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http://www.nytimes.com/2002/12/12/health/12POX.html?tntemail1

Resuming Smallpox Shots Carries Risk

By DENISE GRADY

ost people who are vaccinated against smallpox can expect to have a very sore, swollen arm within a week or so. Many also run fevers and ache all over as if they have the flu, and studies have indicated that 20 percent to 30 percent feel sick enough to miss a few days of work or school.

More serious complications are possible. For every million people vaccinated, 15 suffer life-threatening complications like encephalitis, and 1 or 2 of the 15 die. Hundreds of others suffer serious skin rashes, infections and other problems, based on studies done before 1972, when the vaccination was routine in the United States.

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As vaccination resumes, an essential concern will be to identify people who should not be vaccinated because they are at high risk of being harmed.

Vulnerable people must also avoid close contact with those who have recently been vaccinated and who are likely to be shedding live viruses that can infect others with the vaccinia virus, the virus used to make the vaccine. The smallpox vaccine does not contain the smallpox virus.

Special semi-permeable bandages may help prevent newly vaccinated people from transmitting vaccinia to others, but the bandages have to be worn for several weeks.

People with certain medical problems are vulnerable because the vaccinia can multiply too much in them. Their immune systems cannot control it. People at risk include those with the skin rashes like eczema or atopic dermatitis, or even a history of those conditions — a category that includes about 15 million Americans.

The two skin problems are more common today than they were when smallpox vaccination was routine.

People with those disorders are at risk for a condition called eczema vaccinatum, which can cause high fever and severe sores, scabs and deep scars. Although only a minority of people with the skin disorders develop serious problems, there is no way to identify which of them are at risk.

Eczema vaccinatum can be countered with a medicine, vaccinia immune globulin, but it is in short supply, with only a few thousand doses available.

Also vulnerable are people whose immune systems have been weakened by AIDS or certain cancers, or by radiation, chemotherapy, steroids or drugs used to prevent transplant rejection.

People with autoimmune diseases like lupus or rheumatoid arthritis are also included in this group. They are prone to an illness called progressive vaccinia, in which the sore that normally forms at the vaccination site expands abnormally, growing larger and larger, causing tissue death and a systemic infection that may be uncontrollable.

There is no treatment for progressive vaccinia, and its death rate can be as high as 36 percent.

Doctors say that people with H.I.V. or AIDS, totaling about 506,000 in the United States, should not be vaccinated. But the Centers for Disease Control and Prevention estimates that 300,000 Americans are infected with H.I.V. and do not know it. In addition, more than 24,000 health care workers have AIDS.

There is little medical information about how people with AIDS or H.I.V. would react to the vaccine, because those diseases were unknown in the era of routine vaccination. One article, published in The New England Journal of Medicine, described how a 19-year-old soldier had undiagnosed H.I.V., the virus that causes AIDS, when the military vaccinated him in 1984. He developed progressive vaccinia and AIDS, and died.

Pregnant women are also advised to avoid smallpox vaccination until after they have given birth, unless they have been exposed to smallpox. Babies should also not be vaccinated until they are at least a year old.

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ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.