Smallpox Vaccination: Sexually Transmitted Vaccinia

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Vaccine-Preventable Diseases

Military vaccinees may have transmitted vaccinia following smallpox vaccination

The government reinstated smallpox vaccinations for military personnel in 2001.

July 2007

A Midwestern child became the first reported case of eczema vaccinatum in the United States since 1988.

The CDC received several reports of secondary transmission of vaccinia infection, which occurred in contacts of military personnel who had received smallpox vaccine. Researchers discussed the case reports in the Morbidity and Mortality Weekly Report.

The Chicago Department of Public Health and the University of Chicago Pediatric Infectious Disease Service and Infection Control Program informed the CDC about the 28-month-old boy, who presented with a generalized papular, vesicular rash on his face, neck and upper extremities.

Vaccinia transmission

The public health department and University of Chicago clinicians confirmed a diagnosis of eczema vaccinatum following a real-time polymerase chain reaction orthopoxvirus generic assay. The assay confirmed positive results for orthopoxvirus DNA, according to the researchers. The child had a history of failure to thrive and severe eczema.

The child’s father, an active-duty military service member, received his first smallpox vaccine on Jan. 26, 2007, to prepare for his deployment overseas. He and two of his three children had a history of childhood eczema, which are contraindications for smallpox vaccination. The child’s father reported his vaccination site had scabbed over and separated prior to an unplanned visit home from Feb. 16-20 after the military delayed his deployment. He reported keeping the vaccination site bandaged while home. Routine activities with his son included hugging, bathing, wrestling and sleeping.

The child’s mother reported noticing weeping skin lesions on Feb. 24 and a fever on March 1. The child presented to a small hospital in Indiana on March 3 and was transferred to a tertiary clinic in Chicago later in the day because of illness severity, according to the researchers. The rash progressed to umbilicated lesions with an erythematous base on the child’s hands, knees, forearms, neck, chest and face, and the Illinois Department of Public Health Laboratory in Chicago analyzed assay results on March 8.

Clinicians treated the child with immunotherapy and antivirals from March 8-28, according to the researchers. They administered vaccinia immune globulin intravenous (Human; VIGIV) initially, and provided sedation, intubation and mechanical ventilation. On March 10, the child required vasopressor support after his illness progressed to hypothermia and hemodynamic instability. The child then received cidofovir (Vistide, Gilead) and ST-246 (Siga Technologies), an investigational drug, under the Emergency Investigational Drug application. He also received additional VIGIV infusions, according to the researchers.

The child improved and went home on April 19 with no known sequelae, although his skin may have some scarring.

Further transmission

On March 6, the child’s mother developed six vesicular lesions on her face and eventually on her finger and eyelid. She received VIGIV treatment, but her lesions contained no positive orthopoxvirus DNA sequences, according to the researchers. Her lesions began to scab over within 72 hours following treatment. The couple’s other two children stayed with grandparents while the boy was hospitalized.

Public health officials identified 23 family contacts and 73 health care workers who may have had physical contact with the child; one person developed a rash and one person developed a fever, but neither had vaccinia. The family disinfected the house on March 23 because the child’s rash onset occurred prior to hospitalization, and cell culture samples indicated viable virus on several household items, according to the researchers.

The military is investigating the vaccination and familial contact of this service member to determine whether screening and education practices should be adjusted.

Vulvar vaccinia following sex

The CDC also identified a vaccine-strain vaccinia virus obtained from a labial culture from a woman in Alaska in January.

The woman visited a public health clinic on Oct. 10, 2006, because of vaginal tears that became painful. She reported a new sex partner from Sept. 22 through Oct. 1. Investigators who interviewed the woman after the CDC identified vaccinia determined that her sex partner was a military service member stationed locally who received smallpox vaccine three days before he began having sexual intercourse with the woman.

The woman reported using condoms but said that one had broken during intercourse on Oct. 1. She reported seeing no lesions or anything unusual on the man’s penis, and she had no history of genital ulcers or STDs and did not present with fever, dysuria or itching, according to the researchers.

Clinicians found an ulceration on her upper left labia minora and one on her lower right labia minora, vaginal discharge and mild bilateral labial erythema and induration. She tested negative for Neisseria gonorrheae and Chlamydia trachomatis and had normal adnexa, anus, cervix and uterine exams. The clinicians’ primary diagnosis was an STD, and the culture was sent to the Alaska State Virology Laboratory for testing. They made a secondary diagnosis of candidiasis and administered an over-the-counter medication. A clinician diagnosed cellulitis two days later on Oct. 12 and prescribed oral cephalexin.

A virus which had been recovered was unidentified until the CDC Poxvirus Laboratory identified the isolate as a vaccine-strain vaccinia virus, according to the researchers. The service member was not available for an interview because he was overseas, but the military base reported that he had no underlying skin disorders or contraindications and received instructions for caring for the vaccination site following his vaccination, which occurred on Sept. 19. The investigators did not identify any other cases of transmission associated with the vaccinee or the woman.

The U.S. government ceased smallpox vaccination for military personnel in 1990 but reinstated vaccination for military personnel and certain health care workers following the Sept. 11, 2001, terrorist attacks and following the anthrax attacks. As of March, the Department of Defense had administered vaccine to about 1.2 million people.

Clinicians should report suspected vaccinia cases to local or state health departments and the Vaccine Adverse Events Reporting System.

For More Information:

• CDC. Household transmission of vaccinia virus from contact with a military smallpox vaccinee – Illinois and Indiana, 2007. MMWR. 2007;56:478-481.

• CDC. Vulvar vaccinia infection after sexual contact with a military smallpox vaccinee – Alaska, 2006. MMWR. 2007;56:417-419.