Treatment

1
Treatment

• There is no specific treatment for smallpox and
  the only prevention is vaccination.
• All individuals that are diagnosed with smallpox
  should be isolated immediately due to the highly
  contagious nature of the virus. Isolation should
  occur in the home or a non-hospital facility
  because widespread contamination in hospitals is
  a potential threat.
• The most that can be done for patients infected
  with small pox is supportive therapy and
  antibiotics to treat secondary bacterial
  infections that could occur.
• Some studies suggest that Cidofovir (nucleoside
  analog DNA polymerase inhibitor) could possibly
  prevent smallpox infection if administered within
  1 or 2 days after exposure. The potential use of
  this drug is limited because it is administered
  intravenously and can cause serious renal
  toxicity.

2
Identification

• PCR
• In 1995, a new method of identification using PCR
  was developed at the Center for Disease Control.
• Family-specific primers are used first, then
  subgroup-specific primers are used if the former
  is not successful in producing the PCR product.
• TaqI restriction enzyme is used to differentiate
  variola from other orthopoxviruses.
• HhaI restriction enzyme is used to differentiate
  between the different strains of variola.

3
Differential Diagnosis I
4
Differential Diagnosis II
5
Eradication

• In 1967 the World Health Organization embarked on
  a World Eradication Program.
• Smallpox is a good candidate for eradication
  because
• smallpox virus has a single, stable, serotype
• there is no animal reservoir and humans are the
  only hosts
• the antibody response is prompt, so that exposed
  persons can be protected
• the disease is easily recognized clinically, so
  that exposed persons can be immunized promptly
• there is no carrier state or subclinical
  infection

6
Vaccination

• Smallpox vaccine is made from live vaccinia virus
  and does not contain variola virus, the virus
  that causes smallpox. Vaccinia virus is a member
  of the orthopox virus family.
• Vaccination is performed using a bifurcated
  needle. A sterile needle with a droplet of
  vaccine held by a capillary, is held at right
  angles to the skin, while the wrist of the
  vaccinator rests against the arm. 15 vigorous
  strokes are rapidly made in an area approximately
  5 mm in diameter. Blood should appear at the
  vaccination site after 15 to 30 seconds. The
  site of vaccination is covered with a loose
  bandage to prevent individuals from touching the
  area and spreading the virus to other parts of
  their body.
• Neutralizing antibodies developed provide the
  vaccinated individual with immunity, but levels
  of antibodies decline substantially during a 5 to
  10 year period following vaccination.

7
Calf-Lymph Vaccine

• Production
• A cow is intentionally infected with the cowpox
  virus.
• The lymph from the virus filled pustules on the
  cows udder are then collected.
• The virus is separated from any existing bacteria
  and other impurities.
• Dryvax is a stored calf-lymph vaccine
  manufactured in the 1970s by Wyeth Laboratories.
• It is freeze dried and requires dilution before
  use.
• It contains antibiotics and preservatives.

8
Tissue Culture Cell Vaccine

• As of October 2002, tissue culture cell vaccines
  are in preparation by Acambis-Baxter
  Laboratories.
• Two types of cells being used for propagation of
  vaccinia virus
• Vero monkey kidney cells
• Human fibroblast cell line (MRC5)
• It is thought that these vaccines may cause less
  side effects than the calf-lymph vaccine.

9
Smallpox Vaccination Program

• On December 13, 2002 President Bush announced a
  plan to better protect the American people
  against the threat of smallpox attack by hostile
  groups or governments
• Small Response Teams
• Under the plan, the Department of Health and
  Human Services (HHS) will work with state and
  local governments to form volunteer Smallpox
  Response Teams who can provide critical services
  in the event of a smallpox attack.
• The federal government is not recommending
  vaccination for the general public at this time.
• Department of Defense and State Department
  Personnel
• The Department of Defense (DOD) has vaccinated
  the army and certain civilian personnel who may
  be deployed in high threat areas. Some United
  States personnel assigned to certain overseas
  embassies will also be offered vaccination.
• Strengthening Homeland Security
• Immediately after the 9/11 attack, HHS began
  working, in cooperation with state and local
  governments, to strengthen our preparedness for a
  bioterrorist attack by expanding the national
  stockpile of small pox vaccine. According to the
  CDC, the US currently has sufficient quantities
  of the vaccine to vaccinate every single person
  in the country in an emergency.

10
Statistics
11
Vaccination Local
12
Vaccination Local
13
Vaccination Local

14
Complications
15
Complications

• Postvaccinial Encephalitis
• Between 8 to 15 days after vaccination,
  individual develops encephalitic symptoms,-fever,
  headache, vomiting, drowsiness, and sometimes
  spastic paralysis, meningitic signs, coma, and
  convulsions. Recovery is either complete or
  associated with residual paralysis, and sometimes
  death.
• Progressive Vaccinia (Vaccinia Gangrenosa)
• It is a frequently fatal complication in which
  the vaccinial lesions fails to heal and
  progresses to the adjacent skin with necrosis of
  tissue, spreading to other parts of the skin, to
  bones, and to viscera.
• Eczema Vaccinatum
• Vaccinial skin lesions extended to cover all or
  most of the area once, or currently afflicted
  with eczema.
• Generalized Vaccinia
• A secondary eruption, resulting from blood-borne
  dissemination of virus. Lesions emerged between
  6 to 9 days after vaccination and were either few
  in number of generalized.
• Inadvertent Inoculation
• Transmission to close contacts or auto
  inoculation to sites such as face, eyelid, mouth,
  and genitalia, sometimes occurs.

16
VIG

• Vaccinia immunoglobin (VIG) is a collection of
  antibodies prepared from the blood of people who
  have been vaccinated against smallpox.
  Individuals that are at high risk for adverse
  reactions to the vaccinia virus can be given VIG
  along with the vaccine. It is also used to treat
  people who have had adverse affects to the
  vaccine.
• Individuals that are at high risk to side effects
  are those that have the following conditions
• Eczema or atopic dermatitis
• Skin conditions that result in a break of the
  skin such as burns, shingles, impetigo, herpes,
  and psoriasis
• Weakened immune system such as someone who has
  received a transplant, is HIV positive or
  receiving treatment for cancer
• Anyone taking immune suppressing medications like
  corticosteriods
• Pregnant women
• Women that are breastfeeding
• Children under 12 months
• Allergies to the vaccine or any of its components
• Heart disease

17
Post exposure Infection Control

• In the event of a smallpox outbreak
• Patients suspected to have smallpox should be
  vaccinated to ensure that those who are
  misdiagnosed are not placed at risk of getting
  smallpox. Vaccination that is administered
  within the first few days after exposure may
  prevent or significantly reduce subsequent
  illness.
• All health care workers at clinics or hospitals
  that might encounter patients as well as other
  disaster response personal, such as police,
  firefights, transit workers and mortuary staff
  who might have to handle the bodies, should be
  vaccinated.
• Those individuals that have been in the same
  household with infected individuals (face-to-face
  contact) should be vaccinated.
• Possible establishment of separate hospitals for
  smallpox patients.
• Areas of infection and those infected should be
  isolated and quarantined.
• Patients who die of smallpox should be cremated.

18
Decontamination

• In a contaminated area, standard precautions of
  using gloves, gowns, and masks should be
  observed. All waste should be placed in
  biohazard bags and incinerated.
• Contaminated bedding and clothing should be
  autoclaved or laundered in hot water with bleach.
• Standard disinfectants, such as hypochlorite and
  quaternary ammonia are effective for cleaning
  surface.

19
Potential Probability vs. Impact
BIOLOGICAL AGENT
NUCLEAR WEAPON
IMPROVISED NUCLEAR DEVICE
CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL
POTENTIAL IMPACT
RADIOACTIVE MATERIAL
PROBABILITY/LIKELIHOOD
20
Limitations of Biological Agents

• It was formerly thought that smallpox was not
  very suitable for biological warfare, because it
  was too infectious.
• An attack would entail a high risk of a worldwide
  epidemic, striking even the population of the
  attackers.
• Effective dissemination difficult.
• Delayed effects can detract from impact.
• Terrorists generally lack the means for
  vaccinating large groups of people and have less
  opportunity to run large-scale virus cultures. It
  has thus been considered far more probable that
  they would prefer bacterial infectious matter
  such as anthrax, which entails less risk of
  uncontrollable epidemics.
• Only available on the international WMD black
  market.

21
Growing Danger?

• Several factors contribute to the growing danger
  of smallpox as a biological weapon
• A terrorist movement or the military command of a
  state could arrive at the conclusion that an
  attack with variola in the USA could allow the
  epidemic to remain local because of the vigorous
  countermeasures expected. If the risk of a
  worldwide epidemic seems small, an attack might
  be attempted.
• The attacks on September 11, 2001 demonstrated
  the great ruthlessness and considerable resources
  of some terrorists. The fundamentalist ill-will
  toward the USA is another driving force and the
  attacks in the USA with weapons-grade anthrax
  disseminated via the postal service have shown
  that terrorists can get access to pathogens.
• It is now widely considered that the risks of
  variola being used as a weapon have been
  underestimated in the past.

22
Bio-Weapons Chief

• Former Soviet colonel and doctor Kanatjan
  Alibekov, now known as Ken Alibek was the 1st
  Deputy Chief of the secret Soviet germ warfare
  program, Biopreparat, from 1988 to 1992. 
• In 1992, Dr. Alibek defected to the US and has
  since spent his time briefing U.S. Military,
  Intelligence and medical officials about
  biological weapons and defenses. Dr. Alibek holds
  both M.D. And PhD. Degrees.
• In a recent interview Alibek admitted
• for years it (Soviet Union) was researching the
  ways to genetically alter variola major by
  inserting some new genes in this virus genome.
• Q If you had to pick one (1) bio-weapon for an
  terrorist attack on the USA, based on former
  Soviet doctrine, which one would you chose?A
  Smallpox.

23
Ebolapox

• This disease is a genetic recombination of
  smallpox and Ebola.
• It would seem likely that it is more hardy than
  Ebola, more like smallpox, with much more
  resistance to sunlight, heat, cold, drying, and
  humidity. Like smallpox, it could lie dormant for
  weeks in the air.
• Common symptoms beginning 2-3 days after exposure
  are fever, headache, confusion, muscle pain, and
  prostration.
• Physical examination may reveal only conjunctival
  redness, mild hypotension, flushing, and small
  skin hemorrhages (petichiae).
• Full-blown VHF typically evolves to shock and
  generalized mucous membrane hemorrhage, and often
  is accompanied by evidence of lung, bone marrow,
  kidney, and neurologic involvement.

24
Biological Agent Sources

• Home production
• Laboratory / commercial production
• Industrial facilities
• Foreign military sources
• Medical / university research facilities

25
Groups That Threaten

• Lone individual
• Identified local or non-aligned terrorist groups
• Internationally sponsored
• Doomsday cults
• Insurgents

26
Potential Terrorist Targets

• Enclosed spaces
• Large crowds (high profile events)
• Critical facilities and infrastructure
• Accessible facilities with significant
  hazard / damage potential
  (materials in transit)
• Facilities of interest to terrorists cause

27
Why Bio Terrorism?

• Agents are available relatively easy to
  manufacture.
• Large amount not needed in enclosed space.
• NBC incident difficult to recognize.
• Easily spread over large areas.
• Psychological impact.
• Can overwhelm existing resources.
• Great value!
• According to the Stockholm international peace
  research institute, the cost to inflict civilian
  casualties is 2000 per square kilometer with
  conventional weapons, 800 with nuclear weapons,
  and 1 with biological weapons.

28
Biological Warfare Agents Aerosol Particle Size
Maximum respiratory infection is caused by a
particle in the 1 to 5 micron size range. This
particle will reach the alveoli during normal
respiration.
Larger particles (trapped in upper airways)
1-5 micron particles (enter alveoli)
29
Breaking Devices

• Point Source
• Common Items
• Moderate downwind hazard

Vacuum Bottle
Light Bulb
30
Bursting and Exploding Devices

• PointSource
• Moderate downwind hazard
• May destroy agent
• Detectable
• Multiple hazard potential

Timer
Explosive with igniter
Agent reservoir
31
Spraying Devices

• Point Source
• Aerosol can
• Garden sprayer
• Moderate/significant
• downwind hazard

• Line Source
• Moving vehicles
• Significant downwind hazard

Pressurized agent
Agent release valve
Pressure release valve
Pressure vessel
Agent reservoir
Dissemination nozzle
32
Impact of Dissemination Devices
Downwind Hazard
Device
Most Likely Agent
Moderate
Breaking
Chemical
Moderate
Bursting
All
Moderate
Explosive
Radiological (C/B Possible)
- Significant (Line Source) - Moderate/Significant
(Point Source)
Spray
Biological or Chemical
Unpredictable
Vector
Biological or Chemical