Monday, October 24, 2011

Smallpox and the Vaccinia Vaccine

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Smallpox is an acute, contagious, and sometimes fatal disease caused by the variola virus, which is a member of the orthopoxvirus family. It has two forms variola major and variola minor. Variola minor had a very low fatality rate, whereas the latter’s fatality rate was around thirty percent. The disease though, has now been eradicated after a worldwide vaccination program.

It is believed that smallpox originated over 1,000 years ago in India or Egypt and is one of the most devastating diseases known to humanity. In some ancient cultures, smallpox was such a major killer of infants that custom forbade the naming of a newborn until the infant had caught the disease and proved it would survive. The disease killed many kings, queens, and emperors. As many as thirty percent of those infected died and sixty-five to eighty percent of survivors were marked with deep pitted scars on their face. Blindness was also a complication reported from this disease that had no cure.

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In 1777, Edward Jenner demonstrated that inoculation with cowpox could protect against smallpox. During this time, medical personnel had noticed that milkmaids, exposed to cowpox were immune to smallpox. They began taking cowpox from cows and scratching it into the arms of people to protect them from smallpox. At some point, cowpox virus was replaced with vaccinia virus, which is ninety percent identical to smallpox but only rarely causes health problems.

Health systems around the world joined forces to vaccinate against smallpox and the disease was eradicated globally by the 1770’s. The last case of smallpox in the United States was in 1774 and the last naturally occurring case in the world was in Somalia in 1777. After the disease was eliminated from the world, routine smallpox vaccination was stopped among the general public.

In the aftermath of events of September and October 2001, there is a heightened concern that the variola virus might be used as an agent of bioterrorism. Terrorists may have stores of weaponized smallpox or the ability to produce it. It is also possible that a smallpox-like virus could re-emerge in nature as a result of the many poxviruses that exist in animal species. Either of these instances could overwhelm communities, but the Centers for Disease Control National Immunization Program indicates there is enough smallpox vaccine in storage to inoculate the entire United States population.

This disease is difficult to detect because there are only flu-like symptoms and no rash in the beginning. When detected though, if the vaccinia vaccine is given within the first four days after exposure, it will prevent smallpox or significantly reduce the symptoms and risk of death. Smallpox can be spread by air droplets in face-to-face contact with an infected person. Ventilation systems, contaminated clothes, bedding, etc can also transmit it.

The incubation period of smallpox is usually twelve to fourteen days. During this time, the person looks and feels healthy and cannot infect others. This period is followed by the sudden onset of influenza-like symptoms including fever, headache, severe back pain, and abdominal pain and vomiting. Two or three days later, the temperature falls and the client feels somewhat better, then a rash appears, first on the face, hands, and forearms and then a few days later, progressing to the trunk. The rash progresses to papules one to two days after it appears; vesicles appear on the fourth or fifth day; pustules appear by the seventh day and scab lesions appear by the fourteenth day. Smallpox skin lesions are deeply embedded in the dermis and feel like firm round objects embedded in the skin. As the lesions heal, the scabs separate and pitted scarring gradually develops. Smallpox patients are the most infectious during the first week of the rash when the oral mucosa lesions ulcerate and release substantial amounts of virus into the saliva. A patient is no longer infectious after all scabs have separated.

Dryvax® is the vaccinia (smallpox) vaccine licensed in the United States that is a live-virus preparation of infectious vaccinia virus. This vaccine however, does not contain the smallpox virus. Vaccinia vaccine is a highly effective immunizing agent; it is the vaccine that enabled the global eradication of smallpox.

The vaccine itself can cause serious medical complications and possibly even death. The following have been listed by the Centers for Disease Control and Prevention as risks that accompany the smallpox vaccination

- Mild rash

- Swelling and tenderness of lymph nodes

- Fever over 100º

- Secondary blisters elsewhere on the body

- Serious eye infection or loss of vision

- Rash on entire body

- Severe rash on people with eczema

- Encephalitis, which could lead to brain damage

- Severe infection at vaccination site

- Death

Even those who come in contact with the vaccination site can have some of the reactions listed above. The only product available for treatment of these complications is VIG, which is an isotonic sterile solution of the immunoglobin fraction of plasma from persons vaccinated with vaccinia virus.

Vaccinia virus can be cultured from the site of the primary vaccination beginning at the time of development of a papule until the scab separates from the skin lesion. Care must be taken to prevent contact of the site. It should be left uncovered or can be loosely covered with gauze until scab has separated on its own. The vaccination site should be kept dry and no salves or ointments should be applied to the site. Contaminated gauze and the scab, after it has fallen off, should be placed in a sealed plastic bag before disposal in the trash to prevent inadvertent transmission of the live virus in other materials. The site however, continues to shed live virus up to three to four weeks after receiving the vaccination.

The preferred sites for the vaccination are the skins over the insertion of the deltoid muscle or the posterior aspect of the arm over the triceps muscle. Alcohol is not required for skin preparation unless the area is grossly contaminated. If alcohol is used, the area should be completely dry before administering to prevent inactivation of the vaccine by the alcohol. The multiple puncture technique uses a pre-sterilized bifurcated (having two branches; forked) needle that is inserted vertically into the vaccine vial, causing a droplet of vaccine to adhere between the prongs of the needle. The droplet contains the recommended dosage of vaccine, and its presence within the prongs of the bifurcated needle should be confirmed visually. Holding the bifurcated needle perpendicular to the skin, fifteen punctures are rapidly made with strokes vigorous enough to allow a trace of blood to appear after fifteen to twenty seconds. Any remaining vaccine should be wiped off with dry sterile gauze and the gauze disposed of in a biohazard waste container. The site should be inspected six to eight days after the vaccination to determine the response.

Before administering vaccinia vaccine, the physician should complete a thorough patient history among vaccinees and their household contacts. The vaccine should not be administered in pregnant women for routine non-emergency indications. Complications for clients with HIV are unknown, children should not be given the vaccine unless in an emergency situation. Some allergy clients as well, should not be given the vaccine.

Healthcare workers, even if vaccinated, should wear gloves, caps, gowns, and surgical masks. Recently vaccinated healthcare workers should avoid contact with unvaccinated patients, until the scab has separated from the site. If contact is unavoidable, make certain that the site is well covered and thorough hand hygiene is maintained. Instruments should be decontaminated chemically or by heat. Contaminated bedding and clothing, if not incinerated, should be autoclaved or washed in hot water containing hypochlorite bleach. The premises may also be fumigated with formaldehyde.

If exposed to smallpox, immediately notify a healthcare facility for prompt action and to save your life. The report of a suspected smallpox case is a public health emergency. Keep in mind, the best prevention for this deadly disease is the vaccination.

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