Smallpox is an infectious viral disease caused by the DNA virus, variola, with 2 primary forms: variola major (the more severe form) and variola minor.

Although smallpox is considered to be eradicated,15 it still exists at 2 secured locations approved by the World Health Organization (WHO).

Smallpox is transmitted person-to-person via respiratory droplets, with secondary infections occurring in close contacts of the index patients. The period of infectivity begins at the onset of rash and lasts ~7–10 days, decreasing as scabs begin to appear. The incubation period has a range of 7–19 days. Clinical features include high fevers, malaise, prostration, headache, backache, and delirium in some patients, followed by a maculopapular rash that eventually forms pustules. Scabs begin to form 1 to 2 weeks later.1

The fatality rate in unvaccinated individuals is 30%, in contrast to roughly 3% in vaccinated patients. ACAM2000 (live, replication-competent vaccinia virus) Aventis Pasteur Smallpox Vaccine (APSV; live, replication-competent vaccinia virus), and Imvamune (live attenuated replication-deficient vaccinia virus) are the 3 vaccines currently stocked in the U.S. SNS. Although not available to the general public, ACAM2000 is the only vaccine approved by the FDA.

Initial diagnosis in the setting of an outbreak is based on clinical manifestations, but a definitive diagnosis is reached by isolating the virus in cell culture or, more likely, by real-time PCR.1 Treatment is primarily centered on supportive care because no FDA-approved agents are available. Investigational treatments for smallpox can be found in Table 7.

Ebola and Zika Viruses

Ebola is a filovirus that causes severe, often deadline disease, with clinical features of fever, headache, vomiting, diarrhea, and hemorrhage, leading to multiorgan system failure. There is no known effective treatment, so management consists of intensive supportive care.1

Zika, a flavivirus originally from Uganda, has spread to the United States (Florida and Texas), as well as Central and South America. The virus has multiple modes of transmission, with the primary being the bite of an infected mosquito but also through vertical transmission and sexual contact.1

Although Zika infections are usually not life threatening, infection during pregnancy is associated with adverse fetal outcomes. Presently, there are no available effective pharmacotherapies or prophylaxis. Symptoms include fever, rash, arthralgia, conjunctivitis, and headache. Insect repellents containing active ingredients approved by the Environmental Protection Agency (EPA) should be used to prevent mosquito bites.16

The Role of the Pharmacist

The authors note that pharmacists play a “multifaceted and important” role in disaster preparedness and disaster response.

“By training, pharmacists are the medication experts and should be the lead in managing medication supply chains and distribution systems, such as procurement, storage, compounding, and dispensing in emergency situations,” the authors state.

A pharmacist’s expertise “also includes clinical knowledge that can aid physicians and other prescribers in drug information consultation and treatment decision making” and that, in addition, pharmacists “also possess the ability to provide direct patient care by medication therapy management, adherence counseling, monitoring, and immunization.”

The authors recommend 2 resources that provide more specific guidance to pharmacists.17,18


1.    Narayanan N, Lacy CR, Cruz JE, et al. Disaster Preparedness: Biological Threats and Treatment Options. Pharmacotherapy. 2018 Feb;38(2):217-234.

2.    Centers for Disease Control and Prevention. Recommendations of the CDC strategic planning workgroup biological and chemical terrorism: strategic plan for preparedness and response. MMWR Recomm Rep. 2000;49(RR-4):1–14.

3.    Centers for Disease Control and Prevention. Bioterrorism Agents/Diseases. Category A. August 2017. Available from Accessed: February 22, 2018.

4.    USAMIIRD. Medical management of biological casualties handbook, 8th edition. Fort Detrick: The U.S. Army Medical Research Institute of Infectious Diseases, 2014.

5.    Adalja AA, Toner E, Inglesby TV. Clinical management of potential bioterrorism-related conditions. N Engl J Med. 2015;372(10):954–62.

6.    Hendricks KA, Wright ME, Shadomy SV, et al. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis. 2014;20(2).

7.    Cangene Corp. Anthrasil (Anthrax Immune Globulin) package insert. Winnipeg, MB; 2015.

8.    GlaxoSmithKline. Raxibacumab package insert. Research Triangle Park, NC; 2016.

9.    Elusys. Anthim (obiltoxaximab) package insert. Pine Brook, NJ; 2016.

10. Bower WA, Hendricks K, Pillai S, et al. Clinical framework and medical countermeasure use during an anthrax mass casualty incident. MMWR Recomm Rep. 2015;64(4):1–22.

11. Hodowanec A, Bleck TP. Botulism (Clostridium botulinum). In: Bennett JE, Dolin R, Blaser JM, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, Updated Edition, 8th ed. Philadelphia, PA: Elsevier Sanders, 2015. 2763–7.

12. Arnon SS, Schechter R, Inglesby TV, et al. Botulinum toxin as a biological weapon: medical and public health management. JAMA. 2001;285(8):1059–70.

13. Kwit N, Nelson C, Kugeler K, et al. Human Plague—United States, 2015. MMWR Morb Mortal Wkly Rep. 2015;64 (33):918–9.

14. Inglesby TV, Dennis DT, Henderson DA, et al. Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA. 2000;283(17):2281–90.

15. World Health Organization. The global eradication of smallpox. Geneva, Switzerland: World Health Organization, 1979.

16. Center for Disease Control and Prevention. Prevent mosquito bites. August 2017. Available at: Accessed: February 25, 2018.

17. American Pharmacists Association. Report of the 2015 APhA House of Delegates. J Am Pharm Assoc (2003). 2015;55 (4):364–75.

18. American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in emergency preparedness. Am J Health Syst Pharm. 2003;60(19):1993–5.

(Continue to page 4 for the tables…)