Vaccinia Follow-up

  • Author: Jennifer J Lee, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 12, 2012
 

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.
Next

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.
Previous
Next

Deterrence/Prevention

  • Avoiding vaccination of high-risk individuals can prevent vaccinia complications. Recent vaccinees also should avoid high-risk individuals for up to 21 days after vaccination. High-risk individuals include people with eczema, pregnant women, young children, and immunosuppressed individuals.
  • 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.
Previous
Next

Prognosis

  • Recovery from minor vaccinia complications is usually complete.
  • Severe complications, especially in immunocompromised hosts and young children with encephalopathy, carry significant mortality rates.
Previous
Next

Patient Education

  • 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.
Previous
 
Contributor Information and Disclosures
Author

Jennifer J Lee, MD  Resident Physician, Department of Dermatology, University of Texas Southwestern at Austin

Jennifer J Lee, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, California Medical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Dayna Diven, MD  Professor, Department of Dermatology, University of Texas Southwestern Austin Programs

Dayna Diven, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Idaho Medical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Tasneem A Poonawalla, MD  Physician, Department of Dermatology, Dean Clinic

Tasneem A Poonawalla, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Howard L Kaufman, MD  Chief, Division of Surgical Oncology, Columbia University

Howard L Kaufman, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American College of Surgeons, American Medical Association, Association for Academic Surgery, Illinois State Medical Society, Massachusetts Medical Society, New York Academy of Sciences, and Society of Surgical Oncology

Disclosure: Nothing to disclose.

Ken Flanagan  Department of Microbiology and Immunology, Albert Einstein College of Medicine

Ken Flanagan is a member of the following medical societies: American Association for Cancer Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Brenda Jones  MD, Associate Professor of Clinical Medicine, Division of Infectious Diseases, Keck School of Medicine of the University of Southern California

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard B Brown, MD, FACP  Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine

Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Thomas W McGovern, MD, to the development and writing of this article.

References

  1. Couch RB, Winokur P, Edwards KM, Black S, Atmar RL, Stapleton JT, et al. Reducing the dose of smallpox vaccine reduces vaccine-associated morbidity without reducing vaccination success rates or immune responses. J Infect Dis. Mar 15 2007;195(6):826-32. [Medline].

  2. Rimmelzwaan GF, Sutter G. Candidate influenza vaccines based on recombinant modified vaccinia virus Ankara. Expert Rev Vaccines. Apr 2009;8(4):447-54. [Medline].

  3. Tykodi SS, Thompson JA. Development of modified vaccinia Ankara-5T4 as specific immunotherapy for advanced human cancer. Expert Opin Biol Ther. Dec 2008;8(12):1947-53. [Medline].

  4. Perera LP, Waldmann TA, Mosca JD, Baldwin N, Berzofsky JA, Oh SK. Development of smallpox vaccine candidates with integrated interleukin-15 that demonstrate superior immunogenicity, efficacy, and safety in mice. J Virol. Aug 2007;81(16):8774-83. [Medline].

  5. Wertheimer ER, Olive DS, Brundage JF, Clark LL. Contact transmission of vaccinia virus from smallpox vaccinees in the United States, 2003-2011. Vaccine. Dec 19 2011;[Medline].

  6. Redfield RR, Wright DC, James WD. Disseminated vaccinia in a military recruit with human immunodeficiency virus (HIV) disease. N Engl J Med. Mar 12 1987;316(11):673-6. [Medline].

  7. Artenstein AW. New generation smallpox vaccines: a review of preclinical and clinical data. Rev Med Virol. Jul-Aug 2008;18(4):217-31. [Medline].

  8. Baxby D. Indications for smallpox vaccination: policies still differ. Vaccine. 1993;11(4):395-6. [Medline].

  9. Breman JG, Henderson DA. Diagnosis and management of smallpox. N Engl J Med. Apr 25 2002;346(17):1300-8. [Medline].

  10. Buller RM, Palumbo GJ. Poxvirus pathogenesis. Microbiol Rev. Mar 1991;55(1):80-122. [Medline].

  11. Carroll MW, Moss B. Poxviruses as expression vectors. Curr Opin Biotechnol. Oct 1997;8(5):573-7. [Medline].

  12. [Guideline] Casey C, Vellozzi C, Mootrey GT, Chapman LE, McCauley M, Roper MH. Surveillance guidelines for smallpox vaccine (vaccinia) adverse reactions. MMWR Recomm Rep. Feb 3 2006;55(RR-1):1-16. [Medline].

  13. Casey CG, Iskander JK, Roper MH, Mast EE, Wen XJ, Török TJ. Adverse events associated with smallpox vaccination in the United States, January-October 2003. JAMA. Dec 7 2005;294(21):2734-43. [Medline].

  14. Clark J, Diven D. Poxviruses. In: Tyring S, Moore A, Lupi O, eds. Mucocutaneous Manifestations of Viral Diseases. 2nd ed. New York, NY: Informa HealthCare; In press.

  15. Damon I. Orthopoxviruses: Vaccinia (Smallpox Vaccine), Variola (Smallpox), Monkeypox, and Cowpox. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 6th ed. Orlando, FL: Churchill Livingstone; 2005:1742-55.

  16. Egan C, Kelly CD, Rush-Wilson K, Davis SW, Samsonoff WA, Pfeiffer H. Laboratory-confirmed transmission of vaccinia virus infection through sexual contact with a military vaccinee. J Clin Microbiol. Nov 2004;42(11):5409-11. [Medline].

  17. Franz DR, Jahrling PB, Friedlander AM, McClain DJ, Hoover DL, Bryne WR, et al. Clinical recognition and management of patients exposed to biological warfare agents. JAMA. Aug 6 1997;278(5):399-411. [Medline].

  18. Friedman HM. Smallpox, Vaccinia, and Other Poxviruses. In: Isselbacher, et al, eds. Harrison's Principles of Internal Medicine. 13th ed. New York, NY: McGraw-Hill; 1994:798-9.

  19. Grabenstein JD, Winkenwerder W Jr. US military smallpox vaccination program experience. JAMA. Jun 25 2003;289(24):3278-82. [Medline].

  20. Haga IR, Bowie AG. Evasion of innate immunity by vaccinia virus. Parasitology. 2005;130 Suppl:S11-25. [Medline].

  21. Harrop R, Ryan MG, Golding H, Redchenko I, Carroll MW. Monitoring of human immunological responses to vaccinia virus. Methods Mol Biol. 2004;269:243-66. [Medline].

  22. Hopkins RJ, Lane JM. Clinical efficacy of intramuscular vaccinia immune globulin: a literature review. Clin Infect Dis. Sep 15 2004;39(6):819-26. [Medline].

  23. Lane HC, Fauci AS. Microbial bioterrorism. In: Kasper, et al, eds. Harrison's Principles of Internal Medicine. 16th ed. New York, NY: McGraw-Hill; 2005.

  24. Lane JM, Millar JD. Risks of smallpox vaccination complications in the United States. Am J Epidemiol. Apr 1971;93(4):238-40. [Medline].

  25. Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox vaccination, 1968. N Engl J Med. Nov 27 1969;281(22):1201-8. [Medline].

  26. Lewis FS, Norton SA, Bradshaw RD, Lapa J, Grabenstein JD. Analysis of cases reported as generalized vaccinia during the US military smallpox vaccination program, December 2002 to December 2004. J Am Acad Dermatol. Jul 2006;55(1):23-31. [Medline].

  27. Moss B. Genetically engineered poxviruses for recombinant gene expression, vaccination, and safety. Proc Natl Acad Sci U S A. Oct 15 1996;93(21):11341-8. [Medline].

  28. Moss B. Poxvirus entry and membrane fusion. Virology. Jan 5 2006;344(1):48-54. [Medline].

  29. Moss B. Vaccinia virus: a tool for research and vaccine development. Science. Jun 21 1991;252(5013):1662-7. [Medline].

  30. Neff JM. Vaccinia Virus (Cowpox). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone; 2000:1553-5.

  31. Notice to Readers: Newly Licensed Smallpox Vaccine to Replace Old Smallpox Vaccine. MMWR Morb Mortal Wkly. 2008;57:207-208.

  32. Ojeda S, Domi A, Moss B. Vaccinia virus G9 protein is an essential component of the poxvirus entry-fusion complex. J Virol. Oct 2006;80(19):9822-30. [Medline].

  33. Paoletti E. Applications of pox virus vectors to vaccination: an update. Proc Natl Acad Sci U S A. Oct 15 1996;93(21):11349-53. [Medline].

  34. Rotz LD, Dotson DA, Damon IK, Becher JA. Vaccinia (smallpox) vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001. MMWR Recomm Rep. Jun 22 2001;50:1-25; quiz CE1-7. [Medline].

  35. Savona MR, Dela Cruz WP, Jones MS, Thornton JA, Xia D, Hadfield TL, et al. Detection of vaccinia DNA in the blood following smallpox vaccination. JAMA. Apr 26 2006;295(16):1898-900. [Medline].

  36. Sejvar JJ, Labutta RJ, Chapman LE, Grabenstein JD, Iskander J, Lane JM. Neurologic adverse events associated with smallpox vaccination in the United States, 2002-2004. JAMA. Dec 7 2005;294(21):2744-50. [Medline].

  37. Sepkowitz KA. How contagious is vaccinia?. N Engl J Med. Jan 30 2003;348(5):439-46. [Medline].

  38. Stanley SL Jr, Frey SE, Taillon-Miller P, Guo J, Miller RD, Koboldt DC, et al. The immunogenetics of smallpox vaccination. J Infect Dis. Jul 15 2007;196(2):212-9. [Medline].

  39. Stark JH, Frey SE, Blum PS, Monath TP. Lack of transmission of vaccinia virus. Emerg Infect Dis. Apr 2006;12(4):698-700. [Medline].

  40. Townsley AC, Moss B. Two distinct low-pH steps promote entry of vaccinia virus. J Virol. Aug 2007;81(16):8613-20. [Medline].

 
Previous
Next
 
This typical pustular lesion following vaccinia immunization usually appears within 5 days of vaccination and forms a scab by 10-14 days. Vaccination usually leaves a permanent indentation.
Table. Frequency of Complications Related to Vaccination
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
Death00 (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
Encephalitis12.2 (0.6-7.2)3 per 1 million primary vaccinees
Vaccinia necrosum/progressive vaccinia00 (0-3.7)Approximately 1 patient per million during primary or revaccination
Usually fatal over a period of several months
Eczema vaccinatum00 (0-3.7)1 per 100,000 primary vaccinees
1 per 1 million revaccinees
Generalized vaccinia3680 (63-100)Occasional occurrence in immunocompetent individuals
3 per 100,000 primary vaccinees
1 per 1 million revaccinees
Accidental vaccinia48107 (88-129)3 per 100,000 to 1 million vaccinees
Erythematous rash3680 (63-100)Approximately 1 per 100,000 primary vaccinees*
Acute myopericarditis3782 (65-102)100 per 1 million vaccinees
*Incidence was slightly higher when vaccination occurred before age 1 year.
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.