Pediatric emergency medicine trisk 4550 4550
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Smallpox is contagious 1 day prior to the onset of rash.
In contrast to chickenpox, the rash of smallpox starts on the face and
extremities and spreads centrally.
The smallpox rash develops synchronously such that lesions are all in
the same stage.
Strict airborne, droplet, and contact precautions should be instituted
immediately for smallpox victims and should continue until all scabs
have separated.
Smallpox is associated with a high mortality and there is no specific
therapy available.
Background. The global eradication of smallpox represents one of the great
success stories of public health, with the last endemic case occurring in Somalia
in 1977. Since then, research stockpiles of variola virus have been consolidated
into two World Health Organization (WHO)–approved stores at the CDC in
Atlanta and at a Russian institute in Koltsovo. This achievement would seem to
make terrorist use of this virus impossible; however, several factors give cause for
concern. First is the fear that other stockpiles already exist in the hands of
belligerent nations unbeknownst to WHO. Astonishingly, in 2014, vials
containing the smallpox virus were discovered in a storage room of an FDA
laboratory in Bethesda, Maryland. Second, the entire viral genomic sequence is
known and published; therefore, it is likely only a matter of time before
technology permits reconstruction of the virus (the related horsepox virus has
already been synthesized de novo). Finally, although the virulence factors of
variola virus are poorly understood, it may be possible for someone to manipulate
related orthopoxviruses such as monkeypox to enhance their virulence in humans
and create a disease similar to smallpox. In light of these considerations, the CDC
in 2003 recommended a strategy of reintroducing vaccination in the United States
after a nearly 30-year hiatus, with the initial goal of vaccinating up to 10,000,000
front-line EMS and healthcare providers. This program has subsequently proven
controversial and has been suspended; probably fewer than 50,000 civilians were
vaccinated. The U.S. military, however, has vaccinated several hundred thousand
service members and serious adverse events have been rare.
Several factors might make smallpox an attractive weapon to potential
belligerents. First, the duration of immunity after vaccination is a matter of
controversy, with some studies suggesting a duration of only 3 to 5 years, while
other studies suggest the possibility of lifelong immunity. Second, following
