Transcript What You Need to Know About the Vaccinia Virus

Smallpox Vaccination
Mark Upfal, MD, MPH
Detroit Medical Center
Emergency Medicine Grand Rounds
Detroit Receiving Hospital
February 13, 2003
Collaborators: Kay Cadwell, Pat Goins, Kathy Reilly
Topics
Smallpox vaccination &
history
Vaccine effectiveness
Administration/Outcomes
Revaccination
Topics
Adverse Reactions
Treatment
Contraindications
Topics
Smallpox & Vaccination
History
Smallpox
Smallpox on trunk
Pustules
scabs
scars
Jenner 1798 Treatise on Vaccination
Historic Timetable
1796
Dr. Jenner infects James Phipps w/ cowpox
1805
Use of cows to produce vaccine
1940s
Freeze-drying technology
1949
Last US case of smallpox
1965
Licensure of bifurcated needle
1971
Routine vaccination stopped in US
1975
Last case of V. major in Bangladesh
1977
Last case of V. minor in Somalia
1983
Vaccine withdrawn from civilian market
Topics
Smallpox vaccination &
history
Vaccine effectiveness
Protects against orthopox viruses
ATB’s w/in 10 days
Post-exposure – effective if given w/in
4-5 days
Topics
Smallpox vaccination &
history
Vaccine effectiveness
Administration/Outcomes
Administration
No alcohol or prep
Dip into vial & pick up droplet btwn needle prongs
Never vaccinated: 3 rapid punctures perpendicular
to skin, induces trace blood after 15-20”
Previously vaccinated: 3 rapid punctures
perpendicular to skin, induces trace blood after 1520”
Wipe off w/ gauze; dispose waste as biohazard
Vaccine Administration
Method of Administration
Applied to the upper arm
using a multiple-puncture
technique with a bifurcated
needle.
Semipermeable Adhesive
Dressing
Infection control procedures
Normal Vaccination Reaction Time
0
Vaccination
3-4
Papule
5-6
Vesicle with surrounding erythema →
vesicle with depressed center
8-9
Well-formed pustule
12+
Pustule crusts over → scab
17-21
Scab detaches revealing scar
Major reaction
Vesicular or pustular lesion or palpable induration
surrounding a central crust or ulcer
Indicates success
Equivocal reaction
May be technique failure & no immunity
Repeat vaccination
Expected Outcome
Papules 3-5 days
Scab 13-21 days
Pustular lesion
6-12 days
CDC
recommends
daily checks
for HCWs
Topics
Smallpox vaccination &
history
Vaccine effectiveness
Administration/Outcomes
Revaccination
Revaccination
Those vaccinated in 1970’s may not
be protected
May have fewer adverse reactions
Revaccinate researchers every 10 yrs
if still working with the virus
Topics
Adverse Events
Smallpox Vaccination and
Adverse Reactions
Guidance for Clinicians
January 24, 2003 / 52(Dispatch);1-29
Common Side Effects
Local pain (30%), itching (80%) & erythema
Malaise
Low grade fever
Regional lymphadenopathy
Adverse Events
(1/800)
Autoinnoculation
529 per million
Generalized Vaccinia
242 per million
Eczema Vaccinatum
39 per million
Vaccinia necrosum
1.5 per million
Vaccinial Encephalitis
12 per million
Autoinnoculation
Autoinnoculation
Autoinnoculation
Autoinnoculation
Generalized Vaccinia
Generalized vesicular skin lesions w/o eczema
Hx or other preexisting skin dz
Believed 2o to viremia w/ dermal seeding
Usually minor; Few signif. sequelae
Generalized Vaccinia
Generalized Vaccinia
Generalized Vaccinia
Generalized vaccinia
Child recovered without sequela
Generalized Vaccinia
Eczema Vaccinatum
Patients w/ h/o eczema
Generalized dermal spread
Rarely mild cases present only
scattered individual lesions
Eczema Vaccinatum
Can occur w/ inactive eczema
More severe in contacts
Contact almost always in household
Pre-Tx Eczema Vaccinatum
Post-Tx Eczema Vaccinatum
Eczema vaccinatum
Eczema Vaccinatum in a 27 yo
Eczema Vaccinatum in a 22 yo
Eczema vaccinatum
Eczema Vaccinatum
Eczema vaccinatum
Eczema vaccinatum from contact w/
recently vaccinated child
Patient recovered without sequelae
or permanent ocular damage
Vaccinia necrosum
(progressive vaccinia)
Immunocompromised individuals
Severe local spread w/ necrosis
Can be fatal
Progressive Vaccinia in a child with
hypogammaglobulinemia
Progressive vaccinia (vaccinia necrosum)
seen w/ cell-mediated immunodeficiency
Fatal in a child with immunodeficiency
Progressive vaccinia
Progressive vaccinia in
lymphosarcoma
Severe Progressive Vaccinia in
a child with SCID
Vaccinial keratitis
VIG is contraindicated
Vaccinial Keratitis
Encephalitis
VIG not
useful
Fetal Vaccinia (28 week birth)
Strep Infection @ vaccine site
Staph Infection @ vaccine site
Infant with Post-Vaccination
Erythema Multiforme
Adverse Reactions – U.S., 1968
Complication
Rate per Million
doses
529
1/1,890
Generalized
vaccinia
Eczema
vaccinatum
Progressive vaccinia
242
1/4,132
39
1/25,641
1.5
1/666,666
Encephalitis
12
1/83,333
Total
1254
1/797
Autoinoculation
Lane JM, et al. J Infect Dis 1970;122:303-9.
Rate
What’s different today?
Many more immunocompromised
Better administration technique & follow-up
Better screening for contraindications
Better medical care for side effects
Precautions
Potentially infectious from papule (2-5d)
to scab separation (14-21d)
Opsite dressing
Proper waste disposal
Personal hygiene, universal precautions
Wash clothing hot (detergent/bleach)
Per CDC, no need to furlough HCWs
Topics
Adverse Reactions
Treatment
Vaccinia Immune Globulin (VIG)
Ig from vaccinees
Used for eczema vaccinatum, progressive
vaccinia, severe generalized vaccinia & ocular
vaccinia
Not effective in postvaccinial encephalitis
Contraindicated in vaccinial keratitis
Now available both IM & IV
Cidofivir Indications
Failure of VIG treatment
Patient is near death
VIG supplies exhausted
5 mg/kg IV over 60 min. (see
package insert!)
Cidofivir Side Effects
Severe renal toxicity
Administer with IV hydration &
probenicid
Neutropenia, proteinuria, ocular toxicity,
metabolic acidosis
? Carcinogenicity, teratogenicity,
hypospermia
Ocular treatment
VIG only if no keratitis
Trifluridine
Vidarabine (no longer manufactured)
Topics
Adverse Reactions
Treatment
Contraindications
Contraindications
Eczema Hx (incl mild or remitted)
Other acute or chronic skin conditions
if active (burns, impetigo, zoster,
psoriasis)
Immunodeficiency
HIV, CA, Steroids (>20 mg, >2 wks in past 3 mo.),
Organ transplant
Contraindications
Pregnant or planning pregnancy
Household contacts with these
conditions
Serious, life-threatening allergies to
ATBs - polymyxin B, streptomycin,
tetracycline, or neomycin
Contraindications today
Solid organ transplant
184,000
patients
Cancer patients/survivors 8,500,000
HIV positive
550,000 known;
300,000 unknown
Atopic dermatitis
28,000,000
Q&A
*Special thanks to Dr. William Atkinson, CDC National Immunization
program, for his kind contribution of slides to this presentation.