Prevent Spread of Disease

Smallpox is spread through prolonged face-to-face contact via droplets expelled from the patient’s nose and mouth, usually by coughing. Smallpox may also be transmitted through contact with materials from smallpox pustules or scabs. There have also been rare reports of airborne transmission in hospital and laboratory settings. Prevent the spread of disease within your facility and from your facility to the community by adhering to infection and environmental controls.

Limit Access to Healthcare Facility

Only vaccinated individuals should have access to the healthcare facility treating smallpox patients. Facilities may need to limit entrance to only approved, vaccinated individuals during a smallpox emergency. This includes staff, visitors, and any non-staff individuals who provide services for the facility (delivery or service personnel, public health officials, law enforcement, etc.). Limiting access may require designating staff to maintain lists of individuals approved to enter the facility, check identification, and monitor individuals for signs and symptoms of smallpox.

Take Precautions and Use Personal Protective Equipment (PPE)

All staff should follow standard, contact, and airborne precautions, and use the appropriate personal protective equipment (PPE), regardless of vaccination status. This helps assure that healthcare workers are protected regardless of when they were last vaccinated. It also provides additional protection should there be any modification to the infectivity of the smallpox virus. These precautions also apply to visitors and any other person entering the patient’s room.

Train healthcare facility staff prior to an outbreak on:

Prior to entering a smallpox patient’s room, all staff should put on the appropriate PPE:

  • Disposable gown and gloves
  • NIOSH-certified N95 (or comparable) filtering disposable respirator that has been fit-tested for the staff member using it. This is especially important for extended contact in the inpatient setting.
  • Eye protections (such as face shields or goggles), as recommended under standard precautions, if medical procedures may lead to splashing or spraying of a patient’s body fluids.

Staff should remove all PPE, except for the N95 respirator, before leaving the patient’s room. After removing gloves, the staff member should wash his or her hands with soap and water or use an alcohol-based hand sanitizer. Maintaining proper hand hygiene will help limit the spread of disease.

Ensure your facility will have enough PPE available to protect staff caring for one or more patients with smallpox in AIIRs. Include in your emergency plans how you will acquire additional PPE quickly to handle a potential surge.

Disinfect and Sterilize Environmental Surfaces and Patient-Care Equipment

Current practices for disinfection and sterilization of patient-care equipment and environmental surfaces also apply to facilities evaluating and caring for smallpox patients. There is no EPA-registered disinfectant approved to inactivate variola virus (the virus that causes smallpox). Since variola virus is similar to vaccinia virus (the virus used in the smallpox vaccine), any EPA-registered hospital disinfectant approved to inactivate vaccinia virus may be used to disinfect nonporous surfaces contaminated by variola virus. Follow the manufacturer’s recommendations for concentration, contact time, and care in handling. The nature and extent of surface contamination will dictate the level of disinfection (i.e., low-level or intermediate-level) needed to make the surface safe to handle or use.

All personnel performing environmental control tasks in a facility caring for smallpox patients should be vaccinated and wear appropriate PPE.

Specific considerations:

  • Disposable medical instruments and patient-care devices: Place in containment for safe handling. Follow waste management guidelines for Category A waste when discarding. This differs from smallpox vaccination-related waste, which contains vaccinia virus, and is Category B.
  • Ambulances: Disinfect ambulances using EPA-registered hospital disinfectants approved to inactivate vaccinia virus (as described above). Follow manufacturer’s recommendations for use. Fumigation of the interior space is not indicated. Follow guidelines for disposal of medical waste, including disposable medical instruments and patient-care devices, and PPE. Follow instructions for proper handling of patient laundry. Do not transport any non-smallpox patients in the vehicle until disinfection has occurred.
  • Interior surfaces of spaces occupied by smallpox patients: Disinfect non-porous surfaces using EPA-registered hospital disinfectants approved to inactivate vaccinia virus (as described above). Fumigation of rooms, facilities, or vehicles is not indicated for environmental control of variola virus. Additionally, a properly engineered heating, ventilation, and air-condition (HVAC) system can minimize the possibility of airborne spread of variola virus in facilities providing care for smallpox patients. Placing smallpox patients in airborne infection isolation rooms can help to limit distribution of virus in the air.
  • Carpets and upholstery: Use a vacuum cleaner equipped with a high efficiency particulate air (HEPA) filter for cleaning carpeted floors or upholstered furniture. As long as the HEPA filter is installed properly and remains intact during use, you do not need to disinfect the vacuum cleaner. Place the full vacuum cleaner bag in another closable container and discard as routine solid waste. Commercially available products are acceptable to remove visible soil.

Handle Laundry Carefully

Treat laundry carefully, as there have been reports of re-aerosolized transmission of variola virus from infected fabric and bedding (fomites). Never shake or handle the linens roughly, as this may contaminate air, surfaces, and others with infectious particles.

Personnel handling laundry from smallpox patients should be vaccinated and wear appropriate PPE.

  • Bag or contain all laundry and linens at the point of use, following OSHA regulations (OSHA; 29 CFR 1910.1030(d)(4)(iv)). If you have wet textiles, first bag them, and then place the bags in a leak-proof container. Most, if not all, forms of containment used for routine healthcare laundry are acceptable for containing laundry generated in care areas for smallpox patients.
  • Use routine laundry protocols for healthcare facilities to launder materials from smallpox patient care areas (i.e., hot water [160°F or 71°C] washing with detergent and bleach and hot air drying).

Follow Enhanced Waste Management Regulations

Only vaccinated personnel should handle waste from a facility caring for smallpox patients.

All waste contaminated with smallpox (or suspected to be contaminated with smallpox) is a Category A infectious substance regulated as hazardous material under the U.S. Department of Transportation (DOT) Hazardous Materials Regulations (HMR; 49 CFR, Parts 171-180). These regulations require special packaging of hazardous materials prior to shipment or transport. DOT may grant special permits to allow a variance to the regulations, as long as the applicant can demonstrate alternative packaging meets certain requirements. Other state and local transportation guidelines may apply. Include representatives of these departments in your facility’s planning process.

Other options for disposal include:

  • Inactivation through use of appropriate autoclaves
  • Incineration

Note: Waste generated from the smallpox vaccine, which contains vaccinia virus, is a Category B infectious substance under the same regulations.