Smallpox infection occurs in the small blood vessels of the skin and in the mouth and throat, where the virus lives before spreading. On the skin, smallpox causes the characteristic maculopapular rash, followed by fluid-filled blisters. V. major is the more serious disease and has an overall mortality rate of 30 to 35 percent. V. minor causes a milder form of the disease (also known as alastrim, cottonpox, white pox, and Cuban itch), which kills about 1 percent of its victims. Long-term complications of V. major infection include characteristic scars, usually on the face, in 65 to 85 percent of survivors. Blindness due to corneal ulceration and scarring, and limb deformities due to arthritis and osteomyelitis, were less common complications, observed in about 2-5 percent of cases. Smallpox is believed to have originated in human populations around 10,000 BC. NS. The earliest physical evidence of this is pustular eruptions on the mummy of Egypt's pharaoh Ramses V. The disease claimed the lives of about 400,000 Europeans annually during the last years of the 18th century (including five reigning monarchs), and was responsible for a third of all cases of blindness. Among all those infected, 20-60 percent of adults and more than 80 percent of infected children have died from the disease. In the 20th century, smallpox claimed the lives of approximately 300-500 million people. In 1967, the World Health Organization (WHO) estimated that 15 million people were infected with smallpox in a year and two million died. Following a vaccination campaign in the 19th and 20th centuries, WHO certified the global eradication of smallpox in 1979. Smallpox is one of two infectious diseases that have been eradicated, the other being rinderpest, eradicated in 2011.

Classification

Signs and symptoms

Common smallpox

Modified smallpox

Malignant smallpox

Hemorrhagic smallpox

Cause

Causative agents

Broadcast

Diagnostics

Prophylaxis

Treatment

Forecast

Complications

History

The appearance of the disease

Eradication

After liquidation

Society and culture

Bacteriological warfare

Notable cases

Tradition and religion

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Smallpox

Smallpox is an infectious disease caused by one of two variants of the virus, Variola major and Variola minor. The disease is also known by the Latin names Variola or Variola vera, derived from the word varius ("spotted") or varus ("pimple"). The disease was originally known in English as "smallpox" or "red plague"; the term "smallpox" was first used in England in the 15th century to distinguish disease from "great smallpox" (syphilis). The last natural case of smallpox (Variola minor) was diagnosed on October 26, 1977.

Smallpox infection occurs in the small blood vessels of the skin and in the mouth and throat, where the virus lives before spreading. On the skin, smallpox causes the characteristic maculopapular rash, followed by fluid-filled blisters. V. major is the more serious disease and has an overall mortality rate of 30 to 35 percent. V. minor causes a milder form of the disease (also known as alastrim, cottonpox, white pox, and Cuban itch), which kills about 1 percent of its victims. Long-term complications of V. major infection include characteristic scars, usually on the face, in 65 to 85 percent of survivors. Blindness due to corneal ulceration and scarring, and limb deformities due to arthritis and osteomyelitis, were less common complications, observed in about 2-5 percent of cases. Smallpox is believed to have originated in human populations around 10,000 BC. NS. The earliest physical evidence of this is pustular eruptions on the mummy of Egypt's pharaoh Ramses V. The disease claimed the lives of about 400,000 Europeans annually during the last years of the 18th century (including five reigning monarchs), and was responsible for a third of all cases of blindness. Among all those infected, 20-60 percent of adults and more than 80 percent of infected children have died from the disease. In the 20th century, smallpox claimed the lives of approximately 300-500 million people. In 1967, the World Health Organization (WHO) estimated that 15 million people were infected with smallpox in a year and two million died. Following a vaccination campaign in the 19th and 20th centuries, WHO certified the global eradication of smallpox in 1979. Smallpox is one of two infectious diseases that have been eradicated, the other being rinderpest, eradicated in 2011.

Classification

There were two clinical forms of smallpox. Variola major was the severe and most common form, associated with a more extensive rash and a higher fever. Variola minor was a rarer and much less severe disease, with mortality rates of 1 percent or less. Subclinical (asymptomatic) variola virus infections have occurred but were not widespread. In addition, a form called variola sine eruptione (smallpox without rash) was observed in vaccinated individuals. This form was marked by fever after the usual incubation period and could only be confirmed by antibody studies or, less commonly, by virus isolation.

Signs and symptoms

The incubation period between transmission of the virus and the first obvious symptoms of the disease is about 12 days. After inhalation, the variola major virus invades the oropharynx (mouth and throat) or the lining of the respiratory tract, migrates to regional lymph nodes, and begins to multiply. In the initial phase of growth, the virus appears to move from cell to cell, but around the 12th day, many infected cells are lysed and the virus is found in large quantities in the blood (this is called viremia), and the second wave of multiplication occurs in the spleen , bone marrow and lymph nodes. Initial or prodromal symptoms are similar to other viral illnesses such as flu and colds: fever of at least 38.3 ° C (101 ° F), muscle aches, malaise, headache, and prostration. Because the disease often affects the gastrointestinal tract, nausea and vomiting and back pain are common. The prodromal stage, or the stage before the onset of the rash, usually lasts 2-4 days. By 12-15 days, the first visible lesions appear - small reddish spots called enanthemas - on the mucous membranes of the mouth, tongue, palate and throat, and the temperature drops almost to normal. These lesions quickly enlarge and rupture, releasing large amounts of the virus into the saliva. The smallpox virus predominantly attacks skin cells, causing the characteristic pimples (called macula) associated with this condition. The rash develops on the skin 24 to 48 hours after the onset of lesions on the mucous membranes. Usually the macula first appears on the forehead, then quickly spreads to the entire face, proximal parts of the limbs, trunk, and finally to the distal parts of the limbs. The process takes no more than 24-36 hours, after which no new damage appears. Currently, the development of variola major infection can be varied, as a result of which four types of smallpox disease have been identified based on Rao's classification: common, modified, malignant (or flat), and hemorrhagic. Historically, the crude death rate from smallpox has been around 30 per cent; however, malignant and hemorrhagic forms are usually fatal.

Common smallpox

Ninety percent or more of smallpox cases among unvaccinated individuals were of the common type. With this form of the disease, on the second day of the rash, the macules take on the appearance of raised papules. On the third or fourth day, the papules fill with an opalescent liquid, becoming vesicles. This liquid becomes cloudy and cloudy within 24-48 hours, which gives the vesicles the appearance of pustules; however, the so-called pustules are filled with tissue, not pus. By the sixth or seventh day, all skin lesions become pustules. After seven to ten days, the pustules mature and reach their maximum size. The pustules are raised high, usually round, hard and hard to the touch. The pustules are deeply rooted in the dermis, giving them the appearance of a small ball in the skin. Fluid slowly seeps out of the pustule, and by the end of the second week, the pustules descend and begin to dry out, forming crusts. By 16-20 days, crusts have formed over all lesions that have begun to crumble, leaving depigmented scars. Smallpox usually produces a discrete rash in which pustules separate from the skin. The most dense distribution of the rash is on the face; on the limbs it is denser than on the body; and tighter on the distal than the proximal. The disease in most cases affects the palms of the hands and feet. Sometimes the blisters form a coalescing rash that begins to separate the outer layers of the skin from the underlying flesh. Patients with confluent smallpox often remain ill even after a crust has formed over the lesions. In a case series study, the fatality rate for confluent smallpox was 62 percent.

Modified smallpox

With regard to the nature of the rash and the rate of its development, varioloid occurred mainly in previously vaccinated people. In this form, prodromal disease still occurs, but may be less severe than the normal type. During the evolution of the rash, fever is usually not present. Skin lesions are generally smaller and develop more rapidly, are more superficial, and may not show the characteristics of the more typical smallpox. Varioloid is rarely fatal. This form of smallpox is more easily confused with chickenpox.

Malignant smallpox

In malignant smallpox (also called smallpox), the lesions remain almost flush with the skin, while in normal smallpox, raised vesicles form. It is not known why some people develop this type of lesion. Historically, this type of lesion has accounted for 5-10 percent of cases, and the majority (72 percent) were associated with children. Malignant smallpox was accompanied by a severe prodromal phase, which lasted 3-4 days, prolonged high fever and severe symptoms of toxicosis, as well as an extensive rash on the tongue and palate. Skin lesions mature slowly and on the seventh or eighth day they become flat and, as it were, "buried" in the skin. Unlike the common type of smallpox, the vesicles contain little fluid, are soft and velvety to the touch, and may contain hemorrhages. Malignant smallpox is almost always fatal.

Hemorrhagic smallpox

Hemorrhagic smallpox is a severe form that is accompanied by extensive hemorrhage in the skin, mucous membranes and gastrointestinal tract. This form develops in about 2 percent of infections and occurs mainly in adults. With hemorrhagic smallpox, the skin does not blister, it remains smooth. Instead, bleeding occurs under the skin, making it charred and black, hence this form of the disease is also known as smallpox. In the early form of the disease, on the second or third day, hemorrhage under the conjunctiva of the eye makes the whites of the eyes dark red. Hemorrhagic pox also produces dark erythema, petechiae, and hemorrhages in the spleen, kidneys, peritoneum, muscles, and, less commonly, the epicardium, liver, testes, ovaries, and bladder. Sudden death often occurs between the fifth and seventh days of illness, when only a few minor skin lesions are present. The more advanced form of the disease occurs in patients who survive for 8-10 days. Hemorrhages appear in the early eruptive period, and the rash is flat and does not develop beyond the vesicular stage. In patients with an early stage of the disease, a decrease in blood clotting factors (eg, platelets, prothrombin, and globulin) and an increase in circulating antithrombin are found. Patients in the late stage have significant thrombocytopenia; however, clotting factor deficiency is less severe. Some late stage patients also show elevated antithrombin levels. This form of smallpox occurs in 3-25 percent of deaths, depending on the virulence of the smallpox strain. Hemorrhagic smallpox is usually fatal.

Cause

Causative agents

Smallpox is caused by infection with the variola virus, which belongs to the orthopoxvirus genus, the Poxviridae family and the Chordopoxvirinae subfamily. The date of the appearance of smallpox is unknown. The virus most likely originated from a rodent virus 68,000-16,000 years ago. One clade was the main smallpox strains (a more clinically severe form of smallpox) that spread from Asia 400-1600 years ago. The second clade included both alastrim minor (phenotypically soft smallpox), described in the American continents, and West African isolates, which descended from an ancestral strain 1400-6300 years ago. This clade further branched out into two subclades at least 800 years ago. According to a second estimate, the separation of smallpox from Taterapox occurred 3000-4000 years ago. This is consistent with the archaeological and historical evidence for the emergence of smallpox as a human disease, suggesting a relatively recent origin. However, assuming that the mutation rate is close to the herpesvirus mutation rate, the time of the divergence of smallpox from Taterapox is estimated to be 50,000 years ago. While this is consistent with other published estimates, it can be assumed that the archaeological and historical evidence is highly incomplete. More accurate estimates of the mutation frequency in these viruses are needed. Smallpox is a large, brick-shaped virus ranging in size from about 302-350 nm to 244-270 nm, with a single linear double-stranded DNA genome with 186 kbp in size, containing a hairpin loop at each end. The two classic types of smallpox are variola major and variola minor. Four orthopoxviruses cause infections in humans: variola, vaccinia, cowpox, and monkeypox. The smallpox virus naturally infects only humans, although primates and other animals have been infected in laboratory conditions. The vaccinia, cowpox and monkeypox viruses can infect humans and other animals in nature. The life cycle of poxviruses is complicated by the presence of several infectious forms, with different mechanisms of entry into the cell. Poxviruses are unique among DNA viruses in that they replicate in the cytoplasm of the cell and not in the nucleus. To replicate, poxviruses produce a variety of specialized proteins not produced by other DNA viruses, the most important of which is virus-associated DNA-dependent RNA polymerase. Both enveloped and non-enveloped virions are infectious. The viral envelope consists of modified Golgi membranes containing viral specific polypeptides, including hemagglutinin. Infection with variola major or variola minor confers immunity against both types of smallpox.

Broadcast

Transmission occurs by inhalation of variola virus through the air, usually in droplets from the mouth, nose or throat of an infected person. The virus is transmitted from one person to another primarily through prolonged face-to-face contact with an infected person, usually 6 feet (1.8 m) away, but can also be transmitted through direct contact with infected body fluids or infected objects (fomites) such as bedding or clothing. On rare occasions, smallpox is spread by an airborne virus in enclosed spaces such as buildings, buses and trains. The virus can cross the placenta, but the incidence of congenital smallpox is relatively low. Smallpox is not an infectious disease in the prodromal period and viral shedding is usually delayed until a rash appears, often accompanied by damage to the mouth and throat. The virus can be transmitted throughout the illness, but most often it occurs during the first week of the rash. Infectivity decreases after 7-10 days when scabs form over the lesions, but the infected person is contagious until the last pock is gone. Smallpox is highly contagious, but usually spreads more slowly and less widely than some other viral diseases, possibly because transmission requires close contact and occurs after the rash appears. The overall rate of infection also depends on the short duration of the infectious stage. In temperate regions, smallpox infections were highest in winter and spring. In tropical areas, seasonal fluctuations were less evident and the disease was present throughout the year. The distribution of smallpox infections by age depends on the acquired immunity. Immunity after vaccination declines over time, and probably disappears within thirty years. It is not known whether smallpox is transmitted by insects or animals.

Diagnostics

Smallpox is an illness with an acute onset of fever equal to or greater than 38.3 ° C (101 ° F) and then a rash characterized by hard, deep vesicles or pustules at one stage of development for no other apparent cause. If a clinical case is observed, smallpox is confirmed by laboratory tests. Microscopically, poxviruses produce characteristic cytoplasmic inclusions, the most important of which are known as Guarnieri bodies, which are also sites of viral replication. Guarnieri bodies are easily identified in biopsies of skin stained with hematoxylin and eosin and are pink clots. They are found in almost all poxvirus infections, but the absence of Guarnieri bodies is not a sign of the absence of smallpox. The diagnosis of orthopoxvirus infection can also be made quickly by electron microscopic examination of pustular fluid or crusts. However, all orthopoxviruses exhibit identical brick-like virions on electron microscopy. However, if particles with characteristic herpesvirus morphology are observed, smallpox and other orthopoxvirus infections can be eliminated. Accurate laboratory identification of variola virus involves growing the virus on a chorioallantoid membrane (part of a chicken embryo) and examining the resulting lesions under specific temperature conditions. Strains can be characterized by polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP). Serologic tests and enzyme-linked immunosorbent assays (ELISA), which measure specific immunoglobulins and variola virus antigens, have also been developed to aid in the diagnosis of infection. Chickenpox is commonly confused with smallpox. Chickenpox can be distinguished from smallpox in several ways. Unlike smallpox, chickenpox usually does not affect the palms or soles. In addition, chickenpox pustules have different sizes due to differences in the timing of the eruption of the pustules: the smallpox pustules are all almost the same size, since the viral effect progresses more evenly. There are many laboratory methods for detecting chickenpox when evaluating suspected smallpox cases.

Prophylaxis

The earliest procedure used to prevent smallpox is vaccination (known as variolation), which was probably used in India, Africa and China long before the practice was introduced in Europe. However, the idea that vaccination originated in India has been challenged, as few of the ancient Sanskrit medical texts describe the vaccination process. Reports of smallpox vaccinations in China can be found as far back as the late 10th century, and the procedure was widely practiced in the 16th century, during the Ming Dynasty. If successful, the vaccine produced potent immunity to smallpox. However, because a person was infected with the variola virus, a severe infection could develop and the person could transmit smallpox to others. Variation was associated with a mortality rate of 0.5-2 percent, significantly less than the disease-related mortality rate of 20-30 percent. Lady Mary Montague Wortley oversaw the smallpox vaccination during her time in the Ottoman Empire and wrote detailed accounts of the practice in her letters, and enthusiastically facilitated the procedure in England after her return there in 1718. In 1721, Cotton Mather and his colleagues sparked controversy in Boston by inoculating hundreds of people. In 1796, Edward Jenner, a physician in Berkeley, Gloucestershire, rural England, discovered that immunity to smallpox could be obtained by inoculating a person with cowpox material. Cowpox is a poxvirus from the same family as smallpox. Jenner named the material used for the vaccine after the root of the word vacca, which means cow in Latin. The procedure was much safer than variolation and did not involve the risk of smallpox transmission. Vaccination to prevent smallpox has been practiced all over the world. In the 19th century, the vaccinia virus used to vaccinate against smallpox was replaced by the vaccinia virus. The vaccinia virus belongs to the same family as the variola and vaccinia viruses, but is genetically different from both. The origin of the vaccinia virus is not known. The smallpox vaccine is currently a live preparation of the infectious vaccinia virus. The vaccine is administered using a bifurcated needle that is submerged in the vaccine solution. The needle is used to prick the skin (usually in the forearm) several times over a period of several seconds. If successful, redness and an itchy bump develop at the vaccine site within three or four days. In the first week, the bump develops into a large blister that fills with pus and begins to flow out. During the second week, the blister begins to dry out and scabs form. The scabs subside in the third week, leaving a small scar. Vaccine-induced antibodies are cross-protective against other orthopoxviruses such as simian pox virus and variola viruses. Neutralizing antibodies can be detected 10 days after the first vaccination, and seven days after the revaccination. The vaccine was effective in preventing smallpox infection in 95 percent of those vaccinated. Smallpox vaccination provides a high level of immunity for three to five years, after which the immunity decreases. If a person is vaccinated again later, immunity lasts even longer. Studies of smallpox cases in Europe in the 1950s and 1960s showed that the mortality rate among those vaccinated less than 10 years before exposure to the virus was 1.3 percent; it was 7 percent among those vaccinated 11-20 years before infection and 11 percent among those vaccinated 20 or more years before infection. In contrast, 52 percent of unvaccinated individuals have died. There are side effects and risks associated with smallpox vaccination. In the past, approximately 1 in 1000 people vaccinated for the first time have experienced serious, but not life-threatening, reactions, including toxic or allergic reactions at the vaccination site (erythema), spread of vaccinia virus to other parts of the body, and transmission of the virus to other persons. Potentially life-threatening reactions occurred in 14-500 people out of every 1 million people vaccinated for the first time. Based on past experience, it is estimated that 1 or 2 people out of 1 million (0.000198 percent) who receive the vaccine may die as a result, most often due to post-vaccination encephalitis or severe vaccine necrosis (called progressive vaccinia). Given these risks, since smallpox was effectively eradicated and natural cases fell below the number of vaccine-induced diseases and deaths, routine childhood vaccination was discontinued in 1972 in the United States and in the early 1970s in most European countries. Routine vaccination of health-care workers was discontinued in the United States in 1976, and among conscripts in 1990 (although military personnel infiltrating the Middle East and Korea are still being vaccinated). By 1986, routine vaccinations had ceased in all countries. Currently, vaccination is primarily recommended for laboratory workers at risk of occupational exposure.

Treatment

Vaccination against smallpox within three days of exposure will prevent or significantly reduce the severity of smallpox symptoms in the vast majority of people. Vaccination for four to seven days after exposure may provide some protection against illness or may alter the severity of illness. In addition to vaccination, treatment for smallpox is primarily supportive and includes wound care and infection control, fluid therapy, and possible mechanical ventilation. Smallpox and hemorrhagic pox are treated with therapies used to treat shock, such as fluid therapy. Individuals with semi-confluent and confluent smallpox may have similar therapeutic problems to those with extensive skin burns. There is no drug currently approved for the treatment of smallpox. However, antiviral therapies have improved since the last major smallpox epidemics, and research suggests that the antiviral drug cidofovir may be useful as a therapeutic agent. The drug, however, must be injected intravenously and can cause severe kidney toxicity.

Forecast

The overall case fatality rate for the common type of smallpox is about 30 percent, but varies according to the distribution of smallpox: common type of confluent is fatal in about 50-75 percent of cases, common smallpox is fatal in about 25-50 percent of cases, in those cases. when the rash is discrete, the mortality rate is less than 10 percent. The overall mortality rate for children under 1 year old is 40-50 percent. Hemorrhagic and flat types have the highest mortality rates. Mortality in flat type is 90 percent or more, and almost 100 percent in cases of hemorrhagic smallpox. The mortality rate for variola minor is 1 percent or less. There are no signs of chronic or recurrent variola virus infection. In fatal cases of common smallpox, death usually occurs between the tenth and sixteenth days of illness. The cause of death from smallpox is not known, but the infection is now known to affect several organs. Circulating immune complexes that suppress viremia or an uncontrolled immune response may be contributing factors. In early hemorrhagic smallpox, death occurs suddenly about six days after fever develops. The cause of death in hemorrhagic cases involves heart failure, sometimes accompanied by pulmonary edema. In late hemorrhagic cases, high and persistent viremia, severe platelet loss, and poor immune response are often cited as causes of death. In smallpox, deaths are similar to those in burns, with the loss of fluids, protein and electrolytes in such quantities that the body is unable to replace them, and transient sepsis.

Complications

Complications from smallpox occur most commonly in the respiratory system and range from simple bronchitis to fatal pneumonia. Respiratory complications usually develop by the eighth day of illness and can be either viral or bacterial in origin. Secondary bacterial skin infection is a relatively rare complication of smallpox. When this happens, the fever usually remains elevated. Other complications include encephalitis (1 in 500 patients), which is more common in adults and can lead to temporary disability; permanent scars, primarily on the face; and eye complications (2 percent of all cases). Pustules can form on the eyelid, conjunctiva, and cornea, leading to complications such as conjunctivitis, keratitis, corneal ulcers, iritis, iridocyclitis, and optic atrophy. Blindness develops in about 35-40 percent in eyes affected by keratitis and corneal ulcers. Hemorrhagic smallpox can lead to subconjunctival and retinal hemorrhages. In 2 to 5 percent of young children with smallpox, virions reach the joints and bones, causing osteomyelitis variolosa. The lesions are symmetrical and most common in the elbows, tibia and fibula, and characteristically cause epiphysis splitting and periosteal reactions. Swollen joints restrict movement, and arthritis can lead to limb deformities, ankylosis, malformed bones, loose joints, and short toes.

History

The appearance of the disease

The earliest reliable clinical signs of smallpox can be found in the medical literature from ancient India describing smallpox-like diseases (as early as 1500 BC), in the Egyptian mummy of Ramses V, who died more than 3000 years ago (1145 BC). AD) and in China (1122 BC). It has been suggested that Egyptian traders brought smallpox to India during the 1st millennium BC, where it remained as an endemic human disease for at least 2000 years. Smallpox was probably introduced to China during the 1st century AD from the southwest, and was imported from China to Japan in the 6th century. In Japan, the 735-737 epidemic is believed to have killed a third of the population. At least seven religious deities have been dedicated to smallpox, such as the god Sopona in the Yoruba religion. In India, the Hindu goddess of smallpox, Sitala Mata, was worshiped in temples throughout the country. The timing of smallpox in Europe and Southwest Asia is less clear. Smallpox is not clearly described in either the Old or New Testaments of the Bible, or in the literature of the Greeks or Romans. While some sources describe the Plague of Athens, which reportedly originated in "Ethiopia" and Egypt, or the plague that raised in 396 BC. the siege by Carthage of Syracuse with smallpox, many scholars agree that it is highly unlikely that a disease as serious as variola major would have escaped the description of Hippocrates if it had existed in the Mediterranean region during his lifetime. While the plague of Antoninus, which swept through the Roman Empire in 165-180 AD, may have been caused by smallpox, Saint Nikasius of Reims became the patron saint of smallpox victims for allegedly surviving the disease in 450, and Saint Gregory Toursky described a similar outbreak in France and Italy in 580, first using the term smallpox; other historians suggest that Arab armies were the first to transport smallpox from Africa to southwestern Europe during the 7th and 8th centuries. In the 9th century, the Persian physician Razi made one of the most authoritative descriptions of smallpox and was the first person to differentiate smallpox from measles and chickenpox in his Kitab fi al-jadari wa-al-hasbah (Book of Smallpox and Measles). During the Middle Ages, smallpox began to periodically penetrate Europe, but did not take root there until the population increased and population movements became more active during the era of the Crusades. By the 16th century, smallpox had become well known throughout most of Europe. With the introduction of smallpox into populated areas in India, China, and Europe, it has mainly affected children. Periodic epidemics have killed about 30 percent of those infected. Smallpox's permanent existence in Europe was of particular historical significance, as successive waves of exploration and colonization by Europeans were associated with the spread of the disease to other parts of the world. By the 16th century, smallpox had become an important cause of morbidity and mortality in much of the world. There are no reliable descriptions of smallpox-like diseases in the Americas before the arrival of Europeans in the 15th century AD. Smallpox was introduced to the Caribbean island of Hispaniola in 1509, and to the mainland in 1520, when Spanish settlers from Hispaniola arrived in Mexico, bringing smallpox with them. Smallpox killed the entire local Indian population and was an important factor in the Spanish conquest of the Aztecs and Incas. The discovery of the east coast of North America in 1633 in Plymouth, Massachusetts was also accompanied by devastating outbreaks of smallpox among the Indian population, and then among the native colonists. Fatality rates during outbreaks in Native American populations were 80-90%. Smallpox was introduced to Australia in 1789 and again in 1829. Although the disease was never endemic on the continent, it was the leading cause of death in aboriginal populations in 1780-1870. By the mid-18th century, smallpox had become the main endemic disease worldwide, with the exception of Australia and a few small islands. In Europe, smallpox was the leading cause of death in the 18th century, with about 400,000 Europeans killed each year. Up to 10 percent of Swedish children die of smallpox every year, and in Russia, child mortality could be even higher. The widespread use of variolation in several countries, notably Britain and its North American colonies and China, somewhat reduced the incidence of smallpox among wealthy classes in the second half of the 18th century, but no real decline occurred until vaccination became common practice. at the end of the 19th century. Improved vaccines and revaccination practices led to significant reductions in cases in Europe and North America, but smallpox remained largely uncontrolled and was widespread throughout the world. A much milder form of smallpox, variola minor, was discovered in the United States and South Africa in the late 19th century. By the mid-20th century, variola minor coexisted along with variola major in many parts of Africa. Patients with variola minor experience only mild systemic disease, are often on an outpatient basis throughout the disease, and therefore can spread the disease more easily. Infection v. minor induces immunity against the more deadly smallpox variola major. Thus, as v. minor spread throughout the United States, Canada, South America and the United Kingdom, it became the dominant form of smallpox, causing further reductions in mortality.

Eradication

The English physician Edward Jenner demonstrated the effectiveness of vaccinia in protecting people from smallpox in 1796, after which various attempts were made to eradicate smallpox on a regional scale. The introduction of the vaccine to the New World took place in Trinity, Newfoundland, in 1800 by Dr. John Clinch, a childhood friend and medical colleague of Jenner's. Back in 1803, the Spanish Crown organized the Balmis Expedition to transport the vaccine to Spanish colonies in the Americas and the Philippines, and developed mass vaccination programs. The U.S. Congress passed the Vaccination Act of 1813 to ensure the availability of a safe smallpox vaccine to the American public. By about 1817, there was a very powerful government vaccination program in the Dutch East Indies. In British India, a smallpox vaccination program was launched, through Indian vaccinators, led by European officials. However, British vaccination efforts in India and Burma in particular have been hampered by persistent local mistrust of vaccination despite tough legislation and improved vaccine efficacy. By 1832, the United States federal government had established a smallpox vaccination program for Native Americans. In 1842, the United Kingdom banned vaccinations and later launched a compulsory vaccination program. The British government introduced compulsory smallpox vaccination after the passage of an Act of Parliament in 1853. Smallpox vaccination was introduced in the United States from 1843 to 1855, first in Massachusetts and then in other states. While some did not like these measures, coordinated efforts against smallpox continued and the disease continued to decline in wealthy countries. By 1897, smallpox had been largely eradicated from the United States of America. Smallpox had been eradicated in a number of Nordic countries by 1900, and by 1914 the incidence in most industrialized countries had dropped to relatively low levels. Vaccination continued in industrialized countries until the mid to late 1970s to protect against recontamination. Australia and New Zealand are two exceptions; None of these countries had smallpox epidemics or extensive vaccination programs for the population; instead, these countries introduced protection from contact with other countries and strict quarantines. The first widespread (half the world) attempt to eradicate smallpox was in 1950 by the Pan American Health Organization. The campaign was successful in eliminating smallpox in all American countries with the exception of Argentina, Brazil, Colombia and Ecuador. In 1958, Professor Viktor Zhdanov, USSR Deputy Minister of Health, called on the World Health Assembly to launch a global initiative to eradicate smallpox. The proposal (Resolution WHA11.54) was adopted in 1959. At that time, 2 million people died from smallpox every year. Overall, however, progress in eradicating smallpox has been disappointing, especially in Africa and the Indian subcontinent. In 1966, the Smallpox Control Unit was formed, under the leadership of American Donald Henderson. In 1967, the World Health Organization stepped up the global smallpox eradication program, contributing $ 2.4 million a year to the effort, and adopted a new disease surveillance method promoted by Czech epidemiologist Karel Raska. In the early 1950s, there were an estimated 50 million cases of smallpox worldwide each year. In order to eradicate smallpox, it was necessary to stop the spread of each outbreak by isolating cases and vaccinating everyone nearby. This process is known as ring-shaped vaccination (creating a buffer zone). The key to this strategy is community case monitoring (surveillance) and disease containment. The initial challenge faced by the WHO team was insufficient reporting of smallpox cases, as many cases proceeded without the knowledge of the authorities. The fact that humans are the only reservoir for smallpox infection, and that carriers do not exist, played a significant role in smallpox eradication. WHO has established a network of consultants to assist countries in establishing surveillance and disease containment. In the beginning, vaccine donations were provided primarily by the Soviet Union and the United States, but by 1973, more than 80 percent of all vaccines were produced in developing countries. The last major European smallpox outbreak occurred in 1972 in Yugoslavia, after a Kosovo pilgrim returned from the Middle East where he contracted the virus. The epidemic infected 175 people, resulting in 35 deaths. The authorities declared martial law, forced quarantine, and took measures to widely revaccinate the population, with the help of WHO. After two months, the outbreak was over. Before that, an outbreak of smallpox was observed in May-July 1963 in Stockholm, Sweden, she was brought from the Far East by a Swedish sailor. It was fought with the help of quarantine measures and vaccination of the local population. By the end of 1975, smallpox remained only in the Horn of Africa. In Ethiopia and Somalia, where there were few roads, conditions were very difficult. Civil war, famine and refugees made the task even more difficult. In early to mid-1977, these countries underwent an intensive surveillance and containment and vaccination program led by Australian microbiologist Frank Fenner. As the campaign neared its goal, Fenner and his team were instrumental in confirming the liquidation. The last natural case of smallpox (Variola minor) was diagnosed in Ali Maow Maalin, a hospital cook in Merka, Somalia, on October 26, 1977. The last natural case of the more deadly Variola major was discovered in October 1975 in a two-year-old girl from Bangladesh, Rahima Banu. Global smallpox eradication was certified, based on intensive verification activities in various countries, by a commission of eminent scientists on December 9, 1979 and subsequently approved by the World Health Assembly on May 8, 1980. The first two proposals for the resolution: “Having reviewed the development and results of the global smallpox eradication program, initiated by WHO in 1958 and activated since 1967 ... we solemnly declare that the world and its peoples have won freedom from smallpox, which has been the most devastating disease in the form of an epidemic in many countries since the earliest time leading to death, blindness and physical defects and which only ten years ago was widespread in Africa, Asia and South America. "- World Health Organization Resolution WHA33.3

After liquidation

The last cases of smallpox in the world occurred in an outbreak of two cases (one of which was fatal) in Birmingham, UK, in 1978. Medical photographer Janet Parker became infected at the University of Birmingham School of Medicine and died on 11 September 1978, followed by Professor Henry Bedson , the scientist in charge of smallpox research at the university committed suicide. All known smallpox stocks were subsequently destroyed or transferred to two WHO-designated reference laboratories - the US Centers for Disease Control and Prevention and the Russian State Research Center for Virology and Biotechnology Vector. WHO first recommended the destruction of the virus in 1986, and then set a date for destruction on December 30, 1993. The date was then pushed back to June 30, 1999. Due to opposition from the United States and Russia, in 2002 the World Health Assembly decided to allow temporary storage of the virus stocks for specific research purposes. Destruction of existing stocks will reduce the risk associated with ongoing smallpox research. You don't need supplies to respond to smallpox outbreaks. Some scientists argue that the stock could be useful in the development of new vaccines, antiviral drugs, and diagnostic tests. However, a 2010 review by a group of public health experts appointed by WHO concluded that no major public health goal justifies the storage of variola virus in the United States and Russia. The latter point of view is often held by the scientific community, especially among the veterans of the WHO Smallpox Eradication Program. In March 2004, smallpox scabs were found in an envelope in a Civil War medical book in Santa Fe, New Mexico. The envelope was marked as containing vaccine scabs and handed over to scientists at the Centers for Disease Control and Prevention with the opportunity to study the history of smallpox vaccination in the United States. In July 2014, several vials of smallpox virus were found in an FDA laboratory at the National Institutes of Health premises in Bethesda, Maryland.

Society and culture

Bacteriological warfare

The British used smallpox as a biological weapon in the siege of Fort Pitt during the French and Indian Wars (1754-1763) against France and its Indian allies. The actual use of the variola virus has been officially authorized. British officers, including leading British generals, ordered, authorized and paid for the use of the smallpox virus against Native Americans. According to historians, "there is no doubt that the British military authorities approved of the attempts to spread smallpox among the enemies," and that "it was a deliberate British policy of infecting Indian smallpox." The effectiveness of efforts to spread the disease is unknown. There is also evidence that smallpox was used as a weapon during the American War of Independence (1775-1783). According to a theory put forward in the Journal of Australian Studies (JAS) by an independent researcher in 1789, the British Marines used smallpox against indigenous tribes in New South Wales. This was also discussed earlier in the Bulletin of the History of Medicine and by David Day in his book Claiming a Continent: A New History of Australia. Prior to the JAS article, this theory was challenged by some scholars. Jack Carmody argued that the cause of the outbreak was most likely chickenpox, which at the time was sometimes identified as a mild form of smallpox. Although it was noted that during the 8-month voyage of the First Fleet and in the following 14 months, there were no reports of smallpox among the colonists, and that since smallpox has an incubation period of 10-12 days, it is unlikely that it was present during the First Fleet, in It is now known that the probable source was the variola virus bottles owned by the First Fleet surgeons and, in fact, there was a report of smallpox among the colonists. During World War II, scientists from the United Kingdom, the United States and Japan (Unit 731 of the Imperial Japanese Army) were involved in research into the production of biological weapons from the variola virus. The plans for large-scale production were never fully implemented, as scientists felt that the weapon would not be very effective due to the widespread availability of the vaccine. In 1947, a smallpox-based biological weapons plant was founded in the Soviet Union in the city of Zagorsk, 75 km northeast of Moscow. An outbreak of weaponized smallpox occurred during tests at a facility on an island in the Aral Sea in 1971. Pyotr Burgasov, a former chief medical officer of the Soviet army and a senior researcher for the Soviet biological weapons program, described the incident: “The strongest smallpox recipes were tested on Vozrozhdenie Island in the Aral Sea. Suddenly I was informed about the mysterious deaths in Aralsk. The research ship of the Aral Fleet approached the island at a distance of 15 km (although it was forbidden to come closer than 40 km). The ship's laboratory assistant took plankton samples twice a day from the upper deck. Smallpox preparation - 400 gr. of which were blown up on the island - infected her. After returning home to Aralsk, she infected several people, including children. They all died. I suspected the reason for this and called the Chief of the General Staff of the Ministry of Defense and asked to ban the Alma-Ata-Moscow train from stopping in Aralsk. As a result, the spread of the epidemic throughout the country was prevented. I called Andropov, who was the head of the KGB at the time, and told him about an exceptional recipe for smallpox obtained on the island of Vozrozhdenie. " Others argue that the first patient may have contracted the infection while visiting Uyala or Komsomolsk-on-Ustyurt, two cities where the ship was docked. In response to international pressure, in 1991 the Soviet government allowed a joint US-British inspection team to visit four of its main facilities at Biopreparat. The inspectors were greeted unfriendly and were eventually kicked out of the facility. In 1992, Soviet defector Ken Alibek claimed that the Soviet biological weapons program in Zagorsk had produced large quantities - as many as twenty tons - of biological weapons in the form of the smallpox virus (possibly, according to Alibek, to counter vaccines), along with refrigerated warheads to deliver weapons. Alibek's stories about the activities of the former Soviet smallpox program have never been verified by independent experts. In 1997, the Russian government announced that all remaining smallpox samples would be transferred to the Vector Institute in Koltsovo. With the collapse of the Soviet Union and the unemployment of many scientists involved in the weapons program, US government officials have expressed concern that smallpox and its biological weapons expertise may become available to other states or terrorist groups that may wish to use the virus. as a means of biological warfare. The specific charges against Iraq in this regard, however, have proven to be wrong. Concern was expressed about the possibility of reconstructing a virus from existing digital genomes by artificially synthesizing genes for use in biological warfare. The insertion of synthesized smallpox DNA into existing related smallpox viruses could theoretically be used to recreate the virus. The first step to mitigating this risk is believed to be to destroy the remaining stocks of the virus in a way that clearly criminalizes the possession of the virus.

Notable cases

In 1767, 11-year-old composer Wolfgang Amadeus Mozart survived a smallpox outbreak in Austria that killed the Holy Roman Empress Maria Joseph, who became the second wife of Holy Roman Emperor Joseph II, who died of an illness like Archduchess Maria Joseph. Famous historical figures who contracted smallpox: the chief of the Hunkpapa Indian tribe Sitting Bull, Emperor Ramses V of Egypt, Emperor Kangxi (survived), Emperor Shunzhi and Emperor Tongzhi in China, Date Masamune from Japan (lost an eye due to illness). Cuitlahuac, the 10th Tlatoani (ruler) of the Aztec city of Tenochtitlan, died of smallpox in 1520, shortly after its appearance in the Americas, and the Inca emperor Huayna Capac died of smallpox in 1527. More modern public figures affected by the disease include Guru Har Krishan, 8th Guru of the Sikhs, in 1664, Peter II of Russia in 1730 (died), George Washington (survived), King Louis XV in 1774 (died) and Maximilian III, Elector of Bavaria in 1777. In many eminent families around the world, several people were often sick who were infected and / or died from the disease. For example, several relatives of Henry VIII survived the disease, but remained after it in injuries and scars. These include his sister Margaret, Queen of Scots, his fourth wife, Anne of Cleves, and his two daughters, Mary I of England in 1527 and Elizabeth I of England in 1562 (she often tried to mask pock marks with makeup as an adult). His great-niece Maria Stuart became infected as a child, but she did not have any visible scars. In Europe, smallpox deaths often played a large role in dynastic succession. Henry VIII's only surviving son, Edward VI, died of complications, shortly after apparently recovering from an illness, thereby negating Henry's efforts to secure the throne with a male heir (his two closest successors were women, both of whom survived smallpox). Louis XV of France assumed the throne from his great-grandfather Louis XIV through a series of smallpox or measles deaths among his relatives who were to have taken the throne earlier. Louis himself died of illness in 1774. William III lost his mother to this disease when he was only ten years old, in 1660, and made his uncle Charles the legal guardian: her death from smallpox indirectly provoked a chain of events that ultimately led to the permanent displacement of the family Stewart of the British throne. William III's wife, Mary II of England, died of smallpox. In Russia, Peter II died of illness at the age of 15. In addition, before becoming the Russian emperor, Peter III was infected with the virus and suffered greatly from it. He left noticeable scars from his illness. His wife, Catherine the Great, was rescued, but the fear of the virus was clearly taking its toll on her. She was so much afraid for the safety of her son and heir Paul, did not allow him to go out to large crowds of people, trying to isolate him. In the end, she decided to get herself vaccinated by the Scottish doctor Thomas Dimsdale. At the time, vaccination was considered a controversial method at the time, however, Catherine did not fall ill. Later, her son Paul was also vaccinated. Catherine wanted to spread vaccinations throughout her empire, stating: "My goal was, through my example, to save from death many of my subjects, who, not knowing the meaning of this technique, and fearing it, were left in danger." By 1800, about 2 million vaccinations had been introduced in the Russian Empire. In China, the Qing dynasty had extensive protocols to protect the Manchus from Beijing's endemic smallpox. US Presidents George Washington, Andrew Jackson, and Abraham Lincoln all had smallpox and recovered from it. Washington contracted smallpox after a visit to Barbados in 1751. Jackson developed the disease after being captured by the British during the American Revolution, and although he recovered, his brother Robert died. Lincoln contracted the infection during his presidency, possibly from his son Ted, and was quarantined shortly after receiving his Gettysburg address in 1863. Renowned theologian Jonathan Edwards died of smallpox in 1758 after being vaccinated. Soviet leader Joseph Stalin contracted smallpox at the age of seven. His face was scarred from the disease. His photographs were later retouched to make the pock marks less visible. The Hungarian poet Kölcei, who wrote the Hungarian national anthem, lost his right eye due to smallpox.

Tradition and religion

In various parts of the Old World, such as China and India, people worshiped various smallpox deities. In China, the goddess of smallpox is referred to as Tou-Shen Nyang-Niang. Chinese believers actively tried to appease the goddess and pray for her mercy, and called the smallpox pustules "pretty flowers," as a euphemism meant not to offend the goddess. In this regard, on New Year's Eve, it was such a custom that children at home put on ugly masks while sleeping in order to hide the beauty and thereby avoid the attraction of the goddess who would pass through the house that night. If there was a case of smallpox, shrines were created in the homes of the victims to be worshiped during illness. If the victim recovered, the shrines were carried away on a special paper stand or in a boat for burning. If the patient did not recover, the shrine was destroyed and cursed in order to drive the goddess out of the house. The first records of smallpox in India can be found in a medical book that dates back to 400 AD. In India, as in China, the goddess of smallpox was created. The Hindu goddess Shitala was worshiped and feared during her reign. It was believed that this goddess was both evil and kind and had the ability to inflict suffering on her victims, being in anger, as well as to calm fevers in those who were already suffering. In the portraits, the goddess is depicted with a broom in her right hand to move the disease to another place, and a pot of cool water, on the other hand, to calm the victims. Shrines were created that many indigenous people in India, both healthy and sick, could worship in an attempt to protect themselves from this disease. Some Indian women, in an attempt to ward off Shitala, placed plates of chilled food and pots of water on their rooftops. In cultures that did not have a special deity to represent smallpox, however, there was often a belief in smallpox demons, which were accordingly blamed for the spread of the disease. Such beliefs were common in Japan, Europe, Africa and other parts of the world. In almost all cultures where the demon was believed, it was believed that he was afraid of red. This led to the invention of the so-called "red treatment", in which the victims were dressed in red and their rooms were also decorated in red. The practice spread to Europe in the 12th century and was practiced (among others) by Charles V of France and Elizabeth I of England. Thanks to Finsen's research showing that red light reduces scarring, this belief persisted into the 1930s.

: Tags

List of used literature:

"Smallpox is not a bad weapon." Interview with General Burgasov (in Russian). Moscow News. Retrieved 2007-06-18

Koplow, David (2003). Smallpox: The Fight to Eradicate a Global Scourge. Berkeley and Los Angeles, CA: University of California Press. ISBN 0-520-23732-3

Massie, Robert K. (2011). Catherine the Great: Portrait of as Woman, pp. 387-388. Random House, New York. ISBN 978-0-679-45672-8

Giblin, James C. When Plague Strikes: The Black Death, Smallpox, AIDS. United States of America: HarperCollins Publishers, 1995

Tucker, Jonathan B. Scourge: The Once and Future Threat of Smallpox. New York: Atlantic Monthly Press, 2001

History

Smallpox is one of the most ancient infectious diseases that have left in the history of mankind sad pages about the general disaster, the "sea".

Apparently, Smallpox originated on the territory of Central Africa, as evidenced by the manuscript monuments of Ancient Egypt. Confirmation that smallpox has been found in Egypt since time immemorial is, in particular, a mummy discovered by archaeologists with traces of smallpox transferred by the deceased, dating back to the 3rd millennium BC. NS. Mention of the disease, on clinical grounds corresponding to smallpox, is found in one of the earliest sources of Indian medical writing (9th century BC). Chinese chronicles report the existence of smallpox in the 12th century. BC. Smallpox is mentioned in the writings of K. Galen, Hippocrates and others.

The first detailed description of Smallpox natural belongs, as many historians of medicine believe, Razi. He believed that both measles and smallpox are diseases that everyone suffers in childhood. Razi was the first to distinguish smallpox from the group of diseases accompanied by rashes into an independent disease. The first physician to describe Smallpox as a contagious disease was Ibn Sina. In the 4th century, smallpox was introduced from northeast Africa to Arabia, and in the middle of the 6th century it penetrated into Europe. Since the period of the Crusades, the epidemics of this devastating disease did not stop on the European mainland. They are registered in the 6th and 7th centuries in France, Italy, Spain, Sicily. In the 13th century, an epidemic of Smallpox was noted in Iceland. The first appearance of smallpox in Germany and Russia dates back to the 15th century. In the early 16th century, smallpox was introduced to America; the first outbreaks were observed here already in 1507 It is known that the introduction of smallpox to this continent occurred during the period of its conquest by the Spaniards; in the detachment, heading at the beginning of the 16th century to the shores of Mexico, was sick with smallpox. The disease is widespread among the local population. In order to destroy the Mexican tribes, the colonialists, in particular, hung clothes in the forests that were infected with the pus of smallpox patients. These clothes attracted the natives, and along with the "gift" they received smallpox, from which they themselves perished and infect others. In 1563, Smallpox was introduced to the territory of Brazil, where 100 thousand people died in the province of Chitu alone. The British introduced the disease to the East Coast of North America. In 1616-1617, the largest epidemic among the Indians was registered here, as a result of which the Algonkzn tribe inhabiting the territory of the present state of Massachusetts was almost completely killed. Smallpox was introduced to Australia at the end of the 18th century.

It is believed that in some years in Europe natural smallpox fell ill 10-12 million people, and the mortality rate was up to 25-40%. Smallpox took a huge number of victims, leaving behind a large number of blind people.

A turning point in the fight against Smallpox was the discovery of smallpox vaccine by E. Jenner (1796). However, despite the fact that smallpox vaccination became known to mankind at the end of the 18th century (see the complete body of knowledge on vaccination), there are clear indications in the literature that even at the beginning of the 20th century, none of the viral infections was as widespread as smallpox ... Nevertheless, since the opening of the I International Sanitary Conference (1851), natural smallpox did not appear on the agenda of international conferences or in the summary of international sanitary rules. And only in 1926, at the XIII International Sanitary Conference, a delegate of Japan proposed to add Smallpox to the list of diseases requiring a mandatory declaration. However, the delegate of Switzerland objected to this proposal, arguing that natural smallpox exists everywhere: there seems to be no country that can be said to be free of smallpox. During the discussion, the conference nevertheless decided to include Natural Smallpox in the number of "conventional" diseases, however, a mandatory declaration was required only in the event of an epidemic outbreak, while notification of individual cases of Natural Smallpox was considered optional.

The existence of foci of Smallpox in Asia, Africa and South America posed a potential threat to epidemics if preventive measures were weakened. Smallpox is imported to countries free of this infection every year. As a result of the analysis of the epidemic situation, it became clear that not a single country in the world during the period of rapid development of international air and other types of communications is guaranteed against the import of Smallpox, and quarantine measures in conditions of mass movement of people became more and more difficult. Taking into account the above, in 1958, at the XI session of the World Health Assembly (WHA), the Soviet delegation made a proposal to eliminate Smallpox all over the world. After discussing the Soviet proposal, the Assembly unanimously adopted a landmark resolution proclaiming a global smallpox eradication program. As a result of the united efforts of all countries of the world, Smallpox was eliminated in South America in 1971, in Asia - in 1975, in Africa - in 1977.The last case of Smallpox in the world was registered in Somalia on October 26, 1977 Officially victory over Smallpox was proclaimed at the World Health Assembly in May 1980, at which the role of the USSR in this victory was noted. Academician BV Petrovsky spoke on behalf of the European region. The successful implementation of the global program for the eradication of Smallpox was facilitated by: a favorable situation in the world, when, thanks to the brilliant victory of the Soviet Union and its allies over fascism, the prerequisites were created for uniting the efforts of all countries of the world aimed at combating especially dangerous infections; coordination of all work on the elimination of Smallpox natural by a single center, which was the WHO; supplying all endemic countries with a vaccine that meets the WHO requirements for both potency and stability; vaccination by methods that exclude an error in the vaccination technique; the establishment of an epidemiological surveillance service, which, at the end of the campaign, is a central element in the strategy for the eradication of Smallpox; ensuring effective leadership and oversight with the participation of WHO international staff in the implementation of national programs.

The Soviet Union, being the initiator of the smallpox eradication program in the world, actively participated in its implementation. In particular, our country donated over 1.5 billion doses of smallpox vaccine to WHO and many countries. Soviet institutions and specialists helped in setting up smallpox vaccine production in other countries, organizing and conducting national programs, and carrying out laboratory diagnostics of smallpox and smallpox-like diseases.

Geographic distribution and statistics

The greatest distribution in the world Natural smallpox reached in the 18th century. After the introduction of smallpox vaccination according to Jenner in many countries, the incidence began to decline. However, since only a part of the population was vaccinated against smallpox, epidemics continued in the 19th and 20th centuries.Analysis of the incidence of smallpox in the 20th century shows that before the First World War, in addition to old foci in Asia, Africa, America, there were systematic outbreaks in Europe. The epidemiological situation in Europe and the United States deteriorated sharply after the First World War. So, in Italy in 1917-1919, natural smallpox fell ill over 40 thousand people. In 1920 alone, 167,300 cases of Smallpox were reported in Europe. In 1926, when the first Weekly Epidemiological Brief was published by the Hygiene Section of the League of Nations Secretariat, in the United States, Smallpox was recorded in 27 states. In the 30s, the incidence of smallpox natural in a significant majority of European countries fell sharply, mainly due to the completeness and quality of vaccination of the population. In the USSR, by 1936, natural smallpox was eliminated. Since 1943, as a result of the weakening of preventive measures in some European countries, large epidemics were again registered. Natural smallpox So, in 1943, 1219 diseases were registered in Greece, in Italy in 1944 and 1945 - 2878 and 3116, respectively. After the Second World War, isolated diseases and epidemic outbreaks, mainly imported in nature, were recorded in Australia, Europe and North America. The last such outbreak was registered in 1972 in Yugoslavia, during which 25 people died out of 175 cases.

The distribution of Smallpox by country has been systematically published by WHO in its annual statistical reports based on information received from governments. However, the identification and registration of smallpox patients, especially in developing countries, were far from complete. Both during the boom years and during the recession, the incidence in the world, as a rule, was determined by its level in Asia.

Information about the number of registered diseases Natural smallpox in the world for 1950-1978, as well as the number of countries where this disease was registered, are given in table. 1. Analysis of these data shows that, despite a significant decrease in the incidence of Smallpox natural in the 50s of the 20th century, the disease was recorded in more than 60-80 countries almost every year.

Etiology

The causative agent Natural smallpox - a virus (variola virus) - was first discovered by J. V. Buist (1886), and then E. Paschen (1906), who proposed a special color for its detection, after which the virions observed using light microscopy were named “ Pashen's little calf ”. The virus belongs to the Poxviridae family, the Chordopoxvirinae subfamily, the Orthopoxvirus genus. The genome of the Smallpox virus is represented by a double-stranded linear DNA, the number of structural proteins is at least 30. The virus virions during electron microscopic examination have a characteristic brick-like shape with rounded corners (Figure 1) and dimensions of 150 × 200 × 300 nanometers. The structure of the virion according to AA Avakyan and AF Bykovsky is shown in Figure 2. Natural smallpox virus is actively reproduced in primary and transplanted cell cultures of various origins, causing a cytopathic effect and the phenomenon of hemadsorption; possesses a weak hemagglutinating activity, replicates well in developing chick embryos upon infection on the chorion-allantoic membrane (Figure 3, a). The natural smallpox virus is a little pathogenic for animals, monkeys of some species are susceptible to it, which develop a disease that resembles human smallpox in its manifestations (especially in higher monkeys). Smallpox virus natural is also pathogenic for white mice (with intracerebral injection) during the first 10-12 days of the postnatal period, later these animals become insensitive to the virus. Infection with natural smallpox virus in humans and animals is accompanied by the formation of anti-smallpox antibodies. The similarity of the antigenic structure of the natural smallpox virus and the vaccinia virus, which causes vaccinal disease (see the complete body of knowledge), is the basis for the use of vaccinia virus as an antigen in the formulation of diagnostic reactions. In natural cells of humans, susceptible animals, chicken embryos and cell cultures affected by the Smallpox virus, cytoplasmic inclusions of Guarnieri's body are formed (Figure 4). Natural smallpox virus is resistant to environmental factors, which contributes to its long-term (within months) preservation in the crusts of smallpox pustules.

Rice. 1. Micropreparation of skin in case of smallpox: in the thickness of the epidermis there are large bubbles (indicated by an arrow), formed as a result of balloon dystrophy; staining with hematoxylin eosin; × 80. Rice. 2. Micropreparation of the skin in case of smallpox: the arrows indicate the intradermal pustule; staining with hematoxylin eosin; × 80. Rice. 3. Macrodrug of the trachea, main bronchi and lung tissue (longitudinal section) in case of smallpox: arrows indicate pustular eruptions on the tracheal mucosa: there are multiple foci of miliary necrosis in the lung tissue. Rice. 4. Macrodrug of a part of the stomach in case of smallpox: arrows indicate large smallpox pustules in the gastric mucosa. Rice. 5. Microscopic preparation of skin in case of smallpox: desquamation of the epithelium (1), continuous foci of hemorrhagic impregnation of the dermis (2); staining with hematoxylin eosin; × 80. Rice. 6. Micropreparation of a lung in case of smallpox: arrows indicate miliary foci of necrotizing pneumonia; staining with hematoxylin-eosin; × 80.

In addition, smallpox viruses, genetically close to the causative agent Natural smallpox, can cause smallpox in domestic and wild animals (monkeys, cows, horses, sheep, goats, pigs, rabbits, birds). The disease is more often caused by a pathogen specific to this type of animal. However, there are known cases of the disease (for example, in horses and other animal species) caused by the causative agent of vaccinia. Man is susceptible only to some viruses of animal smallpox (monkeys and cows). Monkeypox virus was isolated in 1958 in Copenhagen. The first case of human disease caused by this virus, accompanied by pustular rashes, indistinguishable from rashes with Smallpox natural, was registered in August 1970 in the Republic of Zaire. From 1970 to 1980, 51 human cases of monkeypox were reported in Africa. At the same time, monkeypox virus was isolated from 29 patients. According to Bremen (J. G. Breman) and co-authors (1980), the possibility of transmission of the causative agent of this infection from person to person is allowed.

See the complete body of knowledge Poxviruses.

Epidemiology

The source of infection is a sick person during the entire illness, from the beginning of the incubation period until the crusts fall off. A source of infection can be a patient with any form of smallpox, including smallpox without a rash. The period of maximum infectiousness of the patient Natural smallpox is from the 3rd to the 8th day after the onset of the fever.

The infectiousness of the patient depends on the degree and severity of the clinical manifestations of the disease. Patients with a severe form of the disease with profuse rashes are of the greatest epidemiological importance. With erased forms of Smallpox natural, a significant reduction in the time of infectiousness of the patient is observed - sometimes up to several hours. The likelihood of transmission of the virus depends on the frequency and degree of contact between the sick person and the susceptible person. The degree of protection from disease after vaccination depends on the interval between the last vaccination and contact with the patient.

Although smallpox crusts contain a large number of viruses, the most important factor in the spread of infection is the isolation of the virus from the respiratory tract. The main route of transmission of infection is airborne. Dispersion of the virus with droplets of mucus and saliva occurs when talking and especially when sneezing and coughing. The virus can also be dispersed with dust particles by shaking infected linen and clothing - dust-air path. Due to the high resistance of the Smallpox virus in the environment, things and objects infected with it can serve as factors of transmission of the pathogen when they are shipped over long distances (infected linen, cotton, carpets, and so on). Cases of the occurrence of generalized smallpox in persons who took part in the autopsy of the corpses of people who died from Smallpox natural, and the processing of sectional material are described. There are known cases of transplacental transmission of the virus. Described laboratory infections Natural smallpox

Although a person's susceptibility to smallpox natural is considered absolute, observations indicate that after a single contact with a patient, 35-40% of people who have not been previously vaccinated and have not been ill in the past get sick. the first case was diagnosed a few weeks after the onset of the disease. In countries where routine vaccination and revaccination against Smallpox natural was carried out, during its import, the epidemic process was characterized by a significant number of erased forms, which was due to the high level of collective immunity of the population. This feature made it difficult to diagnose the disease in a timely manner and led, accordingly, to a delay in the implementation of anti-epidemic measures. Analysis of smallpox outbreaks associated with the importation of infection into Europe and North America showed that they were almost always the result of an erroneous diagnosis in the first patients. Smallpox natural transmission from one area of ​​the country to another or from country to country has usually been carried out by traveling patients who are in the incubation period of the disease.

Features of the distribution of Smallpox natural in the recent past can be traced to the following examples. The artist K., after a two-week stay in India, returned to Moscow on December 22, 1959. On December 23, he felt unwell and on the 24th went to the clinic, where he was diagnosed with influenza. On December 26, a rash appeared on the abdomen and chest, the patient's condition worsened, and on the 27th he was admitted to the Moscow Clinical Hospital. SP Botkin diagnosed with toxic flu and drug disease. The patient died on December 29. They returned to this case on January 15, 1960, when the patients who had contact with the deceased K. were diagnosed with Natural smallpox. also a hearth in a hospital among patients and service personnel. These two foci, in turn, led to the formation of the third urban foci Natural smallpox. The total number of patients by this time had reached 19. The large dispersal of contacts in the city required urgent measures. During the examination in the city, 9342 people were identified who, in one way or another, had contact with the sick. Of these, 1210 contacts with patients were directly isolated in a special hospital in Moscow and 286 in hospitals in the Moscow region. Simultaneously with the identification of contact persons, vaccination was carried out. Between 16 and 27 January 1960, 6,187,690 people were vaccinated. As a result of the energetic measures taken, the outbreak did not go beyond Moscow. The last patient from among those in the isolation ward was registered on February 3. An indicator of the effectiveness of the measures taken is that the outbreak was eliminated within 19 days from the moment when they began to be carried out.

In April 1960, there was a second case of importation of Natural Smallpox to Moscow. Smallpox natural was suspected and later confirmed in passenger R.S., who was traveling by plane from Delhi in transit through Moscow. This case turned out to be the only one, and R.S., 40 days after the onset of the illness, left for her homeland in a satisfactory condition.

As a result of the implementation of the global program for the eradication of Smallpox, natural smallpox, thanks to the coordinated and energetic actions of many states and a scientifically based strategy, for the first time in the history of mankind, the fight against one of the most dangerous infections, which claimed millions of lives in the past, was crowned with success. However, this success should not lead to premature calm. It should be remembered that cases of Smallpox natural disease may recur. So, for example, there is a potential danger of infection of Smallpox natural in laboratory conditions, similar diseases are registered in London (1973) and in Birmingham (1978). In the first case, two more people became infected from a sick worker.

Pathogenesis

The virus penetrates the mucous membrane of the nasopharynx and upper respiratory tract, less often through the skin and enters the regional lymph nodes, including the pharyngeal lymphatic ring, where it multiplies. Accumulation of the pathogen in the lungs is possible. After 1-2 days, the first generations of the virus enter the blood from these organs - primary, or minor, viremia (see the complete body of knowledge), from where the pathogen disseminates into the organs of the reticuloendothelial system. Here, the virus multiplies with its secondary release into the blood - secondary, or large, viremia, this process is accompanied by the appearance of clinical signs of the disease. The duration of this phase is 5-10 days. The stage of secondary viremia is followed by secondary dissemination of the virus, especially into ectodermal tissues, previously sensitized during primary viremia. The virus easily adapts to the epithelial cells of the skin and mucous membranes, multiplies intensively, causing clinical manifestations in the form of an evolving monomorphic rash on the skin with the stages of spot - papule - vesicle - pustule - ulcer - crust - scar, and on the mucous membranes of the eyes, respiratory tract, esophagus, urinary system, vagina and anus with stages spot - papule - vesicle - erosion. Secondary viremia and secondary dissemination of the virus leads to severe intoxication (see full body of knowledge), manifested by fever, headache, insomnia, muscle pain and lower back pain.

The disease varies from mild forms (smallpox without rash) to extremely severe with severe capillarotoxicosis and hemorrhagic manifestations. An important role is played by the addition of a secondary infection (pneumonia and others).

Pathological anatomy

The earliest changes in the skin are expansion of capillaries in the papillary layer of the dermis, edema and the appearance of perivascular infiltration by lymphoid and histiocytic cellular elements. Changes in the epidermis very quickly join, which are expressed in swelling of epithelial cells and proliferation of cells of the basal layer. Increasing edema and penetration of serous exudate into the thickness of the epidermis lead to the appearance of small intraepidermal vesicles - balloon dystrophy (color picture 1). This process is accompanied by discomplexation and separation of cells with the formation of epithelial cords located perpendicular to the surface of the epidermis, as a result of which the epidermal vesicle is divided into several chambers. This phenomenon is called reticular dystrophy. A large multi-chambered bladder is gradually formed, which looks at first as a papule (see the complete body of knowledge), and then as a vesicle (see the complete body of knowledge), towering above the skin. Very quickly, due to the growing inflammation in the papillary layer of the dermis, the vesicle fills with leukocytes, the exudate becomes serous-purulent and purulent, an intraepidermal pustule is formed (color picture 2). In its center, the phenomena of necrobiosis are rapidly growing, and the previously observed slight depression intensifies, forming a typical central depression. Necrosis in the center of the pustule (see the complete body of knowledge) is accompanied by the formation of crusts. The bottom of the pustule is the infiltrated papillary layer of the dermis, however, due to the fact that the basal layer of the epidermis can still be preserved not only along the edges of the pustule, but also throughout it, then, apparently, complete healing of the defect without a scar is possible. The formation of a scar at the site of a pustule is determined, as a rule, by the depth of destructive changes and suppurative process in the dermis. Vesicular and pustular rashes are observed not only on the skin, but also on the mucous membrane of the mouth, nose, larynx, pharynx, trachea, esophagus, stomach, intestines, vagina (color Figure 3.4). In these cases, the development of typical pustules often does not occur, since in connection with the anatomical features of the epithelium, a bubble breakthrough and the formation of erosion quickly occur (see the complete body of knowledge).

With a milder form of Smallpox natural in the initial stages, the same changes in the skin are observed as in the pustular form, however, the process ends with the formation of a vesicle, followed by resorption of its contents and very rarely with the development of pustules.

In some cases, erythrocytes are found in the exudate, and the process can take on a hemorrhagic nature with the development of a hemorrhagic form of Smallpox natural In such cases, the formation of typical vesicles and pustules may not be observed. The skin of the face, trunk, limbs is sharply edematous, dotted with many small-spot and large-spotted hemorrhages that rise above the surface, resembling hemorrhagic urticarial rashes. In many areas, the epidermis exfoliates, forming skin imperfections with a bright red moist bottom. Microscopically, in the skin, diffuse hemorrhages are visible, occupying the entire thickness of the dermis (color picture 5) without signs of specific changes. At the same time, balloon and reticular degeneration of epidermal cells develops in many areas with the formation of small and then larger bubbles merging with each other, the contents of which remain hemorrhagic or serous-hemorrhagic. A sharp edema, massive hemorrhages, an increasing intraepidermal accumulation of hemorrhagic and serous-hemorrhagic exudate, apparently, cause, in such cases, the detachment of the epidermis, its sloughing and the formation of various sizes of erosive bleeding surfaces.

With various forms of Smallpox natural, in addition to skin lesions, typical morphological changes develop in a number of internal organs. These processes include necrotizing orchitis, necrosis and hemorrhage in the bone marrow, necrotizing tonsillitis (in the tonsils, necrotic foci are found in the lymphatic, follicles and crypts, while the epithelium lining the crypts undergoes hydropic dystrophy, reminiscent of that in the epidermis). Necrotizing tonsillitis can be caused, apparently, both by the influence of the smallpox virus and by the phenomena of agranulocytosis. In rare cases, there is a uniform lesion of the lung tissue in the form of disseminated miliary necrosis, widespread miliary necrotizing pneumonia (color picture 6). The epithelium of the trachea, bronchi, bronchioles is thickened, swollen, in places discomplexed with the formation of small vesicles.

The spleen is enlarged due to plethora and hyperplasia of the pulp, often with symptoms of myelosis. In the kidneys, liver, heart, dystrophic changes expressed in varying degrees are observed.

Immunity

After the illness, persistent, often lifelong immunity remains (see the complete body of knowledge). However, repeated illnesses are known (according to WHO, approximately 1 patient per 1000 patients). In these cases, the disease is mild, deaths are rare. Immunity in Smallpox is natural, not only tissue, but also humoral, which is confirmed by the detection in the blood during illness, and especially after recovery, virus neutralizing, complement-fixing, precipitating antibodies and antihemagglutinins. First of all, aityhemagglutinins are detected - on the 2-3rd day of illness. Later, neutralizing antibodies are found, but they persist longer and more stable than antihemagglutinins. Comilement-fixing antibodies appear on the 8-10th day of illness and persist for several months. However, the relationship between the level of antibodies and the strength of immunity has not been established. The reproduction of the virus in the skin and mucous membranes is suspended with the development of cellular immunity due to the production of interferon (CM) in the cells.

The body's immunity to Smallpox is created artificially, through active immunization with smallpox vaccine. The duration and intensity of immunity after vaccination depends on the quality of the smallpox vaccine, as well as the individual characteristics and state of human health (see the complete body of knowledge Opoinoculation).

Clinical picture

Distinguish between mild, moderate and severe forms of the disease. The most typical clinic of the moderate form of Smallpox is natural, in which the following periods of the disease are distinguished: incubation; prodromal, or initial; the appearance of a smallpox rash; pustulization, or suppuration; drying period; convalescence period.

An incubation period of 10-12 days is considered fairly constant. It can be shorter - up to 7 days and longer - up to 15 days, very rarely - up to 17.

In typical cases, the disease begins acutely with chills, fever up to 40 °, severe weakness. Immediately appear headache (in the back of the head) and muscle pain, anxiety, insomnia, sometimes delirium and even loss of consciousness. Pain in the lumbar region and sacrum (rachialgia) is especially common. The mucous membrane of the lips is dry, the tongue is coated, the mucous membrane of the soft palate, pharynx and nasopharynx is hyperemic. Swallowing may be difficult. Sometimes, especially in children, there is pain in the epigastric region, repeated vomiting. Tachycardia and tachypnea, cough and runny nose are characteristic. The liver and spleen are enlarged. Oliguria and moderate albuminuria are noted, in the blood - usually mononuclear leukocytosis. On the 2-3rd day from the beginning of the prodromal period, about 1/3 of patients develop a so-called prodromal rash, which may resemble a rash with scarlet fever, measles, rubella. It can be erythematous or, in severe cases, petechial, but always with a typical localization in the neck, along the projection of the pectoralis major muscles and especially in the femoral triangle (Figure 5, left), the base of which is the diameter of the lower abdomen, and the top is the area of ​​the knee joints (the so-called Simon's triangle). The prodromal rash is ephemeral, lasts from several hours to 1-2 days (more often within one day) and then disappears until the appearance of typical smallpox elements or turns into profuse hemorrhages, which portends a severe course of the disease. The prodromal period lasts 2-4 days.

Smallpox rash occurs at the end of the 3-4th day of illness, when the temperature drops to subfebrile numbers or even to normal and the patient's condition improves. Behind the ears, on the forehead, in the area of ​​the temples, a rash appears at the same time in the form of spots, while the elements of the rash are in the same stage of development - the monomorphism of the rash (color picture 2, 10, 11). In 2-3 days, the rash spreads to the skin of the neck, trunk and extremities (color picture 2, 3), then within 2-3 days it evolves from a spot to a papule (about a day after the onset of the rash) and vesicles (color picture 4, 5 , 12, 13). Vesicles are always multi-chambered (they do not collapse when punctured), filled with a transparent liquid, surrounded by a dense red roller or corolla, have an umbilical depression in the center, tense to the touch.

One of the features of the rash in natural smallpox is its centrifugal prevalence and symmetry (Figure 5, a and b), covering the skin of the palms and feet. There are observations indicating that in the area of ​​the armpits, even in seriously ill patients, there is no rash, while in chickenpox it is observed.

Rice. 1. General view of a child with smallpox: pustular. rash (8th day of rash). Rice. 2-9. The chest and abdomen of a child with smallpox, at various stages of the disease: the development of elements of the rash from papules to pustules and peeling. Rice. 2. Papular rash (single papules on the 2nd day of rash). Rice. 3. Vesicular rash (3rd day of rash). Rice. 4-5. Vesicular rash (4-5th day of rash). Rice. 6-7. Pustular rash (7-8th day of rash). Rice. 8. Formation of crusts (13th day of rash). Rice. 9. Peeling (20th day of rash). Photos by WHO.

During the course of the disease, the vesicles change in size from 1 to 3 millimeters or more in diameter (color drawing 2, 3, 4, 10, I, 12). Their color is pale red or pink. Full development of vesicles occurs by the 5-6th day from the moment of the rash (9-10th day of illness).

Somewhat earlier, a rash on the skin (exanthema) or simultaneously with it, a rash appears on the mucous membranes of the mouth, soft palate, nasopharynx, eyes, bronchi, esophagus, urethra, vagina, anus (enanthema). The evolution of the elements of the rash on the mucous membranes is similar to its evolution on the skin and includes their successive transformation (spot - papule - vesicle - erosion). In the blood during this period, short-term leukopenia is detected.

From the 9-10th day of illness (less often from the 8th day), a period of pustulization, or suppuration, begins. The temperature rises again to 39-40 ° and is of an irregular character. Typical for Smallpox is the natural second temperature wave that appears during this period (the so-called "suppurative fever"). The general condition of the patient worsens, the pulse and respiration become more frequent, albuminuria and oliguria appear. The appearance of these symptoms is explained by the suppuration of the vesicles and their transformation into pustules (the contents of the vesicles first become cloudy and then purulent). The pustules are tense and surrounded by an edematous-hyperemic roller of pink color, resembling pearls (color drawing 1, 6, 7, 14, 15, 16).

Pustulization of vesicles on the skin also occurs centrifugally and usually begins with the face, which becomes edematous, the eyelids are edematous and ulcerated, nasal breathing is difficult, so the patient's mouth is open almost all the time. During this period, maceration of the vesicles located on the mucous membranes is observed, as a result of which they turn into erosion and ulcers, which soon fester due to infection with secondary microflora; severe pain in the oral cavity, difficulty in the act of chewing and swallowing, fetid odor from the mouth, pain in the eyes and photophobia, phonation disorder, pain during urination, defecation.

The patient's condition becomes serious. Heart sounds are muffled, tachycardia is expressed, hypotension appears. Moist wheezing is possible in the lungs. The liver and spleen are enlarged. In the blood - neutrophilic leukocytosis. The patient is agitated, hallucinations, delusions are often observed.

The phenomenon of secondary retraction of pustules in connection with the beginning of resorption of their contents is a sign of the transition of pustulization into the next period of drying of the elements. At the same time, there is a decrease in swelling and soreness of the skin, an improvement in the general condition of the patient and a decrease in temperature. This period begins from the 11th - 12th day of illness and lasts until the 15th - 16th day.

From the 16-17th day of the disease, brown crusts or scabs (color drawing 8, 17) are formed - a sign of incipient convalescence. Rejection of the crusts begins on the 18th day and on the 30-40th day of illness, they completely disappear, leaving reddish-brown spots, which later turn pale (color drawing 9.18). When the papillary layer of the dermis is damaged, radiant scars are formed that remain for life. The average duration of the disease with its typical moderate course is 5-6 weeks

Mild forms include varioloid, smallpox without rash, smallpox without fever, alastrim (see complete body of knowledge).

Varioloid is characterized by a long incubation period, the prodromal rash is often erythematous in nature. The appearance of a smallpox rash is characterized by its atypism, the presence of a large number of elements that usually appear from the 2-4th day of fever, reaching the stage of the vesicle and almost never turning into pustules (if they have formed, then the appearance of the umbilical depression is delayed). The same character of the elements is observed on the mucous membranes of the mouth and pharynx. Due to the absence of suppuration, there is also no "suppurative fever", that is, the temperature curve appears as one humped. The course of the disease is short, the bubbles quickly dry up into crusts, which begin to fall off already on the 7-8th day from the moment of appearance. And since the elements of the rash are usually located superficially, without capturing the papillary layer of the dermis, scars are almost not formed after the crusts fall off. The outcome is always favorable, there are usually no complications. Diagnosis of this form of Smallpox natural is often difficult due to the ease of the process and the possible polymorphism of the rash. Varioloid is observed in individuals who have partially retained their immunity (who had previously been ill with smallpox or vaccinated), although the virus remains virulent and pathogenic, and the patient is infectious.

Smallpox without rash is also observed in the presence of acquired immune resistance. In these cases, a rash on the skin is not detected, and damage to the mucous membranes can be typical, as in the moderate form, as well as changes in the lungs, where infiltrates are often detected, often diagnosed as primary pneumonia.

With Smallpox, a natural rash without fever on the skin and mucous membranes is detected in small quantities, but it is still typical, with the corresponding phases of its transformation.

Severe forms of smallpox natural are pustular-hemorrhagic, or black, smallpox, fulminant smallpox and malignant confluent smallpox.

Pustular hemorrhagic smallpox, sometimes also called late hemorrhagic smallpox, is characterized by a shortened incubation period, an acute onset of the disease with signs of early intoxication and hemorrhagic syndrome. A hemorrhagic rash appears after a smallpox rash, starting with the papule stage, and is especially intense during the formation of pustules, the contents of which become bloody. The most intense hemorrhagic changes are observed between the 6th and 10th day from the onset of the disease. As a result of the transformation of hemoglobin, the pustules acquire a black color (hence the name "smallpox"). Patients have severe tachycardia, deafness of heart sounds and hypotension. Hemorrhagic pneumonia is possible. In the blood, leukopenia with relative lymphocytosis and thrombocytopenia are more common.

An even more severe form is considered to be fulminant smallpox, or early hemorrhagic smallpox, which is also characterized by a short incubation period and severe intoxication. Hemorrhagic rash appears already in the prodromal period, before the appearance of smallpox elements, both on the skin and mucous membranes, and in all internal organs. Bleeding from the nose, gums, hemoptysis, and bloody vomiting are common. Hyperthermia, excruciating pain and weakness are typical.

Typical for malignant confluent Smallpox natural is the presence of confluent smallpox rash not only on the face and arms, but also on the trunk, especially in the back, on the legs, on the mucous membranes with the usual stages of its development. Vesicles are small in size, delicate, soft, velvety-like, located close to each other. With the formation of pustules, they merge. With localization of pustules on the mucous membrane of the eyes, keratitis may develop (see the complete body of knowledge), panophthalmitis (see the complete body of knowledge); the tissues of the patient's face are infiltrated, the eyes are closed, the eyelids are edematous and glued together by detachable pustules. Other symptoms of the disease are also sharply expressed, including hyperthermia, changes in the heart and lungs.

Complications.

Most often, complications arise during the period of suppuration or hemorrhagic rashes, when, due to the addition of a secondary infection, combined intoxication with severe damage to the central nervous system and the cardiovascular system is observed. Possible encephalitis (see full body of knowledge) or encephalomyelitis (see full body of knowledge), meningitis (see full body of knowledge), acute psychosis, toxic myocarditis (see full body of knowledge) or even septic endomyocarditis. Tracheitis (see full body of knowledge), tracheobronchitis, pneumonia (see full body of knowledge), abscess (see full body of knowledge), phlegmon (see full body of knowledge), otitis media (see full body of knowledge), orchitis (see full body of knowledge) ... One of the unfavorable complications is blindness due to the appearance of pockmarks on the cornea and choroid of the eyes, followed by the formation of cicatricial changes (see Belmo's complete body of knowledge). A serious complication of Smallpox is also damage to the osteoarticular apparatus in the form of specific metaepiphyseal osteomyelitis with subsequent involvement of the joints in the process (see the complete body of knowledge Osteoarthritis).

Diagnosis

The diagnosis in typical cases is based on anamnesis data (where the patient was, with whom he was in contact), epidemiological and clinical data, manifestations of the disease. However, before the onset of the typical smallpox rash, recognizing natural smallpox is extremely difficult.

The most difficult diagnosis Natural smallpox in the prodromal period and the period of the appearance of smallpox. In this regard, it is necessary to take into account the whole complex of information about the disease, that is, epidemiological and clinical, data - acute onset of the disease with a sharp increase in temperature, severe intoxication, agitation and anxiety of patients, characteristic rachialgia, ephemeral prodromal rash (disappears after 1-2 days) and its localization, a decrease in intoxication and a decrease in temperature with the onset of a rash, the nature of a smallpox rash, damage to the mucous membranes, leukocytosis. The final diagnosis is made on the basis of laboratory data.

Laboratory diagnostics. The main tasks of laboratory research for suspected smallpox are the detection of the pathogen (or its antigens) and its differentiation with other viruses (viruses of the herpes group or orthopoxviruses) that can cause diseases clinically similar to smallpox.

Most often, there is a need to differentiate the variola virus with varicella, herpes simplex, vaccinia, cowpox, and in African countries - also monkeypox.

Scraping of papules, the contents of skin lesions (vesicles, pustules), crusts of smallpox pustules can be used as material for research. In the absence of skin lesions, swabs are taken from the pharynx, blood; pieces of internal organs are examined from the corpse. For the immunofluorescent method, smears are made from the bottom of the opened skin elements. The material is taken under aseptic conditions using sterile dishes and instruments. Methods for laboratory diagnosis of smallpox can be divided into three groups: morphological methods based on the detection of virions in the test material; serological methods that make it possible to detect viral antigens or antibodies; biological methods that ensure the isolation of the pathogen from the test material. In addition, there are tests (table 2) that allow, where necessary, to differentiate the natural smallpox virus from some other viruses.

The main morphological method for the detection of poxvirus virions is electron microscopy (see the complete body of knowledge). The presence of poxvirus is determined by the characteristic shape and size of virions (Figure 1). Electron microscopy makes it possible to detect in the material under study on the basis of morphological features and virions of the herpes group (round shape, the presence of a shell spaced from the virion, and others), which immediately makes it possible to exclude the diagnosis of smallpox. By morphological examination, however, it is impossible to differentiate the natural smallpox virus from other poxviruses. Therefore, when poxviruses are detected, isolation of the pathogen and its further identification are required for the final diagnosis. Electron microscopy, in addition to a quick response (less than 2 hours), gives a high percentage of virus detection and allows you to detect a virus that has lost its ability to reproduce.

The widely used detection of poxvirus virions by means of light microscopy in smears previously stained by various methods from patients has practically lost its significance. Of the painting methods proposed for this purpose, in addition to the original Paschen method (painting with carbolic fuchsin with preliminary treatment with Leffler's mordant), the Morozov painting was the most widespread (see Morozov's complete body of knowledge).

The most technically simple serological method is the precipitation reaction in agar gel using hyperimmune anti-smallpox serum, vaccinia virus (control antigen) and the test material. However, this method makes it possible to differentiate related orthopoxviruses only using specially prepared adsorbed monospecific sera (the exception is cowpox virus, which forms a precipitation band with a so-called spur). In terms of its sensitivity, the precipitation reaction (see the complete body of knowledge) is inferior to the method of electron microscopy, as a result of which it is used mainly for serol. identification of isolated cultures of the virus. To detect smallpox antigen, an indirect hemagglutination reaction (RNGA) is also used. For the reaction, ram erythrocytes sensitized with the Jg G-fraction of serum to vaccinia virus are used. The specificity of hemagglutination is checked in a parallel study with the addition of serum to the vaccinia virus, when the phenomenon of "quenching" of hemagglutination occurs. RND is distinguished by its high sensitivity and speed of the response (2-3 hours), however, this reaction does not make it possible to differentiate the natural smallpox virus with related orthopoxviruses. In about 7% of cases, nonspecific reactions may occur. It is also possible to use the hemagglutination inhibition reaction (RTGA) for diagnostic purposes. This reaction is set with 2-4 AE (agglutinating units) of the vaccinia virus and chicken erythrocytes, which are highly sensitive to this virus. Since in the vast majority of smallpox patients antihemagglutinins appear already in the first days of the disease, their increase in dynamics in those who were not vaccinated against smallpox or those vaccinated many years ago is an important evidence of the presence of smallpox in a patient. Along with the above gray l. reactions, it is possible to use radio and enzyme-immune reactions for this purpose. The radioimmune reaction is based on the use of an isotope-labeled antiserum, and the enzyme-immune reaction is based on an antisera conjugated with an enzyme (horseradish peroxidase, alkaline phosphatase). Both reactions are characterized by a very high sensitivity, but the latter compares favorably with the former in the simplicity of its formulation.

From biological methods, the isolation of the virus on the chorion-allantoic membrane of the developing chick embryo is used. Embryos of 12 days of age are infected, which are incubated after infection for 48-72 hours at t ° 34.5-35 °. The presence of smallpox virus is determined by the development on the chorion-allantoic membrane of small, up to 1 millimeters in diameter, white, rounded pockmarks that rise above the surrounding unaffected tissue (Figure 3, a). These features of smallpox formed on the envelope distinguish the natural smallpox virus from other orthopoxviruses, in particular the vaccinia virus (Figure 3, b), vaccinia, monkeypox and others. The method of isolating the virus on the chorion-allantoic envelope is available to most laboratories. Isolation of the pathogen can be carried out on various cell cultures, in the monolayer of which the virus causes a cytopathic effect of a focal type and gives the phenomenon of hemadsorption. The specificity of the cytopathic action can be checked in the serum neutralization test for vaccinia virus, as well as by the presence of cytoplasmic inclusions in the infected cells. When isolating the virus in cell culture, the differentiation of the smallpox virus with other orthopoxviruses by the nature of the cytopathic action is difficult. Virus (antigen) detection in cell culture can be significantly accelerated using fluorescent antibodies (see complete body of knowledge Immunofluorescence) or immunoperoxidase techniques. For this purpose, the infected cells are treated with fluorescent anti-smallpox (for the direct method) or anti-species (for the indirect method) serum. The presence of antigen is determined by the bright green glow of the cytoplasm. When using the immunoperoxidase technique, peroxidase-labeled anti-smallpox or anti-species sera are used, respectively. In this case, the presence of smallpox antigen is manifested by a dark brown staining of the cell cytoplasm. Both methods can be used to detect antigen in materials from patients, if the latter contains intact cells.

The most rational in terms of speed and efficiency laboratory research for the diagnosis of smallpox natural is the combined use of electron microscopy and virus isolation in chicken embryos. The first of these methods allows you to quickly establish whether the suspicious material contains virions of poxviruses or viruses of the herpes group, and the second provides not only isolation of the pathogen, but also its differentiation with other orthopoxviruses.

With an indistinct picture of lesions on the chorion-allantoic membrane of chick embryos, a number of additional tests are available for intragroup differentiation of orthopoxviruses: infection of rabbits with the studied virus culture (by applying it to the area of ​​scarified skin); determination of the ability to form pockmarks on the chorion-allantoic membrane of chicken embryos infected with the virus culture and incubated at t ° 39.5 °; the establishment of the presence or absence of cytopathic action and the phenomenon of hemadsorption during infection with a culture of the virus of a transplanted line of pig kidney kidney cells - SPEV-sign (table 2).

Differential diagnosis. Smallpox is differentiated with chickenpox (see the complete body of knowledge), impetigo, drug rash (see the complete body of knowledge Drug allergy), measles (see the full body of knowledge), rubella (see the full body of knowledge), exudative erythema (see the full body of knowledge) Erythema exudative multiforme), scarlet fever (see full body of knowledge), hemorrhagic diathesis (see full body of knowledge), as well as diseases caused by viruses of smallpox of cows and monkeys.

With chickenpox, the prodromal period is often not expressed or rarely exceeds one day; the temperature is not higher than 38.5 °, with the onset of the rash, as well as with each new rash, the temperature rises and falls after its end. The rash begins on the scalp and cheeks, on the palms and soles of the rash is extremely rare. Characterized by polymorphism of the rash in the same areas, the rash ends within 2-6 days. The main element of the rash is a spot that turns into a papule of soft consistency, almost no different from the consistency of the surrounding tissues, their color is bright red; the cycle of a spot - a papule - a vesicle takes place within a few hours. The vesicles are unicameral and collapse when punctured, the umbilical pressure is extremely rare, it serves as a sign of incipient drying; crusting occurs quickly. The scars remaining after the crusts fall off, superficial, disappear after a few months.

Scarlet fever, measles and rubella, exudative erythema, impetigo, drug rash are differentiated according to clinical manifestations characteristic of these nosological forms.

Differentiation of hemorrhagic forms Smallpox natural with hemorrhagic diathesis, in particular Shenlein-Henoch disease, scurvy and others, is carried out taking into account the fact that they develop gradually and are secondary. For example, Shenlein-Genoch disease occurs in patients suffering from various kinds of infectious-toxic-allergic diseases (rheumatism, scarlet fever, tonsillitis, pneumonia, a reaction to arsenic, quinine, barbiturates, sulfonamides, antibiotics, ftivazide, and so on). At the same time, the rash is polymorphic, initially it is detected as erythematous, papular or urticarial, then the elements of the rash turn into hemorrhages within several hours, but not simultaneously. Hemorrhages often necrotize with the formation of deep ulcerative defects, around which an edematous shaft is created.

When differentiating Smallpox natural from diseases of people caused by viruses of smallpox of cows or monkeys, their clinical picture should be taken into account.

Clinical, the picture of the disease when a person is infected with the cowpox virus is characterized by the development of a typical smallpox rash on the skin of the hands; sometimes it can be localized on the skin of the forearms, face, which is considered as a result of the transmission of the virus by the patient himself. Local lesions may be accompanied by the development of lymphangitis and lymphadenitis, moderate fever and general malaise. The local process is benign and the disease ends with recovery. Generalized forms are extremely rare.

Clinical, the picture of the disease when a person is infected with the monkeypox virus is characterized by the appearance of a smallpox rash on the skin and mucous membranes, which goes through all stages of development, characteristic of the moderate form of Smallpox natural The disease is accompanied by a significant increase in temperature, intoxication; can be fatal.

Differential diagnosis is carried out on the basis of epidemiological data, clinical, picture, as well as laboratory data (table 2).

Treatment

Treatment is symptomatic. Mostly used are cardiovascular and sedatives. Antipyretic drugs are recommended to be prescribed carefully, only at a very high temperature (when it is a threatening prognostic symptom), since interferon in viral diseases in the required quantities is produced only at a certain temperature reaction (optimum 38 °). To prevent complications Smallpox natural, it is necessary to prescribe antibacterial agents of a wide spectrum of action.

Particular importance is attached to patient care: the skin must be wiped with products that refresh the skin and reduce itching - camphor alcohol, 40-50% ethyl alcohol, potassium permanganate solution (1: 5000); the oral cavity, as well as the conjunctiva, should be washed with a solution of boric acid.

Discharge of convalescents from the hospital is made after complete falling off of crusts and scales, in the absence of visible changes on the mucous membranes and a negative result of virological examination of the separated mucous membrane of the nasopharynx.

Prophylaxis

Despite the end of the global smallpox eradication program, there is a need for strict epidemiological surveillance to detect orthopoxvirus-related diseases in humans as early as possible.

Correct timely organization of anti-epidemic measures (see the complete body of knowledge) guarantees the localization of the emerging focus of diseases. This obliges medical workers, primarily of the district network and sanitary-epidemiological institutions, if the patient is suspected of having Smallpox natural, to carry out all the measures reflected in the comprehensive plan for ensuring the sanitary protection of the territory (see the complete body of knowledge) from the importation and spread of quarantine diseases , which is compiled by the health authorities in accordance with the specific working conditions.

A patient with natural smallpox or suspected of this disease is immediately isolated with subsequent hospitalization in a hospital department located in a separate building or in an isolated part of a building, preferably one-story, equipped like boxes. If it is impossible to hospitalize a patient in a hospital, it is necessary to equip a special room for hospitalization of patients. In the building where the hospitalization of patients is planned, the possibility of air penetration between separate rooms through the openings of ventilation, heating and other communications should be eliminated. In the territory adjacent to the hospital, it is prohibited to live and find persons who are not related to the service of the smallpox hospital. The patient is sent to the hospital, accompanied by a paramedic; in this case, a regimen should be observed that prevents the spread of infection.

The transport on which the patient is delivered is disinfected on the territory of the hospital.

After the evacuation of the patient, the final disinfection of the room where the patient was is is carried out.

All staff and patients in other departments of the hospital must be vaccinated against smallpox, regardless of the duration of the previous vaccination and revaccination. The question of contraindications is decided by the doctor in each individual case.

To serve the patient in the hospital, special medical personnel are allocated.

The hospital has a strict anti-epidemic regimen.

Material for laboratory research is immediately taken from the patient (scraping of papules, contents of vesicles, pustules, crusts, discharge of the nasopharyngeal mucosa, blood) and sent in special packaging to the virological laboratory.

Persons suspected of the disease Natural smallpox, until the diagnosis is clarified, should be isolated from patients with an established diagnosis in a specially allocated room (if possible individually).

The corpses of those who died from Smallpox natural and suspicious of this disease are subjected to postmortem examination and virological research. An autopsy is performed by a pathologist in the presence of a quarantine infection specialist. Material from a corpse for virological or bacteriol. tests are taken and sent to the laboratory in accordance with the instructions for laboratory diagnosis Natural smallpox

Persons who directly communicated with the patient, as well as who had contact with the patient's linen and things, should be isolated for 14 days and vaccinated against Smallpox natural, regardless of the duration of the previous vaccination or revaccination and any medical contraindications to vaccination.

In case of close contact with the sick, newborns are vaccinated from the first day of life.

Isolation of persons in contact with the patient (see complete body of knowledge Observation) is carried out in small groups according to the timing of contact and the alleged source of infection, using separate rooms for this. For persons who have been in direct contact with patients, along with vaccination, the appointment of emergency prophylaxis is shown - donor smallpox gamma globulin, as well as the antiviral drug methisazone (see the complete body of knowledge), which is also prescribed for the prevention and treatment of skin post-vaccination complications that develop after vaccination against smallpox. Donor anti-smallpox gammaglobulin is injected intramuscularly at a dose of 0.5-1 milliliters per 1 kilogram of body weight. Metisazone is prescribed for adults at 0.6 grams 2 times a day for 4-6 days in a row. A single dose of methisazone for children is 10 milligrams / kilogram of the child's weight, the frequency of administration is 2 times a day for 4-6 days in a row.

In the settlement where the patient is identified, immediate universal vaccination and revaccination against Smallpox natural of the entire population, regardless of age, are carried out. The question of the scale of smallpox vaccination in a city, district, region, republic, and the like is decided depending on the epidemiological situation.

If vaccination is contraindicated according to the doctor's opinion, prophylaxis of Smallpox natural is carried out with the help of donor smallpox gammaglobulin or metisazone.

For the purpose of early detection of patients with Smallpox natural, suspicious of this disease, as well as persons who are not vaccinated or vaccinated with a negative result, in the settlement where the patient is found, daily rounds are carried out.

The general management of activities in the outbreak is carried out by the Extraordinary Anti-Epidemic Commission, which is created by decision of the Council of Ministers of the republic, regional, regional, city and district Councils of People's Deputies.

In accordance with the International Health Regulations, the government of the country in which a case of Smallpox is registered is obliged to urgently inform WHO.

In order to prevent the introduction of infection into the territory of the country, the health authorities are guided by the International Health Regulations, as well as the regulation on the sanitary protection of the territory of the USSR.

Prevention measures against human infection with smallpox of cows or monkeys are reduced to timely isolation of sick animals, removal of sick people from caring for animals, vaccination with smallpox vaccine and current disinfection (see the complete body of knowledge Smallpox in animals, in humans).

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(Variola vera)whom he fell ill after a trip to India, thereby provokingan outbreak of this disease in Moscow …»

What is this story?

With the Khrushchev thaw, the "iron curtain" opened slightly. Numerous delegations began to be sent abroad. The press called it "building bridges of friendship." In the mid-1950s, the Kremlin proclaimed India a fraternal state. Indian tea appeared on all counters in Soviet stores. I remember from childhood that some varieties of tea were sold in round metal boxes. Well, cinemas all over the sixth part of the globe were simply occupied for many decades by simple to naive two-part Indian melodramas, which delighted the male population with their staged fights and squeezed tears from naive Soviet women.

It was on one of these foreign trips to fraternal India that the famous Soviet artist Aleksey Alekseevich Kokorekin went. He did not even suspect what catastrophic consequences for him and for the people of his circle of friends this trip would lead.

The two-week trip passed quickly. On the very first day of his return, namely in the evening, the artist felt bad. The temperature rose quickly, a strong cough. The whole body was tormented by the strongest pain. The next day he went to the clinic.

The therapist diagnosed the flu. Despite taking prescribed medications, Kokorekin's condition worsened by leaps and bounds. A rash all over the body was added to the fever and severe cough. The artist had to be hospitalized in the Botkin hospital. The hospital explained the rash simply - an allergic reaction to medication. True, one of the young doctors, having learned that Kokorekin had just returned from India, suggested that he was sick with smallpox. A venerable professor, scolded a young employee, explaining to her “on the fingers” that in December in Moscow people are sick with the flu. And the artist was confirmed with the first diagnosis - influenza and placed in a common ward with influenza patients.

Already on December 23, on the third day of hospitalization, the doctors realized that Kokorekin was doomed and would die in the next few minutes. Close relatives were admitted to the farewell ward.

The death of a famous person put the doctors at the Botkin Hospital in a dead end - they could not pinpoint the cause of death even after the autopsy. The hospital management was forced to turn to one of the luminaries of Soviet medicine, academician Nikolai Kraevsky. But he could not help either. It is now impossible to believe in it, but pathologists for a whole DAY adhered to the diagnosis of "plague in question". Can you imagine what such a diagnosis meant in multimillion-dollar Moscow?

The artist was buried hastily and with all precautions. Just in case, the body was cremated. The funeral ceremony took place on December 31 ... But the cremation and funeral did not put an end to this story.

The pre-New Year bustle played a cruel joke on the doctors, who, like all Soviet people, were busy preparing for the New Year 1960. However, after two weeks of the new year, several patients at the Botkin Hospital simultaneously developed fever, cough, and rash. But this did not alert the doctors, who believed that in the very near future they would be able to establish the allergen, which, in their opinion, was the cause of the rash. True, just in case, the material from the skin of the most severe patient was sent to the Research Institute of Vaccines and Serums ...

On January 15, 1960, Academician Morozov, barely looking through a microscope, authoritatively declared - Paschen's little body. Everyone was shocked - after all, these were smallpox virus particles!

This news was immediately brought to the top leadership of the country and caused, to put it mildly, a real commotion. After all, two weeks have passed since the artist's death, and during this time a huge number of people could have become infected ... But how to treat them if there is no medicine for smallpox? Smallpox is not cured. They either die or recover from it. In addition, this disease never manifests itself in any one single case, but only in the form of an epidemic ...

Why did none of the doctors, except for the young employee who observed the artist, remember about smallpox? And the whole point was that this disease in the USSR had long been defeated. The last outbreak of smallpox in the Soviet Union was suppressed 25 years ago in 1936. Compulsory vaccination of the population played its role. By the early 1960s, mention of smallpox in the USSR could only be found in medical textbooks. Doctors "lost the habit and forgot" about this disease ...

The country's top leadership was well aware that Moscow, and possibly the entire Soviet Union, was targeted by a ruthless killer of entire nations. The reaction was immediate - immediately the entire personnel of the Moscow police and the KGB were raised to their feet. The Academy of Sciences, all the capital's doctors and state security personnel were transferred to an emergency mode of operation.

The task was set extremely tough - the law enforcement agencies had to establish ALL CONTACTS of the artist as soon as possible from the moment he boarded the plane flying to India. At the risk group, 75 passengers of that flight and the crew of the plane, customs officers, all of Kokorekin's relatives, the doctors who treated him, the patients of the hospital where he was lying and, accordingly, all the people who communicated with the specified contingent ...

The doctors were entrusted with the most difficult task - to urgently isolate all these people in quarantine. The whole difficulty of performing this task was that it was necessary to isolate those people who, even for a short time, found themselves in those rooms where the artist was and whom he saw even fleetingly, not to mention a short shake of hands. And you don't need to be a strong mathematician to understand an elementary truth - the number of such people in two weeks now amounts to several thousand people. It remains only to establish how many thousands this number is calculated. The capital's militia, doctors and the State Security Committee have never carried out such a grandiose work.

In addition, this story had a political background. In February 1960, that is, less than a month later, the Peoples' Friendship University was to be opened in Moscow. This broad gesture emphasized the international policy of the USSR. It was planned that the main contingent of students will be from the poorest countries of Africa and Asia. And it had to happen that a month before the opening of the university it turned out that contacts with people from these countries are far from safe ...

It was decided to divide the fight against the epidemic into two centers. The first is the Botkin hospital. The second is the circle of Kokorekin's relatives and acquaintances. It was necessary to act quickly in both directions at once. Botkin hospital was instantly transferred to the barracks position. They did not let anyone out of it, did not let anyone in and did not report anything to the relatives of the patients and the medical staff. As a result, the entire fence of the hospital was hung with perplexed relatives of patients and doctors, trying to understand the meaning of what was happening. But in those days, the authorities acted toughly, decisively and without unnecessary explanations in order to prevent panic. It is in our time the media, such as the TV channel "Rain", would "suck" endlessly the current situation, and then everything happened in complete secrecy. Although what kind of secrecy could there be when several thousand people were involved in eliminating the consequences of the epidemic?

The infection spread quickly and in the most incredible ways. Here is a sample list of those infected:

A teenage boy lying in a box on the second floor above the sick artist's room. In this case, the virus has entered through the ventilation duct;

A patient from another building became infected from the gown of the doctor who had previously examined Kokorekin;

The receptionist who allowed one of the doctors to use the office phone to call home became infected from the telephone receiver;

A stoker who only once walked along the corridor of the department where the artist was lying, without communicating with anyone ...

The medical staff of the Botkin hospital, on pain of dismissal, had no right not to tell anyone about the reasons for such a strange and quickly introduced quarantine. The relatives of the patients sounded the alarm, besieged representatives of the authorities of all ranks, trying to somehow contact their sick relatives. But it was all in vain. The hospital was in a vacuum. One can only guess about the degree of excitement, if only there were 2500 patients in it at that time. I'm not even talking about the almost 5,000 service personnel. In order to somehow accommodate such a large number of people in one place for a long time, the necessary number of beds and mattresses was found. But they could not find the linen. And then, by a special decree of the government of the USSR, the stocks of linen from the NZ category for air defense were raised ...

As soon as the specialists began to study the contacts of the deceased artist, the contacts of his relatives, a kind of hellish lottery emerged here as well. Sick: a friend of the artist's second wife, who contracted the infection in the Sandunov baths when she was there with the artist's current wife, subsequently infecting her husband and son; an insurance agent who visited the artist in early January, since Kokorekin's life was insured; the wife of a friend of Kokorekin, who ran in to check on for a few minutes and, as a result, fell ill herself, infecting her husband, and he had several of his friends ...

The work to eliminate the epidemic was carried out without any respite. In all medical institutions, the police and the KGB, the lights did not go out all night for several weeks. It is difficult to convey in words what was happening in Moscow these days. Ambulances barely had time to leave at new and new addresses of contacts from the environment of the artist and his acquaintances. All potentially dangerous people were instantly isolated from society. But the number of contacts was enormous. Among the contacts there were also record holders. So the teacher of the Moscow Institute of Railway Engineers managed to take offsets from 120 students. All students were tracked down and quarantined. The same fate befell all the classmates of the artist's daughter. The hospital therapist, whom Kokorekin first turned to, managed to attend 117 patients. It is clear that all these people were isolated without unnecessary talk. Contact persons, and even only suspects, were searched for in the most incredible places. Without talking, they were removed from trains, planes and isolated, isolated, isolated ... The places in which the contactees were kept were subject to serious disinfection. Kokorekin's son-in-law studied at the Mendeleev Institute. Everyone suspected of having contact with him was isolated along with the teachers ... As a result of the most meticulous interrogations, all men and women were forced to name their lovers, alcoholics of their drinking companions, and innocent girls with tears in their eyes named all the guys with whom they kissed. In a word, it was cooler than the coolest detective ...

It seemed that there would be no end to this. After all, sooner or later the situation had to get out of control. In total, more than 9,000 people were quarantined in Moscow and the Moscow region. For this, the largest infectious diseases hospital in the capital on Sokolinaya Gora was released, as well as several other hospitals. However, there were still not enough places. Therefore, quarantines were arranged at the place of residence of citizens who were strictly prohibited from leaving the premises. At that time, cars were constantly rushing around Moscow, in which there were people in overalls. All suspicious places in the capital were actively disinfected.

In addition, one more detail was revealed, which complicated the task for the investigators. The artist's second wife handed over some of the things he brought from India for resale to a thrift store! And in those days, scarce things were easily sold by commissioners bypassing the store counter. Therefore, the search for buyers of all things turned out to be very difficult and unpleasant for the representatives of the trade.

Meanwhile, rumors were crawling and multiplying around the city - a disease appeared in the city that mows hundreds of people down. Here and there false witnesses appeared who claimed that all the morgues in Moscow were filled with corpses, and at night people in cemeteries were buried in zinc coffins ...

Doctors believed that the main thing that could stop the epidemic was universal vaccination. Now it's hard to believe, but then, within five days, the entire population of Moscow was vaccinated against smallpox. And this is almost seven million people. In order to do this, more than 10,000 vaccination teams were urgently organized. For this, doctors of various specialties were mobilized; medical assistants, medical students, as well as everyone who was familiar with the vaccination method. The daily rate is 1.5 million doses of the vaccine. Not a single person, from babies to the very old, has escaped vaccination. Moreover, even the dying were vaccinated ...

The smallpox outbreak in Moscow was extinguished only after a month. True, the question arose, how, in a country that seemed to have defeated smallpox, so many people who were vaccinated against smallpox became infected with it? The investigation showed that several factors played a cruel joke at once: the population of the entire country cannot be vaccinated, since there are contraindications, negligence, carelessness, disorganization, etc. In addition, over time, the problem of vaccination against smallpox in the USSR began to be treated formally. After all, there was no one to get infected inside the country. An interesting fact is that the artist Kokorekin was vaccinated against smallpox just a year before his trip to India ...

The results of a smallpox outbreak in Moscow in 1960: dozens of people fell ill, but most of their lives were saved. In addition to the artist Kokorekin, three more died. The capital was saved from the epidemic by the efficient work of medical and law enforcement services.

It must be said that smallpox fevers, similar to those in Moscow, were experienced both in Europe and in America. But at the end of the twentieth century, smallpox on Earth was gone. And the elimination of this disease occurred on the initiative of Soviet doctors. To our shame, this fact is practically unknown in Russia. Whereas in the West, the victory over smallpox is equated with the greatest accomplishments.

It all started back in 1958 at a session of the World Health Organization. Viktor Zhdanov, deputy. Minister of Health of the USSR, proposed a global program for the eradication of smallpox. By that time, this disease literally tormented 67 countries of the world in Asia, Africa, Latin America, Oceania. Every year, the disease carried tens of thousands of people to the grave.

The idea of ​​the Soviet delegation in the medical circles of the world was initially perceived as impracticable. Therefore, in 1959, the USSR practically single-handedly began the implementation of this program. The Soviet vaccine began to be regularly supplied all over the world to fight smallpox. And only eight years later, the United States joined this program, which seriously helped with money. From that moment on, the world was divided, as it were, into two parts. Where the Western countries had more influence, they worked, and Soviet doctors worked in the zones of influence of the USSR. It was one of the few cases in history when countries from two warring camps, together fought a world disease. And the disease was defeated - the last time a smallpox outbreak was recorded in Somalia in 1977.

On the Soviet side, about 60 specialists took part (we do not value our heroes, even the exact number of specialists in this program is unknown!). Svetlana Marinnikova is the only woman who was a member of the leadership of the global anti-smallpoint commission. She argued that doctors are going to retroactively assess the feat of their colleagues, having addressed a letter to the almighty Putin. I do not know whether this appeal to the GDP took place or not.

In May 1980, the UN issued a document that spoke of the complete victory over smallpox in all corners of the globe. However, the Motherland never found out about the feat of our doctors. None of the participants from our side was not even awarded, they did not even hear oral gratitude. None of the major media outlets even paid attention to this victory over smallpox. The episode, which entered the golden fund of history, was simply not noticed in the USSR, and then in Russia. But the West added the names of its participants to the honorary list. In the United States, the former director of the smallpox program was awarded the country's highest honor.

And in Russia, only one person, Vladimir Fedorov, has a gold medal, which was presented to him by the government of Afghanistan, and which he never wore. Do you know why? According to our rules, a person who does not have awards from his country has no right to wear foreign awards!))))) That is why Vladimir Fedorov keeps his award in a drawer ...

At the moment, pathogenic smallpox strains are stored only in two places in the world - in Atlanta, at the Center for Disease Control and Prevention (USA) and at the Novosibirsk Center for Virology and Biotechnology.

True, one must always remember that human smallpox has been defeated, but not monkeypox. In countries such as Congo, monkey meat is most actively used for food. And who knows what the mutation of this disease can lead to?

Attempts to prevent contagious diseases, in many ways reminiscent of the technique that was adopted in the 18th century, were undertaken in antiquity. In China, smallpox vaccination has been known since the 11th century. BC e., and it was carried out by inserting a piece of matter soaked in the contents of smallpox pustules into the nose of a healthy child. Sometimes dry smallpox crusts were also used. In one of the Indian texts of the 5th century, it was said about a method of fighting smallpox: “Take smallpox matter with a surgical knife either from the udder of a cow or from the arm of an already infected person, make a puncture on the arm of another person until it bleeds between the elbow and shoulder, and when there is pus will enter the body with blood, a fever will be found. "

There were folk ways to combat smallpox in Russia. Since ancient times, in the Kazan province, smallpox scabs have been ground into powder, inhaled, and then steamed in a bath. For some, it helped, and the disease passed in a mild form, for others it all ended very sadly.

It was not possible to defeat smallpox for a long time, and it reaped a rich mournful harvest in the Old World, and then in the New. Smallpox has claimed millions of lives across Europe. Representatives of the reigning houses also suffered from it - Louis XV, Peter II. And there was no effective way to deal with this scourge.

Inoculation (artificial infection) was an effective way to combat smallpox. In the 18th century, it became fashionable in Europe. Whole armies, as was the case with the troops of George Washington, underwent mass inoculation. The top officials of the states have shown themselves the effectiveness of this method. In France in 1774, the year Louis XV died of smallpox, his son Louis XVI was inoculated.

Shortly before this, under the influence of previous smallpox epidemics, Empress Catherine II turned to the services of an experienced British inoculant physician, Thomas Dimsdale. On October 12, 1768, he inoculated the empress and heir to the throne, future emperor Paul I. Dimsdale's inoculation was not the first to be done in the empire's capital. Before him, the Scottish doctor Rogerson vaccinated the children of the British consul against smallpox, but this event did not receive any resonance, since it was not given the attention of the empress. In the case of Dimsdale, it was about the beginning of mass vaccination in Russia. In memory of this significant event, a silver medal was knocked out with the image of Catherine the Great, with the inscription "I set an example with myself" and the date of the significant event. The doctor himself, in gratitude from the empress, received the title of hereditary baron, the title of physician-in-chief, the rank of actual state councilor and a lifetime annual pension.

After successfully completing an exemplary inoculation in St. Petersburg, Dimsdale returned to his homeland, and in St. Petersburg the work he had begun was continued by his compatriot Thomas Goliday (Holiday). He became the first doctor of the Smallpox (Ospoprivalny) house, where those who wished were vaccinated for free and were awarded a silver ruble with a portrait of the empress as a reward. Golidey lived in St. Petersburg for a long time, became rich, bought a house on the English Embankment and received a plot of land on one of the islands of the Neva delta, which, according to legend, was named after him, converted into a more understandable Russian word "Golodai" (now Dekabristov Island).

But long-term and full-fledged protection against smallpox still has not been created. Only thanks to the English doctor Edward Jenner, and the method of vaccination discovered by him, was it possible to defeat smallpox. Thanks to his observation, Jenner collected information on the incidence of “cowpox” in milkmaids for several decades. The English physician concluded that the contents of young immature vaccinia pustules, which he called "vaccine", prevented smallpox from falling on the hands of thrush, that is, during inoculation. This led to the conclusion that artificial cowpox infection is a harmless and humane way to prevent smallpox. In 1796, Jenner conducted a human experiment, vaccinating an eight-year-old boy, James Phipps. Subsequently, Jenner discovered a way to preserve graft material by drying the contents of pustules and storing it in glass containers, which allowed the dry material to be transported to various regions.

The first vaccination against smallpox in Russia according to his method was made in 1801 by Professor Efrem Osipovich Mukhin to the boy Anton Petrov, who, with the light hand of Empress Maria Feodorovna, received the surname Vaccines.

The vaccination process at that time was significantly different from modern smallpox vaccination. The inoculation material was the contents of the pustules of vaccinated children, a "humanized" vaccine, as a result of which there was a high risk of collateral infection with erysipelas, syphilis, etc. As a result, A. Negri proposed in 1852 to receive a smallpox vaccine from vaccinated calves.

At the end of the 19th century, the successes of experimental immunology made it possible to study the processes that occur in the body after vaccination. Outstanding French scientist, chemist and microbiologist, founder of scientific microbiology and immunology Louis Pasteur concluded that the vaccination method can be applied to the treatment of other infectious diseases.

On the model of chicken cholera, Pasteur for the first time made an experimentally substantiated conclusion: "a new disease protects against the next." He defined the absence of recurrence of an infectious disease after vaccination as "immunity". In 1881, he discovered the anthrax vaccine. Subsequently, the rabies vaccine was developed to combat rabies. In 1885, Pasteur organized the world's first anti-rabies station in Paris. The second antirabies station was created in Russia by Ilya Ilyich Mechnikov, and began to appear throughout Russia. In 1888, a special institute for the fight against rabies and other infectious diseases was created in Paris with funds raised by international subscription, which later received the name of its founder and first leader. Thus, the discoveries of Pasteur laid the scientific foundations for the fight against infectious diseases by the method of vaccination.

I.I. Mechnikov and P. Ehrlich made it possible to study the essence of the organism's individual immunity to infectious diseases. Through the efforts of these scientists, a harmonious doctrine of immunity was created, and its authors I.I. Mechnikov and P. Ehrlich were awarded the Nobel Prize in 1908 (1908).

Thus, scientists of the late XIX - early XX centuries managed to study the nature of dangerous diseases and propose effective ways to prevent them. The fight against smallpox turned out to be the most successful, since the organizational foundations for the fight against this disease were also laid. The smallpox eradication program was proposed in 1958 by the USSR delegation at the XI Assembly of the World Health Organization and was successfully implemented in the late 1970s. joint efforts of all countries of the world. As a result, smallpox was defeated. All this made it possible to significantly reduce mortality in the world, especially among children, and increase the life expectancy of the population.

Also see Smallpox - a list of diseases called smallpox

Smallpox or, as it was also called earlier, smallpox is a highly contagious viral infection that only humans suffer from. It is caused by two types of viruses: Variola major and Variola minor. People who survive after smallpox can lose some or all of their vision, and almost always there are numerous scars on the skin in the places of the former ulcers.

Historical overview

Smallpox in antiquity and the Middle Ages

Smallpox has been known to mankind since ancient times. Various sources attribute its first appearance to either Africa or Asia. In India in ancient times there was a special goddess of smallpox - Mariatale; she was portrayed as a young woman in red clothes with a very irritable character - according to legend, once she was angry with her father for something and in anger threw her gold necklace in his face, and where the beads touched the skin, pustules appeared. With this in mind, the believers tried to appease and propitiate Mariatale, making sacrifices to her. In Korea, smallpox epidemics were attributed to the visitation of a spirit who was called "the distinguished guest of smallpox." An altar was set up for him, where they brought the best food and wine.

Some researchers believe that smallpox is mentioned in the Bible, where, in the description of the ten Egyptian executions, it is said: "... and there will be an inflammation with abscesses on people and on livestock, throughout the land of Egypt." V.V.Svyatlovsky wrote that smallpox was spread from India to other regions by the troops of Alexander the Great. In the II century BC. NS. this disease struck the Roman legions of Marcus Aurelius, and in 60 BC appeared in ancient Rome. In the 6th century AD, smallpox ruled in Byzantium, being brought into the last of Africa under Justinian I. Further, history witnessed the appearance of smallpox in Syria, Palestine and Persia in the 7th century, Sicily, Italy, Spain and France in the next, VIII, century ...

From the VI century. smallpox appears under its still-preserved Latin name variola, first used by Bishop Marius of Avanches in 570 A.D. Since that time, smallpox, under its unchangeable name, has claimed many lives every year in Europe. We will not follow her from century to century, but let us dwell on some of the amazing moments of her unhindered domination. Smallpox spread to horrific proportions among the Normans during their invasion of Paris. King Cobbo's lieutenant also fell ill. The king, out of fear that the infection would reach him and his court, ordered to kill all the infected, as well as all those who were with the sick. Such a radical measure gives an idea of ​​the strength and severity of the disease against which it was taken. On the other hand, it was already early to present to medicine an unrelenting demand for salvation from this disease and severely punished the helplessness of doctors. The Burgundian queen Austrigilda, dying of smallpox, asked her husband, as a last favor, to execute her both doctors if they could not save her. King Guntran fulfilled her request and ordered that the scientists doctors Nikolaus and Donatus be hacked with swords. The spells, prayers and talismans invented against smallpox, of course, did not in the least contribute to the weakening of smallpox. Its spread reached such an extent that it was rare to meet a person who did not suffer from smallpox; therefore, in the Middle Ages, the Germans developed a saying: “Von Pocken und Liebe bleiben nur Wenige frei”. In France in the 18th century, when the police were looking for a person, it was indicated as a special sign: "It has no signs of smallpox." The widespread use of smallpox was one of the reasons for the abuse of cosmetics: a thick layer of white and blush applied to the face allowed not only to give the skin the desired shade, but also to mask smallpox scars.

Among the Arabs, according to the testimony of the Arab physician Aron, who lived in the 7th century, smallpox has been known since ancient times. Ar-Razi and Avicenna left the classic descriptions of smallpox. Ar-Razi also mentioned variolation, the inoculation of mild human smallpox, which was the first serious human counteraction in his fight against this infectious disease.

Variolation

Variolation consisted of inoculating smallpox pus from a mature pustule of a patient with smallpox, which led to mild smallpox disease. This method was known in the East at least from the early Middle Ages: in India, records of the 8th century have been preserved about it, and in China - in the 10th century. Variolation was performed on young girls destined for harem life in order to preserve their beauty from smallpox scars. Also, this method was used in Africa, Scandinavia, among the local peoples of the Urals and Siberia.

This technique was first brought to Europe from Turkey by the wife of the British ambassador to Constantinople, Mary Wortley Montague, in 1718, who, having learned about variolation from the Turks, instilled in her six-year-old son. In England, after experiments on criminals and children from church shelters, smallpox was inoculated in the family of British King George I.

In the first 8 years in England, smallpox was inoculated to 845 people, of whom 17 could not bear it and died, that is, variolation gave 2% mortality. Since smallpox resulted in 10 to 20 times more mortality, variolation was at first very popular. However, since the latter sometimes led to the death of those vaccinated against smallpox, often caused epidemics itself and did not always protect those who underwent inoculation from subsequent infection with smallpox, it gradually fell out of use. The English physician Geberden proved at the end of the 18th century that in 40 years of using variolation in London alone, 25,000 more patients died than in the same number of years before the introduction of vaccinations. Variation was banned in France by an act of parliament in 1762, but existed in England until 1840. Despite this, the doctor Watson, not having a safe smallpox vaccine, applied it in 1862 on a ship at sea, when an epidemic broke out among the sailors. and all 363 vaccinated survived, while 9 out of 12 smallpox patients died.

Vaccination

In the late 18th century, several observers noticed cowpox, a disease common in horses and cows. In the latter, it manifested itself in the form of pustules, bubbles with purulent contents on the udder, very reminiscent of smallpox eruptions in humans. However, cowpox in animals was significantly more benign than smallpox in humans and could be transmitted to it. Milkmaids often carried vaccinia, but were not subsequently infected with cowpox. The fact that in the English army of the eighteenth century the incidence of smallpox in the cavalry was significantly lower than in the infantry is a phenomenon of the same order.

As early as 1765, the doctors Sutton and Fuester told the London Medical Society that smallpox in dairy cows, if infected with it, protects him from the disease of smallpox. The London Medical Society did not agree with them, recognizing their observation as a mere coincidence, not worthy of further research. However, in 1774, the English farmer Jestley successfully inoculated his family with vaccinia, and the German teacher Plett did the same in 1791. Independently of them, it was discovered by the English physician and naturalist Jenner, who, observing natural cases of vaccinia for 30 years, 2 May 1796 decided to make a public experiment in vaccinating cowpox. In the presence of doctors and an outside public, Jenner removed smallpox from the hand of a young milkmaid Sarah Nelmes, who had contracted cowpox by accident, and inoculated it in eight-year-old boy James Phipps. Smallpox started, developed only in two vaccinated places and proceeded normally. Then, on July 1 of the same year, Jenner inoculated Phipps with smallpox, which, like a protected vaccine, did not take. Osovopivanie // Encyclopedic Dictionary of Brockhaus and Efron: In 86 volumes - SPb., 1890-1907.

Two years later, Jenner published An Inquiry Into the Causes and Effects of the Variolae Vaccinae, a Disease Discovered in Some of the Western Counties of England, Particularly in Gloucestershire And Known by the Name of Cow-pox. In this pamphlet, Jenner pointed out that vaccinia and smallpox are two forms of the same disease, so that the transfer of vaccinia imparts immunity to natural immunity.

Man's retreat from the way of life predetermined for him by nature was for him the cause of many diseases. Adoring glitter, indulging his desire for luxury, and loving entertainment, he surrounded himself with a great number of animals that, perhaps, were not originally intended to be his companions ... A cow, a pig, a sheep, and a horse - all of them, for various purposes, are under his guardianship and patronage ... Wouldn't it be reasonable to assume that the source of smallpox is an infectious matter of a special kind, originating from a horse's disease, and that accidental circumstances, which arose again and again, changed this disease so that it acquired the infectious and malignant form that we usually seen in the devastation among us?