indians.
1870 last great epidemic in Europe.
1947 last case in US.
1977 last case in the world -Somalia.
           Smallpox - Stevan Cordas DO MPH   5
Last known case of smallpox




         Smallpox - Stevan Cordas DO MPH   6
      U.S. Smallpox Hospital
Minton House, Cape Girardeau, Missouri




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Smallpox - Stevan Cordas DO MPH   8
            The virus
Orthopoxvirus include smallpox, monkeypox,
rabbitpox, camelpox, cowpox, and other
animal pox viruses, all of which cross react
serologically. Large DNA virus.
Pox viruses enter the respiratory tree mucosa
and produce a brief viremia followed by a
latent period of 4 to 14 days. The incubation
period of smallpox is 7 to 17 days with 10-12
days the mean.
             Smallpox - Stevan Cordas DO MPH    9
        The prodrome
Smallpox prodrome occurs abruptly and
lasts 2 to 3 days. It produces
headaches, fever often 102º or more,
prostration, and backache. Infection
and enanthema of the pharynx and
tongue occur initially. This precedes the
appearance of dermal rash by one day.

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           The Rash
The epithelial capillary bed is invaded
and a characteristic rash appears. The
kidney, spleen, lymph nodes, liver bone
marrow and other organs become
heavily infected.
The rash at first is macular then in one
or two days, 2 to 3 mm papules form.

            Smallpox - Stevan Cordas DO MPH   11
            The Rash
In another 2 or 3 days 3 to 5 mm vesicles
form. They first occur on the face and
extremities and affect the palm and soles
(centrifugal distribution). Lesions in a region
appear the same age.
Between 4 and 7 days after the rash appears,
pustules are present which last 5 to 8 days.
Umbilication and crusting then occur.


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Smallpox - Stevan Cordas DO MPH   13
     Types of smallpox
Ordinary (Variola major) three
subtypes. About 30 % mortality.
  Confluent – confluent rash on the face and
  forearms.
  Semiconfluent – Confluency only on face,
  discrete otherwise.
  Discrete – areas of normal skin between
  the lesions, even on the face.
   • Rao 1972

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Smallpox - Stevan Cordas DO MPH   15
     Types of smallpox
Variola sine eruptione – fever without
rash – must be confirmed serologically.
Flat type – lesions remain flat and
confluent. Usually fatal. 3-5% of cases
Hemorrhagic type – early –with
purpuric rash –always fatal. Late
bleeding into the pustules – usually
fatal. 5-7% of cases

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Smallpox - Stevan Cordas DO MPH   17
Differential Diagnosis -Varicella
   Varicella – usually in children less than 10.
   No significant prodrome.
   Starts on trunk and doesn’t affect palms or
   soles.
   Different appearances of lesions in a given
   region of the body.
   Rapid progression to vesicles in 24 hours.
   Not morbidly ill.
   Lesions not hard, fragile.
                 Smallpox - Stevan Cordas DO MPH   18
Varicella lesions




    Smallpox - Stevan Cordas DO MPH   19
Other diseases in differential
 Impetigo
 Herpes Zoster disseminated
 Stevens Johnson syndrome
 Drug eruptions
 Bullous Pemphigoid
 Molluscum contagiosum
 Secondary syphilis
 Disseminated herpes simplex
 Foot and mouth disease
             Smallpox - Stevan Cordas DO MPH   20
Mulloscum Contagiosum




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     Laboratory testing
Direct fluorescent antibody
Indirect fluorescent antibody
Electron microscopy
Polymerase chain reaction
Serologic studies
Culture
  3 specimens from each person
            Smallpox - Stevan Cordas DO MPH   22
Treatment of febrile vesicular
          eruption
 Isolate immediately – Airborn and contact
 precautions.
 Divide into high risk, moderate risk and low
 risk of having Variola. Check CDC site.
 Contact health department and infectious
 disease specialist.
 Supportive care and testing per support
 (response) team.
 Vaccinia immune globulin and cidofovir.

              Smallpox - Stevan Cordas DO MPH   23
Vaccination
   Effective up to 72 hours after the
   prodrome symptoms start. Not after the
   rash starts.
   It is a live virus of vaccinia (similar to
   cowpox) so site must be covered and
   taken care of until scab falls off.


               Smallpox - Stevan Cordas DO MPH   24
             Vaccine
Vaccine is 95% effective.
Lasts for 3 to 5 years then wanes.
Revaccination lasts longer.
Vaccine is given on upper arm with bifucated
needle.
If vaccine successful – red itchy bump forms
in about 3 days. In first week a large blister
appears. Then scab forms and falls off the
third week.

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Smallpox - Stevan Cordas DO MPH   26
Complications of vaccine
If exposed to smallpox the risks of
smallpox out way the risks of the
vaccine. About 14 to 52 per million
vaccinated will get serious side effects
and about 1 to 2 out of a million will die
as a result of the vaccine.
Most suffer from low grade fever, flu-
like symptoms and sore arm.
            Smallpox - Stevan Cordas DO MPH   27
Complications of vaccine
About a thousand out of a million will
get more serious problems such as
spreading the vaccinia from the local
site to a distant site. It can cause
blindness if it gets in the eye.
Bloodborn (generalized vaccinia)
Erythema multiforme at site of lesion
Encephalitis
            Smallpox - Stevan Cordas DO MPH   28
Eczema Vaccinatum CDC




       Smallpox - Stevan Cordas DO MPH   29
Autovaccination CDC




     Smallpox - Stevan Cordas DO MPH   30
Fatal Vaccinia Necrosum                    CDC




         Smallpox - Stevan Cordas DO MPH         31
Do not give vaccine to the
        following
Children under 12 months.
Pregnant women
Do not give to children under age 18 except
under emergency conditions. - Advisory
Committee on Immunization Practices.
Immune depressed individuals.(HIV etc.)
Those with eczema or certain skin conditions.
If you are living with such patients except
under emergency conditions.
             Smallpox - Stevan Cordas DO MPH   32
Major criteria of Smallpox
Febrile prodrome 1 to 4 days before
rash occurs with fever (they all have a
fever), fatigue, headache, backache,
perhaps vomiting, abdominal pain.
Rash follows which is firm, hard, deep.
May be confluent or umbilicated
Lesions all in the same stage of
development.

            Smallpox - Stevan Cordas DO MPH   33
       Minor criteria
Centrifugal distribution with greatest
concentration on face and extremities.
Patient appears morbid
First lesions in mouth, face and
extremities
Lesions on soles and palms
Slow development of lesions.
           Smallpox - Stevan Cordas DO MPH   34
Local Public Health Departments
   Tarrant county - 1800 university drive.
   Fort worth Texas 817–871-8828
   Dallas county – 2377 north Stemmons
   freeway Dallas Texas 214-819-2004




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posted:4/12/2012
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