eMedicine Specialties > Infectious Diseases > Viral Infections

Smallpox: Follow-up

Author: Aneela Naureen Hussain, MD, FAAFM, Assistant Professor, Department of Family Medicine, State University of New York Downstate Medical Center; Consulting Staff, Department of Family Medicine, University Hospital of Brooklyn
Coauthor(s): Fazal Hussain, MD, MBBS, Director, Clinical Research, King Faisal Cancer Centre; Maqsood Alam, MD, Fellow, Department of Infectious Diseases, State University of New York Downstate Medical Center; Dennis J Cleri, MD, FACP, FAAM, FIDSA, Chairman, Graduate Medical Education Committee, Professor of Medicine, Associate Professor of Infection Disease, Seton Hall University; Director, Internal Medicine Residency Program, St Francis Medical Center
Contributor Information and Disclosures

Updated: Oct 20, 2008

Follow-up

Deterrence/Prevention

  • Vaccination: One of the best ways to prevent smallpox is through vaccination. Vaccine given to individuals before exposure to smallpox can completely protect them. Vaccination within 3 days after exposure prevents or greatly lessens the severity of smallpox in most people. Vaccination 4-7 days after exposure likely offers some protection from disease or may decrease the severity of disease. Vaccination does not protect patients with smallpox who have already developed a rash.
    • Vaccinated persons normally exhibit an accelerated immune response. Thus, whenever possible, assigning those who have previously been vaccinated to duties involving close patient contact is prudent.
    • Persons with known or possible exposure to smallpox should be vaccinated if the exposure has occurred within 3 days unless the patient has specific contraindications for which the risks of immunization are considered even greater than the dangers associated with contracting smallpox.
  • Vaccinia immune globulin (VIG): This is indicated when the vaccination is contraindicated.
  • Hospital infection control: Whenever possible, patients should be cared for at home in the event of a large smallpox outbreak. However, in the event of an outbreak with only a few cases or when patients cannot be cared for at home, hospital admission is advisable.
    • Individuals with smallpox should be placed in isolation in rooms under negative pressure that are equipped with high-efficiency particulate air (HEPA) filtration.
    • All persons caring for patients with smallpox should be vaccinated, except those with contraindications to the vaccine, who should be furloughed. Ideally, all health care workers caring for patients with smallpox should be vaccinated; however, this may not be possible in the event of an epidemic because a large number of persons are required for the delivery of care.
    • Patients with smallpox should be isolated under strict airborne and contact precautions, and the number of personnel in contact with them should be limited, as should the caregivers in contact with other patients who do not have smallpox.
    • Wear appropriate protective equipment when in contact with persons who may be infected with smallpox.
    • Properly dispose of all protective equipment (ie, in biohazard bags) before leaving the anteroom.
    • Avoid transporting the patient through the hospital (eg, use in-room portable radiograph equipment); if transporting the patient is unavoidable, have the patient wear a surgical mask and the health care worker a mask with an N-95 respirator.
    • If smallpox infection is confirmed, place contacts under fever surveillance for 18 days after their last contact with the infected patient.
    • Contacts or a supervisor should monitor the patient’s temperature twice daily. If the patient’s temperature is higher than 38.1°C (100.5°F), public health authorities should be notified immediately.

      Typical temperature chart of a patient with small...

      Typical temperature chart of a patient with smallpox infection (from Henderson, 1999).

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      Typical temperature chart of a patient with small...

      Typical temperature chart of a patient with smallpox infection (from Henderson, 1999).

    • The vaccine should be administered to all persons who had contact with a patient confirmed to have smallpox. Additionally, the vaccine should be administered to personnel without contraindications who will be involved in the future evaluation or care of patients possibly infected, if not already a contact.
    • Do not reuse equipment or the room for other patients unless it has been properly decontaminated.
    • The CDC recommends that authorities should consider designating specific hospitals for smallpox care and that all persons isolated for smallpox should be vaccinated.

Complications

  • Skin
    • Formation of furuncles and/or abscesses secondary to bacterial infection
    • Sepsis
    • Pockmarks
  • Eyes
  • Joints and bones
    • Arthritis
    • Osteomyelitis variolosa
    • Symmetrical elbow joint involvement 
  • Respiratory system
    • Pulmonary edema
    • Pneumonitis
  • Central nervous system - Encephalitis (1 in 500 cases)
  • Other - Dehydration

Prognosis

  • The mortality rate in patients with untreated smallpox is 30% or higher. The more severe hemorrhagic and malignant forms of smallpox are usually fatal.

Patient Education

  • Isolation
  • Barrier protection - Gown, mask, gloves
  • Cremation of corpses
  • Isolation of contacts if fever or rash develops
  • Surveillance of all face-to-face contacts
  • For excellent patient education resources, visit eMedicine's patient education article Smallpox.

Miscellaneous

Medicolegal Pitfalls

  • Persons with known cardiac disease (eg, previous myocardial infarction, angina, congestive heart failure, cardiomyopathy) should receive smallpox vaccination. Myocardial infarctions and angina without myocardial infarction have been reported following smallpox vaccinations. The association between smallpox vaccination and these cardiac events is not clear.
  • Pregnant women who receive the smallpox vaccine are at risk of fetal vaccinia, which usually results in stillbirth or death of the infant. Pregnant women should not receive smallpox vaccination, and women should be advised against becoming pregnant for 4 weeks after smallpox vaccination.

Special Concerns

  • Bioterrorism: Based on the following CDC criteria, smallpox is a high-priority (category A) agent for bioterrorism, defined as follows:
    • Easily disseminated or transmitted from person to person
    • High mortality rate and potential for significant public health effect
    • Probable instigator of panic and social disruption
    • Special actions required for public health preparedness
 


More on Smallpox

Overview: Smallpox
Differential Diagnoses & Workup: Smallpox
Treatment & Medication: Smallpox
Follow-up: Smallpox
Multimedia: Smallpox
References
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References

  1. Espy MJ, Cockerill III FR, Meyer RF, et al. Detection of smallpox virus DNA by LightCycler PCR. J Clin Microbiol. Jun 2002;40(6):1985-8. [Medline].

  2. Ropp SL, Jin Q, Knight JC, et al. PCR strategy for identification and differentiation of small pox and other orthopoxviruses. J Clin Microbiol. Aug 1995;33(8):2069-76. [Medline].

  3. Bray M, Martinez M, Smee DF, et al. Cidofovir protects mice against lethal aerosol or intranasal cowpox virus challenge. J Infect Dis. Jan 2000;181(1):10-9. [Medline].

  4. De Clercq E. Cidofovir in the treatment of poxvirus infections. Antiviral Res. Jul 2002;55(1):1-13. [Medline].

  5. Smee DF, Bailey KW, Sidwell RW. Treatment of lethal vaccinia virus respiratory infections in mice with cidofovir. Antivir Chem Chemother. Jan 2001;12(1):71-6. [Medline].

  6. Smee DF, Bailey KW, Wong MH, et al. Effects of cidofovir on the pathogenesis of a lethal vaccinia virus respiratory infection in mice. Antiviral Res. Oct 2001;52(1):55-62. [Medline].

  7. Alibek K, Handelman S. Biohazard. In: The Chilling True Story of the Largest Covert Biological Weapons Program in the World - Told from Inside by the Man Who Ran It. New York, NY: Random House; 1999.

  8. ARF BM, Moyer RW. Entomopoxvirus B. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:914-8.

  9. Aylward B, Hennessey KA, Zagaria N, Olivé JM, Cochi S. When is a disease eradicable? 100 years of lessons learned. Am J Public Health. Oct 2000;90(10):1515-20. [Medline].

  10. Bergoin M. Entomopoxvirus A. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:911-3.

  11. Brauner SC, Pavan-Langston D. Smallpox, vaccinia, and the eye. Int Ophthalmol Clin. Spring 2006;46(2):11-25. [Medline].

  12. Breman JG, Arita I, Fenner F. Preventing the return of smallpox. N Engl J Med. Jan 30 2003;348(5):463-6. [Medline].

  13. Breman JG, Henderson DA. Diagnosis and management of smallpox. N Engl J Med. Apr 25 2002;346(17):1300-8. [Medline].

  14. Bugert JJ, Melquiot N. Molluscipoxvirus. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:880-4.

  15. Centers for Disease Control and Prevention. Emergency Preparedness and Response. Smallpox. Available at: http://www.bt.cdc.gov/agent/smallpox/index.asp. Atlanta, Ga: Centers for Disease Control and Prevenion; 2004:[Full Text].

  16. Centers for Disease Control and Prevention (2002). Smallpox vaccine overview. Available at: http://www.bt.cdc.gov/agent/smallpox/vaccination/facts.asp. [Full Text].

  17. Centers for Disease Control and Prevention, National Immunization Program. Smallpox: What Every Clinician Should Know [video online]. Available at: http://www.cdc.gov/nip/ed/smallpox-trg/clinician-should-know/default.htm. Atlanta, Ga: Centers for Disease Control and Prevention;. Apr 2003;[Full Text].

  18. Cleri DJ, Porwancher RB, Ricketti AJ, et al. Smallpox as a bioterrorist weapon: myth or menace?. Infect Dis Clin North Am. Jun 2006;20(2):329-57, ix. [Medline].

  19. Cleri DJ, Ricketti AJ, Villota FJ, et al. Smallpox, monkeypox, other pox diseases and vaccination. Infect Dis Pract Clin. 2005;29:396-406.

  20. Cleri DJ, Villota FJ, Porwancher RB. Smallpox, bioterrorism, and the neurologist. Arch Neurol. Apr 2003;60(4):489-94. [Medline].

  21. Department of Defense. MILVAX. Department of Defense Smallpox Vaccination Program. Available at: http://smallpox.mil/. Arlington, Va: Department of Defense; 2004. [Full Text].

  22. Eichner M. Case isolation and contact tracing can prevent the spread of smallpox. Am J Epidemiol. Jul 15 2003;158(2):118-28. [Medline].

  23. Essani K, Bejcek BE, Paulose M. Yatapoxvirus. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:907-10.

  24. Federici BA. Entomopoxvirus C. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:919-21.

  25. Fenner F, Henderson DA, Arita I, et al. Smallpox and Its Eradication. In: Communicable Disease Surveillance and Response. Available at: http://www.who.int/emc/diseases/smallpox/Smallpoxeradication.html. Geneva, Switzerland: on: World Health Organizati; 1988:1460. [Full Text].

  26. Frey SE, Newman FK, Cruz J, et al. Dose-related effects of smallpox vaccine. N Engl J Med. Apr 25 2002;346(17):1275-80. [Medline].

  27. Greenberg RN, Kennedy JS. ACAM2000: a newly licensed cell culture-based live vaccinia smallpox vaccine. Expert Opin Investig Drugs. Apr 2008;17(4):555-64. [Medline].

  28. Greenberg RN, Kennedy JS. ACAM2000: a newly licensed cell culture-based live vaccinia smallpox vaccine. Expert Opin Investig Drugs. Apr 2008;17(4):555-64. [Medline].

  29. Gross CP, Sepkowitz KA. The myth of the medical breakthrough: smallpox, vaccination, and Jenner reconsidered. Int J Infect Dis. Jul-Sep 1998;3(1):54-60. [Medline].

  30. Henderson DA. The looming threat of bioterrorism. Science. Feb 26 1999;283(5406):1279-82. [Medline].

  31. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA. Jun 9 1999;281(22):2127-37. [Medline].

  32. Immunization Practices Advisory Committee (ACIP). Vaccinia (smallpox) vaccine. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep. Dec 13 1991;40:1-10. [Medline].

  33. Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA. May 12 1999;281(18):1735-45. [Medline].

  34. Johnson RT. Postinfectious demyelinated diseases. In: Viral Infection of the Nervous System. Williams & Wilkins; 1981:765-73.

  35. Kerr PJ, McFadden G. Leporipoxvirus. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:873-9.

  36. Kitching RP. Capripoxvirus. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:869-72.

  37. Kman NE, Nelson RN. Infectious agents of bioterrorism: a review for emergency physicians. Emerg Med Clin North Am. May 2008;26(2):517-47, x-xi. [Medline].

  38. Lawler JV, Burgess TH. Smallpox. In: Roy MJ, ed. Physician's Guide To Terrorist Attack. Totowa, NJ: Humana Press; 2003:197-220.

  39. LeDuc JW, Jahrling PB. Strengthening national preparedness for smallpox: an update. Emerg Infect Dis. Jan-Feb 2001;7(1):155-7. [Medline].

  40. Letai AG. Smallpox and smallpox vaccination. N Engl J Med. May 8 2003;348(19):1920-5; author reply 1920-5. [Medline].

  41. Meltzer MI, Damon I, LeDuc JW, et al. Modeling potential responses to smallpox as a bioterrorist weapon. Emerg Infect Dis. Nov-Dec 2001;7(6):959-69. [Medline].

  42. Mercer A, Fleming S. Parapoxvirus. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:896-901.

  43. Moss B, Senkevich TG. Orthopoxvirus. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:885-95.

  44. Neff J, Modlin J, Birkhead GS, et al. Monitoring the safety of a smallpox vaccination program in the United States: report of the joint Smallpox Vaccine Safety Working Group of the advisory committee on immunization practices and the Armed Forces Epidemiological Board. Clin Infect Dis. Mar 15 2008;46 Suppl 3:S258-70. [Medline].

  45. Ness TL, Moyer RW. Suipoxvirus. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:902-6.

  46. Preston R. The Demon in the Freezer: A True Story. New York, NY: Random House; 2002.

  47. Redfield RR, Wright DC, James WD, et al. Disseminated vaccinia in a military recruit with human immunodeficiency virus (HIV) disease. N Engl J Med. Mar 12 1987;316(11):673-6. [Medline].

  48. Reeder MM, Palmer PES. Smallpox osteomyelitis (osteomyelitis variolosa). In: The Radiology of Tropical Medicine With Epidemiological, Pathological and Clinical Correlation. Baltimore: Williams & Wilkins; 1981:765-73.

  49. Ropp SL, Esposito JJ, Loparev VN, Palumbo GJ. Poxviruses infecting humans. In: Murray PR, ed. Manual of Clinical Microbiology. Washington, DC: American Society of Microbiology; 1999:1137-44.

  50. Ryabchikova E, Sokunova E, Kononova J, Guskov A. Studies of Variola Virus Replication in Cell Cultures and Chick Embryo Chorion-allantois Membrane. In: Price R, ed. ASA Newsletter. Available at: http://www.asanltr.com/newsletter/02-3/articles/023a.htm. Aberdeen, Md: Applied Science and Analysis; 2002:Article 023a. [Full Text].

  51. Ryan MA, Seward JF. Pregnancy, birth, and infant health outcomes from the National Smallpox Vaccine in Pregnancy Registry, 2003-2006. Clin Infect Dis. Mar 15 2008;46 Suppl 3:S221-6. [Medline].

  52. Skinner MA, Laidlaw SM, Boulanger D. Avipoxvirus. In: Tidona CA, Darai G, eds. The Springer Index of Viruses. Berlin: Springer-Verlag; 2002:864-8.

  53. Stearn EW, Stearn AE. The Effect of Smallpox on the Destiny of the Amerindian. Boston, Mass: Bruce Humphries; 1945.

  54. Strikas RA, Neff LJ, Rotz L, et al. US Civilian Smallpox Preparedness and Response Program, 2003. Clin Infect Dis. Mar 15 2008;46 Suppl 3:S157-67. [Medline].

  55. Torres Cantero AM. Is smallpox "in" again?. J Epidemiol Community Health. Apr 2004;58(4):279. [Medline].

  56. Tudor V, Strati I. The clinical picture. In: Smallpox: Cholera. Tunbridge Wells, Kent: Abacus Press; 1977:34-71.

  57. U.S. Bureau of the Census. Statistical Abstract of the United States: 1999. 119th ed. Washington, DC: Bureau of the Census; 1999.

  58. US Army Center for Health Promotion and Preventive Medicine. Current issues in Smallpox. Available at: http://chppm-www.apgea.army.mil/risk/current.aspx. [Full Text].

  59. US Army Medical Research Institute of Infectious Diseases. Smallpox. In: Kortpeter M, Christopher G, Cieslak T, et al, eds. USAMRIID's Medical Management of Biological Casualties. Available at: http://www.usamriid.army.mil/education/bluebook.html. 4th ed. Fort Detrick, Md: Operational Medicine Department; 2001:44-8. [Full Text].

  60. Wells TS, LeardMann CA, Smith TC, et al. Self-reported adverse health events following smallpox vaccination in a large prospective study of US military service members. Hum Vaccin. Mar-Apr 2008;4(2):127-33. [Medline].

  61. World Health Organization. WHO Fact Sheet on Smallpox. In: Communicable Disease Surveillance and Response. Available at: http://www.who.int/emc/diseases/smallpox/factsheet.html. Geneva, Switzerland: Oct 2001:[Full Text].

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Further Reading

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Keywords

smallpox, Poxvirus variolae, variola virus, variola, variola vera, variola major, variola minor, orthopoxvirus, poxvirus, hemorrhagic smallpox, ordinary smallpox, flat smallpox, modified smallpox, alastrim, amass, cottonpox, milkpox, whitepox, Cuban itch, Kaffir, biological agent, bioterrorism, bio-terrorism, biological attack, pox virus, malignant smallpox, fulminant smallpox, variola sine eruptione, variola sine exanthemata, smallpox vaccination, vaccinia immune globulin, vaccinia immunoglobulin, VIG, VIGIV, osteomyelitis variolosa, variola residua, fetal vaccinia

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Contributor Information and Disclosures

Author

Aneela Naureen Hussain, MD, FAAFM, Assistant Professor, Department of Family Medicine, State University of New York Downstate Medical Center; Consulting Staff, Department of Family Medicine, University Hospital of Brooklyn
Aneela Naureen Hussain, MD, FAAFM is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Medical Women's Association, Medical Society of the State of New York, and Society of Teachers of Family Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Fazal Hussain, MD, MBBS, Director, Clinical Research, King Faisal Cancer Centre
Fazal Hussain, MD, MBBS is a member of the following medical societies: American College of Radiology
Disclosure: Nothing to disclose.

Maqsood Alam, MD, Fellow, Department of Infectious Diseases, State University of New York Downstate Medical Center
Maqsood Alam, MD is a member of the following medical societies: American Medical Association and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Dennis J Cleri, MD, FACP, FAAM, FIDSA, Chairman, Graduate Medical Education Committee, Professor of Medicine, Associate Professor of Infection Disease, Seton Hall University; Director, Internal Medicine Residency Program, St Francis Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Duane R Hospenthal, MD, PhD, Chief, Infectious Disease Service, San Antonio Military Medical Center, Brooke Army Medical Center; Professor of Medicine, Uniformed Services University of the Health Sciences
Duane R Hospenthal, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Society for Infectious Diseases, International Society of Travel Medicine, and Medical Mycology Society of the Americas
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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