Chapter 4 Travel-Related Infectious Diseases
Smallpox & Other Orthopoxvirus-Associated Infections
Andrea M. McCollum
CDC is tracking an outbreak of mpox that has spread across several countries that don’t normally report mpox, including the United States. CDC recommends vaccination for people who have been exposed to mpox and people who are at higher risk of being exposed to mpox. Learn more by visiting the 2022 U.S. Mpox Outbreak webpage.
INFECTIOUS AGENT
Smallpox is caused by variola virus, genus Orthopoxvirus. Other members of this genus that can infect humans are vaccinia virus, mpox 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.
Mpox
After zoonotic transmission, mpox spreads from person to person via infectious respiratory secretions or through direct contact with infectious skin lesions (including scabs). 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.
Mpox
Mpox 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 mpox 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 mpox-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 mpox 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).
Mpox
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 mpox.
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, mpox, cowpox, vaccinia (naturally occurring), and other similar orthopoxviruses
| CLINICAL CHARACTERISTIC | SMALLPOX | MPOX | 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
- 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.
- 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.
- McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis. 2014 Jun;58(2):260–7.
- 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.
- 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.