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ASA NEWSLETTER
 
 
March 2003
Volume 67
Number 3

Smallpox: Vaccination Risks and Making a Choice

ASA Task Force on Infection Control of the
Committee on Occupational Health


Eradication of smallpox was a medical triumph over a disease that had been a human scourge for centuries.1 While the smallpox virus has been confined to research laboratories, a renewed fear of the disease has emerged as a tool of bioterrorism.2 This concern has not just developed since the events of September 11, 2001. In fact, an exercise called “Dark Winter” in June 2001 simulated a covert smallpox attack on the United States under the premise that there was insufficient vaccine and no prior vaccinations had taken place.3 This scenario resulted in significant morbidity and a presumed 30 percent mortality (an historical average). To meet the potential dreaded consequences of a smallpox attack, President Bush announced on December 13, 2002, recommendations for a smallpox readiness program that included the formation of health care response teams. These teams will be composed of health care workers and other critical personnel who will administer care to victims in the event of an attack.

Health departments around the country are now developing and implementing readiness programs. As health care workers, we need to become knowledgeable about the disease. We must understand who can be vaccinated, the appropriate care of a vaccination site and the risks of our own vaccination to our patients, both healthy and immunocompromised, as well as our families and ourselves — for while vaccination is relatively safe, it is not risk-free.

Smallpox is caused by the variola virus. It is spread by respiratory mechanisms such as coughing that release droplet nuclei and aerosols or by direct contact with an infected person or items such as contaminated clothing or bed linens.1 Following an incubation period of seven to 17 days, a prodrome consisting of fever, malaise, headache and backache occurs. An oral enanthem appears that signals the onset of oropharyngeal infectiousness. A rash then appears that at first is macular, then papular and progresses to the formation of vesicles, then pustules. Next, pustules crust over and fall off, leaving the characteristic disfiguring scars of smallpox. A patient is considered infectious until the pustules have scabbed over and the scabs have fallen off, and patients must remain in isolation until this phase is complete.

The fatality rate of smallpox can reach 30 percent and is associated with toxemia, intravascular volume depletion and, occasionally, a hemorrhagic diathesis.1,2 The last natural case of smallpox occurred in 1977.2 Health care workers immunized against smallpox must still employ respiratory and contact isolation precautions when dealing with infected people.5

Since there is no effective treatment for smallpox, people need to be vaccinated with the live vaccinia virus. While related to variola virus, the vaccinia virus does not cause smallpox, but it does help the body to develop immunity to the smallpox virus. The vaccine distributed for use today is a relicensed vaccine of the original calf-derived Dryvax® product from Wyeth-Ayerst. This vaccine has been in storage since 1985 and is derived from the New York City Board of Health-strain of live vaccinia virus. The vaccinia strain used in this preparation has been shown to cause less adverse effects than other vaccine strains.6

Vaccination ceased in the United States in 1972.2 Immunity after vaccination lasts three to five years, although it is thought that immunity may last longer. Even though immunity wanes, it still offers some degree of protection as demonstrated by a decreased mortality rate among individuals who develop smallpox but have a history of vaccination. For those never vaccinated or with distant vaccination, the vaccine must be given within three to four days after exposure to smallpox to protect against infection.2 Individuals who were vaccinated longer than three years ago will require revaccination.

Once an individual is vaccinated, it can take three weeks from the initial appearance of a macule (three to seven days) at the vaccine site to a complete response, which ultimately results in a scab. Until the scab falls off at approximately three weeks, the vaccine site should be considered contagious.1 This highlights the importance of strict hand washing and meticulous care of the inoculation site and all materials that come in contact with the vaccination site. In many instances, vaccine recipients may be required to report to designated health care officers for care of the vaccine site prior to their workday.

In an attempt to eliminate the possibility of transmission of vaccinia, the vaccine site must be properly covered, usually with gauze and a semipermeable dressing and clothing over the dressing. The Centers for Disease Control and Prevention recommends that during the time of potential infectivity, vaccinees and/or guardians should keep the vaccine site covered and should not touch, scratch or rub the vaccine site (the area tends to be itchy) while avoiding contact with susceptible individuals.5,6 The vaccinee should avoid touching, rubbing or otherwise performing any maneuvers that might transfer vaccinia virus to the eye, surrounding or distant skin, or mucous membranes. The vaccine site dressing or covering should be discarded in a closed plastic bag. After any contact with the vaccine site or covering, one should thoroughly wash his or her hands with soap and warm, running water.5,6

Since the vaccine is live, a major concern during the vaccination process is transmission of vaccinia through inadvertent inoculation during the time the vaccinated person is infectious. Infection can occur by spreading from the site of inoculation to nonvaccinated individuals or by autoinoculation from the site of vaccination to other parts of the body of the vaccinated person. There have been several well-documented cases of inadvertent inoculation from touching the dressings or clothing that was in contact with the vaccination site.7 The eye is a common site for autoinoculation. Ocular vaccinia manifestations include keratitis, conjunctivitis and blepharitis. Unintended inoculation of others can result in potentially life-threatening systemic infection.

All potential vaccine recipients should be screened for contraindications to voluntary vaccination, including a history of skin conditions such as eczema, atopic dermatitis, impetigo, psoriasis, unhealed burns, contact dermatitis or active chickenpox. In addition, contraindications to vaccination include pregnancy (or plans to conceive within a month), breastfeeding mothers, immunosuppression (e.g., cancer therapy, status post-transplant, systemic or possibly inhaled steroids, HIV, AIDS, eye disease of the conjunctiva that may result in itching of the eye and therefore increase the risk of autoinoculation, eye disease requiring topical steroid drops and children less than 12 months of age.4,5,7,8 The risk in individuals with immunosuppression is due to the possibility of progressive systemic infection from vaccinia virus because of poor immune localization to the vaccination site.8

Household contact with anyone having any of the above conditions also precludes voluntary vaccination due to the risk of transmission except for children less than 12 months of age. The risk of transmission is low in settings where meticulous care of the vaccination site is taken. Additional contraindications to smallpox vaccine include hypersensitivity to any of the vaccine components such as streptomycin, tetracycline, polymyxin or neomycin. Chickenpox vaccine should not be given within 30 days of smallpox vaccine because of the difficulty in differentiating the rash of chickenpox from early vaccinia.5 While many relative contraindications to pre-exposure vaccination exist, exposure to the smallpox virus changes the risk-to-benefit ratio of vaccination given the potential lethal consequences of smallpox infection.

Reactions to vaccination tend to be less severe in those who have received prior immunization. However, mass vaccination programs stopped about 30 years ago in the United States.4 The adverse reactions associated with the smallpox vaccine can be mild, consisting of a rash at the site of inoculation and associated with fever, headache and malaise. There are a variety of other reactions delineated in the 19689 survey of American physicians in which all the recipients had been vaccinated for the first time. They were divided into two categories: 1) serious but not life-threatening reactions and 2) life-threatening reactions.

The serious but not life-threatening reactions were the most common and in order of decreasing frequency were (per million vaccinees):
Inadvertent inoculation 529
Generalized vaccinia 241
Erythema multiforme 164
Total 935

Life-threatening reactions were less frequent and in order of decreasing frequency were (per million vaccines):
Postvaccinal encephalitis 12
Progressive vaccinia 1.5
Eczema vaccinatum 38.5
Total 52
Death 1.5
Recent experience with the smallpox virus in Israel has demonstrated an overall complication rate, including the rate of severe complications (postvaccinal encephalitis and permanent neurologic sequelae), that is consistent with previously published data in Israel and the United States.10 The recent Israeli data is useful to review since it includes a proportion of the population that had not previously received smallpox vaccine, further demonstrating that smallpox vaccine administered in a controlled setting is relatively safe. Extrapolation as to what we can expect in the United States once the first phase of the vaccine program begins is probably reasonable even though the vaccines administered in Israel and the United States are different preparations.


Frequently Asked Questions from Health Care Workers Concerning Smallpox

The New York City Department of Health and Mental Hygiene has compiled a list of “Frequently Asked Questions About Smallpox Vaccine and the Voluntary Program for Vaccination of Health Care Smallpox Response Teams.”11 It offers answers to some questions that physicians and others have asked about the vaccination process. Two of the 46 questions and answers are listed here.

Will I still be able to take care of patients after I get the smallpox vaccine?
Yes. It is acceptable to continue work after getting the smallpox vaccine as long as your vaccine site is covered with the correct type of dressing (gauze and a semipermeable dressing), you wear long-sleeved shirts or sweaters, the vaccine site is checked every day before you work, and you are careful to wash your hands after touching the vaccine site or dressing, even if you are wearing gloves.

The vaccine site will be checked before every work shift by health professional employees or other staff designated by your hospital to do these checks until your scab falls off. If you take proper care to wash your hands whenever touching the vaccination site or the dressing and before and after seeing any patient, there should be little risk to your patients, even to those who have weakened immune systems (e.g., HIV infection or cancer patients). In the past, the spread of vaccinia virus from the vaccine site to patients in the hospital was very rare.

However, if any of the following occur, the hospital will advise you not to come to work:
• If you are ill and physically unable to work.
• If your vaccine site becomes very red and swollen with pus and cannot be covered adequately with a dressing
• If you do not follow infection control measures of washing your hands with soap and water (or an approved hand-hygiene disinfection product) after touching your vaccine site or the dressing and before and after every time you touch a patient.
Some hospitals may, depending on your job duties, decide to temporarily re-assign you to a different job or to put you on leave until the vaccine-site scab falls off. This decision will be made by each hospital and may apply to certain staff only.


Why is it OK for me to work with patients who are likely to have health problems (such as HIV, cancer, pregnant women and patients with eczema) after I get smallpox vaccine but not OK for my close household or intimate contacts to have one of these diseases or conditions?
In the hospital setting, it is much less likely for staff to have close, prolonged intimate contact than it is at home. Household or other close contacts are more likely to spend longer periods of time with the person who is vaccinated as well as to be more intimate than health care workers and their patients. Because of the special precautions used in hospital settings (which are not as easy to follow in household settings), spread of the vaccinia virus (in the vaccine site) from health care providers to their patients has been low in the past. Also, as long as the vaccine is covered well by a dressing (gauze bandage and semipermeable dressing) as well as your clothing and you are sure to wash your hands thoroughly before and after touching the vaccine site and dressing, and before and after touching your patients, the risk to your patients is thought to be low. In a recent study, no vaccine virus (the vaccinia virus) was found on the outside of the dressing (gauze bandage and semipermeable dressing) of any vaccinated person.

As physicians, we will be called upon in the event of a bioterrorist event, and smallpox vaccinations will be offered to us. Many questions will be raised as we respond to this call to arms. Resources such as the Centers for Disease Control and Prevention Web site <www.cdc.gov/smallpox> are available to educate us. Knowledge of the disease, the vaccination process, its risks and benefits and how it will affect us, our patients and our families are important to understand so that each individual can make an informed decision as we consider our role in public service in the effort against bioterrorism.

The fact sheet “Frequently Asked Questions About Smallpox Vaccine and the Voluntary Program for Vaccination of Health Care Smallpox Response Teams” can be accessed at <www.nyc.gov/html/doh/html/cd/cdsma.html>.


References:
1. 29 F, Henderson DA, Arita I, Jezek Ladnyi ID. Smallpox and its eradication. Geneva: World Health Organization, 1988. <www.who.int/emc/diseases/smallpox/Smallpoxeradication.html>. Accessed January 27, 2003.
2. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon: Medical and public health management. JAMA. 1999; 281:2127-2137.
3. O’Toole T, Mair M, Inglesby TV. Shining light on “Dark Winter.” Clin Infect Dis. 2002; 34:972-983.
4. Breman JG, Henderson DA. Diagnosis and management of smallpox. N Engl J Med. 2002; 346:1300-1308.
5. Centers for Disease Control and Prevention. <www.bt.cdc.gov/agent/smallpox/index.asp>. Accessed January 27, 2003.
6. Centers for Disease Control and Prevention. Smallpox vaccination and adverse reactions. Guidance for clinicians. MMWR Dispatch. 2003; January 24; 52.
7. Sepkowitz KA. How contagious is vaccinia? N Engl J Med. 2003; 348:439-446.
8. Moses AE, Cohen-Poradosu R. N Engl J Med. 2002; 346:1287.
9. Lane JM, Ruben FL, Neff JM, et al. Complications of smallpox vaccination: National surveillance in the United States, 1968. N Eng J Med. 1969; 281:1201-1207.
10. Haim M, Gdalevich M, Mimouni D, et al. Adverse reactions to smallpox vaccine: The Israel Defense Force experience, 1991 to 1996: A comparison with previous surveys. Military Med. 2000; 165:287-289.
11. New York City Department of Health and Mental Hygiene Question and Answer Fact Sheet for Health Care Workers Considering Volunteering for the Smallpox Vaccine “Frequently Asked Questions About Smallpox Vaccine and the Voluntary Program for Vaccination of Health Care Smallpox Response Teams.” <www.nyc.gov/html/doh/html/cd/cdsma.html>. Accessed on December 24, 2002.
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Helene Lupatkin, M.D., is Assistant Professor, Department of Medicine, Division of Infectious Diseases, New York University School Of Medicine, New York, New York.
Helene Lupatkin, M.D.


  Joel F. Lupatkin, M.D., is Attending Anesthesiologist, Hospital For Joint Diseases, New York University School Of Medicine, New York, New York.
Joel F. Lupatkin, M.D.

   
Andrew D. Rosenberg, M.D., is Chair, Department of Anesthesiology, Hospital For Joint Diseases and Associate Professor of Clinical Anesthesiology, New York University School of Medicine, New York, New York.
Andrew D. Rosenberg, M.D.

    Samuel Hughes, M.D., is Professor of Clinical Anesthesia and Perioperative Medicine, University of California-San Francisco, San Francisco, California, and Chair, ASA Infection Control Task Force.
Samuel Hughes, M.D.

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