SMALLPOX

CHICKENPOX

Dr. Adeel Ahmed Khan

Trainer, Saudi Board Program of
Preventive Medicine, Makkah
Ministry of Health, KSA
 Session Outcomes

• To describe the epidemiology of small pox &

chicken pox diseases in terms of agent
characteristics, transmission, host
characteristics and control
 Roadmap
 Identification
 Communicable agent
 Occurrence
 Reservoir
 Mode of transmission
 Incubation period
 Period of communicability
 Susceptibility and resistance
 Methods of control including
 Preventive measures
 Control of patient, contacts and the immediate environment
 Epidemic measures
 Disaster implications
 International measures
 Bioterrorism measures
SMALLPOX
 Introduction

 Also known by Latin names Variola or Variola

vera, derived from varius ("spotted") or
varus ("pimple")
 Disease originally known in English as the
"pox” or "red plague“
 The last naturally occurring case of smallpox
(Variola minor) was diagnosed on 26 October
1977
 History

• Mummified remains of Ramses. (1157 B.C.)

• Smallpox was likely carried from
Egyptian traders to India
• By 1967 it became a major killer in not
less than 33 countries
• Those who survive became immune
• As a result, physicians intentionally
infected healthy persons with smallpox
organisms
Edward Jenner
 Jenner’s
contribution
• He found that, the cowpox would protect the patient
from smallpox
• He proposed it in 1798
• In England vaccination with cowpox
became compulsory in 1853

• Jenner was honored for his technique, and ‘Vaccine’

became the universally used term to indicate
introducing material under the skin to produce a
protection against disease
Public health significance &
occurrence

 1980: WHO declared smallpox the first communicable

disease ever to be globally eradicated. This was a direct
consequence of the Global Smallpox Eradication Program
which was achieved by a population based smallpox
vaccination strategy

 Virus retained legally under strict security in two WHO

collaborating centers in the USA and Russian Federation
 part of the bio-weapons research of certain countries

 A single confirmed case of smallpox would prompt a global

public health alert from the WHO
 Identification and
Communicable agent

 An acute infectious disease

 Agent: Variola virus is a DNA virus of the genus Orthopoxvirus

 The virus used in the live smallpox vaccine is known as the vaccinia
virus and is also a member of the genus Orthopoxvirus

 Identification:
 Signs and symptoms: sudden onset of fever, headache, backache,
vomiting and sometimes convulsions (esp. in children)
 3rd day: Typical rash-centrifugal, passing through macule,
papule, vesicle, pustule, scab and scarring
 Subtypes

 V. major: produces a more serious disease

and has an overall mortality rate of 30–35%
 V. minor: causes a milder form of disease;
kills about 1% of its victims
 Stages of Smallpox
• Incubation Period
– 12-14 days, person is not contagious
• Prodrome Phase
– Begins abruptly with fever, malaise, headache, head and body
aches, prostration, and often nausea and vomiting
– Body temperature rises to at least 101 F and is often higher

• When the first visible lesions appear the fever may start to
go down - most contagious period
• Rash emerges as small red spots on tongue and in mouth
(about 24 hours before the appearance of rash on the skin)
• Lesions in the mouth and pharynx enlarge and ulcerate
quickly, releasing large amount of virus into the saliva
 Stages: Rash
Phase
• Centrifugal
distribution
• Palms and soles are
involved
• Lesions are all in the
same stage of
development on that part
of the body (unlike
chickenpox)
Lesions in small pox
Difference in pattern of
lesions
 Diagnosis: on the basis of a consistent
clinical presentation combined with the
results of electron microscopy and PCR
testing

 Reservoir: only humans

 Mode of transmission

 Most frequently from an infectious person via

direct deposition of large, infective, airborne
droplets of saliva onto the nasal, oral or
pharyngeal mucosal membranes during close,
face to face contact with a susceptible individual

 The virus is unlikely to survive on its own for

more than 48 hours when exposed to normal
environmental conditions
Period of communicability

 Patients not infectious during the asymptomatic

incubation period
 They become increasingly infectious after onset of
fever, usually resulting from release of virus from
oropharyngeal lesions

 Contact tracing: cases regarded as infectious 24

hours prior to recognition of fever, and any
contacts identified from this time on need
suitable management
Susceptibility & resistance

 Resolved infection confers lifetime immunity

 Pregnant women and those who are

immunocompromised are more susceptible
to variant forms of smallpox
 Complications

 Long-term complications of V. major infection

include characteristic scars, commonly on
the face, which occur in 65–85% of survivors

 Blindness resulting from corneal ulceration

and scarring, and limb deformities due to
arthritis and osteomyelitis are less common
complications, seen in about 2–5% of cases
 Smallpox eradication

 Favorable epidemiological factors:

 No known animal reservoir
 No long-term carrier of virus
 Life-long immunity after recovery from disease
 Detection of cases comparatively simple
 No disease transmission in sub-clinical cases
 Vaccine highly effective, easily administered,
heat stable conferring long-term protection
 International cooperation
 Control measures

 Preventive measures
 In the event of an outbreak: a stepwise process to
vaccinate persons

 Control of case
 Any patient raising a concern of smallpox must be
notified to the Communicable Diseases Section of the
Department of Health as soon as possible
 All such patients (and their possessions) should be
placed in the best available form of isolation as soon as
possible
Control of environment

 All persons in contact with a case of

smallpox must wear the appropriate PPE and
in order to limit any further spread

 Every effort must be made by relevant staff

to limit spread through the routes namely
infectious respiratory droplets and bodily
fluids or contaminated clothing, dressings,
linen, towels or clinical waste
 Control

• 1958: Soviet Union proposed to the WHO that a

global smallpox eradication program be
undertaken
• The campaign was based on a two fold strategy
– 1. Mass vaccination campaigns in each country using
a vaccine of ensured potency and stability that would
reach at least 80% of the population
– 2. Surveillance-Containment - isolation of patients
and the vaccination of family members and other
contacts in the immediate vicinity
 Control

• Ring vaccination:
• Incorporated into the current CDC Smallpox Plan
• The strategy involves the following steps:
– Rapid identification and isolation of all smallpox cases
– Identification and vaccination of contacts of smallpox
cases
– Monitoring contacts for development of fever and
isolating them if fever occurs
– Vaccination of household members of contacts if no
contraindications to vaccination exist
International measures

 If there are smallpox cases overseas then

the Government may divert all aircraft from
that country, to a limited number of airports
where screening, immunization and
appropriate isolation and quarantine
measures will be applied as required
Bioterrorism measures

 The risk of a terrorist smallpox attack is

currently low but is being taken very
seriously
 Many countries are staging prevention and
control exercises
 Multimillion doses of vaccine are being held
in readiness
 WHO is urging countries to develop and
strengthen preparedness plans
CHICKENPOX/HERPES
ZOSTER
 Introduction

• Acute, highly infectious disease caused by

Varicella- Zoster (V–Z) virus
• World-wide in distribution and occurs in
endemic and epidemic forms
• Chickenpox and Herpes zoster as different
host responses to the same etiological agent
 Epidemiological
determinants
• Agent: Human (alpha) herpes virus
– Primary infection causes chicken pox
– Recovery followed by latent infection
– Reactivation results in zoster- a painful, vesicular,
pustular eruption in distribution of one or more
sensory nerve roots
– Can be grown in tissue culture
• Incubation period: 14-16 days (7-21 days)
 Source of infection

• Usually a case of chicken pox

• Virus present in oropharyngeal secretions and
lesions of skin and mucosa
• Rarely may be a patient with herpes zoster
• It can be isolated from the vesicular fluid
during the first 3 days of illness
 Infectivity

• Period of communicability: 1-2 days before

the appearance of rash, and 4-5 days
thereafter
• It tends to die out before the pustular stage
• Patient ceases to be infectious once the lesion
have crusted
• Secondary attack rate: About 90% in
household contacts
 Host factors

• Age
– Children under 10 years of age
– Few escape until adulthood but can be severe in
adults
• Immunity
– One attack give durable immunity
– Maternal antibody protects the infant for few
months
– No age is exempt in the absence of immunity
– IgG antibodies persist for life and correlate with
protection
– Cell mediated immunity is important in
 Environmental
factors

• It shows a seasonal trend, occurring mostly

during the first six months of the year
• Overcrowding
• In temperate climates, there is little evidence
of seasonal trend
 Transmission

• Droplet infection and droplet nuclei

• ‘Face to face’ (personal) contact
• Portal of entry: respiratory tract
• Virus is extremely labile, so fomites unlikely to
transmit
• Contact infection plays a significant role when an
individual with herpes is an index case
• Congenital varicella - it crosses the placental
barrier and infects the foetus
 Clinical features

• Clinical spectrum
– Mild illness with few scattered lesions
– Severe febrile illness with widespread rash
• Pre-eruptive stage
– Sudden onset with mild to moderate fever
– Pain in the back, shivering and malaise
– Duration about 24 hours
– In adults, prodromal illness is usually more severe
and may last for 2-3 days before the rash
 Clinical features

• Eruptive stage: in children the rash comes on day the

fever starts and first sign
• The distinctive features of rash are
– Rash is symmetrical
– Appears on the trunk and then comes to face, arms ,legs
– Mucosal surfaces (buccal, pharyngeal) are involved
– Axilla affected. Palms and soles usually not involved
– The density of eruption diminishes centrifugally
– Pleomorphism - All stages of rash (papules, vesicles and
crusts) may be seen simultaneously in the same area
 Clinical features
• Evolution of rashes
– The rash advances quickly through the stages
of- macule  papule  vesicle  scab
– Vesicles filled with clear fluid resembling ‘dew-
drops’
– Superficial in site, with easily ruptured walls and
surrounded by an area of inflammation
– Vesicles may form crusts directly. Many lesions
may abort
– Scabbing begins 4-7 days after the rash appears
• Fever not high but exacerbations with fresh
crop
 Complications

• It’s a mild, self-limiting disease

• Patients at risk of complications are
– Immunosuppressive patients
– Cancer patients
– Recipients of organ transplants
– Chemo, radio, steroid therapy recipients
– HIV infected
– Children with leukemia
 Complications

• Haemorrhages (varicella haemorrhagica)

• Pneumonia
• Encephalitis
• Acute cerebellar ataxia
• Reye’s syndrome
• Maternal varicella may cause foetal wastage & birth defects
• Acute retinal necrosis
• Secondary bacterial infections (Cellulitis, erysipelas,
epiglottitis, osteomyelitis, scarlet fever and meningitis)
• Pitted scars
 Congenital defects in
babies
• Damage to brain: encephalitis, microcephaly, hydrocephaly,
aplasia of brain
• Damage to the eye: microphthalmia, cataracts, chorioretinitis,
optic atrophy
• Other neurological disorder: damage to cervical and
lumbosacral spinal cord, motor/sensory deficits, absent deep
tendon reflexes, anisocoria/Horner's syndrome
• Damage to body: hypoplasia of upper/lower extremities, anal
and bladder sphincter dysfunction
• Skin disorders: (cicatricial) skin lesions, hypo pigmentation
 Laboratory diagnosis

• Most rapid and sensitive

– Examination of vesicle fluid
under electron microscope
– Round particles which may
be used for cultivation
• Scrapings of floor of
vesicles show
multinucleated giant cells
coloured by Giemsa stain
• Serology for
epidemiological surveys
 Control

• No specific treatment for chicken pox

• Notification
• Isolation of cases for about 6 days after onset
of rash
• Disinfection of articles soiled by nose and
throat discharges
• Antiviral drugs provide effective therapy for
varicella (acyclovir, valaciclovir, famiciclovir
and foscarnet)
 Prevention

• Varicella zoster immunoglobulin (VZIG)

• VZIG given within 72 hours of exposure
has been recommended for prevention
– Dosage: 1.25 - 5ml intramuscularly
– Usedfor immunosuppressed contacts of
acute cases or newborn contacts
– Provide improvement in high risk children
with varicella
 Vaccine

• Live attenuated vaccine

• Mild local reaction at inoculation site is 1%
• A general reaction mainly rash or
mild varicella may occur
• Seroconversion in healthy
seronegative children is over 90%
• Age shift of peak incidence due
to vaccinations is a major concern
 Vaccine

• Monovalent vaccine
• One or two dose schedule (0.5 ml subcutaneous
injection)
• For children between 12-18 months
• Two dose schedule for persons aged >13 years
• Minimum interval between doses 6 weeks
• Combination vaccines (MMRV) for children 9
months to 12 years
• Duration of immunity probably 10 years
Difference in pattern of
lesions
Difference between small pox and chicken p
Small pox Chicken pox
Incubation 12 days (7-17) 15 days (7-21)
Prodromal Severe Mild
Distribution of rash Centrifugal Centripetal
Palms and soles involved Not involved
Axilla free Axilla affected
Extensor surfaces Flexor surfaces
Characteristics of rash Deep seated Superficial
Multilocular, umbilicated Unilocular, dew drop
One stage at a time Pleomorphic
No inflammation around Inflammation seen
the vesicles
Difference between small pox and
chicken pox
Small pox Chicken pox
Evolution of rash Slow and majestic, Very rapid
passing through
definite stages of
macule, papule, vesicle
and pustule

Scabs 10-14 days Scabs in 4-7 days

Fever Subsides with Fever appears with
appearance of rash, each fresh crop of rash
may rise again at the
pustular stage
Thank you