smallpox vaccination mark upfal, md, mph detroit medical center emergency medicine grand rounds...
TRANSCRIPT
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Smallpox VaccinationMark Upfal, MD, MPHDetroit Medical Center
Emergency Medicine Grand Rounds
Detroit Receiving Hospital
February 13, 2003
Collaborators: Kay Cadwell, Pat Goins, Kathy Reilly
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Topics
Smallpox vaccination & history
Vaccine effectiveness
Administration/Outcomes
Revaccination
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Topics
Adverse Reactions
Treatment
Contraindications
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Topics
Smallpox & Vaccination History
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Smallpox
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Smallpox on trunk
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Pustules scabs scars
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Jenner 1798 Treatise on Vaccination
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Historic Timetable1796 Dr. Jenner infects James Phipps w/ cowpox
1805 Use of cows to produce vaccine
1940s Freeze-drying technology
1949 Last US case of smallpox
1965 Licensure of bifurcated needle
1971 Routine vaccination stopped in US
1975 Last case of V. major in Bangladesh
1977 Last case of V. minor in Somalia
1983 Vaccine withdrawn from civilian market
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Topics
Smallpox vaccination & history
Vaccine effectiveness
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Protects against orthopox viruses
ATB’s w/in 10 days
Post-exposure – effective if given w/in 4-5 days
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Topics
Smallpox vaccination & history
Vaccine effectiveness
Administration/Outcomes
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No alcohol or prep
Dip into vial & pick up droplet btwn needle prongs
Never vaccinated: 3 rapid punctures perpendicular to skin, induces trace blood after 15-20”
Previously vaccinated: 3 rapid punctures perpendicular to skin, induces trace blood after 15-20”
Wipe off w/ gauze; dispose waste as biohazard
Administration
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Vaccine Administration
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Method of Administration
Applied to the upper arm using a multiple-puncture technique with a bifurcated needle.
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Semipermeable Adhesive Dressing
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Infection control procedures
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Normal Vaccination Reaction Time
0 Vaccination
3-4 Papule
5-6 Vesicle with surrounding erythema → vesicle with depressed center
8-9 Well-formed pustule
12+ Pustule crusts over → scab
17-21 Scab detaches revealing scar
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Major reaction
Vesicular or pustular lesion or palpable induration surrounding a central crust or ulcerIndicates success
Equivocal reactionMay be technique failure & no immunity
Repeat vaccination
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Expected Outcome
Papules 3-5 days Pustular lesion6-12 days
Scab 13-21 days
CDC recommends daily checksfor HCWs
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Topics
Smallpox vaccination & history
Vaccine effectiveness
Administration/Outcomes
Revaccination
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Revaccination
Those vaccinated in 1970’s may not be protected
May have fewer adverse reactions
Revaccinate researchers every 10 yrs if still working with the virus
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Topics
Adverse Events
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Smallpox Vaccination and Adverse Reactions
Guidance for Clinicians
January 24, 2003 / 52(Dispatch);1-29
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Common Side Effects
Local pain (30%), itching (80%) & erythema
Malaise
Low grade fever
Regional lymphadenopathy
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Adverse Events(1/800)
Autoinnoculation 529 per million
Generalized Vaccinia 242 per million
Eczema Vaccinatum 39 per million
Vaccinia necrosum 1.5 per million
Vaccinial Encephalitis 12 per million
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Autoinnoculation
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Autoinnoculation
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Autoinnoculation
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Autoinnoculation
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Generalized Vaccinia
Generalized vesicular skin lesions w/o eczema Hx or other preexisting skin dz
Believed 2o to viremia w/ dermal seeding
Usually minor; Few signif. sequelae
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Generalized Vaccinia
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Generalized Vaccinia
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Generalized Vaccinia
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Generalized vaccinia
Child recovered without sequela
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Generalized Vaccinia
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Eczema Vaccinatum
Patients w/ h/o eczema
Generalized dermal spread
Rarely mild cases present only scattered individual lesions
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Eczema Vaccinatum
Can occur w/ inactive eczema
More severe in contacts
Contact almost always in household
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Pre-Tx Eczema Vaccinatum
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Post-Tx Eczema Vaccinatum
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Eczema vaccinatum
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Eczema Vaccinatum in a 27 yo
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Eczema Vaccinatum in a 22 yo
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Eczema vaccinatum
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Eczema Vaccinatum
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Eczema vaccinatum
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Eczema vaccinatum from contact w/ recently vaccinated child
Patient recovered without sequelae or permanent ocular damage
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Vaccinia necrosum (progressive vaccinia)
Immunocompromised individuals
Severe local spread w/ necrosis
Can be fatal
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Progressive Vaccinia in a child with hypogammaglobulinemia
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Progressive vaccinia (vaccinia necrosum)seen w/ cell-mediated immunodeficiency
Fatal in a child with immunodeficiency
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Progressive vaccinia
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Progressive vaccinia in lymphosarcoma
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Severe Progressive Vaccinia in a child with SCID
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Vaccinial keratitis
VIG is contraindicated
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Vaccinial Keratitis
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Encephalitis
VIG not useful
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Fetal Vaccinia (28 week birth)
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Strep Infection @ vaccine site
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Staph Infection @ vaccine site
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Infant with Post-Vaccination Erythema Multiforme
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Adverse Reactions – U.S., 1968
Complication Rate per Million doses
Rate
Autoinoculation 529 1/1,890
Generalized vaccinia
242 1/4,132
Eczema vaccinatum
39 1/25,641
Progressive vaccinia 1.5 1/666,666
Encephalitis 12 1/83,333
Total 1254 1/797
Lane JM, et al. J Infect Dis 1970;122:303-9.
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What’s different today?
Many more immunocompromised
Better administration technique & follow-up
Better screening for contraindications
Better medical care for side effects
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Precautions
Potentially infectious from papule (2-5d) to scab separation (14-21d)
Opsite dressing
Proper waste disposal
Personal hygiene, universal precautions
Wash clothing hot (detergent/bleach)
Per CDC, no need to furlough HCWs
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Topics
Adverse Reactions
Treatment
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Vaccinia Immune Globulin (VIG)
Ig from vaccinees
Used for eczema vaccinatum, progressive vaccinia, severe generalized vaccinia & ocular vaccinia
Not effective in postvaccinial encephalitis
Contraindicated in vaccinial keratitis
Now available both IM & IV
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Cidofivir Indications
Failure of VIG treatment
Patient is near death
VIG supplies exhausted
5 mg/kg IV over 60 min. (see package insert!)
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Cidofivir Side Effects
Severe renal toxicity
Administer with IV hydration & probenicid
Neutropenia, proteinuria, ocular toxicity, metabolic acidosis
? Carcinogenicity, teratogenicity, hypospermia
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Ocular treatment
VIG only if no keratitis
Trifluridine
Vidarabine (no longer manufactured)
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Topics
Adverse Reactions
Treatment
Contraindications
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Contraindications
Eczema Hx (incl mild or remitted)
Other acute or chronic skin conditions if active (burns, impetigo, zoster, psoriasis)Immunodeficiency
HIV, CA, Steroids (>20 mg, >2 wks in past 3 mo.), Organ transplant
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Pregnant or planning pregnancy
Household contacts with these conditions
Serious, life-threatening allergies to ATBs - polymyxin B, streptomycin, tetracycline, or neomycin
Contraindications
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Contraindications today
Solid organ transplant patients
184,000
Cancer patients/survivors 8,500,000
HIV positive 550,000 known; 300,000 unknown
Atopic dermatitis 28,000,000
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Q & A
*Special thanks to Dr. William Atkinson, CDC National Immunization program, for his kind contribution of slides to this presentation.