Chicago—Like so many other Americans, Inger Damon, MD, PhD, chief of the Poxvirus Section of the Centers for Disease Control and Prevention (CDC) in Atlanta, felt life change on September 11, 2001. "A few hours after the terrorist attacks, I walked over to the office of a colleague and told him that the emphasis in our lab would now change from basic science research on smallpox to diagnosis." Damon, who has been working at the CDC since 1999, is helping the agency and the country gear up for a possible bioterrorism attack.
A recent interview with her focused on what community physicians need to know about smallpox—a disease that has not occurred naturally anywhere in the world since 1977 (see p 2533). "I think it's going to be heightened awareness," said Damon. "Understanding what are the clinical presentations of smallpox, what are the common forms, which are the uncommon forms, that the differential diagnosis includes varicella, disseminated herpes infections, Enterovirus, and erythema multiforme."
Noting that the first case of disseminated anthrax in the United States, which killed a photo editor in Boca Raton, Fla, was diagnosed by an astute physician in that community, Damon considered some often-asked questions.
IF SMALLPOX IS SUSPECTED
What actions should be taken by a community physician who suspects that a patient has smallpox? "The recommendation right now is to contact state and local epidemiologists," said Damon. She noted that state and local health departments could help in diagnosis, in containment of the case, in airborne contact precautions, in ensuring that appropriate personal protective equipment is worn, and in ensuring that appropriate supportive therapy is made available to the patient.
At this time, there is no curative treatment for those who contract smallpox. According to Damon, the case fatality rate ranges from 10% to 30% in individual outbreaks. More information is available at http://www.cdc.gov.
What about quarantining those exposed to smallpox? "There's been a lot of discussion about this," Damon said. "It's difficult in that quarantine becomes a logistical problem." She noted that while the possibility of quarantine has been considered at the federal level, no final recommendations have yet been made.
The chapter "Smallpox as a Biological Weapon" by Donald A. Henderson, MD, MPH, and others in Bioterrorism: Guidelines for Medical and Public Health Management (Henderson DA, Inglesby TV, O'Toole T, eds. Chicago, Ill: AMA Press; 2002, 99-120), provides more information on preparedness to face this potential bioterrorist threat. The guidelines state that as soon as smallpox is diagnosed, all those in whom the disease is suspected should be isolated immediately and all face-to-face contacts and family members who share living quarters should be vaccinated and placed under surveillance. Patients with smallpox should be isolated, say the guidelines, but because of the possibility of aerosolized dissemination of the disease to other hospital patients, it is preferable to arrange for isolation in the case patients' own homes or in a specially designated hospital.
ON THE LOCAL LEVEL
Pamela Diaz, MD, director of Infectious Diseases and Emergency Preparedness for the Department of Public Health in Chicago, Ill, explained in a recent interview how state and local governments are preparing for a possible smallpox outbreak. "It really requires a collaborative effort between public health, the health care work force in hospitals, and other agencies within cities and at the state and federal level."
Preparedness, said Diaz, involves plans to vaccinate members of a smallpox response unit designated to respond to suspected cases. She noted that all the nurses in Chicago Public Health Department clinics have been trained in smallpox vaccine administration. And to assist in what she called "another extremely important area, the investigation of an outbreak, identifying contacts," the city health department has been cross-training epidemiologists to use resources throughout the department.
Diaz added that "all levels of the health care workforce need to be prepared if they suspect something unusual in their practice." The Chicago Medical Society is working with the Public Health Department to train physicians and clinicians, she said, emphasizing the important role general physicians would play in the event of an outbreak. "Not only do they need to know how to recognize smallpox and what to do," said Diaz, "they would have a vital role in educating patients and calming their fears."
While the focus in Chicago is on preparing the city, and at the CDC is on preparing the United States, for a possible bioterrorist attack, such an attack could take place anywhere on the globe. Damon said, "There is planning under way in other developed countries." But given the enormous expense of trying to protect a large population from the ravages of a widespread smallpox outbreak, she noted that people in less well-developed countries remain the most vulnerable. "The great tragedy will be that if smallpox is ever reintroduced, it will hurt third-world countries far more than it will hurt developed countries."
