Criteria for admission of rash diseases to High-Security Care Dr Barbara Bannister Royal Free Hospital, London UK

It’s all about risk assessment There is suspected smallpox in the absence of cases in the world There is suspected smallpox when cases have already occurred You might want to consider suspected Marburg or Ebola fever CCHF may present with a haemorrhagic rash

Let’s talk about smallpox The UK and USA both have plans for dealing with first recognised cases of smallpox Both also have plans for following, more numerous admissions They both have very similar diagnostic algorithms (ie risk assessments) for recognising smallpox

Prodromal smallpox 4th day Fever Prostration Sometimes erythema of face, peripheries and loins Could be measles, scarlet fever, Kawasaki, allergy

Papular rash 5th and 6th day Face, chest peripheries, including palms and soles Painful, burning Could be early varicella, other herpes, furunculosis, erythema multiforme, allergic reaction, guttate psoriasis

Vesicular rash 7th day Varicella should be healing by now Could be other herpes, erythema multiforme, other poxvirus, allergy For the first time this is characteristic of smallpox, even to a novice

Other algorithm features Other characteristics include dense lesions on the peripheries, including the palms and soles

Other diagnostic methods Electron microscopy of vesicle scrapings, throat swabbings or scabs PCR for orthopox and variola specific sequences Cell culture Light microscopy of tissues or vesicle scrapings could show inclusion bodies

Grading of the risk Situation Possible Probable Confirmed No known cases in the world Fever, compatible illness with rash, any supportive epidemiol. PLUS positive EM PLUS positive PCR, culture, etc.

Then consider other levels of alert… Other cases in the same country-or town Patient works in the same building as a case Patient works in the same offices as a case The patient is a household contact of a case The patient is an EM technician Vaccinated-or not? Can we lab-confirm all cases?

Other risk assessments Smallpox Marb/Ebo CCHF High Contact with case or material Ditto: includes animals Tick bite, infected humans/animals near Medium In infected area/lab/hos End/epidemic area/lab ditto Low ! Illness, no exposure Ditto

LAB CLIN EPI SYND