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Travelers' Health
1. Travelers Health
2. CDC Yellow Book
3. Contents
4. Chapter 4 (78)
5. Smallpox & Other Orthopoxvirus-Associated Infections
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CHAPTER 4 TRAVEL-RELATED INFECTIOUS DISEASES
* Chapter 4 - Shigellosis
* Chapter 4 - Strongyloidiasis
SMALLPOX & OTHER ORTHOPOXVIRUS-ASSOCIATED INFECTIONS
Andrea M. McCollum
INFECTIOUS AGENT
Smallpox is caused by variola virus, genus Orthopoxvirus. Other members of this
genus that can infect humans are vaccinia virus, monkeypox virus, and cowpox
virus. In 1980, the World Health Organization officially declared the worldwide
eradication of smallpox.
TRANSMISSION
SMALLPOX & VACCINIA
Smallpox spread from person to person is principally respiratory; contact with
infectious skin lesions or scabs is an uncommon mode of transmission.
Vaccinia virus is the live-virus component of contemporary smallpox vaccines.
Rarely, infection can occur from touching the fluid or crust material from the
inoculation lesion of someone recently vaccinated against smallpox. Human
contact with animals infected with vaccinialike viruses has resulted in zoonotic
infections in Colombia, Brazil, and India.
MONKEYPOX
After zoonotic transmission, monkeypox spread from person to person is
principally respiratory; contact with infectious skin lesions or scabs is
another, albeit less common, means of person-to-person spread. African rodents
and primates may harbor the virus and infect humans, but the reservoir host is
unknown.
COWPOX
Cowpox infection occurs after contact with infected animals; person-to-person
transmission has not been observed.
EPIDEMIOLOGY
SMALLPOX & VACCINIA
The last documented case of naturally occurring (endemic) smallpox was in 1977.
A single confirmed case of smallpox today could be the result of an intentional
act (bioterrorism) and would be considered a global public health emergency.
Infections with wild vaccinialike viruses have been reported among cattle and
buffalo herders in India and among dairy workers in southern Brazil and
Colombia. Travelers touching affected bovines may acquire a localized, cutaneous
infection. Immunosuppressed people or those with certain skin conditions are at
an increased risk of developing systemic illness from handling infected animals.
MONKEYPOX
Monkeypox is endemic to the tropical forested regions of West and Central
Africa, notably the Congo Basin. Refugees and immigrants leaving the Democratic
Republic of the Congo may be infected with monkeypox virus, but reports of this
are rare. Recent literature documents the presence of this disease in other
countries (Cameroon, Central African Republic, Côte d’Ivoire, Liberia, Nigeria,
Republic of Congo, and Sierra Leone). Short-term travelers to monkeypox-endemic
areas would not generally be at risk of infection. In 2018, however, both the
United Kingdom and Israel reported imported cases of the disease in travelers
returning home after visits to Nigeria. Rodents imported from West Africa were
the source of a human monkeypox outbreak in the United States in 2003.
COWPOX
Human infections with cowpox and cowpoxlike viruses have been reported in Europe
and the Caucasus (cowpox and Akhmeta virus in Georgia). Travelers with direct,
hands-on contact with affected bovines, felines, rodents, or captive exotics
(zoo animals) may be at risk for cutaneous infection.
CLINICAL PRESENTATION
Table 4-20 summarizes key clinical characteristics for orthopoxvirus infections
in humans.
SMALLPOX
Acute onset of fever >101°F (38.3°C), malaise, head and body aches, and
sometimes vomiting is followed by development of a particular, characteristic
rash: firm, deep-seated vesicles or pustules in the same stage of development.
Clinically, the most common rash illness likely to be confused with smallpox is
varicella (chickenpox).
MONKEYPOX
As with smallpox, people experience a febrile prodrome followed by a widespread
vesiculopustular rash involving the palms and soles. Marked lymphadenopathy is a
distinguishing feature of monkeypox.
VACCINIA AND COWPOX
Human infections with vaccinia, wild vaccinialike viruses, cowpox, and
cowpoxlike viruses are most often self-limited, characterized by localized
vesicular-pustular (and in cowpox, occasionally ulcerative) lesions. Fever and
other constitutional symptoms may occur briefly after lesions first appear.
Lesions can be painful and can persist for weeks. Immunocompromised patients or
those with exfoliative skin conditions (such as eczema or atopic dermatitis) are
at higher risk of severe illness or death.
DIAGNOSIS
PCR testing or virus isolation confirms orthopoxvirus infection. Health care
providers can refer to the CDC smallpox website
(www.cdc.gov/smallpox/index.html) for guidance on the application of a clinical
algorithm designed to aid in distinguishing orthopoxvirus infections from other
disseminated rash illnesses, namely chickenpox
(www.cdc.gov/smallpox/clinicians/algorithm-protocol.html). CDC (770-488-7100)
can aid in clinical and laboratory diagnosis.
TABLE 4-20. CLINICAL CHARACTERISTICS OF SMALLPOX, MONKEYPOX, COWPOX, VACCINIA
(NATURALLY OCCURRING), AND OTHER SIMILAR ORTHOPOXVIRUSES
CLINICAL CHARACTERISTIC SMALLPOX MONKEYPOX COWPOX, VACCINIA, AND SIMILAR
ORTHOPOXVIRUSES Incubation period (days) 7–19 5–17 2–4 Fever Yes, febrile
prodrome present before the onset of lesions Yes, febrile prodrome present
before the onset of lesions Yes, often with the onset of lesions Malaise Yes Yes
Yes Headache No Yes Yes Lymphadenopathy No Yes Yes Lesion distribution
Centrifugally disseminated rash; lesions often present on palms and soles
Centrifugally disseminated rash; lesions often present on palms and soles Often
localized lesions on the hands, face, and neck due to contact transmission
Lesion characteristics Lesions are deep-seated and profound, well circumscribed,
and often have a central point of umbilication. Lesions slowly progress from
macule to papule to vesicle to pustule to crust, over a period of 2–4 weeks.
TREATMENT
Treatment of orthopoxvirus infections is mainly supportive: hydration,
nutritional supplementation, and prevention of secondary infections. Vaccinia
and cowpox lesions should remain covered until the scab detaches to diminish
chances of spreading virus to other parts of the body or to other people.
Orthopoxvirus infections in patients at high risk for severe outcomes (for
example, immunocompromised or having an underlying skin condition) or with
ocular infections represent significant management challenges. Clinicians should
consult with CDC to explore treatment options including investigational use of
antivirals.
PREVENTION
Smallpox vaccine is not recommended for the average international traveler. It
is recommended only for laboratory workers who handle variola virus (the agent
of smallpox) or closely related orthopoxviruses and health care and public
health officials who would be designated first responders in the event of an
intentional release of variola virus. In addition, members of the US military
may be required to receive the vaccine.
To reduce the chances of contracting other orthopoxvirus infections, travelers
should avoid contact with rodents and sick or dead animals, including pets and
domestic ruminants (cattle, buffalo), and direct contact with ill humans. For
more information about orthopoxviruses, contact the CDC Poxvirus Inquiry Line
(404-639-4129).
CDC websites: www.cdc.gov/poxvirus/index.html and
www.cdc.gov/smallpox/index.html
BIBLIOGRAPHY
1. Campe H, Zimmermann P, Glos K, Bayer M, Bergemann H, Dreweck C, et al.
Cowpox virus transmission from pet rats to humans, Germany. Emerg Infect
Dis. 2009 May;15(5):777–80.
2. Durski KN, McCollum AM, Nakazawa Y, Petersen BW, Reynolds MG, Briand S, et
al. Emergence of monkeypox—West and Central Africa, 1970–2017. MMWR Morb
Mortal Wkly Rep. 2018 Mar;67(10):306–10.
3. McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014
Jun;58(2):260–7.
4. Petersen BW, Harms TJ, Reynolds MG, Harrison LH. Use of vaccinia virus
smallpox vaccine in laboratory and health care personnel at risk for
occupational exposure to orthopoxviruses—recommendations of the Advisory
Committee on Immunization Practices (ACIP), 2015. MMWR Morb Mortal Wkly Rep.
2016 Mar;65(10);257–62.
5. Trindade GS, Guedes MI, Drumond BP, Mota BE, Abrahao JS, Lobato ZI, et al.
Zoonotic vaccinia virus: clinical and immunological characteristics in a
naturally infected patient. Clin Infect Dis. 2009 Feb 1; 48(3):e37–40.
* Chapter 4 - Shigellosis
* Chapter 4 - Strongyloidiasis
--------------------------------------------------------------------------------
Page last reviewed: June 24, 2019
Content source: National Center for Emerging and Zoonotic Infectious Diseases
(NCEZID)
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