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Smallpox Vaccine Spread Virus Through Family

Case report on U.S. soldier details how his wife and infant daughter were infected

TUESDAY, Feb. 10, 2004 (HealthDayNews) -- It was the kind of virus you would never want to pass on to your family.

But in the case of a 27-year-old soldier stationed in Washington state, it happened despite the soldier's best efforts to safeguard his wife and infant daughter after he received his military smallpox vaccination last year.

Given on May 4, 2003, his vaccine was part of the U.S. government's immunization program to guard against possible biological attacks. This was the first time the soldier had received the vaccine, because he was born after the government discontinued routine childhood smallpox immunizations in 1971.

The soldier then had what is called a "major reaction," which is normal and even expected. The place on his arm where the shot was given had been administered became red, then formed a blister, then a pustule and then scabbed over. He also had some swelling in the lymph nodes in his armpits.

Because the vaccinia virus used in the smallpox vaccine is a live virus, reactions can occur, though not often. The vaccinia virus is not smallpox, but a pox-like virus related to smallpox.

"It's not a bad thing. It just means that the vaccine is working," Dr. Mary P. Fairchok, chief of pediatric infectious diseases at Madigan Army Medical Center in Tacoma, Wash., says of the soldier's reaction. "You expect this kind of thing."

Fairchok is senior author of an article outlining the case in the Feb. 11 issue of the Journal of the American Medical Association.

At the time of the vaccination, the soldier, and all others receiving a smallpox immunization, received a handout as well as a briefing on how to care for the site.

By his accounts and those of his 27-year-old wife, the soldier followed all precautions. Although he slept in the same bed as his spouse, he washed his hands, kept the site covered with gauze until it had fully healed and had limited contact with his 5-month-old daughter who was still breast-feeding.

"They couldn't be absolutely sure the gauze hadn't fallen off in bed, but neither he nor his wife recalled that," Fairchok says.

The man rolled his bath towels so that the side that had touched his arm was to the inside, and he disposed of all tissues immediately in the garbage. Although his wife did all the laundry, she said she hadn't seen any drainage on clothing or linens.

Nevertheless, in mid-May, the wife developed red, tender swelling around both her nipples. The area blistered, then ulcerated, leaving open sores around the nipple area. No one, including her doctor, suspected it was a vaccinia reaction, so she continued breast-feeding until May 29, when it became too painful.

On the day she stopped breast-feeding, her baby developed a tell-tale blister on her upper lip, which turned into a pustule and formed a crust. The next day, she developed a similar lesion on her left cheek. On June 2, a pediatrician saw the facial lesions as well as one on her tongue and diagnosed her with suspected vaccinia. She was transferred to Madigan Army Medical Center, where she came under Fairchok's care.

No one knows exactly how the transmissions occurred.

"The wife claims she had no direct contact whatsoever [with the site], and she said there was no contact between her breast and his arm, so they have no idea," Fairchok says. The wife may also have forgotten to wash her hands between doing the laundry and breast-feeding.

Because the tissue around the nipple area is thinner than the surrounding skin, the vaccinia virus is more likely to spread in that area, Fairchok adds.

From there, it was an easy hop to the suckling baby. "It's pretty obvious that the baby got it because of the nursing," Fairchok says. The little girl had lesions on her cheek, lip and tongue, where she would have had contact with the breast.

It is unusual for vaccinia to be passed through tertiary (thirdhand) contact. And never has there been a documented case of a nursing infant being inadvertently inoculated in this way.

Luckily, this story had a happy ending.

Mother, father and baby are fine. The baby's 4-year-old brother was never infected. "We were worried that [the baby] might scar up, but she didn't at all," Fairchok says. "The only bad thing was mom had to stop breast-feeding."

Right now, the U.S. Centers for Disease Control and Prevention says that, while breast-feeding mothers should not be vaccinated against smallpox, it is safe for a woman to breast-feed if she comes into close contact with someone who has been vaccinated recently as long as they take appropriate precautions.

The study authors, however, feel the CDC needs to revise guidelines to advise vaccine recipients not to sleep in the same bed as a breast-feeding mother and to do their own laundry. The agency should also emphasize that mothers wash their hands before nursing.

A CDC spokesman says the agency usually does not comment on other people's work, but it plans to stick with current guidelines.

"That's the recommendation we have to this point, and that's the recommendation we will keep to this point," says Von Roebuck. "We're always open to suggestions or ideas, but we're keeping to these recommendations at this point."

"This is very unusual and, with all the vaccinations we've done, we've had very, very few secondary cases. But we just thought the CDC ought to publicize the fact that this can happen," Fairchok says. "If there is a breast-feeding mom in the home and someone is immunized, that breast-feeding mom should exercise extreme precautions about washing hands and handling laundry."

More information

Here is the U.S. Centers for Disease Control and Prevention fact sheet on smallpox vaccines for women who are pregnant or breastfeeding. The Department of Defense has information on its smallpox vaccination program.

SOURCES: Mary P. Fairchok, M.D., chief, pediatric infectious disease and pediatric residency program director, Madigan Army Medical Center, Tacoma, Wash; Von Roebuck, spokesman, U.S. Centers for Disease Control and Prevention, Atlanta; Feb. 11, 2004, Journal of the American Medical Association
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