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Consensus Statement |

Smallpox as a Biological Weapon:  Medical and Public Health Management

Donald A. Henderson, MD, MPH; Thomas V. Inglesby, MD; John G. Bartlett, MD; Michael S. Ascher, MD; Edward Eitzen, MD, MPH; Peter B. Jahrling, PhD; Jerome Hauer, MPH; Marcelle Layton, MD; Joseph McDade, PhD; Michael T. Osterholm, PhD, MPH; Tara O'Toole, MD, MPH; Gerald Parker, PhD, DVM; Trish Perl, MD, MSc; Philip K. Russell, MD; Kevin Tonat, PhD; for the Working Group on Civilian Biodefense
JAMA. 1999;281(22):2127-2137. doi:10.1001/jama.281.22.2127.
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Objective To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of smallpox as a biological weapon against a civilian population.

Participants The working group included 21 representatives from staff of major medical centers and research, government, military, public health, and emergency management institutions and agencies.

Evidence The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox as well as this article. The literature identified was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group.

Consensus Process The first draft of the consensus statement was a synthesis of information obtained in the evidence-gathering process. Members of the working group provided formal written comments that were incorporated into the second draft of the statement. The working group reviewed the second draft on October 30, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.

Conclusions Specific recommendations are made regarding smallpox vaccination, therapy, postexposure isolation and infection control, hospital epidemiology and infection control, home care, decontamination of the environment, and additional research needs. In the event of an actual release of smallpox and subsequent epidemic, early detection, isolation of infected individuals, surveillance of contacts, and a focused selective vaccination program will be the essential items of an effective control program.

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Figure 1. Typical Temperature Chart of Patient With Smallpox Infection
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Chart shows approximate time of appearance, evolution of the rash, and magnitude of infectivity relative to the number of days after acquisition of infection.3,26,29
Figure 2. Typical Case of Smallpox Infection in a Child
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Figure shows the appearance of the rash at days 3, 5, and 7 of evolution. Note that lesions are more dense on the face and extremities than on the trunk; that they appear on the palms of the hand; and that they are similar in appearance to each other. If this were a case of chickenpox, one would expect to see, in any area, macules, papules, pustules, and lesions with scabs. Reproduced with permission from the World Health Organization.2
Figure 3. Vaccination With the Bifurcated Needle
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The requisite amount of reconstituted vaccine is held between the prongs of the needle and vaccination is done by multiple punctures; 15 strokes, at right angles to the skin over the deltoid muscle, are rapidly made within an area of about 5 mm in diameter.
Figure 4. Typical Appearance of an Evolving Primary Vaccination Take
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Reproduced with permission from the Centers for Disease Control and Prevention.3

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