Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Brandon L. Ignatowski
Introduction
Smallpox is a highly contagious disease that disfigures those affected by it, and it has
been around for thousands of years. It was eradicated in the US in 1949, and in 1980 the World
Bray, & Huggins, 2003). Since the eradication of smallpox, there have been samples kept by the
government for research purposes in case of another outbreak. Unfortunately, this has created
fear among people that these samples can be used for biological warfare by other countries.
Smallpox is spread many ways, including the following: directly and indirectly through infected
people, through contaminated items, and through terroristic actions (Mayo Clinic, 2014). It is
important for physicians to recognize differences between smallpox and similar skin illnesses in
order to limit the effect of contagion. This is why the CDC created an algorithm for physicians to
assess their patients before it spreads to others (Moore, Seward, & Lane, 2006). Unfortunately,
there is still no definitive treatment or cure once someone contracts the virus.
The variola virus is the agent that gives rise to smallpox, and it belongs to the genus
Orthopoxvirus (Babkin & Babkina, 2015). Furthermore, the Poxviridae family and
Chordopoxvirinae subfamily has eight genera, including the following: smallpox virus,
monkeypox virus, vaccinia virus, and cowpox virus. These viruses are closely related to each
other and infectious to humans. All of them are classified in the single genus Orthopoxvirus
(Espy et al., 2002). Rodents used to carry the smallpox virus, but thousands of years ago it
jumped to African hunters. When it jumped from rodents to humans, it spread across Africa and
beyond. During the seventh and eighth centuries, it was carried by Arab armies out of Africa to
Southwestern Europe. Then in the eleventh and thirteenth centuries it spread throughout China
SMALLPOX VIRUS 3
from the Silk Road during the Crusades (Bourzac, 2002). Smallpox was also believed to be what
caused the Athens defeat by the Spartans during 430 B.C. It was also what caused the Aztec
population to shrink from 25 million people to three million people over a 50-year span.
Eventually, smallpox came to America when the Europeans introduced it to the Native
Americans during the 16th century by giving them blankets contaminated with it (Bourzac, 2002).
The last naturally acquired case of smallpox occurred in Somalia in 1977, and three years later
WHO declared that it was eradicated. This eradication program is considered to be one of the
greatest successes of the public health field. Unfortunately, over 30 years after it has been
eradicated, there remains a concern for public health officials and the public that it will be
reintroduced into society. For instance, the Soviet Unions former deputy director for the
bioweapons program wrote that the Soviet Union had stockpiles of this virus that was to be used
as a weapon of war. When the scientists left the Soviet Union, there was no proof they did not
take some of this with them for later use. Also, there have been claims that Iraq, Iran, and North
Korea still have this virus stored in their countries (Breman & Henderson, 2002; Moore et al.,
2006). The fear and concern that comes from the possibility of other countries having access to
the smallpox virus is warranted for most. In 1970, Germany was attacked with aerosolized
smallpox over a large distance that infected people at low doses. This incidence infected one
person and spread to 19 others within the hospital the patient was transferred to. This example
shows the danger of smallpox aerosol and how rapidly it can spread (Koren & Bisesi, 2003).
government made it a priority to correct this problem. The CDC created an algorithm to identify
the differences between smallpox and chicken pox due to the mistaken diagnoses that took place.
SMALLPOX VIRUS 4
Many physicians were unclear of the subtle differences between these two, and this allowed
smallpox to spread further and cause more danger (Moore et al., 2006). The clinical presentation
of smallpox is important for physicians to recognize in order to understand the different types.
The most common type of smallpox (nearly 90%) is called ordinary smallpox and is
characterized by raised pustular lesions. The mortality rate for this type of smallpox is 10% when
it has discrete lesions, and it has a mortality rate of 60% when it has confluent lesions. The more
rare and lethal types of smallpox are flat and hemorrhagic and do not produce typical pustular
rashes. Although, flat smallpox only occurs in about seven percent of patients that are not
hemorrhages on their skin and mucous membranes. These unvaccinated cases of smallpox have
Clinical Features
The clinical features of ordinary smallpox are important for physicians to recognize. This
is because ordinary smallpox is the most common and simplest type to identify in order to
prevent it from spreading. The incubation period for ordinary smallpox is 12-14 days, with a
range of seven to 19 days. It is common that skin lesions will appear on the face and body within
one to two days. They develop in different phases and worsen over time. For instance, the lesions
are first macular and then turn into papules by the second day. Next, they turn into vesicles
between the fourth and fifth day, and by the end of the first week they turn into pustules (Moore
et al., 2006). The complications and sequelae created by smallpox are crucial for physicians to
recognize in order to prevent new outbreaks of this disease. Smallpox creates many different
complications for those infected. These include bacterial infections of the patients skin, joints,
SMALLPOX VIRUS 5
bones, organs, and other regions. Smallpox causes myriad problems like deep facial pockmarks,
Differential Diagnoses
Once the clinical presentation, features, and complications of smallpox is recognized and
understood, physicians must be careful not to create a differential diagnosis. There are many skin
illnesses that can be confused with smallpox, and if misdiagnosed this disease can have grave
consequences that spread to many people. For instance, there are rash illnesses that are
sometimes confused with smallpox, and physicians must understand the clinical differences in
order to properly identify this virus before it is transmitted to others. The vesicular and pustular
rashes that are sometimes confused with smallpox include chickenpox, acne, herpes zoster,
herpes simplex, molluscum contagiosum, impetigo, scabies, syphilis, and drug reactions. There
are also other poxviruses that can be confused with smallpox, including the following:
monkeypox, cowpox, and tanapox (Moore et al., 2006). Unfortunately, Orthopoxviruses have
early symptoms that are non-specific, and this makes it difficult to differentiate between other
skin illnesses. For instance, varicella-zoster virus (VZV) and herpesviruses have similar early
differentiate them. This was done by looking at the melting temperatures of each in order to
properly diagnose them (Carletti et al., 2005). With the many different skin illnesses and
poxviruses, it is easy to understand how this virus can go untreated or worsen before it is
properly diagnosed. Chicken pox and smallpox are the two that are most commonly confused.
Smallpox is sometimes diagnosed in adults because adults rarely contract chicken pox.
Therefore, the CDC has created an algorithm to identify the differences between the two (Moore
et al., 2006). This has helped decrease false diagnoses in patients suffering from smallpox.
SMALLPOX VIRUS 6
Transmission
Smallpox is difficult to treat and diagnose, but it is important that people understand the
causes and how it is spread to ensure eradication. Smallpox is caused by the variola virus
infecting someone, and it can be transmitted in different ways. These include person-to-person,
indirectly from an infected person, through contaminated items, and as a terroristic weapon
(Mayo Clinic, 2014). Person-to-person contact is when smallpox is transmitted through the air by
droplets from a persons cough, sneeze, or from talking. It can be spread indirectly from an
infected person when the virus spreads farther than face-to-face contact, like through ventilation
systems. It can be spread through contaminated items, like someones bedding and clothing, but
because it is through an inanimate object it is the least way infection occurs. Finally, it can be
spread through terroristic actions. It can be deliberately released into the air in order to infect and
kill people, which is why the fear of keeping stockpiles of this virus raises alarm for many people
(Mayo Clinic, 2014). Smallpox can be transmitted many different ways, but no matter how it is
transmitted it causes many signs and symptoms within the infected person.
There are many ways this virus is spread, but once it is contracted there are many signs
and symptoms that one can recognize in order to prevent this from happening. As mentioned
previously, the first symptoms to occur usually take place within 12 to 14 days from the time one
is infected with the variola virus. There is an incubation period of seven to 17 days that occurs,
but within this incubation period the infected person looks and feels healthy. It is not possible to
infect others during this incubation period. Although, during the first week it can spread if the
lesions ulcerate. (Espy et al., 2002). Once the incubation period is over there are sudden flu-like
symptoms that occur within the infected individual. For instance, these symptoms include fever,
SMALLPOX VIRUS 7
headache, severe fatigue, severe back pain, vomiting, and overall discomfort (Mayo Clinic,
2014). A few days after these signs and symptoms take place, red spots begin to appear on the
hands, face, forearms, and trunk of the infected individual. Within a couple of days after the red
spots appear, they suddenly begin to blister and fill with clear fluid. Finally, after the fluid-filled
blisters take form, scabs begin to take shape. This occurs approximately eight to nine days later,
and then they fall off forming deep scars on the individual (Mayo Clinic, 2014). Most people that
are infected with smallpox end up surviving, however, there are few varieties that are always
deadly once contracted. These varieties usually affect pregnant women and people with
compromised immune systems (Mayo Clinic, 2014). Once they contract this variety of smallpox,
they most likely will never survive. Those that contract the less deadly variety of smallpox do not
escape unscathed either. As mentioned previously, those that do end up recovering from
smallpox usually end up receiving scars all over their body and sometimes go blind.
In order to avoid the complications associated with smallpox, there are certain tests and
diagnoses that must be considered. Despite everything physicians know about this virus, it is
highly unlikely they would know what it was in the early stages of an outbreak. This would
ultimately allow it to spread causing an epidemic. Therefore, even one confirmed case of
smallpox would be considered an international health emergency. The CDC is able to use one
tissue sample from a skin lesion of an infected person to perform definitive testing (Mayo Clinic,
2014). This would help them identify it in the early stages and set-up a quarantine in order to
conclusive cure for it at this time. They would be quarantined and physicians would focus on
relieving the symptoms that occur to ensure the patient is comfortable. Although, sometimes
SMALLPOX VIRUS 8
smallpox causes bacterial infections within the lungs and on the skin, these infections can be
treated with antibiotics (Mayo Clinic, 2014). Due to the fact there is no cure for this viral
infection, prevention remains the main focus among physicians and the CDC. During an
outbreak of smallpox, those that are infected would be isolated in order to keep the virus from
spreading to others. People that had contact with the infected would need to receive a smallpox
vaccine to prevent the severity of this disease, but this can only work if it is given to the
individual within a four-day time period of exposure. This vaccine is related to the smallpox
virus, but it can have detrimental health effects like heart and brain infections. This must only be
considered if an outbreak occurs because of the potential risks of this vaccine (Mayo Clinic,
2014). Unless there is an actual outbreak that occurs, the risks of vaccination far outweigh the
benefits.
The smallpox vaccination was invented by Dr. Edward Jenner in the 18th century, and this
led to the 1949 eradication in the US and to a worldwide eradication in 1980 by WHO. Due to
the fear and virulence of smallpox, it is estimated that millions of Americans have been
vaccinated for this disease. It is understood that the US government has over 100 million doses
of smallpox for research, and they also have signed contracts to purchase much more in case of
an outbreak in the US. The problem with these vaccinations is that it would most likely only
work for naturally occurring smallpox, and if genetically altered smallpox was introduced it
would become a problem for the government to handle (Bourzac, 2002). It is not known how
long immunity to smallpox lasts after receiving an immunization, so if there was an outbreak it is
likely people would receive another vaccination after having contact with someone who is
exposed to the virus (Mayo Clinic, 2014). Parents were forced to vaccinate their children up until
SMALLPOX VIRUS 9
1972, but because the last outbreak was in 1949 in the US this is no longer required. Since the
complications of smallpox vaccinations are much greater than the benefits, it is no longer
required for school children to be vaccinated. These complications include a toxic or allergic
reaction at the vaccination site, spread of the virus to other parts of the body, and spreading it to
other individuals. Unfortunately, about half of the US population has never been vaccinated for
smallpox, which means they have no immunity to it. Also, of the 120 million Americans that
have been vaccinated, many have not received a booster shot in decades. This means that their
immunity is probably decreasing or no longer effective (Bourzac, 2002). This creates problems if
another outbreak were to occur because there would be no protection from the virus.
Antiviral Prophylaxis
There is no cure for smallpox infections at this time, and vaccines have not been given
universally since its eradication. Although, it has been considered that antiviral prophylaxis
would be valuable to defend against another outbreak. Originally, there were minimally
protective antiviral medications available to the public, but a long-lasting drug has now been
created to fight against poxviruses. This long-lasting antiviral prophylaxis is cidofovir, but it is
not going to be given out unless an outbreak occurs (Bray & Roy, 2004). This creates a problem
with those who contract smallpox because they will only be partially protected. Cidofovir is an
intravenous drug that requires additional hydration for the patient in order to prevent
nephrotoxicity, and this would make it difficult to administer in large quantities during an
epidemic. Supplying this drug in large quantities is a problem because if a terrorist attack were to
occur using smallpox as the weapon, protecting the masses would not seem to be realistic.
Smallpox infection begins when the variola virus enters the respiratory tract if aerosolized, like
in a bioterrorist attack, or transmission occurs through saliva droplets released from the
SMALLPOX VIRUS 10
oropharynx of smallpox patients. This allows cidofovir to block the airways if it is aerosolized,
or it can stop transmission if it is in oral form by creating a respiratory tract barrier (Bray & Roy,
2004). Regardless of the possibilities this antiviral prophylactic may provide, there are obstacles
Conclusion
Smallpox comes from the variola virus, which is believed to have been transferred
to humans from rodents. This was eventually spread worldwide throughout different cultures,
while wreaking havoc on livestock, humans, and populations. Eventually this has been
eradicated through WHO, and it is considered one of the greatest contributions to the public
health field. There are even trial antiviral prophylactics that are being tested in case of another
outbreak. Despite the advances in understanding of this virus, there remains the fear it will be
used as a bioterrorist weapon. Without worldwide immunizations, there remains the chance that
if an outbreak occurs the human immune system will be unable to fight it off.
SMALLPOX VIRUS 11
References
Babkin, I., & Babkina, I. (2015). The origin of the variola virus. Viruses, 7, 1100-1112.
Baker, R., Bray, M., & Huggins, J. (2003). Potential antiviral therapeutics for smallpox,
Bourzac, K. (2002). Smallpox: Historical review of a potential bioterrorist tool. Journal of Young
Bray, M., & Roy, C. (2004). Antiviral prophylaxis of smallpox. Journal of Antimicrobial
Chemotherapy, 54(1),1-5.
Breman, J., & Henderson, D.A. (2002). Diagnosis and management of smallpox. The New
Carletti, F., Di Caro, A., Calcaterra, S., Grolla, A., Czub, M., Ippolito, G.,Horejsh, D.
Espy, M., Cockerill, F., Meyer, R., Bowen, M., Poland, G., Hadfield, T., & Smith, T.
Microbiology, 40(6),1985-1988.
SMALLPOX VIRUS 12
Koren, H., & Bisesi, M. (2003). Handbook of Environmental Health. Fourth Edition,
http://www.mayoclinic.org/diseases-conditions/smallpox/basics/definition/con-20022769
Moore, Z., Seward, J., & Lane, J. (2006). Smallpox. Lancet, 367, 425-35.