Vaccinia Treatment & Management

Updated: Oct 01, 2019
  • Author: Nikesh A Patel; Chief Editor: John L Brusch, MD, FACP  more...
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Medical Care

Treatment for the complications associated with vaccinia virus is supportive.

VIG may be helpful in selected patients, such as those with generalized vaccinia and eczema vaccinatum or those at high risk for developing complications following vaccination with vaccinia. VIG is less successful when used for treatment of progressive vaccinia and CNS complications.

VIG was developed from pooled sera collected from vaccinated patients in the 1960s and is available from the Centers for Disease Control and Prevention (CDC) in Atlanta, GA.

VIG is contraindicated in patients with allergies to VIG or sensitivity to human pooled serum.

The first drug for the treatment of smallpox, tecovirimat, was approved in July 2018 should smallpox ever be used as a bioweapon. Tecovirimat is an antiviral that inhibits the activity of the orthopoxvirus VP37 protein. The effectiveness of tecovirimat against smallpox was established by studies in animals infected with viruses closely related to variola virus, which demonstrated higher survival rates compared with those of placebo. The safety of tecovirimat was demonstrated in 359 healthy human volunteers, in whom the most frequently reported adverse effects included headache, nausea, and abdominal pain. [10]

Cidofovir and adefovir are being investigated to evaluate the clinical effect and outcomes as a secondary treatment of vaccinia-related complications that do not respond to VIG treatment. An oral form of this drug is currently under development.

To obtain tecovirimat, clinicians should contact the Centers for Disease Control and Prevention (CDC) Emergency Operations Center at 770-488-7100, which will coordinate shipment with the US government’s Strategic National Stockpile (SNS).

The antiviral agent cidofovir is available from the SNS as an investigational agent for treatment of smallpox. Cidofovir is approved in the United States for CMV retinitis.


Surgical Care

Surgery is usually unhelpful in the treatment of complications, although debridement of nonviable tissue in cases of vaccinia necrosum may be considered. Obtaining a biopsy of suspected lesions can aid in the diagnosis.



Consultation with a dermatologist may be helpful when the diagnosis of a skin lesion is in doubt.

Suspected cases of vaccinia-related complications should be treated in consultation with an expert in infectious diseases and poxvirus virology.

Selective consultation for specific adverse events is indicated (eg, an ophthalmologist for eye complications or a neurologist for nervous system complications).



No special dietary precautions apply to patients with vaccinia-related complications.



No specific activity limitations apply to patients with vaccinia-related complications.



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). [2]

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. [2]

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. [11]

Avoid vaccination of children younger than 18 years unless indicated by a smallpox emergency. [2]

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: [2]

  • 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)

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.