- Author: Nikesh A Patel; Chief Editor: Mark R Wallace, MD, FACP, FIDSA more...
Further Outpatient Care
Immunocompetent individuals with generalized vaccinia require supportive care and isolation from immunocompromised individuals until the infection resolves.
Less severe complications (eg, accidental infections) can be treated expectantly in an outpatient setting, provided the patient can avoid contact with high-risk individuals.
Further Inpatient Care
Patients with minor complications related to vaccinia immunization can usually be treated in an ambulatory setting. Severe complications require hospital admission and supportive intervention.
Infected patients should be isolated in a reverse airflow setting until the diagnosis is confirmed. These patients should avoid contact with other immunosuppressed persons (eg, persons with neutropenic cancer, HIV infection). These patients should also avoid contact with pregnant women, individuals with eczema, and young children.
Note that health care workers, including nurses, phlebotomists, house staff, and nutritionists, should also avoid direct contact with infected patients.
Routine vaccination with smallpox (vaccinia) vaccine, live (ACAM2000) is recommended by the CDC for occupations who directly handle cultures or animals contaminated or infected with replication-competent vaccinia virus, recombinant vaccinia viruses derived from replication-competent vaccinia strains (ie, those that are capable of causing clinical infection and producing infectious virus in humans), or other orthopoxviruses that infect humans (eg, monkeypox, cowpox, and variola).
Health care personnel (eg, physicians and nurses) who currently treat or anticipate treating patients with vaccinia virus infections and whose contact with replication-competent vaccinia viruses is limited to contaminated materials (eg, dressings) and persons administering smallpox vaccine who adhere to appropriate infection prevention measures can be offered vaccination with ACAM2000, but vaccination is not recommended as routine.
Avoiding vaccination of high-risk individuals (eg, immunosuppressed patients, pregnant women) can prevent vaccinia complications. Recent vaccinees also should avoid high-risk individuals for up to 21 days after vaccination. Recent evidence shows that TNF-alpha may play a role in resisting vaccinia virus infection of the skin; thus, patients on TNF-alpha-antagonists may also be at high risk.
Avoid vaccination of children younger than 18 years unless indicated by a smallpox emergency.
Current guidelines recommend that vaccinees defer blood donation for 21 days after vaccination or until the scab separates, whichever is later. Further studies indicate that extending the duration may be appropriate.
Contraindications to nonemergency use of smallpox vaccine include the following:
Persons with a history or presence of atopic dermatitis or other active exfoliative skin conditions (eg, eczema, burns, impetigo, varicella zoster virus infection, herpes simplex virus infection, severe acne, severe diaper dermatitis with extensive areas of denuded skin, psoriasis, or Darier disease [keratosis follicularis])
Persons with conditions associated with immunosuppression (eg, HIV infection or AIDS, leukemia, lymphoma, generalized malignancy, solid organ transplantation, or therapy with alkylating agents, antimetabolites, radiation, tumor necrosis factor [TNF] inhibitors, or high-dose corticosteroids [≥2 mg/kg body weight or ≥20 mg/day of prednisone or its equivalent for ≥2 weeks], hematopoietic stem cell transplant recipients <24 months post-transplant or ≥24 months, but who have graft-versus-host disease or disease relapse, or autoimmune disease [eg, systemic lupus erythematosus] with immunodeficiency as a clinical component)
Children younger than 1 year
Women who are pregnant or breastfeeding
Persons with a serious allergy to any component of ACAM2000
Persons with known underlying heart disease with or without symptoms (eg, CAD or cardiomyopathy)
Primary vaccinees with 3 or more known major cardiac risk factors (ie, hypertension, diabetes, hypercholesterolemia, heart disease at age 50 years in a first-degree relative, and smoking)
Recovery from minor vaccinia complications is usually complete.
Severe complications, especially in immunocompromised hosts and young children with encephalopathy, carry significant mortality rates.
Patients should be instructed about proper wound care after vaccination with vaccinia virus. This includes changing any bio-occlusive dressings and avoiding inappropriate disposal of infected bandages.
Patients must be educated to avoid high-risk individuals during the period of maximal viral shedding, approximately 10 days after exposure to the virus.
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|Complication||Number of cases from 450,293 vaccinations administered between 12/13/2002 and 5/28/2003||Department of Defense rate per million vaccinees (95% confidence interval)||Historical number of cases from 1950s and 1960s|
|Death||0||0 (0-3.7)||Age 1 y at first vaccination - 5 per 1 million primary vaccinees|
|Age 1-4 y at first vaccination - 0.5 per 1 million primary vaccinees|
|Age 5-19 y at first vaccination - 0.5 per 1 million primary vaccinees|
|Age ≥ 20 y at first vaccination - No data|
|Encephalitis||1||2.2 (0.6-7.2)||3 per 1 million primary vaccinees|
|Vaccinia necrosum/progressive vaccinia||0||0 (0-3.7)||Approximately 1 patient per million during primary or revaccination|
|Usually fatal over a period of several months|
|Eczema vaccinatum||0||0 (0-3.7)||1 per 100,000 primary vaccinees|
|1 per 1 million revaccinees|
|Generalized vaccinia||36||80 (63-100)||Occasional occurrence in immunocompetent individuals|
|3 per 100,000 primary vaccinees|
|1 per 1 million revaccinees|
|Accidental vaccinia||48||107 (88-129)||3 per 100,000 to 1 million vaccinees|
|Erythematous rash||36||80 (63-100)||Approximately 1 per 100,000 primary vaccinees*|
|Acute myopericarditis||37||82 (65-102)||100 per 1 million vaccinees|
|*Incidence was slightly higher when vaccination occurred before age 1 year.|