MINNESOTA
DEPARTMENT
OF HEALTH
D ISEASE C ONTROL N EWSLETTER
Volume 31, Number 1 (pages 1-12)
January/February 2003
Smallpox and Smallpox Vaccination
Smallpox
Smallpox is a contagious and often fatal
disease caused by the variola virus, an
orthopox virus. Three other orthopox
viruses (vaccinia, cowpox, and
monkeypox) also can infect humans.
Variola virus is fragile and can be killed
with standard hospital disinfectants,
heat, or ultraviolet light. In laboratory
tests, 90% of aerosolized smallpox virus
died within 24 hours. There is no
specific treatment for smallpox, al­
though vaccination is effective as a
preventative measure. The smallpox
vaccine is made from vaccinia virus.
Smallpox survivors have life-long
immunity, but often are left scarred and
sometimes blind. There are two
variants of smallpox: variola major and
variola minor. Variola major has a
fatality rate of approximately 30%; more
than 90% of variola major infections are
“classic” (or “ordinary”) smallpox.
Variola minor is less virulent and has a
fatality rate of less than 1%. Two other
rare forms of smallpox - hemorrhagic
smallpox and flat smallpox - have
fatality rates of > 90%. Modified
smallpox, which occurs in vaccinated
individuals, generally has a mild course.
Aggressive vaccination campaigns in
the 1960s and 1970s led to the eradica­
tion of smallpox worldwide. The last
reported case of smallpox in Minnesota
occurred in 1947; the last naturally
occurring case worldwide (a case of
variola minor) occurred in Somalia in
1977. Routine smallpox vaccination in
the United States stopped in 1972.
Clinical Presentation
Incubation period
Exposure to the smallpox virus is
followed by an incubation period that
averages 12-14 days but can range
from 7-17 days.
Initial symptoms - prodromal period
Day 0: At the end of the incubation
period, the first symptoms of smallpox
appear, including sudden onset of fever
(101o - 104o F), prostration, headache,
backache, myalgias, and sometimes
vomiting.
Rash onset
Day 3-4: Minute red spots appear on
the mucous membranes of the mouth,
tongue, pharynx, and palate. Fever
often drops.
Day 4-6: Macules appear on the face,
then on proximal extremities and trunk,
and then on distal extremities.
Day 6-8: Mucous membrane lesions
evolve into papules, and then vesicles,
which break open and shed virus.
Macules on the skin become papules
within 1-2 days and then fill with fluid
within another 2 days. All skin lesions
within a single part of the body are at
the same stage of development.
Day 8-10: Fluid inside the vesicles
appears opaque, and the lesions
appear like pustules. Fever may recur.
Day 10-14: Pustules increase in size
and become umbilicated. Crusting
begins. Fever may drop.
Day 14-20: Scabs develop.
Day 20-28: Most crusts have sepa­
rated, leaving depigmented or
erythematous scars. Scabs on the
palms and soles may be the last to
separate.
Transmission
Humans are the only natural hosts of
the smallpox virus; it is not transmitted
by animals or insects. Smallpox
usually is transmitted by aerosols or
droplets and is spread through face-to-
face contact. Smallpox also can be
spread during direct contact with
infected bodily fluids or contaminated
bedding or clothing. Rarely, smallpox
is spread by airborne transmission in
enclosed settings. The smallpox
patient is most contagious from onset
of rash to about 10 days later; how­
ever, the virus may be cultured from
the pharynx shortly before the rash
appears. The patient remains conta­
gious until all scabs have separated.
Differential Diagnosis
The most common illness confused
with smallpox is varicella (chickenpox).
Other differential diagnoses include
vaccinia, herpes zoster, herpes
simplex virus (HSV), molluscum
contagiosum (especially in HIVinfected patients), coxsackievirus,
drug-induced rashes, erythema
multiforme, secondary syphilis,
impetigo, scabies, insect bites, contact
dermatitis, monkeypox, and cowpox.
To assist in the diagnosis of smallpox,
major and minor criteria have been
developed by the Centers for Disease
Control and Prevention (CDC) to
determine whether a particular rash
represents low, moderate, or high risk
for smallpox (Figure 1).
continued...
Inside:
Proposed New Immunization
Requirements...............................10
Subject Index for the Disease
Control Newsletter, 2002............ 11
Changes in Reporting Race/
Ethnicity Data on Disease Report
Forms............................................11
Figure 1. Evaluating Patients for Smallpox
Patient with acute, generalized
vesicular, or pustular rash illness
Institute Airborne, Contact, and
Standard Precautions;
alert Infection Control on admission
Low risk of smallpox
History and
exam highly
suggestive of
varicella
Varicella
testing
optional
Diagnosis
uncertain
Test for varicella
and other
conditions, as
indicated
Moderate risk of smallpox
High risk of smallpox
Infectious Disease and/or
Dermatology consultation;
contact MDH immediately at 612676-5414 or 1-877-676-5414;
varicella and other lab testing, as
indicated
Infectious Disease
and/or Dermatology
consultation;
contact MDH
immediately at
612-676-5414 or
1-877-676-5414
No diagnosis
made;
ensure adequacy
of specimen;
Infectious
Disease/Dermatology
consultant re­
evaluates patient
Non-smallpox
diagnosis
confirmed;
report results to
Infection Control
Response team
advises on
management and
specimen collection
Testing at CDC
and MDH
Smallpox Criteria
Cannot rule out
smallpox;
classify as high
risk
Major Criteria
• Febrile prodrome: occurring 1-4 days before rash
onset; fever >101°F and at least one of the following:
prostration, headache, backache, chills, vomiting, or
severe abdominal pain
NOT smallpox;
perform further
testing
Smallpox
• Classic smallpox lesions: deep-seated, firm/hard,
round, well-circumscribed vesicles or pustules; as they
evolve, lesions may become umbilicated or confluent
• Lesions at same stage of development: on any one
Risk of Smallpox
part of the body (e.g., face or arm), all lesions are at
the same stage of development (i.e., all vesicles or all
pustules)
High risk of smallpox - report immediately to MDH
• Febrile prodrome (defined at left), AND
• Classic smallpox lesions, AND
• Lesions at same stage of development
Minor Criteria
• Centrifugal distribution: greatest concentration of
Moderate risk of smallpox - urgent evaluation, contact MDH
• Febrile prodrome, AND
• One other major smallpox criterion
lesions on face and distal extremities
• First lesions on the oral mucosa/palate, face, or
OR
• Febrile prodrome, AND
• >4 minor smallpox criteria
forearms
• Patient appears toxic or moribund
Low risk of smallpox - manage as clinically indicated
• Slow evolution: lesions evolve from macules to
• No febrile prodrome
papules to pustules over days; each stage lasts 1-2
days
OR
• Febrile prodrome, AND
• <4 minor smallpox critierion
• Lesions on the palms and soles
2
Laboratory Evaluation
The laboratory testing algorithm used
for vesicular or pustular rash illnesses
is based on the patient’s level of risk for
smallpox. Depending on the level of
risk, testing may be conducted at either
local laboratories, the Minnesota
Department of Health (MDH) Labora­
tory Response Network level B/C Public
Health Laboratory, or CDC. Physicians
must call MDH if the patient is at
moderate or high risk for smallpox.
Once determined, the smallpox risk
level should be noted clearly on the
laboratory requisition form sent with
specimens. Specimens sent to MDH
should be collected using the protocol
outlined in Figure 2. Specific laboratory
tests that can be performed are
outlined below:
Laboratory Tests
Local laboratory
• Direct fluorescent antibody
(DFA) for varicella zoster
virus (VZV) and HSV
• Routine viral and bacterial
cultures
• VZV serology
MDH laboratory
• DFA/polymerase chain
reaction (PCR) for VZV and
HSV
• PCR for enterovirus, vaccinia,
orthopoxviruses (pending),
and variola virus (pending)
• Viral culture (lesion should be
unroofed; obtain pustular fluid
and cells)
CDC laboratory
• Electron microscopy (may
identify orthopoxvirus but not
specific for variola)
• Variola PCR
• Orthopox culture
• Serology
Laboratorians from any area of the
laboratory who receive a specimen
labeled as “vesicle,” “blister,” “rash,” or
other words suggestive of acute/
generalized vesicular or pustular rash
illnesses without a noted risk level
should contact the physician before
processing the specimen. Vesicular or
pustular rashes associated with
adverse smallpox vaccine events are
classified as “moderate” risk.
Standard Precautions are extremely
important, as specimens submitted to
the laboratory may contain infectious
agents, such as vaccinia or variola
viruses. Standard Precautions, a Class
2 biosafety cabinet, and good tech­
nique theoretically should protect the
Figure 2. Specimen Collection and Transport of Samples
Moderate or high risk of smallpox (see Figure 1)
•
•
•
•
Call MDH at 612-676-5414 or 1-877-676-5414 to determine risk
level, to obtain details regarding specimen collection, and for
specimen transport arrangements.
Obtain fluid and cells from two or more unroofed vesicles/pustules
·
collect a minimum of four touch prep slides
·
collect 2-4 non-cotton swab samples in transport media
Other potential specimens include skin from top of lesions, scabs,
punch biopsies, and blood.
Collect acute serum.
Samples from patients with a moderate risk of smallpox may be
raised to the high-risk category if a non-variola diagnosis cannot be
established.
Low risk of smallpox (see Figure 1)
•
Collect specimens according to the institution’s protocols for rashlike illnesses such as VZV, HSV, and enterovirus or for other
diseases in the differential diagnosis.
•
If a diagnosis cannot be made and vaccinia virus and variola virus
infection cannot be ruled out by laboratory or clinical findings,
contact MDH. The patient’s risk category may be increased in such
circumstances.
3
laboratorian from most pathogens in
patient specimens. However, due to
the extreme danger posed by poxvi­
ruses to both the laboratorian and the
community, specimens from patients
with a moderate or high risk of smallpox
should be tested only in specifically
designated BSL 3 or 4 laboratories.
Variola virus, vaccinia virus, and other
poxviruses grow readily on many cell
lines such as Vero, HeLa, SF, and
MRC-5. Accidental isolation of vaccinia
virus by a clinical virologist is possible
during the vaccination campaign.
Therefore, if an unusual cytopathic
effect is observed in any cell culture,
especially involving giant multinucle­
ated cells, and other agents such as
VZV and HSV have not been identified,
laboratory personnel should contact the
ordering physician before proceeding
with identification. If a diagnosis of
smallpox or vaccinia virus infection
cannot be ruled out, the cell culture
should be sealed, stored securely, and
MDH should be contacted for further
instructions. Staining cells suspected
of harboring poxviruses is not recom­
mended.
Infection Control
Isolation of confirmed or suspected
smallpox patients is necessary to limit
the exposure of non-immune persons.
Guidelines for triage and management
of a possible smallpox patient in an
outpatient clinic are outlined in Figure 3.
The patient should be placed in strict
Airborne, Contact, and Standard
Precautions (Table 3). Airborne
Precautions include a closed door, a
negative pressure room with >6 air
exchanges per hour, and exhaust to the
outside or through HEPA filtration.
Caregivers should be vaccinated and
must wear NIOSH-approved respiratory
protection (i.e., N-95 respirators) and
personal protective equipment (PPE)
including gowns, gloves, face shields,
and hair and shoe covers when in
contact with smallpox patients or
contaminated material to prevent
inadvertent spread of variola virus to
susceptible persons and potential selfexposure to other infectious agents
(http://www.health.state.mn.us/divs/dpc/
biot/ppeposter.pdf). Personnel should
remove and correctly dispose of all
protective clothing and decontaminate
their hands with antimicrobial soap and
water or >60% alcohol-based hand rubs
before contact with non-vaccinated
Figure 3. Outpatient Clinic Guidelines for Triage and Management of Possible Smallpox Cases
Clinical case definition of smallpox: an illness with acute onset of fever > 101o F, followed by a rash characterized by firm,
deep-seated vesicles or pustules at the same stage of development, without other apparent cause.
SCHEDULER/
SCREENER
Patient calls for
appointment to be
seen for new rash,
recent fever, and
acute illness.
MANAGEMENT
Notify clinic nursing staff and front desk that patient is
coming and arrange for pending arrival and priority triage/
assessment.
Instruct patient to:
• avoid contact with other patients in clinic,
• cover mouth and nose with a tissue if coughing or
sneezing, and
• notify receptionist immediately upon arrival that priority
triage is required.
TRIAGE
Verify complaint of
new rash with
recent fever and
acute illness.
Immediately place patient in Airborne Precautions. Do not allow patient to remain in common waiting area.
• Use negative airflow room, if available. If no negative airflow room is available, use other designated area.
• Keep door closed.
• Post sign on door indicating that respiratory protection is required to enter room.
• All personnel must wear respiratory protection (N95 mask, if available) when in patient’s room.
• Put surgical mask on patient.
• Patient must keep mask on, if possible, until smallpox and other airborne disease are ruled out.
• Minimize number of people entering room.
• Keep ancillary services to a minimum.
• Confine procedures to room.
• If patient must leave the room, he or she must keep surgical mask on at all times.
• Personnel must wear gloves, if touching rash, and a gown, if anticipating extensive close contact.
• Gloves, mask, and gown must be discarded immediately upon exiting room, followed by thorough hand hygiene.
persons. Reusable bedding and
clothing can be autoclaved or laun­
dered in hot water with detergent and
bleach. Laundry-handlers should be
vaccinated before handling contami­
nated items. In the case of a large
outbreak, home isolation and care or a
shared isolation facility may be used.
Homes should have nonshared
ventilation, heating, and air-conditioning
systems. Access should be limited to
recently vaccinated persons with a
“take.” If multiple suspected smallpox
patients are placed in the same
isolation facility, they each should be
vaccinated to guard against accidental
exposure in the event that their final
diagnosis is not smallpox.
to prevent contact with nonvaccinated
or nonimmune persons, until smallpox
can be ruled out by clinical or labora­
tory examination.
Vaccinating contacts of smallpox
patients within 3-4 days of exposure will
prevent or significantly modify the
severity of their disease, if infected.
Vaccination within 7 days after expo­
sure likely offers some protection from
developing disease and/or may modify
the severity of disease. Contacts
should monitor their body temperatures
for 17 days following exposure. If a
vaccinated or unvaccinated contact
experiences a fever >101o F (38o C), he
or she should be isolated immediately
Smallpox Vaccination Program
Due to the concern regarding a
potential bioterrorism attack involving
smallpox, recommendations for
smallpox vaccination have been
developed by the Advisory Committee
on Immunization Practices (ACIP) and
CDC. A smallpox “event” is defined as
the discovery and recognition of a case
of smallpox (variola), naturally or
intentionally occurring anywhere in the
world.
There is no known treatment for
smallpox. Laboratory studies suggest
that cidofovir, an antiviral agent, has
activity against smallpox. Research
evaluating cidofovir and other agents is
ongoing. Consultation with MDH and
CDC regarding antiviral therapy is
recommended in cases of smallpox.
Supportive care is the mainstay of
smallpox therapy and consists of
intravenous fluids, control of fever and
pain, and antibiotics, if secondary
bacterial infections occur.
4
“Pre-event” (or “pre-release”) refers
to the period in which no known
cases of variola exist anywhere in the
world. Pre-event vaccination plans
generally involve health care workers
who would provide care to suspected
smallpox patients and public health
workers who would investigate a
suspected outbreak of smallpox. The
need for pre-event vaccination is
based on calculable risk assess­
ments that consider the risk for
disease versus the risks/benefits of
vaccination.
“Post-event” refers to the period after
a case of variola is recognized
anywhere in the world. Plans for
post-event vaccination incorporate
mechanisms for implementation of
rapid mass vaccination.
The federal government has recom­
mended that each state develop both
a pre-event and a post-event
smallpox vaccination plan. The MDH
plan and plans from the other states
were submitted to and approved by
CDC in December 2002.
On December 13, 2002, President
Bush announced the National
Smallpox Vaccination Program, which
includes vaccination of the military and
voluntary vaccination of health care
workers and public health workers who
would care for, contain, and investigate
suspected or confirmed cases of
smallpox. The first phase of this plan
includes vaccination of up to 500,000
military personnel and voluntary
vaccination of up to 500,000 individuals
designated for “smallpox response and
health care teams.” President Bush
also announced that smallpox vaccina­
tion later would be offered to all health
care workers and public safety person­
nel - up to 10 million persons nation­
wide (phase II). Vaccination may be
offered to the general public in 2004
(phase III).
MDH has established nine regional
vaccination clinic sites throughout the
state to accomplish phase I smallpox
vaccination. We anticipate that 3,000
persons may be vaccinated in phase I.
Israel recently completed a large-scale
vaccination program of 15,000-20,000
medical and security personnel, which
began in September 2002. Four
persons were hospitalized for adverse
events: the child of one vaccinee, the
spouse of another vaccinee, and two
vaccinees with high fevers. As part of
the program, vaccine recipients were
asked to donate plasma, in order to
boost the country’s supply of vaccinia
immune globulin (VIG) for treatment of
potential severe vaccine adverse
events. Smallpox vaccination in Israel
continued until 1980 for the general
public and until 1996 for military
personnel; therefore Israel’s smallpox
vaccination program included a very
large pool of previously vaccinated
individuals. Multiple studies have
shown that the risk of an adverse event
due to smallpox vaccination is signifi­
cantly decreased among previously
vaccinated persons and such persons
shed less vaccinia virus.
Dryvax,® the smallpox vaccine currently
licensed in the U.S., is a lyophilized
preparation of live vaccinia virus; it
does not contain smallpox (variola)
virus. The vaccine was prepared from
calf lymph with a seed virus derived
from the New York City Board of Health
(NYCBOH) strain of vaccinia virus. The
vaccine is reconstituted in a diluent
containing 50% glycerin, polymyxin B,
streptomycin, tetracycline, neomycin,
and a small amount of phenol as a
preservative. The vaccine is adminis­
tered using a multiple-puncture tech­
nique with a bifurcated needle. Approxi­
mately 2.7 million doses of Dryvax
currently are licensed for use, including
1 million doses for the Department of
Defense and 1.7 million doses for the
U.S. Department of Health and Human
Services.
A reformulated vaccine using tissue cell
culture techniques with the NYCBOH
strain is being developed, and clinical
trials are underway. Other strains of
vaccinia are under investigation for
potential use in vaccines.
Neutralizing antibodies induced by
smallpox vaccine are cross-protective
for other orthopoxviruses, such as
monkeypox, cowpox, and variola
viruses. Neutralizing antibodies
develop approximately 10 days after
primary vaccination (i.e., persons
receiving vaccination for the first time)
and 7 days after re-vaccination. More
than 95% of primary vaccinees develop
detectable neutralizing antibody.
Neutralizing antibodies are thought to
reflect levels of protection, although this
has not been validated. The presence
of a “major reaction” or “take” after
vaccination is the only reliable marker
correlated with immunity. Lack of a
major or primary-type response during
re-vaccination can indicate the pres­
ence of already adequate neutralizing
antibody levels, but also may indicate
unsuccessful vaccination.
Although the efficacy of smallpox
vaccine never has been measured
precisely in controlled trials, epidemio­
logic studies show a high level of
protection (~100%) up to 5 years
following primary vaccination. Substan­
tial but waning immunity can persist for
10 or more years. If a previously
vaccinated person develops smallpox,
the disease typically is milder. Mack
(1972) examined the smallpox fatality
rate in Europe from 1950 to 1971, with
varying intervals between vaccination
and smallpox infection. He showed that
the fatality rate among those who
contracted smallpox within 10 years of
vaccination was 1%, compared to 10%
among those who developed disease
more than 20 years after vaccination.
Individuals infected with smallpox who
never had been vaccinated experienced
a fatality rate of 50%.
Post-exposure vaccination has been
demonstrated to be extremely effective
in reducing symptoms and/or prevent­
5
ing smallpox disease, especially when
administered within 3 days of exposure
to the variola virus.
Contraindications for Smallpox
Vaccine
There are no absolute contraindications
for vaccination of a person who has had
a high-risk exposure to smallpox, since
those at greatest risk for a serious
adverse effect from vaccination also are
at greatest risk for death from smallpox.
If a relative contraindication to vaccinia
exists, the risk of a serious complication
of vaccination must be weighed against
the risk of a potentially fatal smallpox
infection. When the risk of exposure is
undetermined, the decision to vaccinate
should be made after the clinician’s and
patient’s assessments of the potential
risks versus the benefits of smallpox
vaccination. When vaccinating
individuals with contraindications or
precautions for smallpox vaccine, the
clinician is advised to consult with MDH
and CDC to discuss possible concur­
rent administration of VIG with smallpox
vaccine. If there has been no known
exposure in a post-event situation,
contraindications are the same as in
pre-event circumstances.
Because of the increased risk of
developing eczema vaccinatum,
individuals with active atopic dermatitis/
eczema or history of atopic dermatitis/
eczema of any degree and persons with
household contacts who have active
atopic dermatitis/eczema or a history of
atopic dermatitis/eczema should not
receive the vaccine in non-emergency
situations. Inadvertent transmission of
vaccinia virus has been demonstrated
to occur among household contacts
through common activities such as
sharing towels. ACIP defines eczema
broadly as: “an itchy, red, scaly rash
that lasts for more than 2 weeks and
often comes and goes.” Persons with
other acute, chronic, or exfoliative skin
conditions (e.g., burns, severe acne,
psoriasis, herpes, impetigo, or varicella
zoster) also are at higher risk for
complications and should not be
vaccinated until the skin condition
resolves. Persons with Darier’s
disease (keratosis follicularis) also
should not be vaccinated. Individuals
whose household contacts have acute,
chronic, or exfoliative skin conditions
should not be vaccinated.
Immunocompromised or immunosup­
pressed persons are at much higher
risk for significant adverse events
associated with the smallpox vaccine
(e.g., progressive vaccinia). Such
persons include those with leukemia,
lymphoma, generalized malignancy,
solid organ or stem cell transplantation,
severe autoimmune disease such as
systemic lupus erythematosus, der­
matomyositis, or scleroderma (even in
the absence of disease therapy), or
individuals receiving therapy with
alkylating agents, antimetabolites,
radiation, or high-dose corticosteroid
therapy (i.e., >2 mg/kg body weight or
20 mg/day of prednisone for >2 weeks).
This includes patients with cellular or
humoral immunity disorders, such as
HIV infection or AIDS. The degree of
immunosuppression that would place an
HIV-infected person at greater risk for
adverse events is unknown; therefore,
smallpox vaccine currently is contraindi­
cated for persons with HIV infection.
One case of severe generalized
vaccinia has been reported in an
asymptomatic HIV-infected military
recruit after the administration of
multiple vaccines, which included
smallpox vaccine. Additionally, a 1991
report indicated that two HIV-infected
persons may have died of a progressive
vaccinia-like illness after treatment with
inactivated autologous lymphocytes
infected with a recombinant HIVvaccinia virus. Persons with immunode­
ficiency or immunosuppression or
whose household contacts have such
conditions should not be vaccinated.
Pregnant women should not be vacci­
nated in non-emergency situations.
Those who are planning to become
pregnant should avoid becoming
pregnant for 4 weeks post-vaccination.
Vaccinia virus has been reported to
cause fetal vaccinia infection on rare
occasions (less than 50 reported
cases). Persons with household
contacts who are pregnant (or planning
to become pregnant) should not be
vaccinated.
Women who are breast-feeding should
avoid vaccination to prevent inadvertent
transmission of vaccinia virus from the
vaccination site to their infants via
intimate contact.
Before the eradication of smallpox,
smallpox vaccination was administered
routinely to infants at 1 year of age. The
current vaccine is not licensed for use in
individuals less than 12 months of age,
due to a higher incidence of adverse
reactions (particularly encephalitis) in
young children. The ACIP does not
consider the presence of an infant in a
household as a contraindication for
smallpox vaccination of other eligible
household members. MDH recom­
mends that potential vaccinees with
very young children (<12 months of
age) in the household should consider
deferring vaccination in a pre-event
situation, since the risk of inadvertent
inoculation and the risk of adverse
effects in the contact may be higher in
this situation. The ACIP does not
recommend vaccination of individuals
<18 years of age in a “pre-event”
situation. Children who have had a
definite smallpox exposure (i.e., face-toface, household, or close-proximity
contact with a smallpox patient) should
be vaccinated, regardless of age.
The currently available smallpox
vaccine (i.e., Dryvax) contains trace
amounts of polymyxin B sulfate,
streptomycin sulfate, chlortetracycline
hydrochloride, neomycin sulfate, and
phenol. Persons who experience
anaphylactic reactions to any of these
components should not be vaccinated.
In addition, a rubber stopper is used;
individuals with an anaphylactic reaction
to latex should not be vaccinated.
Future supplies of smallpox vaccine will
be reformulated and may contain other
preservatives or stabilizers.
Individuals with inflammatory eye
conditions are at higher risk of inadvert­
ent autoinoculation post-vaccination
during routine eye care. Of specific
concern is ocular autoinoculation and
the development of vaccinia keratitis,
which can lead to visual impairment.
The ACIP has recommended that
persons receiving steroids for eye
disease not receive smallpox vaccine
until their courses of therapy are
complete.
Elective vaccination should be deferred
for individuals experiencing moderate or
severe acute illnesses.
Smallpox vaccine may be administered
simultaneously with any inactivated
vaccine (e.g., influenza, pneumococcal).
The varicella vaccine and smallpox
vaccine should be administered >4
weeks apart, in order to avoid confusion
during the management of potential
post-vaccine rashes or other complica­
tions.
6
Vaccine “Take”
Clinically, recipients of smallpox vaccine
are considered fully protected after
having a successful response at the site
of vaccination (known as a “take”). The
vaccination site must be inspected 6-8
days after vaccination and the response
interpreted at that time. Two types of
responses have been defined by the
World Health Organization Expert
Committee on Smallpox: 1) a major
reaction, which indicates that virus
replication has taken place and vacci­
nation was successful, and 2) an
equivocal reaction. Immune suppres­
sion of viral replication (as in those
previously vaccinated), impotent
vaccine, flawed vaccination technique,
or an allergic reaction without the
production of immunity can cause a
blunted or equivocal vaccination
response.
A major (primary) reaction is defined as
a vesicular or pustular lesion or an area
of definite palpable induration or
congestion surrounding a central lesion
that might be a crust or an ulcer. Such
a reaction indicates that viral replication
has occurred and vaccination was
successful. The usual progression of
the vaccination site after primary
vaccination is as follows (Figure 4):
•·
The inoculation site becomes
reddened and pruritic 2-4 days
after vaccination and a papule
forms.
•·
A vesicle surrounded by a red
areola forms, which becomes
umbilicated and then pustular
7-11 days after vaccination.
•·
The pustule begins to dry; the
redness subsides; the lesion
becomes crusted, and a scab
forms between the second and
third week.
•
By approximately day 21, the
scab falls off, leaving a
permanent scar that initially is
pink in color but eventually
becomes flesh-colored.
Skin reactions after re-vaccination may
be less prominent and progress more
rapidly. Re-vaccination is considered
successful if a pustular lesion is present
or an area of definite induration or
congestion surrounding a central lesion
(i.e., scab or ulcer) is visible upon
examination 6-8 days after re-vaccination.
Equivocal reactions, including acceler­
ated, modified, vaccinoid, immediate,
early, or immune reactions, all are
defined as responses other than major
reactions. In these cases, vaccination
procedures should be checked and
vaccination repeated using a different
vial and lot of vaccine.
Smallpox Vaccine Reactions
Moderate side effects are common with
smallpox vaccination. Approximately
one third of adults who recently under­
went primary vaccination were suffi­
ciently ill (e.g., fever, malaise, head­
ache, myalgais) to miss normal activi­
ties or to require a day of leave from
work (Frey, 2002).
Swelling and tenderness of regional
lymph nodes frequently occur 3-10 days
after primary vaccination and can
persist for 2-4 weeks after the skin
lesion has healed.
Fever commonly occurs 4-14 days after
primary vaccination. In children, 70%
experience >1 day of temperatures
>100o F, and 15%-20% have tempera­
tures >102o F after primary vaccination.
After re-vaccination, 35% of children
experience temperatures >100o F, and
5% experience temperatures >102o F.
Fever is less common in adults after
vaccination or re-vaccination, with 17%
of primary vaccinees experiencing
temperatures >100o F and 1% having
temperatures >102o F.
A variety of erythematous, maculopapu­
lar, or urticarial rashes can occur
approximately 10 days after primary
vaccination. Usually, the vaccinee is
afebrile and the rash resolves spontane­
ously within 2-4 days. Rarely, bullous
erythema multiforme (i.e., StevensJohnson syndrome) occurs. Bacterial
superinfection of the site may occur,
particularly if there has been maceration
at the site. Viral cellulitis may occur and
can be confused with bacterial cellulitis.
Viral cellulitis typically occurs 8-10 days
post-vaccination and improves within
24-72 hours.
Moderate and severe complications of
smallpox vaccination include general­
ized vaccinia, eczema vaccinatum,
progressive vaccinia (vaccinia
necrosum), postvaccinial encephalitis,
and death. These complications are
rare (Tables 1 and 2) but generally
occur ten or more times more frequently
among primary vaccinees than among
re-vaccinees and are more frequent
among infants than among older
children and adults.
In a 1968 10-state survey of complica­
tions of smallpox vaccination, the
overall rate of serious, though not lifethreatening, adverse events among
primary vaccinees was approximately
1,000 cases/million vaccinees, while the
rate of life-threatening adverse events
was 52 cases/million vaccinees. The
rate of death among primary vaccinees
was 1-2 deaths/million vaccinated and
0.25 deaths/million among revaccinees, most often from
postvaccinial encephalitis or progres­
sive vaccinia. The risk for transmission
of vaccinia to contacts in this survey
was 27 infections/million vaccinations;
44% of those infections of contacts
occurred among children aged <5
years. Approximately 60% of contact
transmissions resulted from inadvertent
inoculation of otherwise healthy people.
Approximately 30% of eczema
vaccinatum cases were a result of
contact transmission. Eczema
vaccinatum can be more severe among
contacts than among vaccinated
persons, possibly because of simulta­
neous multiple inoculations at several
sites. Contact transmission rarely
results in postvaccinial encephalitis or
vaccinia necrosum.
Inadvertent inoculation is the most
frequent complication of smallpox
vaccination and accounts for approxi­
mately 50% of all complications of
primary vaccination and re-vaccination;
it is caused by transfer of vaccinia virus
from the site of vaccination to other
areas of the body. The most common
sites of inadvertent inoculation are the
face, eyelid, nose, mouth, genitalia, and
rectum. Most lesions heal spontane­
ously without specific treatment and can
be prevented by careful hand-hygiene
after touching the vaccination site. VIG
can be useful for extensive or severe
autoinoculation or cases of ocular
implantation, unless vaccinial keratitis is
present. Any inoculation near the eye
warrants an ophthalmology consultation
with a slit-lamp examination to rule out
vaccinia keratitis. Symptoms of
vaccinia keratitis generally appear 10
days after the transfer of vaccinia virus
and include ulceration and clouding of
the cornea. If left untreated, consider­
able corneal scarring and visual
impairment may result. Topical antiviral
agents (e.g., vidarabine and trifluridine)
and prophylactic topical antibiotics have
been used; topical steroids may be
considered in severe keratitis and iritis
but should not be used acutely without
topical antiviral therapy. VIG is not used
in isolated keratitis, since animal
models suggest that the antigenantibody immune complex may worsen
the keratitis and increase corneal
scarring. However, VIG can be consid­
ered if there is severe ocular disease
(e.g., vision-threatening lid malforma­
tion), if treatment is limited to one dose
and the patient is informed of possible
risks and benefits. All ocular cases
should be managed together with an
opthalmologist. VIG should be used to
treat life-threatening reactions, even in
the presence of keratitis.
Eczema vaccinatum is a localized or
generalized spread of vaccinia virus
among persons with active atopic
dermatitis/eczema or a history of atopic
dermatitis/eczema; it can occur in
vaccinees or their household contacts
who have active atopic dermatitis/
eczema or a history of atopic dermatitis/
eczema and is independent of the
activity (active or quiescent) of the
underlying skin condition. Although the
illness can be moderate, it also can be
severe or fatal. The most serious cases
in vaccine recipients occur among
primary vaccinees or unvaccinated
courtesy of CDC
Figure 4. Primary Vaccination Site Reaction
Day 4
Day 14
Day 7
7
Day 21
contacts of vaccinees. VIG is used to
treat eczema vaccinatum, and multiple
doses may be required. These patients
require prompt evaluation. Volume and
electrolyte support similar to that used
for burn patients may be required, in
addition to care of secondary infections.
Table 1. Vaccine Adverse Reactions and Indications for
Vaccinia Immune Globulin (VIG)
Adverse Reaction
Mild to moderate
inadvertent inoculation
VIG Treatment
usually not required; may be indicated
if severe or for ocular implantation*
erythematous or urticarial rash
not indicated
bullous erythema multiforme
(Stevens-Johnson syndrome)
not indicated
Moderate to severe
generalized vaccinia
Generalized vaccinia is characterized
by a vesicular or pustular rash of
varying extent, distant from the vaccina­
tion site, that occurs among persons
without underlying dermatologic
conditions; it usually occurs 7-9 days
after vaccination and results from a
viremia with implantations in the skin.
The rash generally is self-limited and
requires minor or no therapy, except
among those who appear toxic or who
have serious underlying conditions.
VIG can be used if the illness is severe,
recurrent, or the patient has a serious
underlying illness. Consultation with an
immunologist is suggested for evalua­
tion for a possible immune defect
(particularly B-cell defect).
usually not required; indicated if
patient is severely ill or has serious
underlying illness
eczema vaccinatum
indicated
progressive vaccinia (vaccinia
necrosum)
indicated
postvaccinial encephalitis
not indicated
vaccinial keratitis
contraindicated if isolated keratitis*
Progressive vaccinia (vaccinia
necrosum) is a severe, frequently fatal
illness characterized by progressive
necrosis in the area of vaccination,
often with metastatic lesions to other
areas of skin, bones, or viscera; it
occurs almost exclusively in patients
with impaired immune function,
especially those with cellular immuno-
* VIG is not indicated if isolated vaccinial keratitis is present, since increased
corneal scarring has been observed in animal models. It may be given if
another indication such as eczema vaccinatum is present and may be
considered in severe ocular disease, even in the presence of keratitis (in the
later case, treatment usually should be limited to one dose). All ocular disease
should be managed with an opthalmologist.
Table 2. Rates of Reported Complications Associated with Smallpox Vaccination*
(cases per million vaccinees)
Vaccinee’s age
(yrs) and
vaccination status
Primary vaccination
<1
1-4
5-19
>20
Overall rate
‡
Re-vaccination
<1
1-4
5-19
>20
Overall rate
‡
Inadvertent
inoculation
Generalized
vaccinia
Eczema
vaccinatum
507
577
371
606
394
233
140
212
14
44
35
30
529
242
____
109
48
25
42
Progressive
vaccinia
____
Postvaccinial
encephalitis
Any complication
†
(overall)
4
____
____
42
10
9
____
1,549
1,262
856
1,515
39
2
12
1,254
____
____
____
____
2
5
____
____
____
____
10
9
____
____
____
6
5
200
86
114
9
3
3
2
108
* Adapted from Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox vaccination, 1968: results of ten statewide
surveys. J Infect Dis 1970;122:303-9.
†
Rates of any overall complication by age group include complications not presented in this table, such as severe local
reactions, bacterial superinfection of the vaccination site, and erythema multiforme.
‡
Overall rates for each complication include persons of unknown age.
Table adapted from Vaccinia (Smallpox) Vaccine. MMWR June 22, 1991; 50 (RR-10).
8
deficiency. These patients can present
with an ulcerative vaccination site that
does not appear inflamed and has no
apparent healing after 15 days. There
may be few or no systemic symptoms
initially. Treatment includes hospitaliza­
tion, aggressive VIG (up to 10 ml/kg
IM), and potentially experimental
antiviral therapy such as cidofovir.
Postvaccinial encephalitis or encepha­
lomyelitis is thought to be an autoim­
mune or allergic reaction to the
vaccine. It usually presents 10-14 days
after vaccination, with headache,
vomiting, drowsiness, and fever.
Cerebrospinal fluid may show a
pleocytosis and increased CSF protein.
Approximately 15-25% of vaccinees
with this complication die, and 25% of
survivors have permanent neurological
sequelae. Treatment is supportive care
only; VIG is not indicated. Historically,
the occurrence of this complication was
influenced by the strain of vaccine virus
and was higher in Europe than in the
U.S; the principal strain of vaccinia
virus used in the U.S., NYCBOH, was
associated with the lowest incidence of
postvaccinial encephalitis.
There have been fewer than 50 cases
of fetal vaccinia reported worldwide.
Fetal vaccinia usually results in stillbirth
or death of the infant soon after
delivery. Smallpox vaccine has not
been associated with congenital
malformations.
Treatment of Adverse Events
VIG is derived from the immunoglobulin
fraction of plasma from persons who
have been vaccinated with vaccinia. It
still is under Investigational New Drug
(IND) status. VIG is effective for
treatment of eczema vaccinatum,
progressive vaccinia, severe or
recurrent generalized vaccinia, and
severe accidental implantation (particu­
larly ocular without keratitis). VIG is not
effective in the treatment of
postvaccinial encephalitis. VIG has no
role in the treatment of smallpox
(variola) disease. Current supplies of
VIG are limited and are available only
through CDC. VIG should be reserved
for treatment of vaccine complications
with severe clinical manifestations
(Table 1).
The recommended dose of VIG for
treatment of vaccine-induced complica­
tions is 0.6 ml/kg of body weight,
though this can be increased up to 10
ml/kg for severe, life-threatening
eczema vaccinatum or progressive
vaccinia. VIG is administered intramus­
cularly and should be initiated as soon
as possible after the onset of symp­
toms. Because therapeutic doses of
VIG can be substantial (e.g., 42 ml for a
person weighing 70 kg), it should be
administered in divided doses over a
24-36-hour period. Doses can be
repeated, usually at intervals of 2-3
days, until recovery begins (i.e., no new
lesions appear). Intravenous VIG is
expected to become available shortly
through CDC as an IND; dosing
recommendations for this formulation
will be included in the package informa­
tion.
Cidofovir is a nucleoside analog that
inhibits DNA polymerase. It currently is
licensed for the treatment of retinitis
due to cytomegalovirus. Cidofivir has
demonstrated antiviral activity against
poxvirus in vitro and against cowpox
and vaccinia viruses in mice. Cidofovir
is known to cause renal toxicity and
needs to be administered with IV
hydration and probenecid. An IND
protocol for treatment of severe
vaccinia is being established through
CDC. Cidofivir is considered by CDC to
be a second-line agent for treatment of
adverse effects related to smallpox
vaccine.
The Food and Drug Administration has
not approved the use of any antiviral
compounds for the treatment of
vaccinia virus infections or other
orthopoxvirus infections, including
smallpox. Certain antiviral compounds
have been reported to be active against
vaccinia virus and other
orthopoxviruses, but their safety,
efficacy, and dosing regimen for the
treatment of severe vaccinial adverse
events are unknown. Current research
on future treatments for complications
of smallpox vaccine and for smallpox
itself is focused on evaluating the
safety and efficacy of certain antiviral
compounds, developing a smallpox
vaccine with a safer adverse-event
profile, and developing monoclonal
antibodies against vaccinia virus.
CDC is developing clinical evaluation
tools for significant adverse effects.
These are available at http://
www.bt.cdc.gov/agent/smallpox/
vaccination/.
MDH will assist physicians in the
diagnosis and management of patients
with suspected complications of
9
smallpox vaccination. Physicians can
call MDH at 612-676-5414 or 1-877676-5414 if they have questions, need
clinical assistance, or suspect a need
for VIG. (MDH staff will be available oncall after hours.) MDH will contact CDC
to obtain VIG, which will be shipped
directly to the clinician. Serious
adverse effects should be reported to
MDH and to the national Vaccine
Adverse Event Reporting System
(VAERS).
Preventing Transmission of Vaccinia
Virus
Until the scab has separated from the
vaccination site, scrupulous hand
hygiene must be maintained, since live
vaccinia virus is replicating at the
vaccination site. Thorough handhygiene with antimicrobial soap and
water or >60% alcohol-based hand
rubs should occur after any contact with
the site or materials that have come
into contact with the site. Avoid
touching, rubbing, or scratching the
site.
Health care workers are required to
cover the site with gauze and a semi­
permeable dressing and long sleeves,
when they are at work. Health care
workers must inform their employers of
their vaccinations and follow recom­
mendations outlined by their facility.
ACIP does not require furloughing of
health care workers if their vaccination
sites are completely covered and if the
health care worker follows scrupulous
infection control practices, including
hand-hygiene. Health care workers
must be evaluated prior to each shift
when working with patients to ensure
that they have not developed systemic
symptoms and that their dressing is
intact, with no seepage, erythema, or
lesions extending beyond the dressing.
Dressings should be changed if
exudate is visible at the edge of the
gauze. If erythema or lesions extend
beyond the dressing or if there are
systemic symptoms, the vaccinee
should be sent home. Infection control
recommendations should be reviewed
at every opportunity. Dressings,
bandages, and the scab should be
discarded carefully (e.g., placed in a
sealed plastic bag, if at home, or in a
red biohazard bag, if at work).
In non-patient care settings, the
vaccination site may be covered loosely
with gauze and tape. However,
vaccinees can continue use of the
semi-permeable dressings. An
scab falls off. A vaccinee may go to a
gym if the vaccination site is covered
carefully (e.g., gauze plus semi­
permeable membrane dressing and
long sleeves) and kept dry. Contact
sports should be avoided. Vaccinees
should not use equipment that rubs
against the vaccination site. Vaccinees
Normal bathing/showering can occur
should take extreme caution and use
with a waterproof dressing, as long as
the site is kept dry. No salve or ointment meticulous hand-hygiene when han­
should be placed on the vaccination site. dling contact lenses and should
consider wearing glasses rather than
The vaccinee should take care to
contact lenses to decrease the risk of
prevent contact of the site or contami­
inadvertent inoculation and vaccinia
nated materials from the site with
keratitis. If the vaccinee is caring for
unvaccinated persons. Towels should
young children, the vaccinee should
not be shared and should be laundered
keep the vaccination site dry and
prior to reuse by the vaccinee. Towels,
covered, wear long sleeves, and follow
clothing, or other materials that have
scrupulous hand-hygiene.
had contact with the vaccination site
should be kept separately until laun­
dered; they can be decontaminated with The most critical measure in preventing
inadvertent implantation and contact
routine laundering in hot water with
transmission from smallpox vaccination
detergent with or without bleach.
is thorough hand-hygiene after chang­
ing the dressing and after any other
Recent vaccinees should not use hot
tubs, swimming pools, saunas, or public contact with the vaccination site.
showers or health club towels until the
occlusive bandage generally is not
recommended, due to concerns about
maceration of the site; however results
from limited experience using gauze
plus a semi-permeable dressing are
very favorable.
Table 3. MDH Infection Control Recommendations for Care
of Vaccinia Patients
Patient’s Status*
Airborne
Precautions
Contact Standard
Immunocompetent patient
with localized vaccinia
Immunocompetent patient
with disseminated vaccinia†
Infection control recommendations for
the care of patients with adverse
reactions related to smallpox vaccina­
tion have been developed by MDH and
are outlined in Table 3.
References
CDC. Vaccinia (smallpox) vaccine recommendations of the
Advisory Committee on Immunization Practices (ACIP),
2001. MMWR 2001; 50(RR10):1-25.
CDC. Smallpox vaccination and adverse reactions
guideline for clinicians. MMWR 2003; 52: 1-29. http://
www.cdc.gov/mmwr/preview/mmwrhtml/di52cha1.htm
Frey SE, Couch RB, Taket CO, et al. Clinical responses to
undiluted and diluted smallpox vaccine. New Eng J Med
2002; 347:1265-74.
Henderson DA, Inglesby TV, Bartlett JG, Ascher MS, Eitzen
E, Jahrling PB, et al. Smallpox as a biological weapon:
medical and public health management. JAMA 1999; 281:
2127-30. http://jama.ama-assn.org/issues/v281n22/ffull/
jst90000.html
Lane JM, Ruben FL, Neff JM, Millar JD. Complications of
smallpox vaccination, 1968: results of ten statewide
surveys. J Infect Dis 1970; 122:303-9.
Mack T. Smallpox in Europe, 1950-1971. J of Infect Dis
1972; 125(2):161-9.
For further information
ACIP recommendations
http://www.cdc.gov/nip/publications/ACIP-list.htm
CDC web site
http://www.bt.cdc.gov/agent/smallpox/index.asp
American Association of Dermatology web site
http://www.aad.org/BioInfo/smallpox.html
MDH web site
http://www.health.state.mn.us/bioterrorism/smallpox/
index.html
WHO web site
http://www.who.int/emc/diseases/smallpox/
Center for Infectious Disease Research and Policy web site
http://www1.umn.edu/cidrap/content/bt/smallpox/
Civilian Biodefense Strategies web site
http://www.hopkins-biodefense.org/
Infectious Disease Society of America web site
http://www.idsociety.org/BT/ToC.htm
Immunocompromised patient
with localized or disseminated vaccinia †
* If there is any question about whether vaccinia is localized or disseminated, use Airborne and Contact Precautions.
† Disseminated vaccinia is defined as generalized vaccinia, progressive vaccinia, eczema vaccinatum until all scabs
have separated.
Proposed New Immunization Requirements
A public hearing regarding the Minnesota Department of Health (MDH)’s
intention to adopt new immunization
requirements will be held on Friday,
February 28, 2003, at 9:00 A.M. in the
Mississippi Room at the Snelling Office
Park building, 1645 Energy Park Drive,
St. Paul, Minnesota 55108.
You are encouraged to participate in
this process by presenting your views
orally at the hearing or in writing at any
time before the hearing; comments may
be sent or e-mailed to MDH at the
addresses provided at the end of this
article.
The following are several changes
proposed for the new immunization
requirements; a complete list of all of
proposed changes is available on the
MDH web site at http://
www.health.state.mn.us/divs/dpc/adps/
immrule.htm.
• Require the chickenpox vaccine for
children in child care, kindergarten,
and seventh grade.
• Require the pneumococcal vaccine
for children under 2 years of age
who are in child care.
• Allow vaccine doses administered
4 or fewer days before the minimum age required in law to be
considered valid, in order to be
consistent with nationally established general recommendations.
10
•
Modify the requirement for hepatitis
B so that a hepatitis B vaccine
licensed for an alternative dosing
schedule is valid for the hepatitis B
vaccination requirement.
For more information on the proposed rules, the hearing, and a
summary of the justification for the
proposed changes, visit the MDH
web site or contact Patricia Segal­
Freeman, c/o MDH, ITIH Section, PO
Box 9441, Minneapolis, MN 55440­
9441; phone: (612) 676-5414 or 1­
800-657-3970, fax: (612) 676-5689,
e-mail:
[email protected].
Subject Index for the Disease Control Newsletter, 2002
ANNUAL SUMMARY
Annual Summary of Communicable Diseases
Reported to the Minnesota Department of Health, 2001.............................................................................August/September
ANTIMICROBIAL RESISTANCE
Antimicrobial Susceptibilities of Selected Pathogens, 2001......................................................................................March/April
ARBORVIRAL ENCEPHALITIS
Surveillance, Reporting and Submission of Specimens for Confirmed or Suspected Cases of Arboviral Encephalitis........July
CANCER
Breast Cancer Control in Minnesota...............................................................................................................January/February
Cervical Cancer Control in Minnesota............................................................................................................January/February
Colorectal Cancer in Minnesota................................................................................................................................March/April
Proposed Change in Cancer Reporting Rules.............................................................................................................May/June
Melanoma and Skin Cancer Detection and Prevention........................................................................................................July
HEPATITIS
Avoid Missed Opportunities to Prevent Hepatitis.........................................................................................................May/June
Viral Hepatitis Compendium......................................................................................................................November/December
MISCELLANEOUS
Subject Index for the Disease Control Newsletter, 2001.................................................................................January/February
Redesigned Library Web Site.......................................................................................................................................May/June
Emerging Infections Conference.............................................................................................July, August/September, October
Improving Asthma Management Among Diverse Communities Conference.................................................August/September
Smoking Rates in Minnesota, 1990-2000.......................................................................................................................October
SEXUALLY TRANSMITTED DISEASES
Increasing Incidence of Syphilis in Minnesota, 2002...................................................................................................May/June
Sexually Transmitted Diseases: Treatment Guidelines, 2002......................................................................................May/June
STREPTOCOCCUS
Pulsed-Field Gel Electrophoresis Comparison of Pharyngeal and Sterile Site Group A Streptococcal Isolates..........May/June
Revised Guidelines for Perinatal GBS Disease Prevention............................................................................................October
VACCINE PREVENTABLE DISEASES
Childcare and School Immunization Rule Update........................................................................................................May/June
Vaccine Supply Issues, 2002........................................................................................................................................May/June
Changes in Reporting Race/Ethnicity
Data on Disease Report Forms
The Minnesota Department of Health
(MDH) has revised the format for
reporting race/ethnicity data on all
standardized infectious disease case
report forms.
According to the federal Office of
Management and Budget (OMB)’s
“Standards for Maintaining, Collecting,
and Processing Federal Data on Race
and Ethnicity,” as of January 2003, all
race/ethnicity data reported to federal
agencies must be collected and
reported in a format consistent with the
definitions of race/ethnicity used in the
U.S. Census 2000. In particular, the
OMB standard requires: (1) the option
of selecting multiple race categories,
(2) separation of the former “Asian/
Pacific Islander” race category into
distinct “Asian” and “Native Hawaiian or
Other Pacific Islander” categories, and
(3) minor revisions to race/ethnicity
category titles. MDH’s revised disease
report forms for sexually transmitted
diseases (STDs), HIV/AIDS, tuberculo­
sis, and other communicable diseases
reflect these changes. Other indications, requirements, and procedures for
reporting communicable diseases to
MDH remain unchanged.
MDH requests that you collect and
report race/ethnicity data in this format
11
and use the revised forms as of
January 1, 2003. Copies of the
pertinent revised forms have been
distributed to clinical sites that previ­
ously have reported specific diseases.
Please make a special effort to provide
complete data for each case report.
MDH uses this information to identify
and analyze trends in the incidence and
epidemiology of communicable
diseases in Minnesota and to compile
quarterly and annual reports for
disease surveillance. Clinicians, public
health agencies, and community
organizations use these reports to
monitor disease trends, to evaluate the
impact of prevention programs, and to
assess the need for health-related
services.
When reporting cases of STDs or HIV/
AIDS, please also include complete
information, as appropriate, for any
partners/contacts of cases (e.g.,
untreated partners of STD cases, all
known HIV and syphilis contacts).
MDH relies on this information to locate
and provide services for persons who
need notification, counseling, or
treatment referrals. All contact follow-
up is conducted in a discreet, prompt,
and confidential manner.
By fulfilling your roles and responsibili­
ties regarding disease reporting, you
actively assist MDH in conducting
effective disease surveillance in
Minnesota. Thank you for your
continued contribution to this important
public health activity. Please contact
MDH if you have questions or com­
ments regarding disease reporting on
the revised disease report forms or to
obtain copies of the revised forms.
Aggie Leitheiser, Acting Commissioner of Health
Division of Infectious Disease Epidemiology, Prevention and Control
Harry F. Hull, M.D. ............................ Division Director & State Epidemiologist
Richard N. Danila, Ph.D., M.P.H. ................................ ADIC Section Manager
Kirk Smith, D.V.M., Ph.D. ......................................................................... Editor
Wendy Mills, M.P.H. ................................................................. Assistant Editor
Valerie Solovjovs ................................................................... Production Editor
Disease Reporting Contacts*
STDs: Chris Sachi (612) 676-5203
HIV/AIDS: Donald Stiepan (612) 676­
5736
All other communicable diseases:
(612) 676-5414
* Statewide toll-free number for
reporting communicable diseases:
1-877-676-5414
CHANGING YOUR ADDRESS?
Please correct the address
below and send it to:
DCN MAILING LIST
Minnesota Department of Health
717 Delaware Street SE
PO Box 9441
Minneapolis, MN 55440-9441
The Disease Control Newsletter is available on the MDH Acute Disease Investigation and Control
(ADIC) Section web site (http://www.health.state.mn.us/divs/dpc/ades/pub.htm).
The Disease Control Newsletter toll-free telephone number is 1-800-366-2597.