- Doctors at the Madigan Army Medical Center in Tacoma,
Washington, have documented the case of a breastfed infant who was exposed
to vaccinia virus, which is used as the smallpox vaccine.
-
- The baby's mother had not been vaccinated against smallpox
but her husband, a soldier, was given the vaccine soon before the baby
developed symptoms. The Centers for Disease Control and Prevention (CDC)
already recommends that women who are breastfeeding should not receive
the smallpox vaccine, but there are no guidelines against vaccination of
other people living in the same household.
-
- Transfer of the vaccinia virus within a household remains
"extremely rare," according to Dr Mary P Fairchok, but she said
this case demonstrates the need for extra precautions in households where
a child is breastfeeding. About 10 days after the husband was inoculated,
his wife developed blisters on her nipples. Shortly after, a blister was
seen on the baby's upper lip. Testing showed that vaccinia virus was the
cause of the lesions for both the mother and the child.
-
- "This case showed us that breastfeeding women living
with vaccine recipients should be very careful about possible contact,"
Fairchok told Reuters Health. "They should always wash their hands
prior to nursing, probably not do the laundry of the vaccine recipient,
and potentially not sleep in the same bed or have other intimate contact
until after the vaccine scab has fallen off," Fairchok said. If a
breastfeeding woman who lives with a recently vaccinated person develops
painful sores on her breasts, Fairchok said, she should hold off on breastfeeding
until seeing a health care provider to make sure that the sores are not
due to infection with the vaccine virus.
-
- The Washington physician noted that the infant in the
report recovered well, but she could have ended up with scarring or, if
the infection had spread to her eyes, with vision loss. After being monitored
in the hospital for 12 days, the child was discharged.
-
- Vaccinia virus is related to smallpox virus and produces
immunity to smallpox. Smallpox vaccination can cause severe side effects,
including brain damage and even death, in a small percentage of people,
particularly children and people with weakened immune systems. But even
if individuals who are at high risk of side effects are not given the vaccine,
there are fears that they might be infected by vaccinia virus that is shed
by others during the weeks after vaccination. "The vaccine has been
on the whole very safe, with very few accidental household transfers,"
Fairchok said, but taking a few precautions may minimize the small risk
that a child will become infected.
-
- The parents of the baby who was exposed to vaccinia virus
seemed to take all the appropriate steps to prevent transmission of the
virus. After being vaccinated in early May 2003, the baby's father reported
following all precautions to prevent the spread of vaccinia virus, including
keeping the vaccination site covered. However, the wife did do all of the
family's laundry, so she could have been exposed through contact with infected
clothes, towels, or bed linens Based on this case, Fairchok and her colleagues
advise that the CDC amend its guidelines to recommend that vaccine recipients
not share a bed with a breastfeeding mother and that they do their own
laundry. Also, women who are breastfeeding should be reminded to always
wash their hands before nursing, the authors of the report recommend.
-
- [byline: Merritt McKinney]
-
- -- ProMED-mail <promed@promedmail.org>
-
- [An additional reason for restraint in the use of smallpox
vaccine. - Mod.CP]
-
- SMALLPOX VACCINATION, SECONDARY/TERTIARY TRANSFER *************************************************
A ProMED-mail post <http://www.promedmail.org> ProMED-mail is a program
of the International Society for Infectious Diseases <http://www.isid.org>
Date: Thu 12 Feb 2004 From: ProMED-mail <promed@promedmail.org> Source:
Morb Mortal Wkly Rep 2004; 53(05): 103-5 Fri 13 Feb [edited] <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5305a3.htm>
-
-
- Secondary and tertiary transfer of Vaccinia virus among
US military personnel; US and worldwide, 2002-2004 -------------------------------------------------
In December 2002, the Department of Defense (DoD) began vaccinating military
personnel as part of the pre-event vaccination program (1). Because vaccinia
virus is present on the skin at the site of vaccination, it can spread
to other parts of the body (autoinoculation) or to contacts of vaccinees
(contact transfer).
-
- To prevent autoinoculation and contact transfer, DoD
gave vaccinees printed information that focused on handwashing, covering
the vaccination site, and limiting contact with infants (1,2). This report
describes cases of contact transfer of vaccinia virus among vaccinated
military personnel since December 2002; findings indicate that contact
transfer of vaccinia virus is rare. Continued efforts are needed to educate
vaccinees about the importance of proper vaccination-site care in preventing
contact transmission, especially in household settings.
-
- DoD conducts surveillance for vaccine-associated adverse
events by using automated immunization registries, military communication
channels, and the Vaccine Adverse Events Reporting System (VAERS). Contact
transfer cases are defined as those in which vaccinia virus is confirmed
by viral culture or polymerase chain reaction (PCR) assays. Other cases
are classified as suspected on the basis of lesion description and reported
linkage to a vaccinated person 3 to 9 days before lesion development.
-
- During the period Dec 2002 to Jan 2004, a total of 578
286 military personnel were vaccinated; 508 546 (88 per cent) were male,
and 407 923 (71 per cent) were primary vaccinees (received smallpox vaccination
for the 1st time). The median age of vaccinees was 29 years (range: 17
to 76). Among vaccinees, cases of suspected contact transfer of vaccinia
were identified among 30 persons: 12 spouses, 8 adult intimate contacts,
8 adult friends, and 2 children in the same household. These cases were
reported from Colorado (4), North Carolina (4), Texas (4), Alaska (2),
California (2), one in each of Connecticut, Kansas, New Jersey, Ohio, South
Carolina, Washington state, West Virginia, and overseas (7). The sources
of suspected contact transfer were all male service members who were primary
vaccinees. Except for 6 male sports partners, all infected contacts were
female.
-
- Vaccinia virus was confirmed in 18 (60 per cent) of the
30 cases by viral culture or PCR. Sixteen of the 18 confirmed cases involved
uncomplicated infections of the skin; 2 involved the eye (3). None resulted
in eczema vaccinatum or progressive vaccinia. 12 of the 18 confirmed cases
were among spouses or adult intimate contacts. The observed rate of contact
transfer was 5.2 per 100 000 vaccinees overall or 7.4 per 100 000 primary
vaccinees. Among 27 700 smallpox-vaccinated DoD health-care workers, no
transmission of vaccinia from a vaccinated health-care worker to an unvaccinated
patient or from a vaccinated patient to an unvaccinated health-care worker
has been identified.
-
- 2 of the 18 confirmed cases of transfer of vaccinia virus
resulted from tertiary transfer. One involved a service member, his wife,
and their breast-fed infant; the other involved serial transmission among
male sports partners.
-
- Case reports ------------ Case 1 ------ In early May
2003, a service member received his primary smallpox vaccination. About
6 to 8 days after vaccination, he experienced a major reaction (an event
that indicates a successful take; is characterized by a papule, vesicle,
ulcer, or crusted lesion, surrounded by an area of induration; and usually
results in a scar) (4). The vaccinee reported no substantial pruritus.
He slept in the same bed as his wife and kept the vaccination site covered
with bandages. After bathing, he reportedly dried the vaccination site
with tissue, which he discarded into a trash receptacle. He also used separate
towels to dry himself, rolled them so the area that dried his arm was inside,
and placed them in a laundry container. His wife handled bed linen, soiled
clothing, and towels; she reported that she did not see any obvious drainage
on clothing or linen and had no direct contact with the vaccination site.
-
- In mid-May, the wife had vesicular skin lesions on each
breast near the areola but continued to breastfeed. About 2 weeks later,
she was examined at a local hospital, treated for mastitis, and continued
to breastfeed. The same day, the infant had a vesicular lesion on the upper
lip, followed by another lesion on the left cheek (5). 3 days later, the
infant was examined by a pediatrician, when another lesion was noted on
her tongue. Because of possible early atopic dermatitis lesions on the
infant's cheeks, contact vaccinia infection with increased risk for eczema
vaccinatum was considered. The infant was transferred to a military referral
medical center for further evaluation. On examination, the infant had seborrheic
dermatitis and no ocular involvement. Skin lesion specimens from the mother
and infant tested positive for vaccinia by viral culture and PCR at the
Alaska Health Department Laboratory and at Madigan Army Medical Center.
Because both patients were stable clinically and the lesions were healing
without risk for more serious complications, vaccinia immune globulin was
not administered. Neither patient had systemic complications from the infection.
-
- Case 2 ------ In July 2003, a service member who had
been vaccinated was wrestling with an unvaccinated service member at a
military recreational function when the bandages covering the vaccination
site fell off. The unvaccinated service member subsequently wrestled with
another unvaccinated service member. 6 days later, both unvaccinated service
members had lesions on their forearms, neck, and face. Skin lesion specimens
from both men tested positive for vaccinia virus by PCR and viral culture
at Tripler Army Medical Center's microbiology laboratory.
-
- (Reported by: TW Barkdoll, MD, Okinawa, Japan. RB Cabiad,
Fort Richardson; MS Tankersley, MD, JL Adkins, MD, Elmendorf Air Force
Base; B Jilly, PhD, G Herriford, Alaska Public Health Laboratory. AC Whelen,
PhD, CA Bell, PhD, Tripler Army Medical Center, Honolulu, Hawaii. MP Fairchok,
MD, LC Raynor, MD, VA Garde, MD, VM Rothmeyer, SD Mahlen, PhD, Madigan
Army Medical Center, Fort Lewis, Washington. RJ Engler, MD, LC Collins,
MD, LL Duran, Vaccine Healthcare Center Network, Walter Reed Army Medical
Center; MT Huynh, MD, RD Bradshaw, MD, Bolling Air Force Base, Washington,
DC. JD Grabenstein, PhD, Military Vaccine Agency, U.S. Dept of Defense.)
-
- MMWR editorial note ------------------- The findings
in this report indicate that the primary risk for secondary transfer of
vaccinia was among persons who shared a bed; 12 of the 18 confirmed cases
were spouses or adult intimate contacts. However, the majority of vaccinated
DoD personnel who shared a bed did not transfer vaccinia virus to their
contacts. The frequency of contact transfer in the military vaccination
program is comparable to rates observed during the 1960s, although persons
are less likely to be immune to vaccinia today and thus are more susceptible
to contact transfer (1).
-
- The 1st case of tertiary transfer described in this report
underscores the need for breastfeeding mothers with household contact with
vaccinees to take precautions to prevent inadvertent transmission of vaccinia
to their infants. Direct contact is presumed to be the major mode of transmission,
but clothing and bed linen might act as vectors for secondary transmission.
Tertiary transmission, although rare, is facilitated when the secondary
infection is not recognized. Programs that educate health care workers,
vaccinees, and contacts should note that new vesicles or pustules that
appear <15 days after the vaccinia scab falls off from the vaccination
site might be vaccinia infections. Although an infant living in the home
is not a contraindication to vaccination of a family member in a non-outbreak
setting, measures to prevent transmission include having vaccinees launder
their own linens and towels and change their bandages away from other household
members.
-
- During the 1960s, the rate of unintentional infection
with vaccinia in secondary contacts was 2-6 cases per 100 000 primary vaccinees
(4,6,7). During that period, 2/3 of reported contact infections occurred
among children, typically siblings. Such spread could manifest as an inadvertent
infection or, in more severe fashion, as eczema vaccinatum or progressive
vaccinia. Infections of the skin predominated, with rarer ocular involvement
posing a risk for scarring or keratitis. In the current DoD smallpox vaccination
program, no cases of eczema vaccinatum have occurred, although the population
of atopic dermatitis patients might have increased substantially since
the 1960s (8). During the 1960s, eczema vaccinatum resulted in deaths,
and 2/3 of such cases were related to contact transfer of vaccinia virus
(6). In the current DoD smallpox vaccination program, careful screening
of DoD vaccinees and their household contacts for skin diseases along with
targeted education likely contributed to both screening out vaccine candidates
with personal or close-contact contraindications and educating vaccinees
about proper infection-control measures.
-
- Health care workers and the public should report suspected
cases of contact transfer of vaccinia virus to their state or local health
departments and to VAERS at <http://www.vaers.org>, or by telephone
800-822-7967. Viral culture or PCR assays, important for confirming vaccinia
virus, are available from the majority of state public health laboratories.
-
- References ---------- (1) Grabenstein JD, Winkenwerder
W Jr. US military smallpox vaccination program experience. JAMA 2003; 289:
3278-82. (2) CDC. Recommendations for using smallpox vaccine in pre-event
vaccination program: supplemental recommendations of the Advisory Committee
on Immunization Practices (ACIP) and the Healthcare Infection Control Practices
Advisory Committee (HICPAC). MMWR 2003; 52(RR-7). (3) CDC. Smallpox vaccination
and adverse events: guidance for clinicians. MMWR 2003; 52(RR-4). (4) Garde
V, Harper D, Fairchok M. Tertiary contact vaccinia in a breastfeeding infant.
JAMA 2004; 291: 725-7. (5)Neff JM, Lane JM, Fulginiti VA, Henderson DA.
Contact vaccinia---transmission of vaccinia from smallpox vaccination.
JAMA 2002; 288: 1901-5. (6)Sepkowitz KA. How contagious is vaccinia? N
Engl J Med 2003; 348: 439-46. (7)Engler RJ, Kenner J, Leung DY. Smallpox
vaccination: risk considerations for patients with atopic dermatitis. J
Allergy Clin Immunol 2002; 110: 357-65.
-
- -- ProMED-mail <promed@promedmail.org>
-
-
-
- Patricia A. Doyle, PhD Please visit my "Emerging
Diseases" message board at: http://www.clickitnews.com/ubbthreads/postlist.php?Cat=&Board=emergingdiseases
Zhan le Devlesa tai sastimasa Go with God and in Good Health
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