Further Outpatient Care
Plastic surgery consultation may be necessary for skin disfiguration.
Further Inpatient Care
Supportive care is the primary intervention for a clinically evident smallpox infection. This includes hydration therapy for fluid loss through fever and skin barrier breakdown. Antibiotics may be needed for secondary skin infections. Maintain respiratory and contact isolation for 17 days or until the scabs fall off.
Inpatient & Outpatient Medications
No medications are required for smallpox other than those previously mentioned (see Medication).
Transfer
Make any transfer with full respiratory and contact isolation.
Deterrence/Prevention
In a variola outbreak, the high rate of spread can be reduced by identification of the disease (a high index of suspicion is needed) and rapid containment.
The most likely scenario of a variola outbreak is from a terrorist attack.
Given the highly infective nature of the organism (not taking into account a genetically altered virus), researchers estimate that 1 infected patient could infect as many as 20 new contacts during the infectious stage of the illness. However, based upon historical data, 5-6 close friends or family members was the norm.
Complications
Complications associated with high morbidity and mortality rates that can be reduced are secondary skin infections and dehydration.
Prognosis
Smallpox is one of the most communicable of infectious diseases. Studies have shown that approximately 30% of susceptible contacts became infected. Only measles and influenza have a consistently higher attack rate.
In general, variola has a mortality rate of 30% in the unvaccinated population.
Pregnant women have a heightened morbidity to variola. The morbidity rate is 27% in vaccinated patients and 61% in unvaccinated patients versus a nonpregnant control morbidity rate of 6% (vaccinated) and 35% (unvaccinated).
Patient Education
See the list below:
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Heightened awareness of the manifestations of smallpox may help reduce the population exposed in an outbreak through early diagnosis and preventive medicine, public health initiatives, or both.
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For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center and Skin, Hair, and Nails Center. Also, see eMedicineHealth's patient education articles Biological Warfare, Smallpox, Personal Protective Equipment, and Molluscum Contagiosum.
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Characteristic skin lesion of variola on the arms and legs of an adolescent. Photo used with permission from the World Health Organization (WHO).
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Small child with pustular lesions of variola. Photo used with permission of the World Health Organization (WHO).
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Infant with advanced lesions of variola. Photo used with permission of the World Health Organization (WHO).
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Unvaccinated infant with centrifugally distributed umbilicated pustules on day 3 of ordinary form of variola major strains of smallpox. Reprinted with permission from Fenner F, Henderson DA, Arita I, et al: Smallpox and its eradication. Geneva, Switzerland: World Health Organization; 1988: 10-14, 35-36; photographs by Arita.
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Unvaccinated infant with centrifugally distributed umbilicated pustules on day 5 of ordinary form of variola major strains of smallpox. Reprinted with permission from Fenner F, Henderson DA, Arita I, et al: Smallpox and its eradication. Geneva, Switzerland: World Health Organization; 1988: 10-14, 35-36; photographs by Arita.
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Unvaccinated infant with centrifugally distributed umbilicated pustules on day 7 of ordinary form of variola major strains of smallpox. Reprinted with permission from Fenner F, Henderson DA, Arita I, et al: Smallpox and its eradication. Geneva, Switzerland: World Health Organization; 1988: 10-14, 35-36; photographs by Arita.
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Ordinary form of variola minor strain of smallpox (alastrim) in an unvaccinated woman 12 days after onset of skin lesions. The facial lesions are sparser and evolved more rapidly than the extremity lesions. Reprinted with permission from Fenner F, Henderson DA, Arita I, et al: Smallpox and its eradication. Geneva, Switzerland: World Health Organization; 1988: 10-14, 35-36; photographs by Arita.
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Ordinary form of variola minor strain of smallpox (alastrim) in an unvaccinated woman 12 days after onset of skin lesions. The facial lesions are sparser and evolved more rapidly than the extremity lesions. Reprinted with permission from Fenner F, Henderson DA, Arita I, et al: Smallpox and its eradication. Geneva, Switzerland: World Health Organization; 1988: 10-14, 35-36; photographs by Arita.
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Ordinary form of variola minor strain of smallpox (alastrim) in an unvaccinated woman 12 days after onset of skin lesions. The facial lesions are sparser and evolved more rapidly than the extremity lesions. Reprinted with permission from Fenner F, Henderson DA, Arita I, et al: Smallpox and its eradication. Geneva, Switzerland: World Health Organization; 1988: 10-14, 35-36; photographs by Arita.
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Adult with variola major with hundreds of pustular lesions distributed centrifugally. Fitzsimmons Army Medical Center slide file.
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Hemorrhagic-type variola major lesions. Death usually ensued before typical pustules developed. Reprinted with permission from Herrlich A, Mayr A, Munz E, et al: Die pocken; Erreger, Epidemiologic und klinisches Bild. 2nd ed. Stuttgart, Germany: Thieme; 1967. In: Fenner F, Henderson DA, Arita I, et al: Smallpox and its eradication. Geneva, Switzerland: World Health Organization; 1988: 10-14, 35-36.
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Boy with monkeypox in Democratic Republic of the Congo in 1996. Note the centrifugal distribution as was typical of smallpox. Courtesy of William Clemm.
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Boy with monkeypox in Democratic Republic of the Congo in 1996. Note synchronicity of lesions as was typical of smallpox. Courtesy of William Clemm.
