From Mortality and Morbity
Reports: May 18, 2007 / 56(19);478-481
Household Transmission of Vaccinia
Virus from Contact with a Military Smallpox Vaccinee --- Illinois
and Indiana, 2007
On March 7, 2007, the Chicago
Department of Public Health and the University of Chicago Pediatric
Infectious Disease Service and Infection Control Program notified
CDC of a child with presumed eczema vaccinatum (EV), a
life-threatening complication of vaccinia virus infection (1).
This is the first reported EV case in the United States since 1988 (2).
This report summarizes the epidemiologic and environmental
investigations conducted by local, state, and federal public health
authorities in Illinois and Indiana to determine the source of
exposure and to identify and monitor other persons at risk for
vaccinia virus infection. This case highlights the need for
clinicians to maintain a high index of suspicion when evaluating
recently vaccinated patients and their family members with
vesiculopustular rash.
On January 26, 2007, an active-duty
U.S. service member received a first-time smallpox vaccination in
preparation for overseas military deployment. He had a history of
childhood atopic dermatitis (i.e., eczema) and household contact
with persons with eczema (two of his three children), both of which
are contraindications to vaccination. His deployment was delayed, so
he made an unplanned visit home to visit his family in Indiana
during February 16--20. During this period, he spent time with his
son, aged 28 months, who has severe eczema and a history of failure
to thrive. The father reported his vaccination site had scabbed over
and that the scab had separated before the visit home; he also
reported that he kept the site bandaged during the visit. His
routine activities with his son included hugging, wrestling,
sleeping, and bathing.
On March 3, the child was taken to a
small, local Indiana hospital because of a generalized papular,
vesicular rash on the face, neck, and upper extremities. Because of
the severity of the illness, he was transferred to a tertiary-care
facility in Chicago later that day; contact precautions were
implemented at the hospital. The child's mother indicated that the
boy had a fever 2 days before his hospital admission and weeping
skin lesions as early as February 24. By March 7, the rash had
progressed to umbilicated lesions with an erythematous base,
primarily involving the child's hands, forearms, neck, chest, face,
and knees and encompassing 50% of his keratinized skin. On March 8,
lesion specimens were analyzed at the Illinois Department of Public
Health Laboratory (IDPHL) in Chicago by real-time polymerase chain
reaction (PCR) orthopoxvirus generic assay and nonvariola
orthopoxvirus assay. The results of the assays were positive for
orthopoxvirus DNA, supporting the clinical diagnosis of EV. The
diagnosis of vaccinia was confirmed at CDC.
During March 8--28, the child was
treated with a combination of immunotherapy and antivirals targeting
vaccinia virus. The initial treatment included Vaccinia Immune
Globulin Intravenous (Human) (VIGIV); supportive care included
sedation, intubation, and mechanical ventilation. Despite these
interventions, on March 10, the child's illness had progressed to
hypothermia and hemodynamic instability requiring vasopressor
support. Antiviral therapies with cidofovir and an investigational
drug, ST-246 (SIGA Technologies, Corvallis, Oregon) under an
Emergency Investigational Drug application, were initiated
sequentially,* and additional infusions of VIGIV were administered.
After approximately 1 week of interventions, the child began to
improve. On April 19, the child was discharged home after 48 days of
hospitalization; he has no known sequelae other than possible
scarring of the skin.
Clinical specimens (e.g., lesion
material, blood, and serum) collected during the patient's
hospitalization were analyzed in the CDC Poxvirus Laboratory. All
specimens collected during the first 10 days of his hospitalization
were positive for orthopoxvirus DNA using a real-time PCR assay.
Before VIGIV administration, serum was positive for
antiorthopoxvirus immunoglobulin M (IgM) and negative for
immunoglobulin G (IgG) by enzyme-linked immunosorbent assay.
On March 6, the child's third hospital
day, hospital staff members noticed that the patient's mother had
approximately six vesicular lesions on her face; additional lesions
subsequently developed on her right index finger and near her
eyelid. The mother had a history of facial acne flare-ups and
reported that she had rested her cheek on the child's abdomen while
he was being treated in the hospital. Lesion material was analyzed
by IDPHL and found to contain orthopoxvirus DNA signatures.
The mother was isolated voluntarily in the same room as her son; on
March 10, she received VIGIV treatment. Within 72 hours of the
initiation of VIGIV treatment, her lesions began to scab over.
Evaluation of serum collected from the mother on March 8 indicated
that she had not yet developed an antiorthopoxvirus humoral immune
response (IgG and IgM negative).
The couple has two other children, one
with a history of eczema. Both children left the family residence at
the time of the child's hospitalization and were cared for by their
grandparents. Neither child had symptoms of vaccinia infection at
the time of this report.
Public health and infection-control
professionals interviewed community contacts, family members, and
hospital staff members to identify persons who might have had
physical contact (i.e., skin-to-skin) with the ill child after
February 23 (the day before the child's first possible skin
eruption) or the father while he was home on leave during February
16--20. Twenty-three family contacts, including the two siblings,
and 73 health-care worker contacts were identified. Persons were
monitored daily for the onset of contact vaccinia symptoms for 21
days after their last potential vaccinia exposure. During this
period, one person had a rash, and one had fever; neither person had
vaccinia virus infection. All other potential contacts remained
healthy throughout the follow-up period; no nosocomial transmission
occurred. Hospital and public health officials recommended that the
mother and child remain isolated until they had no more vaccinia
scabs.
Because the child had a rash before
being hospitalized, an environmental assessment of the family home
was conducted on March 13 to determine whether viable vaccinia virus
was still present. Multiple swab samples obtained from the home
(e.g., from a bathroom washcloth, a slipper, a toy drum, a night
stand, a booster seat, and an ointment container) and from items
brought to the child's hospital room (e.g., an infant drinking cup
and a car seat) were positive for vaccinia virus DNA by real-time
PCR assay. Cell culture of samples collected from three of these
items (booster seat, toy drum, and slipper) contained viable virus.
Disinfection procedures were completed on March 23 and included
steam cleaning of carpeted areas, disinfection of household surfaces
with phenolics, and hot washing of clothing and linens after a
phenolic presoak.
Reported by: J Marcinak, MD,
S Vora, MD, S Weber, MD, K Thomson, PhD, S Garcia-Houchins, Univ of
Chicago Comer Children's Hospital; S Gerber, Chicago Dept of Public
Health; C Conover, MD, J Nawrocki, PhD, K Hunt, Illinois Dept of
Public Health. R Panares, MD, B Suter, K Siegfried, Hammond Health
Dept; R Teclaw, DVM, C Graves, MD, W Staggs, MS, D Allen, MS, K
Buffin, MS, P Pontones, MA, Indiana State Dept of Health. V
Fulginiti, MD, Univ of Arizona and Univ of Colorado. L Collins, MD,
Walter Reed Vaccine Healthcare Center. D Scott, MD, Center for
Biologics Evaluation and Research, P Patel, RPh, K Chan-Tack, MD, J
DiGiacinto, PharmD, Div of Antiviral Products, Food and Drug Admin.
I Damon, MD, M Reynolds, PhD, R Regnery, PhD, E Belay, MD, K Karem,
PhD, V Olson, PhD, Y Li, PhD, S Smith, MS, Z Braden, C Hughes, MPH,
Div of Viral and Rickettsial Diseases, National Center for Zoonotic,
Vector-Borne, and Enteric Diseases; A Fleischauer, PhD, P Diaz, MD,
L Rotz, MD, N Pesik, MD, J Barson, DO, W Bower, MD, Div of
Bioterrorism Preparedness and Response, National Center for
Preparedness, Detection, and Control of Infectious Diseases; J
Openshaw, MS, CDC Experience Fellow; R Miramontes, PA-C, E Lederman,
MD, EIS officers, CDC.
Editorial Note:
This report describes the first
documented case of EV in the United States since 1988 (2).
The epidemiologic investigation and clinical history indicated that
secondary transmission of vaccinia virus occurred between the father
and child. The stage of healing of the father's vaccination site
during the exposure period was reported by the father and was not
clinically confirmed, nor was consistent use of a bandage. Serologic
evidence and clinical history further suggests that tertiary
transmission might have occurred between the child and mother. In
addition, the possibility of transmission by fomites (i.e.,
contaminated objects such as toys and towels) cannot be excluded;
the targeted environmental assessment detected infectious virus more
than 1 week after the ill child had left the home.
The World Health Organization declared
smallpox eradicated in 1979. However, smallpox vaccination was
required for U.S. military personnel until 1990, when it was
discontinued. After the September 11, 2001, terrorist attacks and
the 2001 anthrax cases, the U.S. government reinstated smallpox
vaccination for military personnel and selected health-care workers.
The U.S. Department of Defense had vaccinated approximately 1.2
million persons as of March 2007.†
The smallpox vaccine contains live
vaccinia virus, which confers protection against infection from
variola virus, the cause of smallpox. Vaccinia virus can be
transmitted from a vaccine recipient to other persons through direct
(skin-to-skin) contact via material from the unhealed vaccination
site or through indirect contact by means of fomites (4--6).
Vaccinia virus can be cultured from the site of primary vaccination
beginning at the time of development of a papule (i.e., 2--5 days
after vaccination). Generally, a scab forms at the vaccination site
by day 14 and falls off by day 21 (7).
Until the vaccination scab falls off, a person who has been
vaccinated can transmit vaccinia virus to others. Persons who are
infected through contact with a person who has received smallpox
vaccination are at risk for the same adverse reactions to smallpox
vaccination as the vaccine recipient.
EV is a rare but serious reaction to
smallpox vaccine. A history of eczema, atopic dermatitis (regardless
of disease severity or activity), or Darier's disease is a risk
factor for EV, both for vaccine recipients and their close contacts;
having household contacts with any of these conditions also is a
contraindication Although no data exist to predict the risk for EV
among such persons, before 1990, the incidence rate for EV after
smallpox vaccination was approximately eight to 80 cases per 1
million vaccinations (8). The introduction of intramuscularly
administered vaccinia immune globulin treatment was estimated to
have reduced EV-associated mortality from 30%--40% to 7% (9).
Licensed in 2005, VIGIV is the only product available that is
approved by the Food and Drug Administration for treating patients
with EV (8).
Consistent with current Advisory
Committee on Immunization Practices guidelines to prevent
transmission of vaccinia from vaccinated persons to close personal
contacts, persons who have been vaccinated should wear long-sleeved
clothing and cover the vaccination site with gauze or a similar
semipermeable dressing until the scab separates from the skin
independently (i.e., without assistance from the person) (3).
Vaccinated persons should not share towels or clothing with others
and should wash their hands with warm, soapy water or a hand-rub
solution containing >60% alcohol immediately after they touch
their vaccination site or change their vaccination-site bandages (3).
Contraindications to smallpox vaccination should be considered
before the administration of vaccine; these include pregnancy,
immune-compromising conditions (e.g., human immunodeficiency virus
infection), or a chronic skin disease such as eczema. Having
household contacts with any of these conditions also is a
contraindication. Agencies whose health-care providers administer
smallpox vaccine should periodically assess the effectiveness of
vaccine-related education for these providers and for the vaccine
recipients.
The administration of smallpox vaccine
to this service member and his subsequent contact with his family
are under investigation by the U.S. military, which will determine
whether screening and education practices need to be modified (10).
Health-care workers treating patients with EV, generalized vaccinia
infection, or progressive vaccinia infection should follow contact
precautions until patients' scabs have separated. Clinicians should
maintain a high index of suspicion for vaccinia when evaluating
vesiculopapular rashes in patients who have been vaccinated recently
and in their close contacts. Suspected cases of vaccinia should be
reported to state or local health departments and to the Vaccine
Adverse Events Reporting System online (http://vaers.hhs.gov)
or by telephone (800-822-7967). Laboratories that are part of the
Laboratory Response Network (LRN) (http://www.bt.cdc.gov/lrn)
have the ability to assess clinical specimens for the presence of
orthopoxvirus DNA signatures. Specimens from the LRN can be
forwarded to the CDC Poxvirus Laboratory for species confirmation.
References
- Engler RJ, Kenner J, Leung DY.
Smallpox vaccination: risk considerations for patients with
atopic dermatitis. J Allergy Clin Immunol 2002;110:357--65.
- Wien TM, Benton FR, Guill MA.
Eczema vaccinatum in an 18-month-old male. Mil Med
1988;153:397--9.
-
CDC. Smallpox vaccination and adverse reactions. Guidance for
clinicians. MMWR 2003;52(No. RR-4).
-
CDC. Secondary and tertiary transfer of vaccinia virus among
U.S. military personnel -- United States and worldwide,
2002_2004. MMWR 2004;53:103--5.
- Neff JM, Lane JM, Fulginiti VA,
Henderson DA. Contact vaccinia -- transmission of vaccinia from
smallpox vaccination. JAMA 2002;288:1901--5.
- Sepkowitz KA. How contagious is
vaccinia? N Engl J Med 2003;348: 439--46.
-
CDC. Vaccinia (smallpox) vaccine: recommendations of the
Advisory Committee on Immunization Practices (ACIP), 2001. MMWR
2001;50(No. RR-10).
- Wittek R. Vaccinia immune
globulin: current policies, preparedness, and product safety and
efficacy. Int J Infect Dis 2006;10:193--201.
- Kempe CH. Studies smallpox and
complications of smallpox vaccination. Pediatrics
1960;26:176--89.
- Grabenstein JD, Winkenwerder W Jr.
US military smallpox vaccination program experience. JAMA
2003;289:3278--82.
* Cidofovir is administered as a weekly
dose as clinically indicated and reserved as second-line therapy
after VIGIV in the treatment of eczema vaccinatum (3). ST-246
is a smallpox drug candidate with specific antiorthopoxvirus
activity inhibiting virus maturation.
† US Army Center for Health
Promotion and Preventive Medicine. Defense manpower data center
statistical immunization reporting system; 2007.
|