The concept of The concept of disease, controlled disease, controlled by the International by the International Health Regulations Health Regulations Smallpox Smallpox Plague Plague Disease, Prevention, and Disease, Prevention, and Intervention Intervention
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The concept of disease, controlled by the International Health Regulations Smallpox Plague Disease, Prevention, and Intervention.
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The concept of disease, The concept of disease, controlled by the controlled by the
International Health International Health RegulationsRegulations
Smallpox Smallpox PlaguePlague
Disease, Prevention, and Disease, Prevention, and InterventionIntervention
– Minute red spots on the tongue and Minute red spots on the tongue and oral/pharyngeal mucosaoral/pharyngeal mucosa
– Lesions enlarge and ulcerate quicklyLesions enlarge and ulcerate quickly
– Become infectious from lesions in mouthBecome infectious from lesions in mouth– Virus titers in saliva highest and most Virus titers in saliva highest and most
infectious during first week of infectious during first week of exanthem exanthem (skin rash)(skin rash)
• ExanthamExantham (skin rash) – (21 days) (skin rash) – (21 days)- Stages: macules, papules, vesicles, pustules, scabsStages: macules, papules, vesicles, pustules, scabs- Pustules raised, round, firm - like small beads in the Pustules raised, round, firm - like small beads in the
skin (“shotty”)skin (“shotty”)- Umbilication commonUmbilication common
• Begins and most dense on face and extremities Begins and most dense on face and extremities (centrifugal distribution)(centrifugal distribution)
• Lesions on palms and soles (Lesions on palms and soles (>>50% of cases)50% of cases)
• Lesions in same stage and evolve slowly (1-2 Lesions in same stage and evolve slowly (1-2 days/stage)days/stage)
Smallpox RashSmallpox Rash
Day 4 of rash
Ordinary SmallpoxOrdinary Smallpox
Pustular lesions on palms
Flattened lesionson soles
SmallpoxOrdinary Type (Discreet
lesions)
SmallpoxSmallpox
Ordinary Type (Dense lesions)Ordinary Type (Dense lesions)
SmallpoxSmallpox
Flat-typeFlat-type
SmallpoxSmallpox
Hemorrhagic TypeHemorrhagic Type
Varicella
SMALLPOXSMALLPOX
Deep, hard lesionsDeep, hard lesions
Round, well Round, well circumscribedcircumscribed
Confluent or umbilicatedConfluent or umbilicated
Lesions at same stage of Lesions at same stage of
developmentdevelopment
CHICKEN POXCHICKEN POX
SuperficialSuperficial
Not well circumscribedNot well circumscribed
Confluence and umbilication Confluence and umbilication uncommonuncommon
Lesions at all stages of Lesions at all stages of developmentdevelopment
Differential DiagnosisDifferential Diagnosis
SMALLPOX SMALLPOX
CHICKENPOX
SmallpoxSmallpox
ChickenpoxChickenpox
Smallpox
Varicella
Smallpox Outbreak Control Smallpox Outbreak Control Activities and Strategies Activities and Strategies
Surveillance and Containment Surveillance and Containment (Ring Vaccination)(Ring Vaccination)
Case(s)
Contacts of Case(s)
Contacts of Contacts
• Search for casesSearch for cases
• Provide a ring of immunity Provide a ring of immunity around each casearound each case
- Vaccinate close contactsVaccinate close contacts- Vaccinate close contacts of Vaccinate close contacts of
contactscontacts
• Required to control diseaseRequired to control disease- most efficient use of vaccinemost efficient use of vaccine
SurveillanceSurveillancePre-Event SurveillancePre-Event Surveillance– Identify cases with typical presentationIdentify cases with typical presentation– Rapid laboratory confirmation Rapid laboratory confirmation – Confirmation initiates contact vaccination Confirmation initiates contact vaccination – Passive with more specificityPassive with more specificity
Post-Event SurveillancePost-Event Surveillance– Identify Identify allall potential cases (typical/atypical) potential cases (typical/atypical)– Clinical diagnosis can initiate contact vaccinationClinical diagnosis can initiate contact vaccination– Active with increased sensitivityActive with increased sensitivity
Epidemiologic InvestigationEpidemiologic InvestigationIdentify source of initial introduction(s)Identify source of initial introduction(s)
Identify contacts and other population(s) at riskIdentify contacts and other population(s) at risk
Characterize and define outbreakCharacterize and define outbreak– Identify unusual/unexpected featuresIdentify unusual/unexpected features– Scope Scope
Monitor effectiveness of control measuresMonitor effectiveness of control measures
Communicate information and define public Communicate information and define public health recommendationshealth recommendations
Contact TracingContact Tracing
Goal is to find as many contacts as possibleGoal is to find as many contacts as possible– Contact with patient after onset of feverContact with patient after onset of fever– Prioritize based on closeness, length, and date Prioritize based on closeness, length, and date
of exposure of exposure – If too many to find quickly, consider all people in If too many to find quickly, consider all people in
same room (or possibly facility) with smallpox same room (or possibly facility) with smallpox case after onset of fever as contactscase after onset of fever as contacts
ExamplesExamples::– Highest priority - people who live full-time in Highest priority - people who live full-time in
home and other face-to-face contacts after home and other face-to-face contacts after onset of feveronset of fever
– Next priority – non face-to-face contacts Next priority – non face-to-face contacts exposed in a medical care facility or in homeexposed in a medical care facility or in home
– Last priority – people in same facility after onset Last priority – people in same facility after onset of fever (other than home or hospital) but of fever (other than home or hospital) but without face-to-face contactwithout face-to-face contact
Contact TracingContact Tracing
Isolation and QuarantineIsolation and Quarantine
Goals of Smallpox IsolationGoals of Smallpox IsolationProtectProtect others from becoming infected others from becoming infected– Healthcare personnelHealthcare personnel– Response personnelResponse personnel– Other patientsOther patients
IsolateIsolate smallpox patient smallpox patient– Prevent sharing of airspace (respiratory isolation)Prevent sharing of airspace (respiratory isolation)– Prevent direct contact (protective clothing)Prevent direct contact (protective clothing)– Prevent contact with infectious materials Prevent contact with infectious materials
(decontamination)(decontamination)
Prevent sharing of airspacePrevent sharing of airspacewith potentially infectious patientswith potentially infectious patients
Separate facilities for larger groups.Separate facilities for larger groups.
Respirators for unvaccinated care-Respirators for unvaccinated care-
providers.providers.
Personal Protective EquipmentPersonal Protective Equipment
Use disposable gloves, gowns, and shoe Use disposable gloves, gowns, and shoe covers.covers.
Reusable bedding and clothing should be Reusable bedding and clothing should be autoclaved or laundered in hot water with autoclaved or laundered in hot water with bleach.bleach.
Designated Facility Designated Facility for smallpox patientsfor smallpox patientsAerosol precautions Aerosol precautions not needed if not needed if onlyonly potential smallpox potential smallpox cases in facility and cases in facility and no shared ventilationno shared ventilation systemsystem– AllAll people people
Vaccinated contacts with fever (no rash)Vaccinated contacts with fever (no rash)– Two successive temps > 101Two successive temps > 101ºº F (38 F (38ººC)C)
– Less need for medical careLess need for medical care
– No shared ventilationNo shared ventilation system system
– Can be housed in same facility with smallpox Can be housed in same facility with smallpox cases or separate facilitycases or separate facility
– All persons in facility require vaccination All persons in facility require vaccination
Not infectious Not infectious – Own home or other lodgingOwn home or other lodging– No special ventilation or medical requirementsNo special ventilation or medical requirements
All other persons staying in home must also be All other persons staying in home must also be vaccinatedvaccinated– Household members with contraindications stay Household members with contraindications stay
elsewhereelsewhere
Fever surveillance for 18 days from last Fever surveillance for 18 days from last exposure or 14 days from vaccinationexposure or 14 days from vaccination
DecontaminationDecontamination
Air:Air:– UV Light SensitiveUV Light Sensitive
– Exhaust, Good Air FlowExhaust, Good Air Flow
Surfaces:Surfaces:– Diluted bleach solution (Fresh every day)Diluted bleach solution (Fresh every day)
– Hospital disinfectantsHospital disinfectants
Blood, pus contaminated equipment:Blood, pus contaminated equipment:– Wash before disinfectingWash before disinfecting
Blood meal from bacteremic animalBlood meal from bacteremic animal
Regurgitates into human/ animal hostRegurgitates into human/ animal host
Common reservoirsCommon reservoirs– Deer miceDeer mice– Ground squirrelsGround squirrels
EpidemiologyEpidemiologyTransmissionTransmission
Bite of infected fleaBite of infected fleaRespiratory dropletsRespiratory dropletsDirect contact (1,5-2 Direct contact (1,5-2 m)m)Direct skin/mucous Direct skin/mucous membrane less membrane less commoncommonBT event – BT event – Respiratory droplets Respiratory droplets or aerosolsor aerosols
Incubation: 2 to 4 days (range 1 to 6 days)Incubation: 2 to 4 days (range 1 to 6 days)
SymptomsSymptoms– Acute fever, chills, malaise, myalgiasAcute fever, chills, malaise, myalgias– Productive coughProductive cough– Watery mucoid sputum, may be bloodyWatery mucoid sputum, may be bloody– Associated chest pain, increasing dyspneaAssociated chest pain, increasing dyspnea
Pneumonic PlaguePneumonic Plague
Disease ProgressionDisease Progression– Adult Respiratory Distress SyndromeAdult Respiratory Distress Syndrome– Refractory pulmonary edemaRefractory pulmonary edema– Signs of shockSigns of shock– Without treatment in less than 24 hours, Without treatment in less than 24 hours,
almost universally fatalalmost universally fatal
Pneumonic PlaguePneumonic Plague
Coughing patient can spreadCoughing patient can spread
Enlarged hilar nodes and pleural effusionsEnlarged hilar nodes and pleural effusions
Pneumonic PlaguePneumonic Plague
Pneumonic PlaguePneumonic Plague
Pneumonic PlaguePneumonic Plague
Septicemic PlagueSepticemic Plague
Incubation: Most common as complication Incubation: Most common as complication of pneumonic or bubonic plagueof pneumonic or bubonic plagueSymptomsSymptoms– Acute fever, chills, prostration, abdominal Acute fever, chills, prostration, abdominal
pain, nausea, vomitingpain, nausea, vomiting
Disease ProgressionDisease Progression– PurpuraPurpura– DICDIC– Hypotension and other signs of shockHypotension and other signs of shock– Fatal if not treatedFatal if not treated
Infection ControlInfection Control
Large numbers of plague bacilliLarge numbers of plague bacilli
Respiratory droplet spread in close direct Respiratory droplet spread in close direct contactcontact
Respiratory droplet precautions with Respiratory droplet precautions with suspect casessuspect cases
Mycobacterial infection, including scrofula (Mycobacterium tuberculosis and other Mycobacterium species)
• Adenitis occurs in cervical region• Usually painless• Indolent clinical course• More likely to occur in immunocompromised patients
Lymphogranuloma venereum (Chlamydia trachomatis)
• Adenitis occurs in the inguinal region• Sexual exposure 10-30 days previously• Suppuration, fistula tracts common• Exquisite tenderness usually absent• Although patients may appear ill (headache, fever, myalgias), systemic toxicity not present
Usually occur in persons with Usually occur in persons with underlying pulmonary or other underlying pulmonary or other disease or in the elderlydisease or in the elderly
Bird exposure with psittacosisBird exposure with psittacosis
Gram stain may be useful Gram stain may be useful
Community outbreaks not as Community outbreaks not as explosive as pneumonic plague explosive as pneumonic plague outbreakoutbreak
S. pneumoniaeS. pneumoniae usually usually institutionalinstitutional
Community outbreaks of Community outbreaks of Legionnaires' disease often involve Legionnaires' disease often involve exposure to cooling systems exposure to cooling systems
CiprofloxacinCiprofloxacin 500 mg PO BID500 mg PO BID
AlternativeAlternative
ChloramphenicolChloramphenicol 25 mg/kg PO QID25 mg/kg PO QID
Plague Infection Control Plague Infection Control PrecautionsPrecautions
Isolation for 48 hours of antibiotic Isolation for 48 hours of antibiotic treatment or until clinical improvementtreatment or until clinical improvement
Bubonic Standard
Pneumonic Standard and Respiratory
Septicemic Standard
Suspect Respiratory and Isolation
Plague Infection ControlPlague Infection Control
Cohort and Droplet precautions if no Cohort and Droplet precautions if no isolation availableisolation available
Isolation of contacts may increase in Isolation of contacts may increase in importance for outbreak controlimportance for outbreak control
Corpses – Standard PrecautionsCorpses – Standard Precautions