Quarantine and especially dangerous infections

1. Quarantine and especially dangerous infections

2. Smallpox Disease, Prevention, and Intervention

3. Progression of Smallpox • Incubation Period • Prodrome Stage • Macules • Papules • Vesicles • Pustules • Scabs • Scars

4. Smallpox Prodrome • Incubation period 12 days (range 7-17 d) • Prodrome • abrupt onset of fever >101oF • malaise, headache, muscle pain, nausea, vomiting, backache • lasts 1- 4 days

5. Smallpox Rash • Enanthem (mucous membrane lesions) appears ~ 24 hours before skin rash • Minute red spots on the tongue and oral/pharyngeal mucosa • Lesions enlarge and ulcerate quickly • Become infectious from lesions in mouth • Virus titers in saliva highest and most infectious during first week of exanthem (skin rash)

6. Smallpox Rash • Exantham (skin rash) – (21 days) • Stages: macules, papules, vesicles, pustules, scabs • Pustules raised, round, firm - like small beads in the skin (“shotty”) • Umbilication common • Begins and most dense on face and extremities (centrifugal distribution) • Lesions on palms and soles (>50% of cases) • Lesions in same stage and evolve slowly (1-2 days/stage)

8. Ordinary Smallpox

11. Pustular lesions on palms Flattened lesions on soles

12. Smallpox Ordinary Type (Discreet lesions)

13. SmallpoxOrdinary Type (Dense lesions)

14. SmallpoxFlat-type

15. SmallpoxHemorrhagic Type

16. Varicella

17. SMALLPOX Deep, hard lesions Round, well circumscribed Confluent or umbilicated Lesions at same stage of development CHICKEN POX Superficial Not well circumscribed Confluence and umbilication uncommon Lesions at all stages of development Differential Diagnosis

19. CHICKENPOX SMALLPOX

20. Smallpox Chickenpox

21. Smallpox Varicella

22. Bifurcated needle

23. Speed • Simplicity

24. Smallpox Eradication StrategyThe Bifurcated Needle Fenner F et al. Smallpox and its Eradication, pp 570

25. Vaccine Administration

26. Remove needle from sterile packaging.

27. Dip the needle into the vaccine.

28. Do NOT re-dip the needle into the vaccine solution once it has touched the person’s skin.

29. Proper position of hands.

30. Pressure should be sufficient to visibly push down the skin.

31. A trace of blood should be present after 10-20 seconds.

32. Dispose of used needle immediately into sharps container.

33. Cover site with sterile dressing.

34. Smallpox Vaccine Administration

35. “Successful” Smallpox Vaccination

37. Contraindications for Vaccination • Immunodeficiency • Immunosuppressing therapies • Atopic Dermatitis/Eczema; including past history • Acute or chronic skin conditions (until resolved) • Allergies to polymyxin B, streptomycin, tetracycline, or neomycin • Pregnancy

38. Contraindications for Vaccination of Contacts During a smallpox outbreak… NONE!

39. Lymphangitis following smallpox vaccination.

40. Robust take with lymphangitis.

41. Satellite lesions.

42. Allergic reaction to tape

43. Major Complications of Smallpox Vaccination • Inadvertent autoinoculation (IA) • Eczema vaccinatum (EV) • Generalized vaccinia (GV) • Progressive vaccinia (PV) (vaccinia necrosum) • Postvaccinial encephalitis (PE)

44. Inadvertent Autoinoculation

45. Postvaccinial Encephalitis • Signs and and symptoms of classical encephalitis, encephalopathy, demyelinization, or neuropathy • Onset 9-14 days after primary vaccination • Highest risk among children <12 months of age • VIG not proven useful

46. Progressive Vaccinia

47. Eczema Vaccinatum EV in Contact EV 3 days after VIG

48. Generalized Vaccinia

49. Fetal Vaccinia • 47 cases in world literature (as of 1970) • Most from primary vaccination early in pregnancy • Usually results in stillbirth or death soon after delivery • Pregnancy a relative contraindication to vaccination

50. Smallpox Outbreak Control Activities and Strategies