ERIC EJ853620: Smallpox: A Review for Health Educators

6 Pages·2003·0.1 MB·English

by  ERIC

Smallpox: A Review for Health Educators
Timothy J. Bungum
ABSTRACT
Since the declaration of the eradication of smallpox in May of 1980 concern about this virus has ebbed. However,
recent world events, including the destabilization of governments, have raised concerns that smallpox could fall into
the hands of nefarious individuals or groups who might attempt to use the virus as a weapon. In Centers for Disease
Control and Prevention publications the threat of smallpox being intentionally released by bioterrorists is currently
considered possible. Because health educators would likely be involved in public health prevention and response
efforts to a release, it is our responsibility to be knowledgeable about smallpox. This article defines the disease,
describes its history and the successful eradication effort, and discusses public health preparations for the possible
return of this killer.
Since the events of September 11, 2001, health personnel may be involved in bio- egory A bioterrorism agent as are anthrax,
terrorism and especially bioterrorism-re- terrorism prevention and response efforts botulism, tularemia, plague, and viral hem-
lated concerns have increased. Bioterrorism (Garrett, 2000), and because the public may orrhagic fever. Category A agents are those
is defined as the release or threat of release seek smallpox-related information from that pose a risk to national security because
into the civilian population of a natural or health educators, it is the responsibility of they can be easily disseminated or are trans-
altered disease-causing bacteria, virus, or public health personnel to be knowledge- mitted from person to person, result in high
toxin for the purpose of causing illness, able concerning this potential threat. Fur- mortality rates and have the potential for
death, or inculcating fear (Southern Nevada ther, a recent study found that a majority major public health impact, might cause
Area Health Education Center, 2003). For of Americans hold a number of beliefs public panic and social disruption, and re-
rogue nations, organizations, or individu- about smallpox that are false. Authors ex- quire special action for public health pre-
als who do not possess conventional weap- pressed a need for public education about paredness (CDC, 2003a).
ons the advantages of using biological smallpox (Blendon et al., 2003). Health edu- Smallpox is caused by the variola virus,
weapons are numerous. Many biological cators should play a role in improving the which is an orthopoxvirus, as are cowpox,
weapons are accessible or easy to produce; smallpox-related knowledge of Americans. camelpox, and monkeypox. Smallpox is
can be disseminated over large areas; This article provides a description of small- about 200 nm in size and contains a double-
may cause secondary spread; are difficult pox, a history of the disease, briefly de- stranded DNA putative coding for more
to detect; would likely cause panic and scribes the successful eradication effort, and
fear; and the perpetrators would have the discusses current threats and efforts to pro-
opportunity to flee the sites of their attacks tect the population from and respond to a Timothy J. Bungum, DrPH, is an associate
before the effects are noticed (Southern Ne- smallpox attack. professor in the Department of Health Promo-
vada Area Health Education Center, 2003). tion at the University of Nevada-Las Vegas,
A frequently mentioned and potential WHAT IS SMALLPOX? 4505 Maryland Pkwy, Box 453050, Las Vegas,
bioterrorism weapon is smallpox. Smallpox is a serious, contagious, and Nevada 89154-3050; E-mail: Tim.Bungum@
Because health educators and public sometimes fatal disease. Smallpox is a Cat- ccmail.nevada.edu
278 American Journal of Health Education — September/October 2003, Volume 34, No. 5
Timothy J. Bungum
than 200 different proteins (WHO, 2001), tentionally spreading the disease via fo- develops into raised bumps, and by the
making it one of the most complex and larg- mites. The disease is considered to be highly fourth day the bumps fill with an opaque
est viruses (Henderson et al., 1999). It is contagious, but is less transmittable than fluid that has a dip in the center. The fever
known to have emerged in human popula- chickenpox and influenza, diseases that are frequently returns and stays elevated until
tions centuries ago (CDC, 2003c). The also transmitted from infected human lungs scabs form over the bumps (Fenn, 2001).
name variola originates from the Latin word to susceptible lungs (Bray, 1996). The vari- The subsequent phase, called “pustular
for “spotted” and describes the raised ola virus can remain alive outside the hu- rash,” usually lasts for about 5 days, but can
bumps that appear on the faces and bodies man body, but 90% of aerosolized small- continue for up to 9 days. The pustules be-
of those afflicted. Smallpox has two clinical pox dies within 24 hours, and quicker in the come sharply raised and are usually round
forms, variola major, the most common and presence of ultra violet light (CDC, 2003a). and firm to the touch. The infected remain
severe; and variola minor, which is less com- Those in face-to-face contact (<6.5 feet) contagious. Next comes a phase that is char-
mon and less severe and causes a disease with smallpox victims and those in the acterized by pustules and scabs that also
called alastrim, which kills less than 1% of same households are at high risk for infec- persists for about 5 days (CDC, 2003a). If
its victims (Bray, 1996). Within variola ma- tion. Others at risk include people who care the smallpox case is a fatal one, it is usually
jor there are four main types, with “ordi- for smallpox victims, smallpox response at about this time that death occurs, which
nary” the most prevalent, accounting for at teams, and those who would transport is 10–16 days after the first appearance of
least 90% of cases before its eradication smallpox sufferers such as emergency medi- symptoms. By the conclusion of this stage
(CDC, 2003c). Three other types of variola cal technicians. Law enforcement person- most of the sores have scabbed over. Subse-
major are “modified,” a form that produces nel, laboratory workers, and those who dis- quently, the scabs begin to fall off but leave
mild effects and usually occurs in previously pose of medical waste would also be in marks on the skin that usually scar. The in-
vaccinated people; and “flat” and “hemor- jeopardy of infection (WHO, 2001) in the fected remain contagious until the last scab
rhagic” smallpox. Flat and hemorrhagic event of a release. falls off (Fenn, 2001).
variola major are rare but usually fatal The incubation period for smallpox is There is no specific treatment for small
(CDC, 2003a). Historically, variola major 7 to 17 days, with an average of 12 to 14 pox, and the only prevention is vaccination
killed about 30% of the unvaccinated and days. During the incubation period the in- (CDC, 2003c). The aftermath of small pox
3% of the vaccinated, but has killed at fected feel fine and are not contagious. The is either death or permanent immunity.
higher rates. Approximately 80% of Indi- initial symptoms of smallpox, which occur Most survivors are indelibly scarred, and
ans in Santa Domingo succumbed in a 15th during the prodrome phase, are fever; mal- some are blind, especially those who were
century outbreak. Case fatality rates were aise; headache, body aches, and especially also starving while ill (Fenn, 2001). When
similar among North American Indians in backache; and sometimes vomiting. The the disease attacks the eyes, lungs, throat,
the 17th and 18th centuries (Bray, 1996). headache can be splitting and the backaches heart, or liver, death is likely to occur. “Death
Experts are concerned about the vulnerabil- excruciating. The fever is usually in the 101– is frequently caused by multiple hemor-
ity of the U.S. population because America 104°F range and is followed by a rash. At rhages that are sometimes complicated by
ceased vaccinations in 1980. It is estimated this point the smallpox sufferer is usually bronco-pneumonia” (Bray, 1996, p.115).
that only 10–15% of those who were vacci- very ill and incapable of moving about. This Smallpox can also produce secondary
nated before the cessation of that procedure phase persists for 2 to 4 days (Fenn, 2001). bacterial infections that can be as deadly
would retain residual immunity, and one- The third or “early rash” phase is appro- as the smallpox symptoms. Severe dehydra-
quarter of Americans have never been vac- priately characterized by a rash that emerges tion is also common among sufferers, be-
cinated (Garrett, 2000). as small red spots on the tongue and mouth. cause the rash that occurs in the mouth and
The transmission of smallpox is typically It is during this phase, which persists for throat makes drinking difficult. Frequently
person-to-person via aerosol droplets that approximately 4 days, that the ill are at their a loathsome odor that is peculiar to small-
navigate from the lungs of infected humans most contagious. The susceptible that come pox is present as the pustules crack and
to lungs of susceptible people. However, near them risk their lives. As the sores on begin to run. Survival rates are higher if
smallpox can be transmitted by contact with the mouth break open, a rash appears, start- the pustules remain discrete and do not
bodily fluids or contaminated fomites such ing on the face and spreading to the arms run together into a single oozing mass. The
as clothing or bedding. The well-known and legs, then the feet and hands, and fi- oozing mass is characteristic of confluent
instance of British General Jeffery Amherst nally to the remainder of the body, all oc- smallpox, a condition from which 60% die
sanctioning the presentation of smallpox- curring within 24 hours. As the rash ap- (Fenn, 2001).
laden blankets to American Indians in 1763, pears, which will persist for about 15 days,
for the purpose of killing them (Fenn, the fever usually falls and the patient ral- HISTORY OF SMALLPOX
2001), underscores the effectiveness of in- lies. By the third day of this phase the rash The history and origins of smallpox are
American Journal of Health Education — September/October 2003, Volume 34, No. 5 279
Timothy J. Bungum
topics of scholarly discussion, because it is death rates among Native Americans, as stance. During the next smallpox outbreak
difficult to determine when smallpox first opposed to European immigrants, was that his wife and children survived without
appeared, but it can be argued with confi- the practice of smallpox inoculation had showing signs of the disease. In 1796 Ed-
dence that smallpox was causing illness in been employed previously in Europe. Eu- ward Jenner, a British physician, learned of
the Middle East during the 10th century ropeans were not the inventors of inocula- Jesty’s work and coopted the procedure by
(Bray, 1996). Because other diseases that tion; it was employed by the Chinese as early performing an experiment to test the hy-
caused symptoms similar to those of small- as the 11th century. The Chinese version of pothesis that infection with the cowpox vi-
pox were endemic or epidemic in earlier inoculation entailed infecting children with rus would protect one from smallpox. In a
times, and laboratory confirmation of the smallpox by placing scabs that were taken dangerous trial, Jenner intentionally in-
causative disease agents were centuries away, from the infected, preferably from a person fected an 8-year old orphan named James
early claims of smallpox epidemics are dis- with a mild case, into the child’s nostrils. Phipps with the cowpox virus. Six weeks
puted (Bray, 1996). It was not until around The children usually survived the intention- later, after Phipps had recovered from the
910 AD that Arabian physician Rhazes drew ally inflicted smallpox bout and were sub- vaccinia symptoms, Jenner intentionally
the distinction between measles and small- sequently immune (Bray, 1996). The prac- infected the boy with the smallpox virus.
pox (Marks & Beatty, 1976). However, there tice of inoculation did not reach Europe The lad survived and showed no signs of
are reports that smallpox was present much until Mary Wortley Montague accompanied illness. Jenner is thus credited with devel-
earlier in ancient Egypt. The principal ar- her husband, the British ambassador, to oping a safer method of shielding humans
gument supporting this belief is that scars, Constantinople, where she observed from smallpox. This new procedure became
which may have been caused by smallpox, “ingrafting.” This frightening and fascinat- known as “vaccination,” the word coming
have been noted on mummies (Bray, 1996). ing procedure involved deliberately placing from vaca, which is Latin for “cow.” The
Records suggest that smallpox was dis- live smallpox virus into an incision, usually vaccination process does not oblige the pa-
seminated throughout Europe by several on the arm or hand. Similar to the Chinese tient to endure the actual disease as did
vehicles, including merchants who traveled method, the virus was optimally harvested variolation, thus greatly decreasing the risk
along trade routes and those returning from from someone suffering with less severe for patients (Fenn, 2001).
the Crusades of the 11th, 12th, and 14th symptoms. After a brief incubation period, The first smallpox epidemic in the West-
centuries. It is known that smallpox was smallpox ensued, but again the patient usu- ern hemisphere occurred in the late 1400s
endemic in mainland Europe by 1614 but ally survived and suffered with mild effects. or early 1500s (Marks & Beatty, 1976). As
did not reach London until 1628 (Marks & The reasons for the mild symptoms and low stated earlier, the effects of smallpox in the
Beatty, 1996). Some epidemics were so dev- death rates are still not fully understood. New World were devastating, largely killing
astating and sustained that parents did not This procedure is known as “variolation” off the Aztec and Inca civilizations and the
name their children until after they had sur- and required the patient to survive an ac- indigenous peoples of North America,
vived smallpox (Garrett, 2000). tual case of smallpox. To demonstrate the which in effect cleared the way for settle-
During the 16th century Spanish and strength of her belief in the procedure Ms. ment by Europeans (Bray, 1996). During the
Portuguese explorers transported smallpox Montague had her daughter successfully early 1600s there were approximately 25
to Meso-America with devastating conse- inoculated when she returned to England, million Native Americans in North America
quences. The disease killed at high rates and others followed her lead (Fenn, 2001). alone; by 1870 their numbers had been re-
among the natives, who had had no oppor- At about this time Benjamin Jesty, a yeo- duced to less than one million, largely be-
tunity to gain immunity (Bray, 1996). Ad- man British farmer, observed that milk- cause of the dreaded effects of smallpox.
ditional reasons for the high case fatality maids were usually not affected by small- Some European-Americans, in misguided
rates among American natives were poor pox during outbreaks. It was known that notions of supremacy, believed that God
nursing care, the common use of steam milkmaids, in the course of their job du- was acting on their behalf by ridding
baths that compounded the effects of de- ties, were prone to a disease called cowpox America of the Indians and allowing for
hydration, and possibly differences in the or vaccinia, which produced mild symp- their unfettered settlement of the New
immune systems of Native-Americans and toms. Jesty reasoned that cowpox somehow World. Some referred to the massive Native-
Euro-Americans (Fenn, 2001). During one protected the milkmaids during subsequent American deaths as, “the secret judgment
outbreak up to 80% of natives of Santa smallpox outbreaks. Later, when he noted of God” (Marks & Beatty, 1976).
Domingo succumbed to the disease (Bray, that one of his bovines was suffering from During the late 1700s a variolation pro-
1996), and similar case fatality rates were cowpox, he removed infectious matter from cedure was used in America. The American
seen among the Indians in current day New the pustular eruptions that appeared on the version was a 2-week long event that in-
England (Watts, 1997). teats and bags of cows and scratched the cluded extended periods of bed rest and
Another potential explanation for higher skin of his wife and children with that sub- drinking a mercury-laced, milk-based
280 American Journal of Health Education — September/October 2003, Volume 34, No. 5
Timothy J. Bungum
preparation that sometimes caused a loss riod when the troops would be too ill to ef- effective against all strains of smallpox
of teeth. In the course of this procedure, fectively fight. The British, on the other (Bray, 1996).
which was similar to the Turkish method, hand, were not nearly as concerned about The original eradication strategy em-
live variola was placed in an incision and smallpox, because most of their citizens braced by the international team was “mass”
the variolated subsequently suffered a case were inoculated as a matter of course as or “saturation vaccination.” The intent of
of smallpox. Again, most survived because children, the vaccination of children hav- the plan was to vaccinate every person on
the symptoms were usually mild. Those sur- ing become law in England during the 1830s earth. The need for vaccination was stron-
viving then held lifetime immunity from (Bray, 1996). After struggling mightily with gest in developing countries, because cases
smallpox. There were considerable risks the decision, Washington ordered all Con- were rarities in the industrialized world. The
involved with this routine. In instances of tinental troops to be inoculated in 1777. last American smallpox case was diagnosed
the failure to inject sufficient virus, inocu- This was the first large-scale state sponsored in Texas in 1949 (CDC, 2003a).
lation did not occur; injecting too much public health program in American history A shortage of vaccine in Eastern Nigeria
could be lethal, and it was possible to trans- (Fenn, 2001). in 1967 spawned a clever and ingenious
mit and thus cause a lethal case of small- strategy that eventually replaced mass vac-
pox. Further, patients could be infected THE ERADICATION EFFORT cination as the strategy of choice. Dr. Will-
with other blood-borne diseases such as Smallpox was endemic in America for iam Foege, who was originally in Africa on
syphilis. Vaccination was controversial in about 150 years after the Revolutionary War, a church-based medical mission, signed on
late 1700s America and was an illegal and worldwide caused the deaths of more to assist in the eradication effort. Facing the
practice at times. Angry mobs rioted in people in the 20th century than any other vaccine shortage, the thoughtful Foege
Marblehead and Salem, MA, closing one disease (Garrett, 2000). During the 1950s imagined himself as a virus determined to
variolation hospital and razing another. an estimated 50 million cases worldwide survive (Griffin, 2001). Foege formulated a
Others burned the home of a physician who occurred annually (WHO, 2001). The pos- plan that became known as “surveillance
practiced smallpox inoculation in Will- sibility of eradicating smallpox had been and containment,” or “ring vaccination.” In
iamsburg, VA (Fenn, 2001). discussed in the early 20th century, but it employing this tactic every smallpox case
Concurrent with the American Revolu- was not until 1958 that the Soviets proposed was identified, geographically mapped, and
tionary War a smallpox epidemic swept the idea to the World Health Assembly placed under strict quarantine for at least
North America, causing the deaths of more (Green & Ottoson, 1994). Eight years later 20 days (Watts, 1997). Next, people living
people than were killed in the war. That the United States signed on to aid in the within the confines of the geographic “ring”
epidemic is the subject of the recent book, endeavor (Watts, 1997). The rationale be- were vaccinated. The first to be vaccinated
Pox America (Fenn, 2001). This text details, hind the eradication efforts was strong, be- were family members and those who went
among other events, the significant impact cause the disease has no known animal res- to the village markets. The Foege scheme
the disease had on formulating the military ervoir, it is only found in humans. This fact was determined to be a success in Nigeria.
strategies used by General George Washing- made the identification and elimination of Health authorities originally believed that
ton, himself a smallpox survivor. Washing- animals hosting the virus unnecessary. 80–100% of individuals would need to be
ton contracted smallpox as a young man Three additional factors made smallpox an inoculated to halt the spread of smallpox,
while in Barbados, where he had taken his even more enticing target for annihilation. but the Foege strategy was able to do so with
older half-brother to convalesce from tuber- Because all smallpox sufferers develop a dis- less than 50% vaccinated. This tactic, was
culosis. Fortunately for Washington, he sur- tinguishable rash, they could easily be iden- at first not accepted by some others involved
vived with little more than scars on his nose. tified and isolated. Thus, it was a straight- in the effort, but the success of the technique
During the times of our first president 90% forward matter of determining who had was recognized as effective following its use
of the people who attained the age of 21 smallpox, where it was occurring, and iden- in triumphs over smallpox in South Asia
years had survived smallpox (Fenn, 2001). tifying those to be quarantined. Addition- and other parts of Africa, where the final
Because Washington had witnessed the ally, the ill were infectious for short periods cases were occurring. The last person on
havoc caused by smallpox and knew the of time, which allowed limited opportuni- earth to naturally contract smallpox was Ali
risks of inoculation, he was hesitant to re- ties for the virus to find new human hosts. Maow Maalin, a hospital cook from Merker,
quire this procedure of his troops. Because Finally, there was a safe, inexpensive, and Somalia, in September of 1977. At that point
the inoculated would be ill or very ill for effective vaccine that did not require re- a disease chain of at least 1,000, and up to
3 or 4 weeks, the decision to variolate the frigeration. This allowed those involved in 3,000 years, had been broken (Fenn, 2001).
troops was an important one. The general the eradication effort to vaccinate the sus- The entire project cost from 1967–1979 is
feared that the enemy would learn of the ceptible in the earth’s most remote and un- estimated at $3 billion, one of the greatest
American plan and attack during the pe- developed regions. Further, the vaccine was bargains in human history (Green &
American Journal of Health Education — September/October 2003, Volume 34, No. 5 281
Timothy J. Bungum
Ottoson, 1994). recommend efforts be made to locate and and one or two would die. Severe reactions
Ring vaccination is a part of current re- question all persons who had access to the are less common among those who were
sponse plans should a smallpox outbreak virus since 1977 to ensure that no stores previously vaccinated. Typical reactions in-
occur. The size of the ring would be decided have been maintained (Breman, Arita, & clude a sore arm, fever, and swollen glands.
by federal and state officials and would de- Fenner, 2003). The most frequent severe reaction occurs
pend on the size of the outbreak, personnel Because of the changes in world circum- when the vaccine escapes the inoculation
resources, effectiveness of other outbreak stances in the late 1990s, U.S. governmen- site, often because the person vaccinated
control measures, and vaccine availability tal officials saw the need to evaluate the intentionally touched the site and then
(CDC, 2003c). stockpile of smallpox vaccine. Checks of touched either themselves or someone else.
existing vaccine identified potential prob- This “secondary vaccinia” can cause blind-
THE FUTURE lems. About 15.4 million doses were located ness if it spreads to the eyes (CDC, 2003d).
Although smallpox was officially de- in the United States, with approximately 60 Risks of secondary vaccinia are reduced by
clared eradicated in 1980 (Fenn, 2001), the million available worldwide. Further exami- properly caring for the vaccination site,
potential for future smallpox outbreaks is nation of the vaccine caused additional which involves covering it with a bandage,
unknown, because the location and control anxiety, as it appeared that the vacuum pres- properly disposing of bandages, and hand
of remaining samples are questioned. Fol- sure used to store the freeze-dried and crys- washing. The bandage should be changed
lowing the successful eradication effort, the tallized vaccine had been lost (Garrett, every 1–3 days, and used bandages should
World Health Organization (WHO) desig- 2000). The pressure loss could have caused be placed in sealed plastic bags and dis-
nated two repositories of the virus, one in deterioration of the vaccine, making the carded. Vaccinees should keep the site dry,
Atlanta, GA, at the Centers for Disease Con- quality and potency questionable. Also, cover it with a waterproof bandage while
trol and Prevention, and the other at the there were only one million specialized bi- bathing, and change back to a dry gauze
Virology Institute in Moscow (Garrett, furcated needles available, which are used bandage after bathing. Gauze bandages
2000). This agreement appeared to function to deliver smallpox vaccinations, and no should be changed whenever they become
as designed until political unrest in Russia company was manufacturing them. Further, wet. Additionally, it is recommended that
during the 1990s raised questions about the only 675 doses of variola immunoglobulin, vaccinees wear long-sleeved shirts that cover
security of that country’s smallpox stock- which is needed in cases of life-threatening the vaccination site. Hands should be
pile. At that time it was learned that the reactions to the vaccine, were on hand washed thoroughly with antimicrobial soap
Union of Soviet Socialist Republics had al- (Garrett, 2000). and water after any contact with the vacci-
ready relocated their smallpox supply to the However, recently the federal govern- nation site or materials that have come into
Research Institute for Viral Preparations in ment took action to improve readiness for contact with the site (CDC, 2003d).
Novosibrsk, which is located in the Ural a smallpox release. A Cambridge, MA, com- The federally supported vaccination
Mountains. This move took place without pany, OraVax, was commissioned to pro- program, however, is off to a slow start. The
other WHO partners being informed duce smallpox vaccine and will also manu- government had hoped to have about
(Watts, 1997). With the ultimate disintegra- facture the bifurcated needles (LeDuc & 450,000 people who are part of smallpox
tion of the Soviet Union and resulting job Jahrling, 2001). The first phase of the plan response teams vaccinated by March 1,
losses of up to 50,000 scientists who had demands mandatory vaccination of about 2003. Recent data suggests that only 12,404
worked at a minimum of 47 bio-weapons 500,000 military troops, who would poten- had received a vaccination by March 4, 2003.
laboratories and testing sites, the security tially be exposed in an event. The second The goal of phase two is to vaccinate about
of the Russian stockpile was again ques- phase involves the voluntary vaccination of 10.5 million health care and emergency
tioned. It is feared that smallpox could fall civilian health care workers, whose skills responders. One possible reason for the slow
into the hands of extremists, terrorists, would be critical in responding to any response is that some labor unions have
or militia groups, who could intentionally bioterrorism event. Those workers refusing cautioned workers against getting the vac-
initiate an outbreak. No one is sure who vaccination could be quarantined. The cination, because no compensation plan
has the virus, but in 1999 the United States government’s plan will offer the vaccine to had been established for those becoming ill
Congress released a report stating that all Americans by 2004, and currently the or dying as a result of the procedure. This
Iraq was in possession of the virus, a United States has sufficient smallpox vac- is because drug manufacturers expressed
report that has yet to be substantiated. Sci- cine for every American (CDC, 2003c). concern about litigation that could result
entists have proposed that the secretary- The vaccine, however, does carry rare but from use of the vaccine. In response, as a
general of the United Nations should be serious risks. It is estimated that 15 of ev- part of Section 304 of the Homeland Secu-
responsible for the containment of small- ery million vaccinated for the first time rity Act, protection from liability of the U.S.
pox at the international level. Scientists also would face life-threatening complications, government and vaccine manufacturers was
282 American Journal of Health Education — September/October 2003, Volume 34, No. 5
Timothy J. Bungum
granted (CDC, 2003b). However, in early ous and permanent rash if vaccinated www.bt.cdc.gov/agent/smallpox/
March 2003 the administration laid out (CDC, 2003c). vacination/acip-recs-oct2002.asp
a plan to compensate those who are nega- The challenges of preparing for a small- Fenn, E.A. (2001). Pox America. New
tively affected by the vaccine. This plan, pox attack are enormous. It is clear that York: Hill and Wang Publishers.
which must be approved by Congress, calls health educators will play roles in preven- Garrett, L. (2000). Betrayal of trust: The
for paying $262,100 in cases of death or tion and response efforts and should be collapse of global public health. New York:
permanent and total disability, and up to knowledgeable about this disease. As with Hyperion.
$50,000 for those less seriously harmed, plus all potential catastrophic events, we will not Green, L. W., & Ottoson, J. M. (1994).
medical expenses. Civilians volunteering for know if we are prepared for that incident Community health. St. Louis: Mosby.
the program will not be eligible to receive until it occurs. Griffin, T. (2001, March 22). A lifetime
monies from the fund (Meckler, 2003). spent in the war on disease. Seattle Post-
As stated earlier, the vaccine is delivered REFERENCES Intelligencer. Retrieved March 6, 2003, from
by a bifurcated needle that has been dipped Blendon, R. J., DesRoches, C. M., http://seattlepi.nwsource.com
into the vaccine. When removed, the needle Benson, J. M., Herrmann, M. J., Taylor- Henderson, D. A., Inglsby, T. V., Bartlett,
retains a drop of vaccine, and then is used Clark, K., & Weldon, K. J. (2003). The pub- J. G., Ascher, M. S., Eitzen, E., Jahrling, P. B.,
to rapidly prick the skin about 15 times, lic and the smallpox threat. New England Russell, P. K., & Tonat, K. (1999). Smallpox
usually on the upper arm. The needle pricks Journal of Medicine, 348, 426–432. as a biological weapon. Journal of the Ameri-
are not deep, but the spot will be sore and a Breman, J. G., Arita, I., & Fenner, F. can Medical Association, 281, 2127–2137.
few drops of blood may form (CDC, 2003a). (2003). Preventing the return of smallpox. LeDuc, J. W., & Jahrling, P. B. (2001).
If the procedure is a success, which is called New England Journal of Medicine, 348, Strengthening national preparations for
“a take,” a red and itchy bump develops at 463–466. smallpox: An update. Retrieved March 7,
the vaccination site in three or four days. Bray, R. S. (1996). Armies of pestilence: 2003, from Emerging Infectious Diseases at:
During the first week the bump becomes a The impact of disease on history. New York: http://www.cdc.gov/ncidod/eid/vol7no1/
large blister, fills with pus and begins to Barnes and Noble Books. leduc.htm.
drain. Health officials will examine the vac- Centers for Disease Control and Preven- Marks, G., & Beatty, W. K. (1976). Epi-
cination site for a take 6, 7, or 8 days after tion. (2003a). FAQ about smallpox: the dis- demics. New York: Charles Scribner’s and
the inoculation. During the second week ease and the vaccine. Retrieved March 5, Sons.
postvaccination the blister will begin to dry 2003 from http://www.bt.cdc.gov/agent/ Meckler, L. (2003, March 5). Bush pro-
up and scab over. The scab will fall off dur- smallpox/overview/faq.asp poses smallpox compensation fund. Las
ing the third week and leave a small scar. It Centers for Disease Control and Preven- Vegas Sun.
is estimated that the protection will persist tion. (2003b). Section 304 of the Homeland Southern Nevada Area Health Education
for 3 to 5 years (CDC, 2003d) but some be- Security Act (Liability Issues). Retrieved Center. (n.d.). Bioterrorism: Awareness,
lieve benefits will be sustained for at least March 5, 2003 from http://www.bt.cdc.gov/ preparedness and surveillance. Retrieved
10 years. Delivery of the vaccine up to 4 days agent/smallpox/vacination/ February 22, 2003, from http://www.
postexposure, and before the rash appears, Centers for Disease Control and Preven- snahec.org/.
does provide protective immunity or ame- tion. (2003c). Smallpox vaccine overview. Watts, S. (1997). Epidemics and history:
lioration of the severity of disease symp- Retrieved March 5, 2003 from http:// Disease, power and imperialism. New Haven,
toms (WHO, 2001). www.bt.cdc.gov/agent/smallpox/ CT: Yale University Press.
Those who have compromised immune vacination/fact.asp World Health Organization. (2001).
systems, such as the pregnant, the HIV Centers for Disease Control and Preven- WHO fact sheet on smallpox. Retrieved
positive, cancer victims, and organ trans- tion. (2003d). Survey of October 2002 ACIP March 5, 2003, from http://www.who.int/
plant recipients should not be vaccinated. smallpox vaccination recommendations. emc/diseases/smallpox/factsheet.html
Additionally, people with eczema risk seri- Retrieved March 5, 2003 from http://
American Journal of Health Education — September/October 2003, Volume 34, No. 5 283