preparing for and responding to bioterrorism: information for primary care clinicians

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


Diseases of Bioterrorist Potential Diseases of Bioterrorist Potential Smallpox Smallpox

Diseases of Bioterrorist Potential Diseases of Bioterrorist Potential Smallpox Smallpox

CDC, AFIP


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


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


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


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



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


SmallpoxSmallpoxClinical CourseClinical Course

SmallpoxSmallpoxClinical CourseClinical Course

WHO

SmallpoxSmallpoxClinical PresentationClinical Presentation


CDC



WHO

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WHO

SmallpoxSmallpox Clinical ProgressionClinical Progression


WHO




Thomas, D.

Day 14Day 10 Day 21


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



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



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


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


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)


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)


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


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


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


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



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






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



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


Variola vs. VaricellaVariola vs. VaricellaLesion DistributionLesion Distribution

Variola vs. VaricellaVariola vs. VaricellaLesion DistributionLesion Distribution

WHO

Chickenpox

Smallpox


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


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



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


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...





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


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



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


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



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


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


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



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


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


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


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.




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.


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


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



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


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/

These links will take you away from the educational site These links will take you away from the educational site These links will take you away from the educational site These links will take you away from the educational site


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

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


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



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






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


preparing for and responding to bioterrorism: information for primary care clinicians

Documents