You're coming back from a TDY and are stopped by a person in the airport when he noticed your uniform. He's planning on going into the Guard and is concerned about taking the smallpox vaccine.

What do you tell him?

** This actually happened to me in Atlanta .... but the person was asking about anthrax. Bottom line is there are a lot of questions about these vaccines and bioterrorism**

    ** THANKS to COL (Dr.) John D Grabenstein, for his help with this Pearl **

Smallpox vaccine has been in the news recently because of the threat or concern about its use as a biological weapon. There is a vaccine for smallpox with some interesting history.

Some history - Edward Jenner, the father of vaccines, made a simple observation one day. He said, "Farm girls have the clearest skin." This wasn't because of some special soap or cream but because they had most likely been infected with cowpox. After cowpox infection, the farm girls did not subsequently contract smallpox. The variola virus causes smallpox. Vaccinia virus used in modern smallpox vaccine is descended from cowpox virus.

Smallpox is a contagious disease with a fatality rate of about 30%. Survivors may be left with severe scarring and blindness (if ocular involvement). Natural infection confers lifelong immunity. The vaccine protects about 95% of healthy people who receive it. Smallpox was declared 'eradicated' by the World Health Organization (WHO) in May 1980. The last reported case in the US was 1949; the last natural case was in Somalia in 1977. In the US, children stopped receiving routine small-pox vaccination in 1972; recommendations for healthcare workers were rescinding in 1976. DoD continued to vaccinate recruits until about 1990.  The re-institution of smallpox vaccination is being done as a force protection measure. As a former USAF/SG used to say, we protect the 'human weapon system'. About 500,000 DoD personnel, active and reserve, will eventually receive the vaccine, barring any medical or religious contraindications. Health care workers who would first care for victims and personnel deployed or deploying distant from medical reinforcement will be the first to receive the vaccine.  In a non-emergency situation, do not administer the vaccine to anyone with a contraindication. Pregnant women generally defer vaccination. Women should avoid becoming pregnant for four weeks after smallpox vaccination. The vaccine is not recommended for breastfeeding women in non-emergent situations. In an EMERGENCY situation (i.e. outbreak or BW attack with smallpox) there are NO absolute contraindications. A list of contraindications is available at www.smallpox.army.mil . Another great website for information is http://www.bt.cdc.gov/agent/smallpox/vaccination/acip-recs-oct2002.asp.

The smallpox vaccine is a LIVE VIRUS vaccine. Patients with significant compromises of their immune system should not receive this vaccine. Some examples may include HIV/AIDS patients, patient undergoing chemotherapy, patients with congenital immunodeficiencies, and patients on
large doses of steroids. Since this is a LIVE VIRUS vaccine, patients who have been vaccinated will have the virus at the surface of their skin at the vaccination site and may put immunocompromised patients living with them at risk of infection. Consider the patient and their household contacts when determining potential vaccines.

The vaccine is given in a different way than most vaccines. It uses a bifurcated needle dipped in the vaccine solution. The skin is punctured with the bifurcated needle in a tight target area. Give 3 jabs for primary vaccination and 15 jabs for revaccination. The vaccination site is usually
covered to prevent spread of the virus.  A successful vaccination (or "take") evidenced by the formation of a well-formed pustule 6-8 days after inoculation. A major reaction evidenced by a more rapid evolution of the lesion (3-4 days after inoculation with scabbing and ulceration) may indicate residual immunity in a previously immunized patient. Equivocal reactions, rapid development of erythema with/without a pustule, may indicate previous immunization or allergy to vaccine component. Virus neutralizing antibodies appears between 10-13 days after initial vaccination. People who had the vaccine as children will require another inoculation since full immunity lasts about 5-10 years. Revaccination is considered to confer longer lasting immunity. There is some information indicating re-vaccinees may have a lower risk of adverse effects than those who have never received the vaccine. The non-dominant deltoid is the preferred site for the smallpox vaccination. Live (ex. smallpox) and inactivated (ex. anthrax) vaccines can be given at the same time. Live virus vaccines should be given simultaneously or at 28-day intervals.

Side effects - Historically, death has occurred in about 1 to 2 per million vaccines. Local reactions include erythema at the site, lymphedema, satellite lesions, etc. Brief systemic symptoms mimic a viral illness (fever, muscle aches, headache, nausea, fatigue, etc). One potentially serious side effect is vaccinia infection of the eye from touch/scratching the inoculation site and then rubbing the eye. Vaccine recipients may wish to refrain from wearing contact lenses for 30 days after vaccination. Vaccinia ophthalmic infections can be treated with topical trifluridine ophth drops [Viroptic®]. Vaccinia immune globulin (VIG) is available in limited quantities for severe vaccine-related complications. Dose is usually 0.6 ml/kg . Other anti-virals (cidofovir) have activity against vaccinia and other pox viruses. See www.bt.cdc.gov  for more specific details.

Aircrews - USAF guidance states aircrew members should ideally be vaccinated 30 or more days before any contingency or deployment. Every effort should be made to vaccinate at least 15 days before to go beyond the period when most duty limiting side effects might occur. Guidance is service specific so check with your service for details on the small pox vaccinations in your aircrew members.

Important websites for smallpox information:

www.vaccines.army.mil 

http://www.bt.cdc.gov/agent/smallpox/vaccination/acip-recs-oct2002.asp

www.smallpox.army.mil 

http://www.bt.cdc.gov/agent/smallpox/index.asp

www.idsociety.org/bt/toc.htm 

www.immunofacts.com 


REFERENCES:

- The Medical Letter. Small Pox Vaccine. 2002;45:1-3.
-  Frey SE, et al. N Engl J Med 2002;346:1275.
- Sepkowitz KA. N Engl J Med 2003;348:5.