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  • Highly infectious after aerosolization.
  • Person-to-person transmission can occur via droplet nuclei or aerosols expelled from the oropharynx and by direct contact.
  • Contaminated clothing or bed linens can also spread the virus.
  • About 30% of susceptible contacts will become infected.
  • Incubation period is 12-14 days, and ranges 7-17 days.


  • Incubation period is 12-14 days, and ranges 7-17 days.
  • Characteristic rash appears 2-3 days after nonspecific, flu-like prodrome (fever and head­ache).
  • Maculopapular rash begins on mucosa of mouth and pharynx, face, hands, forearms and spreads to legs and centrally to trunk; lesions are more predominant on the face and ex­tremities than on the trunk.
  • Lesions progress synchronously on any given part of the body from macules to papules to vesicles to pustules to crusty scabs.


Laboratory Diagnosis
  • Mask and gloves should be worn by person obtaining specimen, preferably a person who has been recently vaccinated.
  • Vesicular fluid is obtained by opening lesions with the blunt edge of a scalpel, harvesting fluid with a cotton swab; scabs can be removed by forceps.  Swabs and scabs should be placed in a vacutainer, sealed with tape, and placed in a second, durable, watertight con­tainer
  • Laboratory specimens must be handled in a "Biosafety Level 4" facility (e.g. CDC) and will be evaluated with electron microscopy and cell culture.


Patient Isolation 
  • Strict isolation in negative pressure room (high efficiency particulate air filtration ideal) from onset of rash until all scabs separate.
  • Laundry and waste should be autoclaved before being laundered or incinerated.


  • Supportive care is the mainstay of therapy
  • In-vitro antiviral activity against poxviruses has been shown with adefovir, cidofovir, dipivoxil, and ribavirin. (Animal studies suggest that cidofovir may be most effective).


  • Smallpox vaccine would be required for all persons exposed at the time of the bioterrorist attack or anyone with close personal contact with a smallpox case.
  • Vaccine is most effective if given before or within 3 days of exposure.
  • Ideally, all exposed persons should be placed in strict quarantine for 17 days after last contact with a smallpox case.

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