Vaccinia Medication

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

Medication Summary

VIG is the only drug available for amelioration of some vaccinia-related complications. VIG is produced from pooled human sera taken from vaccinia-immunized individuals and is available only from the CDC. VIG has been effective when administered early in cases of vaccinia necrosum and eczema vaccinatum. VIG has not been effective in cases of encephalopathy. The use of VIG for generalized vaccinia reactions is usually unnecessary. Vaccinia immune globulin, intravenous (VIGIV) has recently been approved by the US Food and Drug Administration.

Cidofovir (Vistide, Gilead Sciences, Foster City, Calif), a nucleotide analogue of cytosine, has demonstrated antiviral activity against certain orthopoxviruses in cell-based in vitro and animal model studies. The CDC proposes an investigational use of cidofovir in the treatment of vaccinia-related complications, which has not been studied among humans; thus, the benefits are uncertain.

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Immune globulins

Class Summary

These agents are used for passive immunity. Therapy consists of administration of immunoglobulin pooled from serum of immunized subjects.

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Vaccinia immune globulin intravenous (VIG)

 

Produced from the pooled sera of vaccinia-immunized individuals. Preparation contains antibodies targeted against vaccinia virus. Indicated for the treatment of vaccinia necrosum and eczema vaccinatum.

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Vaccinia immune globulin intravenous

 

Derived from human plasma and manufactured from pooled plasma donors who received booster immunizations with smallpox vaccine (Dryvax). Contains increased antibody levels against vaccinia virus. Indicated to treat rare adverse reactions and aberrant infections caused by vaccinia virus, including aberrant infections (eg, accidental implantation in the eyes, mouth, other potentially hazardous areas), eczema vaccinatum, progressive vaccinia, severe generalized vaccinia, and vaccinia infections in immunocompromised individuals.

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Antiviral Agent

Class Summary

Cidofovir will be released for civilian use by the CDC and for military use by the Department of Defense if the patient meets the following criteria: (1) VIG treatment fails to elicit a response, (2) a patient is near death, or (3) all inventories of VIG have been exhausted. This proposed use of cidofovir is investigational, and its effectiveness in the treatment of vaccinia-related complications among humans is unknown.

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Cidofovir (Vistide)

 

Not licensed for use as a treatment for smallpox. Currently approved for treatment of CMV retinitis in AIDS. Cidofovir is the first member of a group of antivirals known as acyclic phosphonate nucleotide analogs. Cidofovir diphosphate, the active intracellular metabolite of cidofovir, inhibits herpes virus polymerases at concentrations that are 8- to 600-fold lower than those needed to inhibit human cellular DNA polymerases alpha, beta, and gamma. Incorporation of cidofovir into the growing viral DNA chain results in reductions in the rate of viral DNA synthesis. Adefovir, cidofovir, and ribavirin are under investigation for smallpox. Ribavirin as an aerosol treatment for pediatric respiratory syncytial virus is under investigation.

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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.

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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.
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