Traditional Smallpox Vaccines and Atopic Dermatitis Frequently Asked Questions

What is the traditional smallpox vaccine?

The traditional smallpox vaccine is made from a virus called vaccinia, which is a pox-type virus related to smallpox. The vaccine contains live replicating vaccinia virus–not dead virus like many other vaccines. For that reason, the vaccination site must be cared for carefully to prevent the virus from spreading. The vaccine does not contain the smallpox virus and cannot give you smallpox.

Are there alternative vaccines to the traditional vaccine for people with atopic dermatitis/eczema, or for their close contacts?

Yes. In the event of a national smallpox emergency, 20 million doses (covering 10 million people) of a vaccine that is appropriate for immunocompromised individuals have now been stockpiled. These individuals include those suffering from atopic dermatitis or HIV, including children, pregnant women, and nursing mothers.

I thought vaccination for smallpox ended decades ago. Who is still being vaccinated with the traditional vaccine?

The traditional smallpox vaccine is typically administered to certain members of the military or other Department of Defense employees, as well as laboratory workers who work with smallpox or related viruses. It is otherwise unavailable to the general population, but it is stockpiled by the government for use in an emergency.

Why should someone who has atopic dermatitis/eczema and their family members not receive the vaccine?

The traditional smallpox vaccine contains a live virus that can be harmful or even fatal to those with atopic dermatitis/eczema. Family members of eczema sufferers should not take the vaccine unless they have been exposed to smallpox, because the
live virus in the vaccine can harm the afflicted family member on contact.

What are the side effects or risks in receiving the smallpox vaccine?

There are side effects and risks associated with the traditional smallpox vaccine. Most people experience normal, usually mild reactions such as a sore arm, a fever, and body aches. But other people experience reactions ranging from serious to life threatening. People with atopic dermatitis or other eczemas may develop a spreading vaccinia infection called eczema vaccinatum (EV), which can be fatal. Even people who have had atopic dermatitis just once in the distant past may contract this infection.

It is estimated that there are approximately 30 million individuals in the United States who have atopic dermatitis, and many of these people would be susceptible to eczema vaccinatum if vaccinated or in contact with a vaccinee.

When was the last time people were vaccinated for smallpox?

Routine vaccination against smallpox stopped in the Untied States and many other countries in 1972. In 1979, the World Health Organization (WHO) recommended that such vaccinations be stopped in all countries. Vaccination was recommended only for special groups, such as researchers working with smallpox and related viruses. By 1982, routine vaccination had been officially discontinued in 149 of the 158 member countries of WHO. By 1986, routine vaccination had ceased in all countries.

Who is at risk of having eczema vaccinatum?

In the past, eczema vaccinatum has occurred in persons suffering from, or with a history of, atopic dermatitis/eczema who were vaccinated or came into contact with someone else who was vaccinated. Eruption initially occurred at sites on the body
that were affected at that time by eczema or had previously been affected. The eruptions became intensely inflamed and sometimes spread to healthy skin. Symptoms were severe. The prognosis was especially grave for infants with large areas
of affected skin.

What are the dangers of people with atopic dermatitis/eczema acquiring vaccinia from a vaccinated person?

People with atopic dermatitis/eczema should avoid contact with recent recipients of the traditional vaccine. Vaccinia is generally transmitted from person to person through direct contact, so precautions should be taken to reduce the likelihood of such contact. If you accidentally come in contact with someone who has been vaccinated or with something that may be contaminated with live virus, wash immediately an thoroughly with soap and warm water. The period during which a recently vaccinated
person is a threat is up to one month after vaccination.

How is vaccinia transmitted from the vaccination site?

Vaccinia is spread by touching a vaccination site (which appears as a pustule known as a “take”) before it has healed or by touching any materials that might be contaminated with live virus from the site–materials such as bandages, towels, clothing, or washcloths used by a person who has been vaccinated. Vaccinia is not spread through airborne contagion. Transfer of the vaccinia virus can occur from touching the vaccination site before it has healed and then touching other parts of the body, or from contact with a vaccinee whose lesion is in the florid stages.

What are the options for a person with atopic dermatitis/eczema who comes into contact with vaccinia?

With early recognition and appropriate use of Vaccinia Immune Globulin (VIG), mortality can be reduced to zero, and morbidity alleviated. Data supporting the use of VIG is limited, so avoiding contact with the live replicating virus is preferable. However, even if there is a delay in recognition, prompt institution of VIG should be undertaken. Untreated patients become quite ill and evidence systemic symptoms. If unrecognized and untreated, the patient will manifest severe systemic symptoms resembling septic shock, and death ensues.

What if I have atopic dermatitis/eczema and become exposed to smallpox?

If exposure to smallpox occurs, then vaccination is recommended, even for those people with atopic dermatitis/eczema. Vaccination within three days of exposure will completely prevent or significantly modify smallpox in the vast majority of persons. Vaccination four to seven days after exposure likely offers some protection from smallpox or may modify the severity of that disease.