Questions & Answers
Smallpox - Healthcare Workers
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Vaccination for Healthcare Workers

  1. Should vaccinators be vaccinated themselves?

    Yes, Department of Defense personnel who are vaccinating others should be vaccinated themselves. This is outlined in the "Clinical Policy for the DoD Smallpox Vaccination Program (SVP)".


  2. Why aren't ALL healthcare workers getting vaccinated?
    The Department of Defense Smallpox Vaccination Program is designed so that a team at each hospital and clinic is prepared to provide care to the 1st set of smallpox (variola) patients in case of an outbreak. If an outbreak occurred, additional health care workers would then be vaccinated.

Additional Concerns for Healthcare Workers

  1. In addition to the normal side effects already covered in earlier questions, is there more I need to know as a health-care provider?

    Yes. You should know a few of the more serious complications related to vaccination that can occur. Inadvertent inoculation is the most frequent complication of vaccinia vaccination. It accounts for about half of all complications of primary (first) vaccination and revaccination. Inadvertent inoculation usually results from auto-inoculation of vaccinia virus, transferred from the site of vaccination. The most common sites involved are places that itch: the face, eyelids, nose, mouth, genitalia, and rectum.

    Most auto-inoculation lesions heal without specific therapy, but vaccinia immunoglobulin (VIG) can help treat severe cases. If vaccinial keratitis develops, VIG is not recommended because of the risk of corneal scarring.

    Erythematous or urticarial rashes can occur about 10 days after primary (first) vaccination and can be confused with generalized vaccinia. In these circumstances, the vaccinee is usually afebrile and the rash resolves spontaneously within 2 to 4 days. Rarely, an allergic reaction to to the vaccination called erythema multiforme (i.e., Stevens-Johnson syndrome), may occur.

  2. What about moderate to severe adverse reactions?
    Moderate and severe complications of vaccinia vaccination include eczema vaccinatum, generalized vaccinia, progressive vaccinia, and postvaccinial encephalitis. These complications are rare, but occur more often among primary vaccinees than among revaccinees. These serious skin complications also are more frequent among infants than among older children and adults. A study of 10,000 Israeli military recruits aged 18 years or older, who were vaccinated during 1991 and 1996, reported no cases of progressive vaccinia or postvaccinial encephalitis. These results were similar to those reported in previous studies.

  3. What is eczema vaccinatum?
    Eczema vaccinatum is a localized or systemic dissemination of vaccinia virus among people who have atopic dermatitis or a history of atopic dermatitis or other exfoliative skin conditions (e.g., atopic dermatitis). Usually, this illness is mild and self-limited, but can be severe or fatal. The most serious cases among vaccine recipients occur among primary vaccinees, even among people who do not have active skin disease. Severe cases have been observed after recently vaccinated people had contact with people with atopic dermatitis or a history of atopic dermatitis.

  4. What is generalized vaccinia?
    Generalized vaccinia involves a vesicular rash of varying extent that can occur among people without underlying illnesses. The rash is generally self-limited and requires minor or no therapy, except among patients whose conditions might be "toxic" (as it refers to children) or who have serious underlying immunosuppressive illnesses (e.g., acquired immunodeficiency syndrome [AIDS]).

  5. What is progressive vaccinia?
    Progressive vaccinia (also called vaccinia necrosum or vaccinium gangrenosa) is a severe, potentially fatal illness. It appears as progressive necrosis reaching out from the vaccination site, often with metastatic lesions. It occurred almost exclusively among people with cellular immunodeficiency.

  6. What is postvaccinial encephalitis?

    The most serious complication is postvaccinial encephalitis. Two main forms were noted. The first affected children younger than 1 year old receiving their first (primary) smallpox vaccination, involving convulsions. These children may have residual paralysis after recovery.

    The second form affected children 2 years or older, adolescents, and adults receiving their first (primary) smallpox vaccination. These patients developed abrupt onset of fever, vomiting, headache, and malaise, followed by loss of consciousness, amnesia, confusion, convulsions, and coma. About 1 in 3 of these patients died.

Smallpox Vaccination Given Simultaneously With Other Drugs and Vaccines

  1. How does smallpox vaccine interact with other drugs?
    Smallpox vaccine is not known to interact with any medications; however, circulating antibodies from recent blood product administration or the use of immuno-suppressive medications could interfere with smallpox antibody production.

  2. What about giving smallpox vaccinations at the same time as other vaccinations?
    The smallpox vaccine may be administered concurrently with other inactivated vaccines or at any interval before or after inactivated vaccines, consistent with ACIP recommendations. To avoid confusion in determining which vaccine may have caused post-vaccination skin lesions or other adverse events, and to facilitate managing such events, varicella vaccine and smallpox vaccine should be administered at least 4 weeks. Smallpox vaccine should be administered simultaneously with other live virus vaccines or separated by 4 weeks. Do not administer other vaccines near an active smallpox vaccination site.

Questions That Must Be Asked Before Administering Smallpox Vaccine

  1. What should we ask about before people get smallpox vaccine?
    Before smallpox vaccination, ask people if they have any problems with their immune system (e.g., due to cancer treatment, transplantation, AIDS, other conditions), if they are infected with HIV, if they have atopic dermatitis or other chronic skin conditions, if they are pregnant or breastfeeding or if they had atopic dermatitis as a child, or if they have a heart condition. Also, ask about the health of people in the household.

People Who Should Not Be Vaccinated During a Smallpox Outbreak

  1. Who is exempt (contraindicated) from smallpox vaccination in an outbreak?

    No absolute exemptions (contraindications) exist for vaccination of a person with an actual high-risk exposure to smallpox. People at greatest risk for experiencing serious vaccination complications are also at greatest risk for death if exposed to smallpox.

    If a relative contraindication to vaccination exists, the risk for experiencing serious vaccination complications must be weighed against the risk for experiencing a potentially fatal smallpox infection. When the level of exposure risk cannot be determined, the decision to vaccinate should be made after discussion between the clinician and the patient of the potential risks versus the benefits of smallpox vaccination.

Civilian Healthcare Responsibilities

  1. I just got vaccinated against smallpox and I "moon-light" at a civilian hospital downtown. Should I tell the civilian hospital?
    Yes. You should inform the other hospital of your recent vaccination and tell them about your bandaging procedures and infection-control practices. You should then abide by any further instructions from the civilian hospital.