Overview of Smallpox - Minnesota Department of Health · Smallpox Clinical Treatment • Strict...
Transcript of Overview of Smallpox - Minnesota Department of Health · Smallpox Clinical Treatment • Strict...
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Overview of Smallpox
2002
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Smallpox as a Bioterrorism Agent
• Last reported case in Minnesota in 1947 • Eradicated in 1977 • Intelligence reports indicate virus has been
stolen •
•
• Small infectious dose (10-100 organisms) •
each generation
Potential for use as bioweapon High (30%) case fatality rate
Much secondary spread; 10 to 20-fold increase
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• Orthopoxvirus
• Infects only humans in nature
• disinfectants, heat
Variola Virus
Rapidly inactivated by UV light, chemical
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• Variola major
– Severe illness
–
• Variola minor
– Less severe
– 1%
Smallpox Clinical Presentations
Case fatality rate of >30%
Case fatality of <
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Clinical Presentations of Variola Major
• Ordinary (>
• people)
•
•
90% of cases in unvaccinated people)
Modified (mild; occurs in previously vaccinated
Flat (uncommon; usually fatal)
Hemorrhagic (uncommon; usually fatal)
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•
•
• No fever during evolution of rash
• Skin lesions evolve more quickly
•
•
Modified Smallpox
Occurs in previously vaccinated persons
Prodrome may be less severe
Rarely fatal
More easily confused with chickenpox
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Flat Smallpox
• Severe prodrome
• Fever remains elevated throughout course of illness
• Extensive enanthem
• Skin lesions soft and flat, contain little fluid
• Most cases fatal
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• Prolonged severe prodrome
• Fever remains elevated throughout course of illness
•
• Bleeding into skin, mucous membranes, GI tract
•
Hemorrhagic Smallpox
Early or late hemorrhagic signs
Usually fatal
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• Bacterial infection of skin lesions • Arthritis • Respiratory • Encephalitis • Death
–
–
–
Smallpox Complications
30% overall for ordinary smallpox 40%-50% for children <1 year >90% for flat and hemorrhagic smallpox
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Smallpox Prodrome
•
• Prodrome
– abrupt onset of fever >101oF
– malaise, headache, muscle pain, nausea, vomiting, backache
– lasts 1-4 days
Incubation period 12 days (range 7-19 days)
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Smallpox Rash
• Enanthem (mucous membrane lesions) appears approx. 24 hours before skin rash
• Minute red spots on the tongue and oral/pharyngeal mucosa
• Lesions enlarge and ulcerate quickly
• exanthem Virus titers in saliva highest during first week of
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• Exanthem (skin rash) appears 2-4 days after onset of fever
•
• Lesions appear on proximal extremities, spread to distal extremities and trunk
• Vesicles often have a central depression (“umbilication”)
• Pustules raised, round, firm to the touch, deeply embedded in the skin
Smallpox Rash
First appears as macules, usually on the face
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• development
• Most dense on face and distal extremities (centrifugal distribution)
• Lesions on palms and soles (>
Smallpox Rash
Lesions in any one part of the body are in same stage of
50% of cases)
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Day 2 of rash, papules apparent
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Day 3, rash more
discrete and raised above
the skin surface.
Fluid beginning to accumulate
in papules to form
vesicles
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vesicles are more distinct and feel
firm to the touch.
Day 4,
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vesicles becomes
rises and patient feels more ill.
Day 5, fluid in
cloudy, rash now pustular. Fever usually
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rash definitely pustular
Day 7,
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Days 8-9, pustules
increase in size, are
firm to the touch and are deeply embedded in the skin.
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Days 10-14, scabs form. The scabs
contain live virus. Until all scabs fall off, patient
others. may infect
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have fallen off and
depigmented areas evident.
to normal appearance,
the face.
Day 20, scabs
Skin may return
however scars may remain on
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Smallpox Differential Diagnosis
• Varicella (chickenpox)
• Vaccinia
•
•
• Herpes zoster
• Drug-induced rashes
•
• Coxsackie virus
• Herpes Simplex Virus
•
• Molluscum contagiosum (esp. HIV patients)
• Scabies and insect bites
• Impetigo
• Contact dermatitis
Monkeypox
Cowpox
Erythema multiforme
Secondary syphilis
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Smallpox (Variola) • Febrile prodrome
• Centrifugal distribution (most dense on face, thenextremities, less on trunk)
• and evolve at the same rate)
• Rash maculopapular, then vesicular, and laterpustular
•
• Lesions on palms and soles
Synchronous lesions (appear during a 1-2 day period
Lesions firm to touch, deeply embedded in skin
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Chickenpox (Varicella)
•
• Centripetal distribution (greater concentration of lesions on the trunk rather than the face and extremities)
• develop at different stages: papules, vesicles, pustules, and scabs
• probed
• Not on palms and soles
Fever with onset of rash
Lesions appear in crops every few days and
Lesions are more superficial and will burst if
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Day 1-2, difficult to distinguish
rash
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Lesions same stage and
embedded in skin
Lesions in different
stages and more
superficial
deeply
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Scabs not
Most lesions have formed
scabs
yet formed
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Smallpox Major Criteria
•• Febrile prodrome 1Febrile prodrome 1--4 days before rash onset4 days before rash onset; fever of >101 F, and at least 1 additional symptom*
• Rash lesions deep, firm/hard, round and well circumscribed
• On any one part of the body lesions in same stage of development
*Prostration, headache, backache, chills, vomiting or severe abdominal pain
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• Greatest concentration of lesions on face and distal extremities
• Lesions first appeared on oral mucosa/palate, face, forearms
• Patient appears toxic or moribund
• Lesions evolve from macules to papules to pustules over days
• Lesions on palms and soles
Smallpox Minor Criteria
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Risk of Smallpox by Clinical History and Examination
•
– febrile prodrome and
– classic smallpox lesions and
–
•
– febrile prodrome and
– 1 major OR > 4 minor criteria
•
–
–
High risk
same stage of development
Moderate risk
Low risk
no febrile prodrome or
febrile prodrome and < 4 minor criteria
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POSSIBLE CASE OF SMALLPOX
REPORT TO MDH IMMEDIATELY:
1-877-676-5414 or 612-676-5414
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Smallpox Clinical Treatment
• Strict airborne and contact isolation
•
– Ensure adequate fluid intake – Alleviate pain, fever –
•
•
Supportive care is the mainstay of smallpox therapy
Aggressive treatment of secondary infections
Antiviral therapy is experimental (Cidofovir) Vaccination of contacts up to 4 days post-exposure can prevent/attenuate clinical symptoms
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Infection Control
• Strict adherence to Standard, Airborne, and Contact Precautions
• Airborne: – 6
air exchanges per hour. Exhaust outside or through HEPA filtration.
–
Closed door, negative pressure rooms with >
Caregivers must wear NIOSH respiratory protection when entering rooms (N95 masks preferred because PAPRs difficult to clean).
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City Smallpox Hospital, Roseville MN
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Smallpox Information on the Web •
•
• biodefense.org
•
• IDSA Website.
•
American Academy of Dermatology: www.aad.org/BioInfo/smallpx.html
CDC smallpox: www.bt.cdc.gov/agent/smallpox/index.asp
Center for Civilian Biodefense Strategies: www.hopkins-
Center for Infectious Disease Research and Policy: www.umn.edu/cidrap/
www.idsociety.org/BT/ToC.htm
MDH: www.health.state.mn.us/bioterrorism/professionals.html