Smallpox

Mass vaccinations for 500,000 military personnel are underway, as well as plans to vaccinate as many as 500,000 civilian public health and hospital workers.

While smallpox can be prevented through the use of the smallpox vaccine, there is no proven treatment for smallpox.

A smallpox emergency preparedness component should be added to your existing disaster plan including measures to prevent cross-contamination, staff education, community education, patient prioritization and measures to assure patient confidentiality.

Smallpox has been in the news ever since Sept. 11, 2001. Because of the possibility of bioterrorism, government agencies on national, state and regional levels are finalizing plans to combat a potential outbreak. Health care providers nationwide also are taking precautions to prepare for a bioterrorist attack using smallpox. Mass vaccinations for 500,000 military personnel are underway, as well as plans to vaccinate as many as 500,000 civilian public health and hospital workers. Given all of this, there are two things that are known for sure. One, there is a detailed national smallpox response plan and two, there is enough vaccine to inoculate everyone who needs and wants to be vaccinated in the event of an emergency.

What exactly is smallpox, and why are so many resources being devoted to this threat? How can you protect yourself, your staff, and your patients? This column presents some basic information and the resources for learning more about this potential threat. More information will become available as health care professionals analyze reactions to the military and health care worker vaccination programs. At press time, this is what we know.

How Dangerous is Smallpox?

Smallpox is a severe, contagious disease caused by the variola virus. It historically kills 30 percent of its victims. The last case of smallpox reported in the United States was in 1949. In the 1950s, smallpox affected an estimated 50 million people worldwide and caused 6 million fatalities. By the 1960s those numbers had been cut by two-thirds. The last identified case of smallpox occurred in 1977, in Somalia, and the disease was declared eradicated by the World Health Organization (WHO) in 1980, following worldwide vaccination programs.

While smallpox can be prevented through the use of the smallpox vaccine, there is no proven treatment for smallpox. All smallpox cases involve fever; common symptoms include progressive skin rash, headache, backache, chills and vomiting. Symptoms can appear anytime between seven to 17 days following exposure to the disease, but the average interval is 12 to 14 days.

A person who has smallpox is not contagious during this incubation period. The onset of fever can trigger the contagious phase, but smallpox becomes most infectious when the rash occurs. The infected person is contagious until the last smallpox scab falls off, a process that can take several weeks.

How is Smallpox Spread?

Smallpox spreads through contact with an infected person. According to the Centers for Disease Control and Prevention (CDC), direct face-to-face contact is generally required. Smallpox also can be spread through direct contact with bodily fluids or contaminated objects such as clothing, linens, and medical equipment. The virus also can be carried in the air in enclosed settings. The smallpox virus is relatively fragile; it is estimated that 90 percent of airborne virus matter would dissipate or become inactive within 24 hours.

Smallpox is classified as a Category A agent by the CDC. Category A agents are believed to pose the greatest potential threat for adverse public health impact and have a moderate to high potential for large-scale dissemination. Other Category A agents are anthrax, plague, botulism, tularemia (a bacterial disease), and viral hemorrhagic fevers. As more information becomes available, a smallpox emergency preparedness component should be added to your existing disaster plan including measures to prevent cross-contamination, staff education, community education, patient prioritization and measures to assure patient confidentiality.

What Can You Do?

Inoculation is currently a primary focus of emergency preparedness planning. Routine inoculations of children in the United States stopped in 1972, 23 years after the last case of smallpox appeared in this country. Any American over age 30 may remember the process, which is not really a "shot." A two-pronged needle is dipped into the vaccine solution, then used to prick the skin of the upper arm numerous times. The vaccination site grows a red, itchy bump that becomes a blister. The blister begins to dry up and form a scab, and the scab often leaves a scar when it falls off in the third week.

A first-time vaccine is expected to offer full protection for three to five years, after which immunity begins to decrease. Over time, a vaccinated person may still contract the disease and develop symptoms, but may be less likely to die. In the event of a smallpox outbreak, people who received the vaccine years ago should not assume they are immune.

Smallpox vaccine is made from a virus called vaccinia, which is related to, but distinct from smallpox. Because it does not contain the smallpox virus, you cannot get smallpox from the vaccine. However, the live vaccinia virus can spread to other parts of the body, or to other people, if the vaccination site is not properly cared for. The risk of a smallpox terrorist attack remains unknown, but the historical risks from the vaccine are well documented. According to the CDC, it is estimated that between one and two people out of every million vaccinated will die as a result of reactions to the vaccine. Another 1,000 may experience reactions that, while not life threatening, are serious, with another 14 to 52 people experiencing potentially life-threatening reactions.

People most likely to have side effects are those who have, or even once had, skin conditions like eczema or dermatitis and people with weakened immune systems, such as those who have received a transplant, are HIV positive or are receiving treatment for cancer. Anyone who falls within these categories, or lives with someone who falls into one of these categories, should not be vaccinated unless they are exposed to smallpox. Pregnant women, women who are breast-feeding, those who have had a previous allergic reaction to the vaccine, children under 12 months of age and anyone taking medications that weaken the immune system should also not get vaccinated unless exposed. For more information on contraindications please consult with your local public health professional, your physician or the CDC.

Although vaccinia can cause a number of uncomfortable to serious side effects including death, this vaccine will be the best protection for anyone who may be exposed to smallpox. Vaccination within three days of exposure will completely prevent or significantly modify the severity of smallpox in the vast majority of cases. Public health officials report that vaccination within seven days after exposure will offer partial protection or may modify the severity of the disease. As with any vaccination, you must make an informed choice based on the risks associated with the vaccine, versus the likelihood of contracting the disease.

What are Other Health Care Providers Doing?

Because smallpox is still a threat, not a reality, the nationwide smallpox plan involves a phased approach to inoculation. Most military personnel have already been vaccinated. Beginning in February 2003, inoculations for hospital staff who volunteer to be on smallpox response teams were available. According to Meg Montgomery, R.N., infection control coordinator, Yampa Valley Medical Center, local health officials are working to strengthen the national and state programs for smallpox emergency preparedness including smallpox inoculations for health care workers and a communication plan for the general public. "Our goal is to increase awareness and confidence in the role local health care providers play in smallpox emergency preparedness. We have vaccinated a response team and have procedures in place following the CDC guidelines for the safe management of patients and staff."

According to current plans, other emergency personnel would be eligible for vaccination within a few months. By early 2004, the federal government may offer the vaccine to all individuals who meet specific health guidelines. At this time, there is no vaccine available to the general public. There are plans for a synthetic vaccine that will have fewer side effects than the vaccinia-based version. This vaccine is scheduled to be available in 2004. If a bioterrorism smallpox attack occurs, comprehensive emergency vaccination plans would be immediately activated in communities throughout the nation.

Stay Vigilant

Smallpox is not a pretty picture. The collective attitude in every bioterrorism meeting I have attended goes something like this: "Why do we have to waste our time and resources with this?" The unfortunate reality is that our world changed on Sept. 11 and we need to be prepared for the future, whatever it brings. Medical experts and government officials have been working together for years before Sept. 11, 2001, to determine the best way to protect people from a mass smallpox outbreak. More information from public health officials is appearing in the media on a daily basis. Stay tuned, keep informed and be safe.

Learn More About Smallpox

Several Web sites offer comprehensive information about the smallpox vaccination, clinical education and guidelines for bioterrorism emergency preparedness. For details, visit the Centers for Disease Control and Prevention at www.cdc.gov/smallpox,and the Center for Infectious Disease Research and Policy at www.cidrap.umn.edu.

Smallpox: Take the Test

A study that appeared in the January 30 issue of New England Journal of Medicine Indicated that Americans have many misconceptions about smallpox. Take our ten-point test and see what you know.

Ten Point Test

True or False?

1. There is a known treatment for smallpox.

2. Vaccination after exposure to smallpox can be effective.

3. There is not enough vaccine to inoculate everyone in the United States.

4. You cannot get smallpox from the smallpox vaccine.

5. The smallpox vaccine is fatal 25 percent of the time.

6. There has been a smallpox case in the United States within the last five years.

7. A smallpox vaccination provides lifetime protection.

8. Smallpox vaccination will be mandatory for all Americans.

9. Routine smallpox vaccination ended in the United States in 1972.

10. About 45 percent of Americans have never had a smallpox vaccination.

Answers to the Ten Point Test

1. False. There is no known treatment for smallpox.

2. True. Vaccination within a few days after exposure can prevent or reduce the severity of smallpox.

3. False. There is enough vaccine to vaccinate everyone who would need it in the event of an emergency.

4. True. The smallpox vaccine does not contain smallpox virus and cannot spread or cause smallpox.

5. False. Historically, there have been 1-2 fatalities for every 1 million people vaccinated.

6. False. The last case of smallpox reported in the United States was in 1949.

7. False. Past experience indicates that protection lasts for 3 to 5 years, with decreasing immunity thereafter.

8. False. Even after a smallpox attack, there are no provisions for forced vaccinations.

9. True. The last routine smallpox vaccination in the United States was in 1972.

10.True. Anyone born after 1972 has not had a routine smallpox vaccination.

This article originally appeared in the March 2003 issue of HME Business.

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