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Since the terrorist attacks of September 11, 2001, and the anthrax exposures in the following weeks, concern that smallpox could be used as a biologic weapon has increased. Public health departments and the U.S. military have begun the process of vaccinating soldiers and civilian first-responders. Smallpox vaccination carries some serious risks: approximately one in 1 million primary vaccinees and one in 4 million revaccinees will die from adverse vaccine reactions. The most serious side effects of smallpox vaccine include progressive vaccinia, postvaccinial central nervous system disease, and eczema vaccinatum. Some of these reactions can be treated with vaccinia immune globulin or cidofovir. Proper patient screening and site care are essential. Family physicians must learn to screen potential vaccinees for contraindications (e.g., immunodeficiency, immunosuppression, certain skin and eye diseases, pregnancy, lactation, allergy to the vaccine or its components, moderate or severe intercurrent illness) and to treat vaccine-associated adverse reactions. (Am Fam Physician 2003;68:889-96. Copyright(C) 2003 American Academy of Family Physicians.)
Smallpox vaccine evolved from variolation, a technique that was developed in China and the Ottoman Empire. Variolation involved the deliberate exposure of nonimmune persons to material taken from known smallpox victims. Lady Montague, the wife of the British ambassador to the Ottoman Empire, observed variolation firsthand and advocated use of the technique in England. In 1798, the British physician Edward Jenner used a milkmaid's lymph containing cowpox virus to vaccinate a child.1
Over the next 150 years, smallpox vaccine became the most successful vaccine in history. Until 1972, this vaccine was routinely given to U.S. children.2 In 1966, the World Health Organization embarked on a program that culminated in the 1980 declaration that smallpox had been eradicated worldwide.3
Because of the events of September 11, 2001, concern has risen that terrorist organizations or rogue states might use smallpox as a biologic weapon.4 In December 2002, the U.S. government began a smallpox vaccination program for civilian public health and hospital workers, including selected physicians, nurses, and ancillary personnel. The U.S. military also initiated a vaccination program for selected service members.
Smallpox Vaccine
Smallpox vaccine contains live vaccinia virus, a milder cousin of the variola (smallpox) virus.5 It does not contain smallpox virus and cannot cause smallpox. The vaccine contains lyophilized calf lymph and traces of...