Recommendation of the Immunization Practices Advisory Committee Smallpox Vaccine

These revised ACIP recommendations on smallpox vaccine update the previous recommendations (MMWR 1980;29:417-20) to include current information on the changes in the International Health Regulations and the ending of distribution of smallpox vaccine to civilians. The basic recommendation is unchanged--smallpox vaccine is only indicated for civilians who are laboratory workers occupationally exposed to smallpox or other closely related orthopox viruses. SMALLPOX VACCINE

Smallpox vaccine (vaccinia virus) is a highly effective immunizing agent against smallpox. The judicious use of smallpox vaccine has eradicated smallpox. At the World Health Assembly in May 1980, the World Health Organization (WHO) declared the world free of smallpox (1-4). Smallpox vaccination of civilians is now indicated only for laboratory workers directly involved with smallpox (variola virus) or closely related orthopox viruses (e.g., monkeypox, vaccinia, and others). SURVEILLANCE OF SUSPECTED CASES OF SMALLPOX

There is no evidence of smallpox transmission anywhere in the world. WHO has coordinated the investigation of 173 rumors of smallpox between 1979 and 1984 (5-7). All have been diseases other than smallpox, most commonly chickenpox or other rash illnesses. Even so, a suspected case of smallpox is a public health emergency and must be promptly investigated. Assistance in the clinical evaluation, collection of laboratory specimens, and preliminary laboratory diagnosis is available from state health departments and CDC (telephone: (404) 329-3145 during the day and (404) 329-2888 outside usual working hours). MISUSE OF SMALLPOX VACCINE

There is no evidence that smallpox vaccination has any value in the treatment or prevention of recurrent herpes simplex infection, warts, or any disease other than those caused by orthopox viruses (8). Misuse of smallpox vaccine to treat herpes infections has been associated with severe complications (9-11). Smallpox vaccine should never be used therapeutically. SMALLPOX VACCINATION NOT REQUIRED FOR INTERNATIONAL TRAVEL

Smallpox vaccination is no longer required for international travel. In January 1982, the International Health Regulations were changed deleting smallpox from the Regulations (12). The International Certificates of Vaccination no longer include a smallpox vaccination certificate. SMALLPOX VACCINE NO LONGER AVAILABLE FOR CIVILIANS

In May 1983, the only active, licensed producer of smallpox vaccine in the United States discontinued distribution of smallpox vaccine to civilians (13). As a result, smallpox vaccine is no longer available to civilians. SMALLPOX VACCINE AVAILABLE TO PROTECT AT-RISK LABORATORY WORKERS

CDC provides smallpox vaccine to protect laboratory workers occupationally exposed to smallpox virus and other closely related orthopox viruses (14). Vaccine will be provided only for the protection of personnel of such laboratories. The vaccine should be administered to eligible employees under the supervision of a physician selected by the laboratory. Vaccine will be shipped to physicians responsible for vaccinating at-risk workers. Requests for vaccine should be sent to:

Drug Immunobiologic and Vaccine Service Center for Infectious Diseases Building 1, Room 1259 Centers for Disease Control Atlanta, Georgia 30333 (404) 329-3356 SMALLPOX VACCINATION OF MILITARY PERSONNEL

U.S. military personnel are routinely vaccinated against smallpox. CONSULTATION FOR COMPLICATIONS OF SMALLPOX VACCINATION

CDC can assist physicians in the diagnosis and management of patients with suspected complications of smallpox vaccination. Vaccinia immune globulin (VIG) is available when indicated. Physicians should call (404) 329-3145 during the day and (404) 329-2888 evenings and weekends.

The majority of persons with such complications are likely to be recently vaccinated military personnel or their contacts infected through person-to-person spread of vaccinia virus (15-17). Such person-to-person spread can be extremely serious if the person infected has eczema or is immunocompromised.

Health-care workers are requested to report complications of smallpox vaccination to CDC through state and local health departments.

References

1. WHO. Smallpox eradication. Weekly Epidemiological Record 1980;55:33-40.

2. WHO. Smallpox eradication. Weekly Epidemiological Record 1980;55:121-8.

3. WHO. Declaration of global eradication of smallpox. Weekly Epidemiological Record 1980;55:145-52.

4. WHO. Smallpox vaccination policy. Weekly Epidemiological Record 1980;55:153-60.

5. CDC. Investigation of a smallpox rumor--Mexico. MMWR 1985:34;343-4.

6. WHO. Orthopox virus surveillance: post-smallpox eradication policy. Weekly Epidemiological Record 1983;58:149-56.

7. WHO Smallpox Eradication Unit. Personal communication.

8. Kern AB, Schiff BL. Smallpox vaccinations in the management of recurrent herpes simplex: a controlled evaluation. J Invest Dermatol 1959;33:99-102.

9. CDC. Vaccinia necrosum after smallpox vaccination--Michigan. MMWR 1982;31:501-2.

10. U.S. Food and Drug Administration. Inappropriate use of smallpox vaccine. FDA Drug Bulletin 1982;12:12.

11. Freed ER, Duma RJ, Escobar MR. Vaccinia necrosum and its relationship to impaired immunologic responsiveness. Am J Med 1972;52:411-20.

12. WHO. Smallpox vaccination certificates. Weekly Epidemiological Record 1981;39:305.

13. CDC. Smallpox vaccine no longer available for civilians--United States. MMWR 1983;32:387.

14. CDC. Smallpox vaccine available for protection of at-risk laboratory workers. MMWR 1983;32:543.

15. CDC. Contact spread of vaccinia from a recently vaccinated marine--Louisiana. MMWR 1984;33:37-8.

16. CDC. Contact spread of vaccinia from a National Guard vacinee--Wisconsin. MMWR 1985;34:182-3.

17. Urdahl P, Rosland JH. Vaccinia genitalis. Tidsskr Nor Laegeforen 1982;102:1453-4.

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