Treating patients with smallpox in the operating room

AORN Journal, Oct, 2004 by Amy Beasley, Shelley Kenenally, Natalie Mickel, Kija Korowicki, Sue McCann, Julie Arundell, Wylie Simmons, Harold Williams

Recent events around the world have emphasized the need for policies to deal with biological threats, including smallpox. Developing OR guidelines and suggested courses of action to take when dealing with patients who have smallpox is an important step in establishing an emergency preparedness manual.

When administrators at Walter Reed Army Medical Center, Washington, DC, identified the need for a policy for handling patients with smallpox in the OR, they could find no existing written guidelines or policies. Students in a perioperative nursing course at the hospital were given the assignment of creating a template policy for caring for patients with smallpox in need of surgery. The students developed guidelines based on airborne and contact guidelines from the Centers for Disease Control and Prevention (CDC) regarding methicillin-resistant Staphylococcus aureus (MRSA), tuberculosis (TB), and the variola virus.

THE HISTORY OF SMALLPOX

The oldest known case of smallpox dates back to the twelfth century BC. A recent examination of the mummy of Ramses V of Egypt revealed characteristic smallpox blister scars on its face and torso. (1) In 165 AD, the Roman Empire was devastated by a 15-year smallpox epidemic that killed millions. (2) Europe and Asia also experienced millions of deaths caused by this agent during the Middle Ages. (2)

In the eighteenth century, Sir Jeffery Amherst, the commander-in-chief of British forces, used smallpox as a biological war strategy against Native Americans. The British gave blankets laced with smallpox to Native Americans to reduce their numbers. (3) It is alleged that the same tactic was used against colonists during the American Revolutionary War. (3)

During World War II, British and American scientists investigated using smallpox as a biological weapon. (3) President Richard M. Nixon halted this program in 1969, (3) and an international agreement outlawing the development and production of biological weapons was forged in 1972. (3)

The World Health Organization has been working to eradicate smallpox through vaccination since 1959. (2) The smallpox vaccine was developed by Edward Jenner, MD. Jenner discovered that taking pus from a pustule that was caused by cowpox on the hand of a milkmaid and inoculating it into an incision on the arm led to preventing smallpox. (1) The vaccine he developed has been successfully used to eradicate smallpox; the last natural smallpox outbreak was in Somalia in 1977. (2)

SMALLPOX CONCERNS TODAY

Although the 1972 Biological Weapons Treaty, which limits the production of biological warfare agents, was signed by 143 nations, some countries still are manufacturing biological weapons. (4) In 1991, the United States and the former Soviet Union mutually agreed on cross-inspection for smallpox production. Initially, US inspectors found traces of biowarfare research in Soviet laboratories, but after political leaders in the Soviet Union realized the United States truly had abandoned stockpiles of smallpox, they eradicated their supply. (4)

Since 1983, all remaining supplies of the smallpox virus reportedly have been turned over for safekeeping to two designated facilities: (4) the CDC, Atlanta, and Vector Laboratories, Novosibirsk, Siberia. (5) It is speculated, however, that China, Libya, South Africa, Israel, and Pakistan still are harboring secret stockpiles of the virus. (4) This is not surprising because biological weapons are inexpensive. It costs more than $2,000 for conventional weapons to produce the same mass casualties per square kilometer as it does for only $1 in biological weapons, such as smallpox. (6) Smallpox also is effective as a weapon because many members of the younger generation have not received vaccinations against it.

It is extremely important for health care personnel to prepare for a potential smallpox outbreak. Nurses and physicians are the first line of defense in recognizing and treating smallpox. Hospitals must have qualified personnel who are prepared to efficiently and effectively diagnose and treat infected patients to contain and prevent spread of the disease.

The best way to prevent mass confusion in an outbreak situation is for treatment facilities to be ready when there is an occurrence and inform members of the public about the best course of action. In the OR, personnel must understand and know how to carry out protocols already set in place. As in any emergency or disaster situation, it is a priority for all personnel involved to know the applicable procedures and act immediately in the correct manner.

CHARACTERISTICS OF SMALLPOX

Smallpox spreads easily from person to person via droplet nuclei, it takes three to four days for the virus to spread, and a second viremia occurs 12 to 14 days later. Symptoms include high fever, malaise, severe abdominal pain, and, in some cases, delirium. These symptoms occur 13 to 14 days after exposure and last between two and four days. A widespread rash becomes vesicular and then pustular. A concentration of vesicles on the face is typical and causes blindness in many victims. (5)