Northwest Center for Public Health PracticeUniversity of Washington School of Public Health and Community Medicine, December 2002
Preparing for and Responding to Preparing for and Responding to Bioterrorism: Information for Bioterrorism: Information for
Primary Care CliniciansPrimary Care Clinicians
UW Northwest Center for Public Health Practice
Acknowledgements Acknowledgements Acknowledgements Acknowledgements
This presentation, and the accompanying instructor’s manual (current as of 12/02), were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, Washington, and Jeff Duchin, MD with Public Health – Seattle & King County, and the Division of Allergy & Infectious Diseases, University of Washington, for the purpose of educating primary care clinicians in relevant aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use all or portions of the material for its intended purpose. The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide.
Patrick O’Carroll, MD, MPH The Centers for Disease Control & PreventionProject Coordinator
Judith YarrowHealth Policy & Analysis, University of WADesign and Editing
Jane Koehler, DVM, MPHCommunicable Disease Control, Epidemiology and Immunization section, Public Health - Seattle & King County
Ed Walker, MD; University of WADepartment of Psychiatry
UW Northwest Center for Public Health Practice
Diseases of Bioterrorist Potential Diseases of Bioterrorist Potential Smallpox Smallpox
Diseases of Bioterrorist Potential Diseases of Bioterrorist Potential Smallpox Smallpox
CDC, AFIP
UW Northwest Center for Public Health Practice
Diseases of BT Potential Diseases of BT Potential Learning ObjectivesLearning Objectives
Diseases of BT Potential Diseases of BT Potential Learning ObjectivesLearning Objectives
Be familiar with the agents most likely to be Be familiar with the agents most likely to be used in a biological weapons attack and the used in a biological weapons attack and the most likely mode of disseminationmost likely mode of dissemination
Know the clinical presentation(s) of the Know the clinical presentation(s) of the Category A agents and features that may Category A agents and features that may distinguish them from more common diseases distinguish them from more common diseases
Be familiar with diagnosis, treatment Be familiar with diagnosis, treatment recommendations, infection control, and recommendations, infection control, and preventive therapy for management of infection preventive therapy for management of infection with or exposure to Category A agents. with or exposure to Category A agents.
Be familiar with the agents most likely to be Be familiar with the agents most likely to be used in a biological weapons attack and the used in a biological weapons attack and the most likely mode of disseminationmost likely mode of dissemination
Know the clinical presentation(s) of the Know the clinical presentation(s) of the Category A agents and features that may Category A agents and features that may distinguish them from more common diseases distinguish them from more common diseases
Be familiar with diagnosis, treatment Be familiar with diagnosis, treatment recommendations, infection control, and recommendations, infection control, and preventive therapy for management of infection preventive therapy for management of infection with or exposure to Category A agents. with or exposure to Category A agents.
Biological Agents of Highest ConcernBiological Agents of Highest ConcernCategory A AgentsCategory A Agents
Biological Agents of Highest ConcernBiological Agents of Highest ConcernCategory A AgentsCategory A Agents
Easily disseminated, infectious via aerosolEasily disseminated, infectious via aerosol Susceptible civilian populationsSusceptible civilian populations Cause high morbidity and mortality Cause high morbidity and mortality Person-to-person transmission Person-to-person transmission Unfamiliar to physiciansUnfamiliar to physicians – – difficult to difficult to
diagnose/treatdiagnose/treat Cause panic and social disruptionCause panic and social disruption Previous development for BWPrevious development for BW
Easily disseminated, infectious via aerosolEasily disseminated, infectious via aerosol Susceptible civilian populationsSusceptible civilian populations Cause high morbidity and mortality Cause high morbidity and mortality Person-to-person transmission Person-to-person transmission Unfamiliar to physiciansUnfamiliar to physicians – – difficult to difficult to
diagnose/treatdiagnose/treat Cause panic and social disruptionCause panic and social disruption Previous development for BWPrevious development for BW
Biological Agents of Highest ConcernBiological Agents of Highest Concern Category A AgentsCategory A Agents
Biological Agents of Highest ConcernBiological Agents of Highest Concern Category A AgentsCategory A Agents
Variola major (Smallpox)Variola major (Smallpox) Bacillus anthracisBacillus anthracis (Anthrax) (Anthrax) Yersinia pestisYersinia pestis (Plague) (Plague) Francisella tularensisFrancisella tularensis (Tularemia) (Tularemia) Botulinum toxin (Botulism)Botulinum toxin (Botulism) Filoviruses & Arenaviruses (Viral hemorrhagic Filoviruses & Arenaviruses (Viral hemorrhagic
fevers)fevers) Report ANY Report ANY suspected suspected illness due to these illness due to these
agents to Public Health agents to Public Health immediatelyimmediately..
Variola major (Smallpox)Variola major (Smallpox) Bacillus anthracisBacillus anthracis (Anthrax) (Anthrax) Yersinia pestisYersinia pestis (Plague) (Plague) Francisella tularensisFrancisella tularensis (Tularemia) (Tularemia) Botulinum toxin (Botulism)Botulinum toxin (Botulism) Filoviruses & Arenaviruses (Viral hemorrhagic Filoviruses & Arenaviruses (Viral hemorrhagic
fevers)fevers) Report ANY Report ANY suspected suspected illness due to these illness due to these
agents to Public Health agents to Public Health immediatelyimmediately..
Biological Agents of 2nd Highest ConcernBiological Agents of 2nd Highest ConcernCategory B AgentsCategory B Agents
Biological Agents of 2nd Highest ConcernBiological Agents of 2nd Highest ConcernCategory B AgentsCategory B Agents
Coxiella burnettiCoxiella burnetti (Q-fever) (Q-fever) BrucellaBrucella species (brucellosis) species (brucellosis) Burkholderia malleiBurkholderia mallei (glanders) (glanders) Alphaviruses (Venezuelan, Western and Alphaviruses (Venezuelan, Western and
Eastern encephalomyelitis viruses)Eastern encephalomyelitis viruses) Ricin toxin from Ricin toxin from Ricinus communisRicinus communis (castor (castor
bean)bean) Epsilon toxin from Epsilon toxin from Clostridium perfringensClostridium perfringens StaphlococcusStaphlococcus enterotoxin B enterotoxin B
Coxiella burnettiCoxiella burnetti (Q-fever) (Q-fever) BrucellaBrucella species (brucellosis) species (brucellosis) Burkholderia malleiBurkholderia mallei (glanders) (glanders) Alphaviruses (Venezuelan, Western and Alphaviruses (Venezuelan, Western and
Eastern encephalomyelitis viruses)Eastern encephalomyelitis viruses) Ricin toxin from Ricin toxin from Ricinus communisRicinus communis (castor (castor
bean)bean) Epsilon toxin from Epsilon toxin from Clostridium perfringensClostridium perfringens StaphlococcusStaphlococcus enterotoxin B enterotoxin B
Biological Agents of 2nd Highest ConcernBiological Agents of 2nd Highest ConcernFood- or Water-borne Category B AgentsFood- or Water-borne Category B Agents
Biological Agents of 2nd Highest ConcernBiological Agents of 2nd Highest ConcernFood- or Water-borne Category B AgentsFood- or Water-borne Category B Agents
Salmonella speciesSalmonella species
Shigella dysenteriaeShigella dysenteriae
Escherichia coli Escherichia coli 0157:H70157:H7
Vibrio choleraVibrio cholera
Cryptosporidium parvumCryptosporidium parvum
Salmonella speciesSalmonella species
Shigella dysenteriaeShigella dysenteriae
Escherichia coli Escherichia coli 0157:H70157:H7
Vibrio choleraVibrio cholera
Cryptosporidium parvumCryptosporidium parvum
UW Northwest Center for Public Health Practice
Biological Agents of 3rd Highest ConcernBiological Agents of 3rd Highest ConcernCategory C AgentsCategory C Agents
Biological Agents of 3rd Highest ConcernBiological Agents of 3rd Highest ConcernCategory C AgentsCategory C Agents
Emerging pathogens that could be Emerging pathogens that could be engineered for mass dissemination in the engineered for mass dissemination in the futurefuture Nipah virus Nipah virus Hantaviruses Hantaviruses Tick-borne hemorrhagic fever virusesTick-borne hemorrhagic fever viruses Tickborne encephalitis viruses Tickborne encephalitis viruses Yellow fever Yellow fever Multidrug-resistant tuberculosisMultidrug-resistant tuberculosis
Emerging pathogens that could be Emerging pathogens that could be engineered for mass dissemination in the engineered for mass dissemination in the futurefuture Nipah virus Nipah virus Hantaviruses Hantaviruses Tick-borne hemorrhagic fever virusesTick-borne hemorrhagic fever viruses Tickborne encephalitis viruses Tickborne encephalitis viruses Yellow fever Yellow fever Multidrug-resistant tuberculosisMultidrug-resistant tuberculosis
UW Northwest Center for Public Health Practice
Smallpox Smallpox OverviewOverview
Smallpox Smallpox OverviewOverview
Two strains: variola major and variola minorTwo strains: variola major and variola minor Variola minor – milder disease with case Variola minor – milder disease with case
fatality typically 1% or less fatality typically 1% or less Variola major – more severe disease with Variola major – more severe disease with
average 30% mortality in unvaccinated average 30% mortality in unvaccinated
Person-to-person transmissionPerson-to-person transmission
Two strains: variola major and variola minorTwo strains: variola major and variola minor Variola minor – milder disease with case Variola minor – milder disease with case
fatality typically 1% or less fatality typically 1% or less Variola major – more severe disease with Variola major – more severe disease with
average 30% mortality in unvaccinated average 30% mortality in unvaccinated
Person-to-person transmissionPerson-to-person transmission
Smallpox OverviewOverview
Smallpox OverviewOverview
Killed approximately 300,000,000 persons in 20th century
Routine smallpox vaccination in the U.S. stopped in 1972
WHO declared smallpox eradicated in 1980 Vaccine has significant adverse effects No effective treatment
Killed approximately 300,000,000 persons in 20th century
Routine smallpox vaccination in the U.S. stopped in 1972
WHO declared smallpox eradicated in 1980 Vaccine has significant adverse effects No effective treatment
Smallpox OverviewOverview
Smallpox OverviewOverview
Person-to-person transmission
Average 30% mortality from variola major in unvaccinated
A single case is considered a global public health emergency
Person-to-person transmission
Average 30% mortality from variola major in unvaccinated
A single case is considered a global public health emergency
Smallpox Smallpox PathogenesisPathogenesisSmallpox Smallpox PathogenesisPathogenesis
Virus implants on oropharynx or respiratory Virus implants on oropharynx or respiratory mucosa and is transported to regional lymph mucosa and is transported to regional lymph nodes nodes
Day 3-4: Day 3-4: asymptomatic viremia followed by viral asymptomatic viremia followed by viral multiplication in spleen, bone marrow, lymph multiplication in spleen, bone marrow, lymph nodes, lungnodes, lung
Day 8Day 8: secondary viremia leads to fever and : secondary viremia leads to fever and toxemia on day 12-14toxemia on day 12-14
Virus implants on oropharynx or respiratory Virus implants on oropharynx or respiratory mucosa and is transported to regional lymph mucosa and is transported to regional lymph nodes nodes
Day 3-4: Day 3-4: asymptomatic viremia followed by viral asymptomatic viremia followed by viral multiplication in spleen, bone marrow, lymph multiplication in spleen, bone marrow, lymph nodes, lungnodes, lung
Day 8Day 8: secondary viremia leads to fever and : secondary viremia leads to fever and toxemia on day 12-14toxemia on day 12-14
Smallpox Smallpox PathogenesisPathogenesisSmallpox Smallpox PathogenesisPathogenesis
Virus localizes in small blood vessels of Virus localizes in small blood vessels of respiratory and pharyngeal mucosa, then dermis respiratory and pharyngeal mucosa, then dermis = characteristic rash and case communicability= characteristic rash and case communicability
Toxemia: circulating immune complexes and Toxemia: circulating immune complexes and variola antigensvariola antigens
Virus localizes in small blood vessels of Virus localizes in small blood vessels of respiratory and pharyngeal mucosa, then dermis respiratory and pharyngeal mucosa, then dermis = characteristic rash and case communicability= characteristic rash and case communicability
Toxemia: circulating immune complexes and Toxemia: circulating immune complexes and variola antigensvariola antigens
Smallpox Smallpox TransmissionTransmissionSmallpox Smallpox TransmissionTransmission
Infectious dose extremely lowInfectious dose extremely low
Spread primarily by droplet nuclei >aerosols > Spread primarily by droplet nuclei >aerosols > direct contactdirect contact
Maintains infectivity for prolonged periods out of Maintains infectivity for prolonged periods out of hosthost Contaminated clothing and bedding can be infectiousContaminated clothing and bedding can be infectious
Infectious dose extremely lowInfectious dose extremely low
Spread primarily by droplet nuclei >aerosols > Spread primarily by droplet nuclei >aerosols > direct contactdirect contact
Maintains infectivity for prolonged periods out of Maintains infectivity for prolonged periods out of hosthost Contaminated clothing and bedding can be infectiousContaminated clothing and bedding can be infectious
Smallpox Smallpox TransmissionTransmissionSmallpox Smallpox TransmissionTransmission
Transmission does not usually occur until after Transmission does not usually occur until after febrile prodrome febrile prodrome Coincident with onset of rashCoincident with onset of rash Slower spread through the population than chickenpox Slower spread through the population than chickenpox
or measlesor measles Large outbreaks in schools were uncommonLarge outbreaks in schools were uncommon
Less transmissible than measles, chickenpox, Less transmissible than measles, chickenpox, influenzainfluenza
Transmission does not usually occur until after Transmission does not usually occur until after febrile prodrome febrile prodrome Coincident with onset of rashCoincident with onset of rash Slower spread through the population than chickenpox Slower spread through the population than chickenpox
or measlesor measles Large outbreaks in schools were uncommonLarge outbreaks in schools were uncommon
Less transmissible than measles, chickenpox, Less transmissible than measles, chickenpox, influenzainfluenza
SmallpoxSmallpoxTransmissionTransmissionSmallpoxSmallpox
TransmissionTransmission
Secondary cases primarily household, hospital, Secondary cases primarily household, hospital, and other close contactsand other close contacts
Secondary attack rate 37-87% among Secondary attack rate 37-87% among unvaccinated contactsunvaccinated contacts
Patients with severe disease or cough at highest Patients with severe disease or cough at highest risk for transmissionrisk for transmission
Greatest infectivity from rash onset to day 7-10 of Greatest infectivity from rash onset to day 7-10 of rashrash Infectivity decreases with scab formation and Infectivity decreases with scab formation and
ceases with separation of scabsceases with separation of scabs
Secondary cases primarily household, hospital, Secondary cases primarily household, hospital, and other close contactsand other close contacts
Secondary attack rate 37-87% among Secondary attack rate 37-87% among unvaccinated contactsunvaccinated contacts
Patients with severe disease or cough at highest Patients with severe disease or cough at highest risk for transmissionrisk for transmission
Greatest infectivity from rash onset to day 7-10 of Greatest infectivity from rash onset to day 7-10 of rashrash Infectivity decreases with scab formation and Infectivity decreases with scab formation and
ceases with separation of scabsceases with separation of scabs
SmallpoxSmallpoxClinical FeaturesClinical FeaturesSmallpoxSmallpox
Clinical FeaturesClinical Features
Prodrome (Prodrome (incubation 7-19 daysincubation 7-19 days)) Acute onset of fever, malaise, Acute onset of fever, malaise,
headache, backache, vomiting, headache, backache, vomiting, occasional deliriumoccasional delirium
Transient erythematous rashTransient erythematous rash ExanthemExanthem (2-3 days later)(2-3 days later)
Preceded by enanthem on Preceded by enanthem on oropharyngeal mucosa oropharyngeal mucosa
Begins on face, hands, Begins on face, hands, forearmsforearms
Spread to lower extremities Spread to lower extremities then trunk over ~ 7 daysthen trunk over ~ 7 days
Prodrome (Prodrome (incubation 7-19 daysincubation 7-19 days)) Acute onset of fever, malaise, Acute onset of fever, malaise,
headache, backache, vomiting, headache, backache, vomiting, occasional deliriumoccasional delirium
Transient erythematous rashTransient erythematous rash ExanthemExanthem (2-3 days later)(2-3 days later)
Preceded by enanthem on Preceded by enanthem on oropharyngeal mucosa oropharyngeal mucosa
Begins on face, hands, Begins on face, hands, forearmsforearms
Spread to lower extremities Spread to lower extremities then trunk over ~ 7 daysthen trunk over ~ 7 days
CDC
Synchronous progression: Synchronous progression: macules macules vesicles vesicles pustules pustules scabs scabsLesions most abundant Lesions most abundant on face and extremities, on face and extremities, including palms/solesincluding palms/soles
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SmallpoxSmallpoxClinical CourseClinical Course
SmallpoxSmallpoxClinical CourseClinical Course
WHO
SmallpoxSmallpoxClinical PresentationClinical Presentation
SmallpoxSmallpoxClinical PresentationClinical Presentation
CDC
SmallpoxSmallpoxClinical PresentationClinical Presentation
SmallpoxSmallpoxClinical PresentationClinical Presentation
WHO
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SmallpoxSmallpoxClinical PresentationClinical Presentation
SmallpoxSmallpoxClinical PresentationClinical Presentation
WHO
SmallpoxSmallpox Clinical ProgressionClinical Progression
SmallpoxSmallpox Clinical ProgressionClinical Progression
WHO
UW Northwest Center for Public Health Practice
SmallpoxSmallpox Clinical ProgressionClinical Progression
SmallpoxSmallpox Clinical ProgressionClinical Progression
Thomas, D.
Day 14Day 10 Day 21
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SmallpoxSmallpoxClinical ProgressionClinical Progression
SmallpoxSmallpoxClinical ProgressionClinical Progression
SmallpoxSmallpoxClinical TypesClinical TypesSmallpoxSmallpox
Clinical TypesClinical Types
Ordinary smallpox: 90% of casesOrdinary smallpox: 90% of cases Case-fatality average 30%Case-fatality average 30% Occurs in non-immunized persons Occurs in non-immunized persons
Modified smallpoxModified smallpox Milder, rarely fatalMilder, rarely fatal Occurs in 25% of previously immunized Occurs in 25% of previously immunized
persons and 2% of non-immunized persons and 2% of non-immunized personspersons
Fewer, smaller,more superficial lesions that Fewer, smaller,more superficial lesions that evolve more rapidlyevolve more rapidly
Ordinary smallpox: 90% of casesOrdinary smallpox: 90% of cases Case-fatality average 30%Case-fatality average 30% Occurs in non-immunized persons Occurs in non-immunized persons
Modified smallpoxModified smallpox Milder, rarely fatalMilder, rarely fatal Occurs in 25% of previously immunized Occurs in 25% of previously immunized
persons and 2% of non-immunized persons and 2% of non-immunized personspersons
Fewer, smaller,more superficial lesions that Fewer, smaller,more superficial lesions that evolve more rapidlyevolve more rapidly
SmallpoxSmallpoxClinical TypesClinical TypesSmallpoxSmallpox
Clinical TypesClinical Types
Hemorrhagic smallpox: <3% of casesHemorrhagic smallpox: <3% of cases Immunocompromised persons and Immunocompromised persons and
pregnant women at riskpregnant women at risk Shortened incubation period, severe Shortened incubation period, severe
prodromeprodrome Extensive viral multiplication, coagulopathyExtensive viral multiplication, coagulopathy Dusky erythema followed by petechiae and Dusky erythema followed by petechiae and
hemorrhages into skin and mucous hemorrhages into skin and mucous membranes membranes
Almost uniformly fatal within 7 daysAlmost uniformly fatal within 7 days
Hemorrhagic smallpox: <3% of casesHemorrhagic smallpox: <3% of cases Immunocompromised persons and Immunocompromised persons and
pregnant women at riskpregnant women at risk Shortened incubation period, severe Shortened incubation period, severe
prodromeprodrome Extensive viral multiplication, coagulopathyExtensive viral multiplication, coagulopathy Dusky erythema followed by petechiae and Dusky erythema followed by petechiae and
hemorrhages into skin and mucous hemorrhages into skin and mucous membranes membranes
Almost uniformly fatal within 7 daysAlmost uniformly fatal within 7 days
SmallpoxSmallpoxClinical TypesClinical TypesSmallpoxSmallpox
Clinical TypesClinical Types
Malignant, or flat-type smallpox: 7% of casesMalignant, or flat-type smallpox: 7% of cases Slowly evolving lesions that coalesce Slowly evolving lesions that coalesce
without forming pustuleswithout forming pustules Associated with cell-mediated immune Associated with cell-mediated immune
deficiencydeficiency Usually fatal Usually fatal
Variola sine eruptioneVariola sine eruptione Occurs in previously vaccinated persons or Occurs in previously vaccinated persons or
infants with maternal antibodiesinfants with maternal antibodies Asymptomatic or mild illnessAsymptomatic or mild illness Transmission from these cases has not Transmission from these cases has not
been documentedbeen documented
Malignant, or flat-type smallpox: 7% of casesMalignant, or flat-type smallpox: 7% of cases Slowly evolving lesions that coalesce Slowly evolving lesions that coalesce
without forming pustuleswithout forming pustules Associated with cell-mediated immune Associated with cell-mediated immune
deficiencydeficiency Usually fatal Usually fatal
Variola sine eruptioneVariola sine eruptione Occurs in previously vaccinated persons or Occurs in previously vaccinated persons or
infants with maternal antibodiesinfants with maternal antibodies Asymptomatic or mild illnessAsymptomatic or mild illness Transmission from these cases has not Transmission from these cases has not
been documentedbeen documented
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Malignant Smallpox Malignant Smallpox Malignant Smallpox Malignant Smallpox
Thomas, D.
SmallpoxSmallpoxComplicationsComplicationsSmallpoxSmallpoxComplicationsComplications
Encephalitis Encephalitis 1 in 500 cases Variola major1 in 500 cases Variola major 1 in 2,000 cases Variola minor1 in 2,000 cases Variola minor
Keratitis, corneal ulcerationKeratitis, corneal ulceration Blindness in 1% of casesBlindness in 1% of cases
Infection in pregnancyInfection in pregnancy High perinatal fatality rate High perinatal fatality rate Congenital infectionCongenital infection
Encephalitis Encephalitis 1 in 500 cases Variola major1 in 500 cases Variola major 1 in 2,000 cases Variola minor1 in 2,000 cases Variola minor
Keratitis, corneal ulcerationKeratitis, corneal ulceration Blindness in 1% of casesBlindness in 1% of cases
Infection in pregnancyInfection in pregnancy High perinatal fatality rate High perinatal fatality rate Congenital infectionCongenital infection
UW Northwest Center for Public Health Practice
CDC Major Smallpox CriteriaCDC Major Smallpox Criteria CDC Major Smallpox CriteriaCDC Major Smallpox Criteria Febrile prodromeFebrile prodrome Occurring 1-4 days before rash onset: fever Occurring 1-4 days before rash onset: fever
>102>102°°F and at least one of the following: F and at least one of the following: prostration, headache, backache, chills, prostration, headache, backache, chills, vomiting or severe abdominal painvomiting or severe abdominal pain
Classic smallpox lesionsClassic smallpox lesions Deep, firm/hard, round, well-circumscribed; Deep, firm/hard, round, well-circumscribed;
may be umbilicated or confluentmay be umbilicated or confluent
Lesions inLesions in same stage of developmentsame stage of development on any on any one part of the body (e.g., face or arm)one part of the body (e.g., face or arm)
Febrile prodromeFebrile prodrome Occurring 1-4 days before rash onset: fever Occurring 1-4 days before rash onset: fever
>102>102°°F and at least one of the following: F and at least one of the following: prostration, headache, backache, chills, prostration, headache, backache, chills, vomiting or severe abdominal painvomiting or severe abdominal pain
Classic smallpox lesionsClassic smallpox lesions Deep, firm/hard, round, well-circumscribed; Deep, firm/hard, round, well-circumscribed;
may be umbilicated or confluentmay be umbilicated or confluent
Lesions inLesions in same stage of developmentsame stage of development on any on any one part of the body (e.g., face or arm)one part of the body (e.g., face or arm)
More on CDC's response plan...
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CDC Minor Smallpox CriteriaCDC Minor Smallpox CriteriaCDC Minor Smallpox CriteriaCDC Minor Smallpox Criteria
Centrifugal distribution: greatest concentration Centrifugal distribution: greatest concentration of lesions on face and distal extremities of lesions on face and distal extremities
First lesions on oral mucosa or palate, face, First lesions on oral mucosa or palate, face, forearmsforearms
Patient appears toxic or moribundPatient appears toxic or moribund Slow evolution: lesions evolve from macules to Slow evolution: lesions evolve from macules to
papules to pustules over days papules to pustules over days Lesions on palms and soles (majority of cases)Lesions on palms and soles (majority of cases)
Centrifugal distribution: greatest concentration Centrifugal distribution: greatest concentration of lesions on face and distal extremities of lesions on face and distal extremities
First lesions on oral mucosa or palate, face, First lesions on oral mucosa or palate, face, forearmsforearms
Patient appears toxic or moribundPatient appears toxic or moribund Slow evolution: lesions evolve from macules to Slow evolution: lesions evolve from macules to
papules to pustules over days papules to pustules over days Lesions on palms and soles (majority of cases)Lesions on palms and soles (majority of cases)
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CDC Criteria for Determining Risk of SmallpoxCDC Criteria for Determining Risk of SmallpoxCDC Criteria for Determining Risk of SmallpoxCDC Criteria for Determining Risk of Smallpox
High risk: High risk: report immediately report immediately
All three major criteria All three major criteria Moderate risk: Moderate risk: urgent evaluationurgent evaluation
Febrile prodrome and 1 major or Febrile prodrome and 1 major or 4 minor 4 minor criteriacriteria
Low risk: Low risk: manage as clinically indicated manage as clinically indicated
No viral prodrome or No viral prodrome or
Febrile prodrome and <4 minor criteria (no Febrile prodrome and <4 minor criteria (no major criteria)major criteria)
High risk: High risk: report immediately report immediately
All three major criteria All three major criteria Moderate risk: Moderate risk: urgent evaluationurgent evaluation
Febrile prodrome and 1 major or Febrile prodrome and 1 major or 4 minor 4 minor criteriacriteria
Low risk: Low risk: manage as clinically indicated manage as clinically indicated
No viral prodrome or No viral prodrome or
Febrile prodrome and <4 minor criteria (no Febrile prodrome and <4 minor criteria (no major criteria)major criteria)
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CDC Recommended Evaluation of Patients CDC Recommended Evaluation of Patients at High Risk of Smallpoxat High Risk of Smallpox
CDC Recommended Evaluation of Patients CDC Recommended Evaluation of Patients at High Risk of Smallpoxat High Risk of Smallpox
Contact and airborne precautionsContact and airborne precautions Notify infection controlNotify infection control Infectious disease and/or dermatology consult Infectious disease and/or dermatology consult Notify local/state health dept immediatelyNotify local/state health dept immediately
Response team advises on management and Response team advises on management and specimen collection specimen collection
Specimen testing at CDC Specimen testing at CDC
Contact and airborne precautionsContact and airborne precautions Notify infection controlNotify infection control Infectious disease and/or dermatology consult Infectious disease and/or dermatology consult Notify local/state health dept immediatelyNotify local/state health dept immediately
Response team advises on management and Response team advises on management and specimen collection specimen collection
Specimen testing at CDC Specimen testing at CDC
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CDC Recommended Evaluation of Patients CDC Recommended Evaluation of Patients at Moderate Risk of Smallpoxat Moderate Risk of Smallpox
CDC Recommended Evaluation of Patients CDC Recommended Evaluation of Patients at Moderate Risk of Smallpoxat Moderate Risk of Smallpox
Contact and airborne precautions Contact and airborne precautions Notify infection control Notify infection control Infectious disease and/or Dermatology Infectious disease and/or Dermatology
consult consult VZV and/or other lab tests as indicatedVZV and/or other lab tests as indicated If cannot rule out smallpox, contact local/state If cannot rule out smallpox, contact local/state
health dept. immediately health dept. immediately
Contact and airborne precautions Contact and airborne precautions Notify infection control Notify infection control Infectious disease and/or Dermatology Infectious disease and/or Dermatology
consult consult VZV and/or other lab tests as indicatedVZV and/or other lab tests as indicated If cannot rule out smallpox, contact local/state If cannot rule out smallpox, contact local/state
health dept. immediately health dept. immediately
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CDC Recommended Evaluation of Patients CDC Recommended Evaluation of Patients at Low Risk of Smallpoxat Low Risk of Smallpox
CDC Recommended Evaluation of Patients CDC Recommended Evaluation of Patients at Low Risk of Smallpoxat Low Risk of Smallpox
Contact and airborne precautionsContact and airborne precautions
Notify infection control Notify infection control
Evaluate clinically for VZVEvaluate clinically for VZV
Test for VZV and other conditions, as indicated Test for VZV and other conditions, as indicated
Contact and airborne precautionsContact and airborne precautions
Notify infection control Notify infection control
Evaluate clinically for VZVEvaluate clinically for VZV
Test for VZV and other conditions, as indicated Test for VZV and other conditions, as indicated
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Differential Diagnosis of SmallpoxDifferential Diagnosis of SmallpoxVariola vs. VaricellaVariola vs. Varicella
Differential Diagnosis of SmallpoxDifferential Diagnosis of SmallpoxVariola vs. VaricellaVariola vs. Varicella
Smallpox: clinical features
Varicella: clinical features
Febrile prodrome 1-4d before rash onset
Short, mild or no prodrome
Lesions deep, firm, well-circumscribed
Lesions typically superficial, appear delicate
Rash concentrated on face & extremities, lesions on palms & soles
Rash concentrated on trunk and proximal extremities, uncommon on palms & soles
Smallpox: clinical features
Varicella: clinical features
Febrile prodrome 1-4d before rash onset
Short, mild or no prodrome
Lesions deep, firm, well-circumscribed
Lesions typically superficial, appear delicate
Rash concentrated on face & extremities, lesions on palms & soles
Rash concentrated on trunk and proximal extremities, uncommon on palms & soles
Source: CDC
UW Northwest Center for Public Health Practice
Differential Diagnosis of SmallpoxDifferential Diagnosis of SmallpoxVariola vs. VaricellaVariola vs. Varicella
Differential Diagnosis of SmallpoxDifferential Diagnosis of SmallpoxVariola vs. VaricellaVariola vs. Varicella
Smallpox: clinical features
Varicella: clinical features
Rash in same stage of evolution on any one part of body
Rash appears in crops, lesions in different stages of evolution
Rash evolves slowly, papules ->pustules over days
Rash evolves more quickly, some macules ->crusts in 1d
Extremely ill Feel unwell, but not usually extremely ill
Illness lasts 14-21 days Illness lasts 4-7 days, if uncomplicated
Smallpox: clinical features
Varicella: clinical features
Rash in same stage of evolution on any one part of body
Rash appears in crops, lesions in different stages of evolution
Rash evolves slowly, papules ->pustules over days
Rash evolves more quickly, some macules ->crusts in 1d
Extremely ill Feel unwell, but not usually extremely ill
Illness lasts 14-21 days Illness lasts 4-7 days, if uncomplicated
Source: CDC
Variola vs. VaricellaVariola vs. Varicella Lesion DistributionLesion Distribution
Variola vs. VaricellaVariola vs. Varicella Lesion DistributionLesion Distribution
WHO
Chickenpox
Smallpox
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Variola vs. VaricellaVariola vs. VaricellaLesion DistributionLesion Distribution
Variola vs. VaricellaVariola vs. VaricellaLesion DistributionLesion Distribution
WHO
Chickenpox
Smallpox
UW Northwest Center for Public Health Practice
Differential Diagnosis of SmallpoxDifferential Diagnosis of SmallpoxDifferential Diagnosis of SmallpoxDifferential Diagnosis of Smallpox
Varicella Varicella Disseminated Disseminated
herpes zoster herpes zoster Drug eruptions and Drug eruptions and
contact dermatitis contact dermatitis Disseminated Disseminated
herpes simplexherpes simplex
Varicella Varicella Disseminated Disseminated
herpes zoster herpes zoster Drug eruptions and Drug eruptions and
contact dermatitis contact dermatitis Disseminated Disseminated
herpes simplexherpes simplex
ImpetigoImpetigo Erythema multiformeErythema multiforme Scabies, insect bitesScabies, insect bites Bullous pemphigoidBullous pemphigoid Secondary syphillis Secondary syphillis Molluscum contagiosumMolluscum contagiosum Enterovirus exanthemEnterovirus exanthem
ImpetigoImpetigo Erythema multiformeErythema multiforme Scabies, insect bitesScabies, insect bites Bullous pemphigoidBullous pemphigoid Secondary syphillis Secondary syphillis Molluscum contagiosumMolluscum contagiosum Enterovirus exanthemEnterovirus exanthem
SmallpoxSmallpoxDiagnosisDiagnosis
SmallpoxSmallpoxDiagnosisDiagnosis
Clinical diagnosis = public health emergencyClinical diagnosis = public health emergency
Laboratory confirmation: vesicular or pustular Laboratory confirmation: vesicular or pustular fluid on swab or biopsy fluid on swab or biopsy
Seal in vacutainer and overpack - transport to Seal in vacutainer and overpack - transport to state public health laboratory state public health laboratory
Culture (BSL-4 Lab) followed by PCR and RFLPCulture (BSL-4 Lab) followed by PCR and RFLP
Clinical diagnosis = public health emergencyClinical diagnosis = public health emergency
Laboratory confirmation: vesicular or pustular Laboratory confirmation: vesicular or pustular fluid on swab or biopsy fluid on swab or biopsy
Seal in vacutainer and overpack - transport to Seal in vacutainer and overpack - transport to state public health laboratory state public health laboratory
Culture (BSL-4 Lab) followed by PCR and RFLPCulture (BSL-4 Lab) followed by PCR and RFLP
SmallpoxSmallpoxDiagnosisDiagnosis
SmallpoxSmallpoxDiagnosisDiagnosis
EM: characteristic “brick shaped” morphology EM: characteristic “brick shaped” morphology distinct from HSV and VZVdistinct from HSV and VZV
Light microscopy: Giemsa stain Light microscopy: Giemsa stain aggregations aggregations of viral particles (Guarnieri bodies)of viral particles (Guarnieri bodies)
Gel diffusion test: vesicular fluid + hyperimmune Gel diffusion test: vesicular fluid + hyperimmune globulinglobulin
EM: characteristic “brick shaped” morphology EM: characteristic “brick shaped” morphology distinct from HSV and VZVdistinct from HSV and VZV
Light microscopy: Giemsa stain Light microscopy: Giemsa stain aggregations aggregations of viral particles (Guarnieri bodies)of viral particles (Guarnieri bodies)
Gel diffusion test: vesicular fluid + hyperimmune Gel diffusion test: vesicular fluid + hyperimmune globulinglobulin
UW Northwest Center for Public Health Practice
SmallpoxSmallpoxSpecimen CollectionSpecimen Collection
SmallpoxSmallpoxSpecimen CollectionSpecimen Collection
Specimen collection by trained teams Specimen collection by trained teams Only recently, successfully vaccinated Only recently, successfully vaccinated
personnel (within 3yrs) wearing appropriate personnel (within 3yrs) wearing appropriate barrier protection should be involved in barrier protection should be involved in specimen collection specimen collection
Respiratory and contact precautionsRespiratory and contact precautions Testing done by CDC; contact local HD before Testing done by CDC; contact local HD before
collecting clinical specimenscollecting clinical specimens
Specimen collection by trained teams Specimen collection by trained teams Only recently, successfully vaccinated Only recently, successfully vaccinated
personnel (within 3yrs) wearing appropriate personnel (within 3yrs) wearing appropriate barrier protection should be involved in barrier protection should be involved in specimen collection specimen collection
Respiratory and contact precautionsRespiratory and contact precautions Testing done by CDC; contact local HD before Testing done by CDC; contact local HD before
collecting clinical specimenscollecting clinical specimens
More on CDC's response plan...
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UW Northwest Center for Public Health Practice
SmallpoxSmallpoxSpecimen CollectionSpecimen Collection
SmallpoxSmallpoxSpecimen CollectionSpecimen Collection
If necessary, unvaccinated personnel without If necessary, unvaccinated personnel without contraindications to vaccination may collect contraindications to vaccination may collect specimensspecimens
If smallpox confirmed, will need immediate If smallpox confirmed, will need immediate vaccination vaccination
If necessary, unvaccinated personnel without If necessary, unvaccinated personnel without contraindications to vaccination may collect contraindications to vaccination may collect specimensspecimens
If smallpox confirmed, will need immediate If smallpox confirmed, will need immediate vaccination vaccination
SmallpoxSmallpoxMedical ManagementMedical Management
SmallpoxSmallpoxMedical ManagementMedical Management
Respiratory and contact isolation for Respiratory and contact isolation for hospitalized caseshospitalized cases Negative pressure room; HEPA-filtered exhaust Negative pressure room; HEPA-filtered exhaust All health care workers employ aerosol and contact All health care workers employ aerosol and contact
precautions regardless of immunization statusprecautions regardless of immunization status No specific therapy availableNo specific therapy available Supportive care: fluid and electrolyte, skin, Supportive care: fluid and electrolyte, skin,
nutritionalnutritional
Respiratory and contact isolation for Respiratory and contact isolation for hospitalized caseshospitalized cases Negative pressure room; HEPA-filtered exhaust Negative pressure room; HEPA-filtered exhaust All health care workers employ aerosol and contact All health care workers employ aerosol and contact
precautions regardless of immunization statusprecautions regardless of immunization status No specific therapy availableNo specific therapy available Supportive care: fluid and electrolyte, skin, Supportive care: fluid and electrolyte, skin,
nutritionalnutritional
SmallpoxSmallpoxMedical ManagementMedical Management
SmallpoxSmallpoxMedical ManagementMedical Management
Antibiotics for secondary infectionAntibiotics for secondary infection
Antiviral drugs under evaluationAntiviral drugs under evaluation
Notify Public Health and hospital epidemiology Notify Public Health and hospital epidemiology immediatelyimmediately for for suspectedsuspected case case
Antibiotics for secondary infectionAntibiotics for secondary infection
Antiviral drugs under evaluationAntiviral drugs under evaluation
Notify Public Health and hospital epidemiology Notify Public Health and hospital epidemiology immediatelyimmediately for for suspectedsuspected case case
SmallpoxSmallpox OutbreakOutbreak ManagementManagement
SmallpoxSmallpox OutbreakOutbreak ManagementManagement
Case identification, isolation, and immunization Case identification, isolation, and immunization Rapid identification of contacts Rapid identification of contacts Immediate vaccination or boosting of Immediate vaccination or boosting of ALLALL potential potential
contacts including health care workers contacts including health care workers Vaccination within 4 days of exposure may Vaccination within 4 days of exposure may
prevent or lessen disease prevent or lessen disease Isolation with monitoring for fever or rashIsolation with monitoring for fever or rash
18 days from last contact with case18 days from last contact with case Respiratory isolation if possible for febrile contactsRespiratory isolation if possible for febrile contacts
Passive immunization (VIG)Passive immunization (VIG) Potential use for contacts at high risk for vaccine Potential use for contacts at high risk for vaccine
complicationscomplications
Case identification, isolation, and immunization Case identification, isolation, and immunization Rapid identification of contacts Rapid identification of contacts Immediate vaccination or boosting of Immediate vaccination or boosting of ALLALL potential potential
contacts including health care workers contacts including health care workers Vaccination within 4 days of exposure may Vaccination within 4 days of exposure may
prevent or lessen disease prevent or lessen disease Isolation with monitoring for fever or rashIsolation with monitoring for fever or rash
18 days from last contact with case18 days from last contact with case Respiratory isolation if possible for febrile contactsRespiratory isolation if possible for febrile contacts
Passive immunization (VIG)Passive immunization (VIG) Potential use for contacts at high risk for vaccine Potential use for contacts at high risk for vaccine
complicationscomplications
SmallpoxSmallpox OutbreakOutbreak ManagementManagement
SmallpoxSmallpox OutbreakOutbreak ManagementManagement
Strategy for outbreak containment: Ring Strategy for outbreak containment: Ring vaccinationvaccination Isolation of confirmed & suspected smallpox Isolation of confirmed & suspected smallpox
casescases Tracing, vaccination & close surveillance of Tracing, vaccination & close surveillance of
contacts contacts Vaccination of contacts of contactsVaccination of contacts of contacts
Strategy for outbreak containment: Ring Strategy for outbreak containment: Ring vaccinationvaccination Isolation of confirmed & suspected smallpox Isolation of confirmed & suspected smallpox
casescases Tracing, vaccination & close surveillance of Tracing, vaccination & close surveillance of
contacts contacts Vaccination of contacts of contactsVaccination of contacts of contacts
UW Northwest Center for Public Health Practice
Isolation Isolation CDC Smallpox Response Plan CDC Smallpox Response Plan
Isolation Isolation CDC Smallpox Response Plan CDC Smallpox Response Plan
Facility Categories Facility Categories
Type C – Contagious Type C – Contagious
Confirmed and probable casesConfirmed and probable cases
Type X – Uncertain diagnosis Type X – Uncertain diagnosis
Vaccinated febrile contacts without rashVaccinated febrile contacts without rash
Type R – AsymptomaticType R – Asymptomatic
Non-febrile contacts Non-febrile contacts
Facility Categories Facility Categories
Type C – Contagious Type C – Contagious
Confirmed and probable casesConfirmed and probable cases
Type X – Uncertain diagnosis Type X – Uncertain diagnosis
Vaccinated febrile contacts without rashVaccinated febrile contacts without rash
Type R – AsymptomaticType R – Asymptomatic
Non-febrile contacts Non-febrile contacts
Smallpox Outbreak ManagementSmallpox Outbreak ManagementPriority Groups for VaccinationPriority Groups for Vaccination
Smallpox Outbreak ManagementSmallpox Outbreak ManagementPriority Groups for VaccinationPriority Groups for Vaccination
Persons exposed to an intentional releasePersons exposed to an intentional release
Direct (<6.5 feet) face-to-face contacts of Direct (<6.5 feet) face-to-face contacts of case/suspect casecase/suspect case
Persons involved in direct medical or public Persons involved in direct medical or public health management or transport of case/suspect health management or transport of case/suspect casecase
Persons exposed to an intentional releasePersons exposed to an intentional release
Direct (<6.5 feet) face-to-face contacts of Direct (<6.5 feet) face-to-face contacts of case/suspect casecase/suspect case
Persons involved in direct medical or public Persons involved in direct medical or public health management or transport of case/suspect health management or transport of case/suspect casecase
Smallpox Outbreak ManagementSmallpox Outbreak ManagementPriority Groups for VaccinationPriority Groups for Vaccination
Smallpox Outbreak ManagementSmallpox Outbreak ManagementPriority Groups for VaccinationPriority Groups for Vaccination
Others at risk of contact with infectious materialsOthers at risk of contact with infectious materials
Persons whose unhindered function is essential Persons whose unhindered function is essential to support response activitiesto support response activities
Others at risk of contact with infectious materialsOthers at risk of contact with infectious materials
Persons whose unhindered function is essential Persons whose unhindered function is essential to support response activitiesto support response activities
UW Northwest Center for Public Health Practice
Smallpox Outbreak ManagementSmallpox Outbreak ManagementPre-release VaccinationPre-release Vaccination
Smallpox Outbreak ManagementSmallpox Outbreak ManagementPre-release VaccinationPre-release Vaccination
Select individuals vaccinated to enhance Select individuals vaccinated to enhance smallpox response capacitysmallpox response capacity
Smallpox Response TeamsSmallpox Response Teams Designated public health, law enforcement, Designated public health, law enforcement,
and medical personnel in each state/territoryand medical personnel in each state/territory Investigate, evaluate, and diagnose initial Investigate, evaluate, and diagnose initial
suspect cases of smallpoxsuspect cases of smallpox Select personnel at acute health care facilities Select personnel at acute health care facilities
(Smallpox Health Care Teams)(Smallpox Health Care Teams)
Select individuals vaccinated to enhance Select individuals vaccinated to enhance smallpox response capacitysmallpox response capacity
Smallpox Response TeamsSmallpox Response Teams Designated public health, law enforcement, Designated public health, law enforcement,
and medical personnel in each state/territoryand medical personnel in each state/territory Investigate, evaluate, and diagnose initial Investigate, evaluate, and diagnose initial
suspect cases of smallpoxsuspect cases of smallpox Select personnel at acute health care facilities Select personnel at acute health care facilities
(Smallpox Health Care Teams)(Smallpox Health Care Teams)
ACIP, June 2002
Smallpox VaccineSmallpox VaccineSmallpox VaccineSmallpox Vaccine
Made from live Made from live VacciniaVaccinia virus virus ~ 200 million doses in U.S. stores~ 200 million doses in U.S. stores
Intradermal inoculation with bifurcated needle Intradermal inoculation with bifurcated needle (scarification)(scarification) Pustular lesion or induration surrounding Pustular lesion or induration surrounding
central lesion (scab or ulcer) 6-8 days post-central lesion (scab or ulcer) 6-8 days post-vaccinationvaccination
Low grade fever, axillary lymphadenopathyLow grade fever, axillary lymphadenopathy Scar (permanent) demonstrates successful Scar (permanent) demonstrates successful
vaccination (“take”) vaccination (“take”) Immunity not life-longImmunity not life-long
Made from live Made from live VacciniaVaccinia virus virus ~ 200 million doses in U.S. stores~ 200 million doses in U.S. stores
Intradermal inoculation with bifurcated needle Intradermal inoculation with bifurcated needle (scarification)(scarification) Pustular lesion or induration surrounding Pustular lesion or induration surrounding
central lesion (scab or ulcer) 6-8 days post-central lesion (scab or ulcer) 6-8 days post-vaccinationvaccination
Low grade fever, axillary lymphadenopathyLow grade fever, axillary lymphadenopathy Scar (permanent) demonstrates successful Scar (permanent) demonstrates successful
vaccination (“take”) vaccination (“take”) Immunity not life-longImmunity not life-long
WHO
Smallpox VaccineSmallpox Vaccine AdministrationAdministration
Smallpox VaccineSmallpox Vaccine AdministrationAdministration
WHOJAMA 1999;281:1735-45 Vaccine admin instructions
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Smallpox Smallpox VaccineVaccine “Take” “Take”
Smallpox Smallpox VaccineVaccine “Take” “Take”
WHO
Smallpox Smallpox Complications Rates for Primary VaccinationComplications Rates for Primary Vaccination
Smallpox Smallpox Complications Rates for Primary VaccinationComplications Rates for Primary Vaccination
Complication rates lower with revaccinationComplication rates lower with revaccination Primary vaccination: ~1 death/millionPrimary vaccination: ~1 death/million Revaccination: ~0.2 deaths/millionRevaccination: ~0.2 deaths/million Most common complication:Most common complication:
Inadvertent auto- and secondary inoculation Inadvertent auto- and secondary inoculation (skin, eye)(skin, eye)
529/million (30% in one study were contacts)529/million (30% in one study were contacts)
Complication rates lower with revaccinationComplication rates lower with revaccination Primary vaccination: ~1 death/millionPrimary vaccination: ~1 death/million Revaccination: ~0.2 deaths/millionRevaccination: ~0.2 deaths/million Most common complication:Most common complication:
Inadvertent auto- and secondary inoculation Inadvertent auto- and secondary inoculation (skin, eye)(skin, eye)
529/million (30% in one study were contacts)529/million (30% in one study were contacts)
Sources: MMWR June 22, 2001 / 50(RR10);1-25. Vaccinia (Smallpox) Vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001
Vaccines 3rd Ed. Plotkin SA, Orenstein WA. W.B. Saunders, Phila. 1999
Smallpox Smallpox Complication Rates for Primary VaccinationComplication Rates for Primary Vaccination
Smallpox Smallpox Complication Rates for Primary VaccinationComplication Rates for Primary Vaccination
Less commonLess common Post-vaccination encephalopathy (7-42.3/million)Post-vaccination encephalopathy (7-42.3/million)** Post-vaccination encephalitis (12.3/million) Post-vaccination encephalitis (12.3/million)
25% fatal; 23% neurological sequelae25% fatal; 23% neurological sequelae Progressive vaccinia/vaccinia necrosum (1.5/million)Progressive vaccinia/vaccinia necrosum (1.5/million) Generalized vaccinia (241.5/million): severe in 10%Generalized vaccinia (241.5/million): severe in 10% Eczema vaccinatum (38.5/million)Eczema vaccinatum (38.5/million) Fetal vaccinia - rareFetal vaccinia - rare
Less commonLess common Post-vaccination encephalopathy (7-42.3/million)Post-vaccination encephalopathy (7-42.3/million)** Post-vaccination encephalitis (12.3/million) Post-vaccination encephalitis (12.3/million)
25% fatal; 23% neurological sequelae25% fatal; 23% neurological sequelae Progressive vaccinia/vaccinia necrosum (1.5/million)Progressive vaccinia/vaccinia necrosum (1.5/million) Generalized vaccinia (241.5/million): severe in 10%Generalized vaccinia (241.5/million): severe in 10% Eczema vaccinatum (38.5/million)Eczema vaccinatum (38.5/million) Fetal vaccinia - rareFetal vaccinia - rare
Sourced: MMWR June 22, 2001 / 50(RR10);1-25. Vaccinia (Smallpox) Vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001
*Vaccines 3rd Ed. Plotkin SA, Orenstein WA. W.B. Saunders, Phila. 1999
Smallpox Smallpox Vaccine Vaccine ComplicationsComplications
Smallpox Smallpox Vaccine Vaccine ComplicationsComplications
WHO
Smallpox VaccineSmallpox Vaccine ComplicationsComplications
Smallpox VaccineSmallpox Vaccine ComplicationsComplications
WHO
Smallpox Vaccine Smallpox Vaccine Pre-exposure ContraindicationsPre-exposure Contraindications
Smallpox Vaccine Smallpox Vaccine Pre-exposure ContraindicationsPre-exposure Contraindications
ImmunosuppressionImmunosuppression AgammaglobulinemiaAgammaglobulinemia Leukemia, lymphoma, generalized malignancyLeukemia, lymphoma, generalized malignancy Chemo- or other immunosuppressive therapyChemo- or other immunosuppressive therapy HIV infectionHIV infection
History or evidence of eczemaHistory or evidence of eczema Household, sexual, or other close contact with Household, sexual, or other close contact with
person with one of the above conditionsperson with one of the above conditions Life-threatening allergy to polymixin B, Life-threatening allergy to polymixin B,
streptomycin, tetracycline, or neomycinstreptomycin, tetracycline, or neomycin PregnancyPregnancy
ImmunosuppressionImmunosuppression AgammaglobulinemiaAgammaglobulinemia Leukemia, lymphoma, generalized malignancyLeukemia, lymphoma, generalized malignancy Chemo- or other immunosuppressive therapyChemo- or other immunosuppressive therapy HIV infectionHIV infection
History or evidence of eczemaHistory or evidence of eczema Household, sexual, or other close contact with Household, sexual, or other close contact with
person with one of the above conditionsperson with one of the above conditions Life-threatening allergy to polymixin B, Life-threatening allergy to polymixin B,
streptomycin, tetracycline, or neomycinstreptomycin, tetracycline, or neomycin PregnancyPregnancy
SmallpoxSmallpoxVaccinia Immune Globulin (VIG)Vaccinia Immune Globulin (VIG)
SmallpoxSmallpoxVaccinia Immune Globulin (VIG)Vaccinia Immune Globulin (VIG)
Treatment of adverse reactions (AR)Treatment of adverse reactions (AR) Approximately 25 AR’s/100,000 vaccinationsApproximately 25 AR’s/100,000 vaccinations AR rate may be increased in AR rate may be increased in
immunocompromised populationsimmunocompromised populations Post-exposure prophylaxis (if available)Post-exposure prophylaxis (if available)
Pregnant patients: VIG + vaccinia vaccinePregnant patients: VIG + vaccinia vaccine Eczema: VIG + vaccinia vaccineEczema: VIG + vaccinia vaccine Immunocompromised patients: no consensus Immunocompromised patients: no consensus
on VIG alone vs. VIG + vaccinia vaccineon VIG alone vs. VIG + vaccinia vaccine Current supplies Current supplies veryvery limited, but new lots are limited, but new lots are
being produced that conform to IV standardsbeing produced that conform to IV standards
Treatment of adverse reactions (AR)Treatment of adverse reactions (AR) Approximately 25 AR’s/100,000 vaccinationsApproximately 25 AR’s/100,000 vaccinations AR rate may be increased in AR rate may be increased in
immunocompromised populationsimmunocompromised populations Post-exposure prophylaxis (if available)Post-exposure prophylaxis (if available)
Pregnant patients: VIG + vaccinia vaccinePregnant patients: VIG + vaccinia vaccine Eczema: VIG + vaccinia vaccineEczema: VIG + vaccinia vaccine Immunocompromised patients: no consensus Immunocompromised patients: no consensus
on VIG alone vs. VIG + vaccinia vaccineon VIG alone vs. VIG + vaccinia vaccine Current supplies Current supplies veryvery limited, but new lots are limited, but new lots are
being produced that conform to IV standardsbeing produced that conform to IV standards
UW Northwest Center for Public Health Practice
Smallpox Smallpox Summary of Key PointsSummary of Key Points
Smallpox Smallpox Summary of Key PointsSummary of Key Points
The clinical diagnosis of smallpox is a public health emergency; the local or state health department and hospital infection control should be notified immediately for suspected cases, including cases that meet criteria of the CDC smallpox case definition.
CDC criteria for determining the risk of smallpox can help differentiate smallpox from varicella and other rash illnesses.
The clinical diagnosis of smallpox is a public health emergency; the local or state health department and hospital infection control should be notified immediately for suspected cases, including cases that meet criteria of the CDC smallpox case definition.
CDC criteria for determining the risk of smallpox can help differentiate smallpox from varicella and other rash illnesses.
UW Northwest Center for Public Health Practice
Smallpox Smallpox Summary of Key PointsSummary of Key Points
Smallpox Smallpox Summary of Key PointsSummary of Key Points
Smallpox is transmitted person to person; standard contact and airborne precautions should be initiated in all suspected cases until smallpox is ruled out.
Vaccine-induced immunity wanes with time; therefore most people today are considered susceptible to infection.
Smallpox is transmitted person to person; standard contact and airborne precautions should be initiated in all suspected cases until smallpox is ruled out.
Vaccine-induced immunity wanes with time; therefore most people today are considered susceptible to infection.
UW Northwest Center for Public Health Practice
SmallpoxSmallpoxAdditional Images & InformationAdditional Images & Information
SmallpoxSmallpoxAdditional Images & InformationAdditional Images & Information
Herron C. Smallpox — 26 Years Ago Herron C. Smallpox — 26 Years Ago N Engl J Med 1996; 334:1304 N Engl J Med 1996; 334:1304
Moses A. E. & Cohen-Poradosu R. Eczema Moses A. E. & Cohen-Poradosu R. Eczema vaccinatum — a timely reminder. N Engl J vaccinatum — a timely reminder. N Engl J Med 2002; 346:1287. Med 2002; 346:1287.
Herron C. Smallpox — 26 Years Ago Herron C. Smallpox — 26 Years Ago N Engl J Med 1996; 334:1304 N Engl J Med 1996; 334:1304
Moses A. E. & Cohen-Poradosu R. Eczema Moses A. E. & Cohen-Poradosu R. Eczema vaccinatum — a timely reminder. N Engl J vaccinatum — a timely reminder. N Engl J Med 2002; 346:1287. Med 2002; 346:1287.
World Health Organization This link will take you away from the educational siteThis link will take you away from the educational siteThis link will take you away from the educational siteThis link will take you away from the educational site
UW Northwest Center for Public Health Practice
Summary - Category A Critical AgentsSummary - Category A Critical AgentsSummary - Category A Critical AgentsSummary - Category A Critical Agents
Disease Transmit Man to Man
Infective Dose* (Aerosol)
Incubation Period
Duration of Illness Approx. case fatality rate
Inhalation anthrax
No
8,000-50,000 spores
1-6 days 3-5 days (usually fatal if untreated)
High
Pneumonic Plague
High 100-500 organisms
2-3 days 1-6 days (usually fatal)
High unless treated within 12-24 hours
Tularemia No 10-50 organisms
2-10 days (average 3-5)
> 2 weeks Moderate if untreated
Smallpox High Assumed low (10-100 organisms)
7-17 days (average 12)
4 weeks High to moderate
Viral Hemorrhagic Fevers
Moderate 1-10 organisms 2-21 days Death between 7-16 days
High for Zaire strain, moderate with Sudan
Botulism No 0.001 g/kg is LD50 for type A
1-5 days Death in 24-72 hours; lasts months if not lethal
High without respiratory support
Modified from: USAMRIID’s Medical Management of Biological Casualties Handbook
*infectious dose may be less in certain circumstances
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UW Northwest Center for Public Health Practice
SummarySummaryCategory A Critical AgentsCategory A Critical Agents
SummarySummaryCategory A Critical AgentsCategory A Critical Agents
Decontamination of exposed persons Decontamination of exposed persons Showering or washing thoroughly with soap and Showering or washing thoroughly with soap and
water adequate for most; bleach not necessary water adequate for most; bleach not necessary
Infection controlInfection control Standard precautions – all cases Standard precautions – all cases Airborne and contact precautions – smallpox and Airborne and contact precautions – smallpox and
viral hemorrhagic feversviral hemorrhagic fevers Droplet precautions – pneumonic plagueDroplet precautions – pneumonic plague
Decontamination of exposed persons Decontamination of exposed persons Showering or washing thoroughly with soap and Showering or washing thoroughly with soap and
water adequate for most; bleach not necessary water adequate for most; bleach not necessary
Infection controlInfection control Standard precautions – all cases Standard precautions – all cases Airborne and contact precautions – smallpox and Airborne and contact precautions – smallpox and
viral hemorrhagic feversviral hemorrhagic fevers Droplet precautions – pneumonic plagueDroplet precautions – pneumonic plague
UW Northwest Center for Public Health Practice
Resources Resources Resources Resources Centers for Disease Control and Prevention Centers for Disease Control and Prevention
Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System CDC Office of Health and Safety Information System
(personal protective equipment)(personal protective equipment)
USAMRIID USAMRIID –– includes link to online version of Medical includes link to online version of Medical Management of Biological Casualties HandbookManagement of Biological Casualties Handbook
Johns Hopkins Center for Civilian Biodefense Johns Hopkins Center for Civilian Biodefense Studies Studies fact fact sheets and links to other info, including JAMA series sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense and BT-from Working Group on Civilian Biodefense and BT-related anthrax case studiesrelated anthrax case studies
Centers for Disease Control and Prevention Centers for Disease Control and Prevention Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System CDC Office of Health and Safety Information System
(personal protective equipment)(personal protective equipment)
USAMRIID USAMRIID –– includes link to online version of Medical includes link to online version of Medical Management of Biological Casualties HandbookManagement of Biological Casualties Handbook
Johns Hopkins Center for Civilian Biodefense Johns Hopkins Center for Civilian Biodefense Studies Studies fact fact sheets and links to other info, including JAMA series sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense and BT-from Working Group on Civilian Biodefense and BT-related anthrax case studiesrelated anthrax case studies
http://www.hopkins-biodefense.org
http://www.usamriid.army.mil/
http://www.bt.cdc.gov/
http://www.cdc.gov/od/ohs/
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UW Northwest Center for Public Health Practice
Resources Resources Resources Resources
Office of the Surgeon General: Medical Office of the Surgeon General: Medical Nuclear, Biological and Chemical InformationNuclear, Biological and Chemical Information
St. Louis University Center for the Study of St. Louis University Center for the Study of Bioterrorism and Emerging Infections Bioterrorism and Emerging Infections –– fact fact sheets and links sheets and links
Public Health - Seattle & King CountyPublic Health - Seattle & King County
Office of the Surgeon General: Medical Office of the Surgeon General: Medical Nuclear, Biological and Chemical InformationNuclear, Biological and Chemical Information
St. Louis University Center for the Study of St. Louis University Center for the Study of Bioterrorism and Emerging Infections Bioterrorism and Emerging Infections –– fact fact sheets and links sheets and links
Public Health - Seattle & King CountyPublic Health - Seattle & King County
http://www.nbc-med.org
http://www.metrokc.gov/health
http://bioterrorism.slu.edu
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UW Northwest Center for Public Health Practice
Resources Resources Resources Resources
American College of Physicians – links to BT American College of Physicians – links to BT resources, including decision support tools and resources, including decision support tools and palm documents palm documents
Self-Assessment (case scenarios – chemical Self-Assessment (case scenarios – chemical and biological)and biological)
MMWR Rec. and Rep. Case definitions under MMWR Rec. and Rep. Case definitions under public health surveillance.public health surveillance.
American College of Physicians – links to BT American College of Physicians – links to BT resources, including decision support tools and resources, including decision support tools and palm documents palm documents
Self-Assessment (case scenarios – chemical Self-Assessment (case scenarios – chemical and biological)and biological)
MMWR Rec. and Rep. Case definitions under MMWR Rec. and Rep. Case definitions under public health surveillance.public health surveillance.
http://www.acponline.org
http://www.acponline.org/bioterro/self_assessment.htm
1997;46(RR-10):1-55
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In Case of An Event…In Case of An Event…Web Sites with Up-to-Date Information and Web Sites with Up-to-Date Information and
InstructionsInstructions
In Case of An Event…In Case of An Event…Web Sites with Up-to-Date Information and Web Sites with Up-to-Date Information and
InstructionsInstructions
Centers for Disease Control and Prevention Centers for Disease Control and Prevention Saint Louis University, CSB & EISaint Louis University, CSB & EI WA State Local Health Departments/DistrictsWA State Local Health Departments/Districts
Level A Lab Protocols: Presumptive Agent IDLevel A Lab Protocols: Presumptive Agent ID
Centers for Disease Control and Prevention Centers for Disease Control and Prevention Saint Louis University, CSB & EISaint Louis University, CSB & EI WA State Local Health Departments/DistrictsWA State Local Health Departments/Districts
Level A Lab Protocols: Presumptive Agent IDLevel A Lab Protocols: Presumptive Agent ID
http://www.bt.cdc.gov/EmContact/index.asp
http://bioterrorism.slu.edu/hotline.htm
http://www.bt.cdc.gov/LabIssues/index.asp
http://www.doh.wa.gov/LHJMap/LHJMap.htm
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In Case of An Event…In Case of An Event…Web Sites with Up-to-Date Information and Web Sites with Up-to-Date Information and
InstructionsInstructions
In Case of An Event…In Case of An Event…Web Sites with Up-to-Date Information and Web Sites with Up-to-Date Information and
InstructionsInstructions FBI Terrorism Web PageFBI Terrorism Web Page
WA State Emergency Mgt Division – Hazard WA State Emergency Mgt Division – Hazard Analysis UpdateAnalysis Update
Mail Security Mail Security
Links to your state health departmentLinks to your state health department
NIOSH – Worker Safety and Use of PPE NIOSH – Worker Safety and Use of PPE
FBI Terrorism Web PageFBI Terrorism Web Page
WA State Emergency Mgt Division – Hazard WA State Emergency Mgt Division – Hazard Analysis UpdateAnalysis Update
Mail Security Mail Security
Links to your state health departmentLinks to your state health department
NIOSH – Worker Safety and Use of PPE NIOSH – Worker Safety and Use of PPE
http://www.fbi.gov/terrorism/terrorism.htmhttp://www.fbi.gov/terrorism/terrorism.htm
http://www.usps.com/news/2001/press/serviceupdates.htmhttp://www.usps.com/news/2001/press/serviceupdates.htm
http://www.cdc.gov/niosh/emres01.htmlhttp://www.cdc.gov/niosh/emres01.html
http://www.wa.gov/wsemhttp://www.wa.gov/wsem
http://www.astho.org/state.htmlhttp://www.astho.org/state.html
These links will take you away from the educational siteThese links will take you away from the educational siteThese links will take you away from the educational siteThese links will take you away from the educational site