Published Date: 2003-03-06 23:50:00
Subject: PRO> Smallpox vaccination, adverse events - USA (02)
Archive Number: 20030306.0556

SMALLPOX VACCINATION, ADVERSE EVENTS - USA (02)
***********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
[1]
Date: Sat 1 Mar 2003 23:37:03 -0600
From: Kathy LeDell <Kathy.Ledell@state.mn.us>

A comment to moderator MPP regarding the comment about hirsute
vaccinees shaving the vaccination site and surrounding area to permit
a protective dressing to adhere.
I would not recommend shaving the site, but rather clipping excess
hair. We know from studying surgical site infections that shaving the
skin increases the chance of infection. This could be a particular
issue with vaccinia, and we would not want to increase the chance of
satellite lesions.
The issue of what type of semipermeable membrane dressing works best
for healthcare providers is also an important one. This type of
dressing (e.g., OpSite or Tegaderm) must be worn by healthcare
providers when they are working in healthcare facilities.
--
Kathleen LeDell, MPH, RN
Acute Disease Investigation and Control Section
Minnesota Department of Health
Minneapolis, MN
<Kathy.Ledell@state.mn.us>
******
[2]
Date: Mon, 3 Mar 2003 09:20:36 -0500 (EST)
From: Monir Taha <mtaha@hamilton.ca>

Moderator MPP suggests shaving around the inoculation site to permit
adherence of the protective dressing. Shaving can produce
micro-lacerations and abrasions of the skin. Might these not offer
more portals of entry for the vaccinia virus?
--
Monir Taha, MD, MHSc, CCFP, FRCPC
Associate Medical Officer of Health
Hamilton, Ontario, Canada
<mtaha@hamilton.ca>
******
[3]
Date: Tue, 4 Mar 2003 10:34:57 -0500 (EST)
From: Thomas Morris, MD <tmorris@nhcgov.com>

As a recent vaccinee who shared the same problem with the physician
(and strikingly similar descriptors), I would like to point out that
shaving with a blade will cause microabrasions of the skin and may
increase the risk for satellite lesions. I used an electric trimmer
around the site to improve adherence, and have made recommendations
to several vaccination clinics to be prepared for this.
--
Thomas Morris, MD, MPH
Public Health Regional Surveillance Team
Region - 2
Wilmington, NC
******
[4]
Date: Thu, 06 Mar 2003 14:17:50 -0500
From: Julie Mangino MD <mangino-1@medctr.osu.edu>

I would NOT shave but would clip [the excess hair] simply based on
surgical site infection data. I think the raw area from shaving would
potentially lead to contact transmission surrounding the vaccinia
inoculation site; and a potentially expanded site due to
contamination of the shaved area, might not remain within the
confines of a Tegaderm for health care workers.
--
Julie E. Mangino, MD
Associate Professor of Clinical Internal Medicine
Division of Infectious Diseases
Medical Director Dept. of Epidemiology
Columbus, Ohio
<mangino-1@medctr.ohio-state.edu>
[Many thanks to our subscribers for raising questions about the
moderator comment to consider shaving the vaccination site to improve
adhesion of protective dressings following smallpox vaccination. The
above comments led me to do further research on the topic of current
recommendations for smallpox vaccination site preparation and care,
the issue of shaving surgical sites, and the association of
perioperative wounds at the surgical wound site. With respect to the
last issue, the literature clearly supports NOT shaving a surgical
wound site, as the microabrasions associated with the process of
shaving are a risk factor for increased wound infections (see refs
below). Thus, as pointed out by some of our subscribers, the
theoretical risk of satellite lesions from inoculation of the
microabrasions is of sufficient concern to warrant NOT shaving the
site prior to vaccination.
With respect to current recommendations for smallpox vaccination (as
published in: Wharton M, Strikas RA, Harpaz R, Rotz LD, Schwartz B,
Casey CG, Pearson ML, Anderson LJ. Recommendations for Using Smallpox
Vaccine in a Pre-Event Vaccination Program -- Supplemental
Recommendations of the Advisory Committee on Immunization Practices
(ACIP) and the Healthcare Infection Control Practices Advisory
Committee (HICPAC) MMWR, 26 Feb 2003/52 (Dispatch); 1-16), the
recommendations state:
"Optimal infection-control practices and appropriate site care should
prevent transmission of vaccinia virus from vaccinated health-care
workers to patients. Health-care personnel providing direct patient
care should keep their vaccination sites covered with gauze in
combination with a semipermeable membrane dressing to absorb exudates
and to provide a barrier for containment of vaccinia virus to
minimize the risk of transmission; the dressing should also be
covered by a layer of clothing. Dressings used to cover the site
should be changed frequently to prevent accumulation of exudates and
consequent maceration. The most critical measure in preventing
contact transmission is consistent hand hygiene. Hospitals should
designate staff to assess dressings for all vaccinated health-care
workers. When feasible, staff responsible for dressing changes for
smallpox health-care teams should be vaccinated; all persons handling
dressings should observe contact precautions. Administrative leave is
not required routinely for newly vaccinated health-care personnel,
unless they are physically unable to work as a result of systemic
signs and symptoms of illness; have extensive skin lesions that
cannot be adequately covered; or if they are unable to adhere to the
recommended infection-control precautions. Persons outside the
patient-care setting can keep their vaccination sites covered with a
porous dressing; hand hygiene remains key to preventing inadvertent
inoculation."
There is no mention of hair removal around the vaccination site
(either clipping or shaving) to facilitate barrier dressing adhesion.
Given this, it seems as though the most appropriate interpretation of
this situation would be found in the section related to indications
for administrative leave "...if they are unable to adhere to the
recommended infection-control precautions."
<http://www.cdc.gov/mmwr/preview/mmwrhtml/m2d226.htm>
In any event, the failure of the protective dressing to adhere should
be of significant concern to health care workers in contact with
patients who may have increased risk factors for severe disease,
above and beyond the general concerns about contact with others and
the possibility of contact vaccinial infection.
1. Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L., Preoperative
hair removal--a systematic literature review. AORN J 2002
May;75(5):928-38, 940
2. Hamilton HW, Hamilton KR, Lone FJ., Preoperative hair removal. Can
J Surg 1977 May;20(3):269-71,274-5
3. Auerbach A. Prevention of Surgical Site Infections. AHQR Evidence
Report/Technology Assessment. Number 43; 221-243
4. Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The
influence of hair-removal methods on wound infections. Arch Surg
1983 Mar;118(3):347-52
5. Olson M., et al. Pre-operative Hair Removal With Clippers Does Not
Increase Infection Rate in Clean Surgical Wounds. Surgery, Gynecology
& Obstetrics 1996; 162; 181-182.
- Mod.MPP]

See Also

Smallpox vaccination, adverse events - USA 20030301.0515
Smallpox vaccination, adverse event monitoring - USA 20030206.0324
Smallpox vaccination strategies 20030103.0018
2002
----
Smallpox vaccination strategy - Israel (04) 20021225.6123
Smallpox vaccination strategy - Israel (03) 20021222.6113
Smallpox vaccination strategies - USA (09) 20021213.6059
Smallpox vaccination strategies - UK 20021207.6002
Disease surveillance: enhancement (03) 20021107.5740
Smallpox vaccination hazards (03) 20021017.5571
Smallpox vaccination strategy - Israel 20020820.5095
Smallpox vaccine hazards 20020817.5080
Smallpox vaccine, criticism of choice - UK 20020730.4892
Smallpox containment strategies - USA 20020711.4725
Smallpox vaccination (02) 20020710.4715
Smallpox vaccination strategies - USA 20020709.4710
Disease surveillance: enhancement (02) 20020708.4696
Smallpox vaccine, ACIP recommendations - USA (02) 20020621.4560
Smallpox vaccine, ACIP recommendations - USA 20020620.4542
Smallpox vaccination 20020611.4468
.............................mpp/pg/lm
*##########################################################*
ProMED-mail makes every effort to verify the reports that
are posted, but the accuracy and completeness of the
information, and of any statements or opinions based
thereon, are not guaranteed. The reader assumes all risks in
using information posted or archived by ProMED-mail. ISID
and its associated service providers shall not be held
responsible for errors or omissions or held liable for any
damages incurred as a result of use or reliance upon posted
or archived material.
************************************************************
Visit ProMED-mail's web site at <http://www.promedmail.org>.
Send all items for posting to: promed@promedmail.org
(NOT to an individual moderator). If you do not give your
full name and affiliation, it may not be posted. Send
commands to subscribe/unsubscribe, get archives, help,
etc. to: majordomo@promedmail.org. For assistance from a
human being send mail to: owner-majordomo@promedmail.org.
############################################################
############################################################