Early disease management strategies in case of a smallpox outbreak

As a consequence of the threat of smallpox being potentially used as a means of bioterrorism, many countries have developed preparedness plans for smallpox in the past few years. This chapter summarizes some of the most important issues for the management of smallpox. Usually, the strategy for the management of clinical cases of poxviruses includes the early detection of cases, rapid laboratory diagnosis, an assessment of the risk of further spread and containment measures. For the early detection, different systems are being tested to identify suspected cases before a diagnosis is confirmed (e.g., syndromic surveillance). Also it is necessary to provide special training on the disease pattern, including differential diagnosis, to clinicians and practitioners. If a suspected case has been identified, rapid diagnostic tests are required. In addition to the national and international notifications based on given case definitions, certain measures are necessary to allow an initial risk assessment of the epidemic development. For a rapid risk assessment, the investigations should follow the algorithms of epidemiological outbreak investigation such as the tracing and identification of exposed contacts and the sources of infection. Further decisions have to be taken on the basis of a continuous risk assessment. Countermeasures can be divided into medical and non-medical ones. The choice of an adequate vaccination strategy as a medical countermeasure for the case of a re-emergence of smallpox very much depends on the epidemic scenario, and the general availability and quality of a vaccine. Logistic aspects of the vaccination strategies have to be considered in preparedness planning (e.g., resources necessary for the implementation of mass vaccinations), and also the prioritization of groups to be vaccinated. In addition non-medical measures to prevent the spread of infection, such as the isolation of cases and quarantining of exposed persons (e.g., contact persons of confirmed cases) have to be foreseen. The effectiveness of other measures like prohibition of mass gatherings or closure of institutions is often assessed in the light of historical events. However, they have to be considered within today’s ethical and societal context, taking into account, in particular, the increased number of people who are immunocompromised. Since our knowledge of how the virus would behave today is limited to extrapolations from historical data and is therefore imperfect, these measures are still under discussion. All relevant groups should be involved in exercises to assure the effective operation of the plan mainly regarding communication and cooperation.