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J Am Dent Assoc, Vol 137, No 4, 452-460.
© 2006 American Dental Association
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COVER STORY

The smallpox vaccine

An update for oral health care professionals



Joseph Rinaggio, DDS, MS and Michael Glick, DMD


   ABSTRACT
TOP
 ABSTRACT
CLINICAL CHARACTERISTICS OF...
 VACCINATION
 CONTRAINDICATIONS TO SMALLPOX...
 COMPLICATIONS
 TREATMENT OF COMPLICATIONS OF...
 IMPLICATIONS FOR DENTISTRY
 CONCLUSION
 REFERENCES
 
Background. A heightened awareness of the potential for bioterrorist attacks in the United States has led to the expansion of the nation’s supply of smallpox vaccine and the institution of procedures to distribute this vaccine in the unlikely event of a release of this potentially deadly agent.

Methods. The authors conducted a review of the relevant smallpox literature through a MEDLINE search. They also reviewed the Web site of the Centers for Disease Control and Prevention and numerous other Web sites.

Results. The authors considered for inclusion more than 100 articles discussing smallpox, the smallpox vaccine and the role of the dental professional in a bioterrorist attack.

Conclusions. Dentists may detect the initial signs of a smallpox infection, provide information concerning the disease to the public and potentially assist in the administration of smallpox vaccine.

Clinical Implications. Should an intentional release of smallpox occur, the dental professional may play an important role in its treatment and prevention.

Key Words: Smallpox vaccine; variola; vaccinia virus; dental management; bioterrorism

The prospect of an intentional release of a lethal infectious disease agent has resulted in a growing concern among government officials and the health care community. One of the more likely candidates for dispersal in a bioterrorist attack is smallpox (variola major). Its eradication once was considered a triumph of public health, but the possibility of unaccounted stocks of the virus falling into the possession of terrorists is a growing concern.

Central to the eradication of smallpox was widespread immunization. In the United States, childhood immunization against smallpox was discontinued after 1972. This has left the American population susceptible to reintroduction of the disease, since it is estimated that 40 percent of the population is nonimmunized, and 80 percent have no immunity.1 The U.S. government recently began increasing the stockpile of smallpox vaccine and drawing up plans for the rapid vaccination of the population in case of an attack. This pre-event vaccination strategy includes the administration of the vaccine to expanding classes of medical personnel, emergency response workers such as police officers and firefighters, members of the military and, possibly, eligible civilians (those who choose to be vaccinated and have no contraindications).2 Such people then may assist with postevent vaccination of the public after any intentional release of the smallpox virus. The role of the dentist in the management of a bioterrorist attack is ill-defined, but it is possible that dental professionals may be mobilized to assist if the situation were to arise, along with practitioners in other health care disciplines.

This article reviews the clinicopathological features of smallpox disease and aims to familiarize the dentist with the smallpox vaccine and issues surrounding its administration.


   CLINICAL CHARACTERISTICS OF SMALLPOX
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 CLINICAL CHARACTERISTICS OF...
VACCINATION
 CONTRAINDICATIONS TO SMALLPOX...
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 TREATMENT OF COMPLICATIONS OF...
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Smallpox is a highly infectious disease borne by a member of the orthopoxvirus group, whose members include the vaccinia, cowpox and monkeypox viruses.3,4 The disease has been part of human history for at least 2,000 years, and evidence from human remains found in ancient Egypt suggests an even earlier interaction.5 The disease spread to Europe from Africa and Asia, and then across the ocean to the New World, resulting in a catastrophic decline, estimated at more than 50 percent, of the native population.3,5,6 This dramatic mortality illustrates the consequence of introduction of such a virulent pathogen to an immunologically naive community.

Smallpox disease is acquired through exposure of the respiratory or oropharyngeal mucosa to viable virions through either contaminated aerosols, lesional tissue, body fluids or fomites.3,4,7 Studies have found smallpox virions in saliva before the manifestation of generalized signs and symptoms. The highly infectious nature of this disease can be appreciated by the estimation that 15 virions may be enough to transmit disease, while titers of the virus emitted by oropharyngeal shedding are as high as 106 to 108 virions per milliliter.8,9

During the incubation period, which usually lasts between 12 and 14 days after exposure, there is viral proliferation within the lymph nodes and subsequent angiolymphatic dissemination, thereby seeding other lymphoid tissues throughout the body.3 In the following prodrome, the infected person will experience nonspecific symptoms, among them a fever that may exceed 104 F/40 C, headache, backache and malaise.3,4 This phase lasts two to three days, with infected people exhibiting a lower degree of infectivity than is seen during the full expression of the disease.4,7 Immediately after the prodrome, affected people develop an erythematous enanthem involving the oral and oropharyngeal mucosae, with the onset of a cutaneous rash occurring the next day.4,7 Skin lesions begin as reddish macules and progress to papules, forming vesicles after two to five days and reaching their full size as pustules of 4 to 6 millimeters in diameter within approximately four to 10 days.2,4 The lesions develop into scabs approximately two weeks after the onset of the rash. These eventually detach, sometimes leaving prominent scars and areas of hypopigmentation.3,7 The period from the development of the mucosal rash up to the 10th day of the cutaneous rash represents the stage at which the disease is most contagious.7 Patients are capable of spreading smallpox until all scabs have exfoliated.7 It is not known if smallpox is associated with a carrier state.

The vesicular eruption of smallpox superficially may resemble that of chickenpox, but certain clinical features allow discrimination of the two conditions.3,4 The lesions of smallpox are concentrated on the face, arms and legs ("centrifugal spread"), and all are at approximately the same stage of development at a given time.3 In chickenpox, the distribution of the exanthem exhibits a predilection for the trunk ("centripetal spread") and lesions tend to occur in clusters, showing a variation in lesional maturation in different regions of the body.3 In smallpox, eruptions commonly occur on the palms and soles, a highly unusual location for the lesions of chickenpox.3


   VACCINATION
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Attempts to prevent the development of full-blown smallpox by exposing otherwise healthy people to diseased tissue date back at least 1,000 years, probably originating in Asia.1,10 On the basis of the awareness that those who survived the disease were protected from reinfection, those who performed this form of inoculation, also known as "variolation," took lesional tissue such as pus and scabs from those with mild disease and introduced it to the skin or, in powdered form, to the respiratory tract of the unexposed recipient. This led to a milder form of disease with an increased survival rate.5 Although largely successful in reducing smallpox deaths, it still could result in the full disease with the potential for infected people to spread it to others.

This technique was in practice in the Ottoman Empire by the 17th century, from where it then spread to Europe. Variolation was brought to England in 1721 by Lady Mary Wortley Montague, wife of the British ambassador to the Ottomans. After witnessing the procedure in Istanbul, Turkey, she had her two children inoculated against smallpox by the surgeon of the British Embassy. News of the technique reached the royal family, who allowed the variolation of a group of prisoners and, after ascertaining the prisoners’ subsequent protection against smallpox, of some of the royal children.5,10

That people who had contracted cowpox previously also received protection against smallpox was part of the general knowledge of rural western Europe.10 Furthermore, soon after its introduction, it was noted that variolation did not produce a reaction in people with a history of cowpox infection.

During his early medical training, 18th-century English physician Edward Jenner became aware of the anecdotal evidence of crossimmunity between cowpox and smallpox and decided to test its veracity.10 In 1796, Jenner obtained lesional pus from a local milkmaid who had contracted cowpox. He then applied this material to an incision made in the arm of an 8-year-old boy.10 The boy did not react to a variolation attempted six weeks afterward, a result confirmed by a repeat test.

The modern smallpox vaccine, responsible for the official worldwide eradication of the disease in 1980,11 employs another orthopoxvirus known as vaccinia, which also leads to crossimmunity with smallpox while resulting in a milder illness.12 The only vaccine currently under license in the United States for the prevention of smallpox is Dryvax, a live-virus compound produced by Wyeth Laboratories (Marietta, Pa.) and available for nonmilitary use only through the Centers for Disease Control and Prevention (CDC).13 It is based on the New York City Board of Health strain of vaccinia virus, which is regarded as being less likely to induce postprocedure complications.8

The vaccine is applied to dry skin over the deltoid muscle with a bifurcated needle, which, after being submerged in the vaccine suspension, retains approximately 2.5 microliters of the solution between its prongs (Figure 1Go).2,12,13 The needle is held roughly perpendicular to the surface of the skin and agitated quickly, penetrating the epithelium and producing a drop of blood when the procedure is performed correctly.12,13 The number of penetrations will vary according to the recipient’s vaccination history: two to three for an initial vaccination, approximately 15 for a repeat.2,12,13 If the procedure does not result in slight bleeding, an additional three insertions are made without reintroducing the needle into the vaccine container.13 The site then is dried with sterile gauze, and both the applicator and contaminated gauze are discarded in an appropriate biological waste receptacle.


Figure 1
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  		Figure 1. Bifurcated needle used for percutaneous application of smallpox vaccine, shown with a droplet of vaccine solution between prongs. Source: Centers for Disease Control and Prevention.

 
After the procedure, the vaccine site should be covered promptly with a dry sterile dressing, with care taken not to touch the affected skin, which could potentially transmit vaccinia virions to other body parts or to people who have not yet been immunized.3 Bandages or surgical dressings can be replaced each day or on alternating days and discarded in a sealed plastic bag. Any clothing, towels or bedclothes that have contacted the inoculation site can be washed in a standard laundry machine using hot water.14

Successful vaccination—referred to as a "take"—results in the initial production of an erythematous papule in approximately three days (Figure 2Go).3 One week after vaccination, the lesion matures into a pustule, eventually crusting over and separating two to three weeks later.2 It is not unusual for the recipient to experience subsequent fever, malaise, lymphadenopathy, and diffuse erythema and swelling over the inoculation site.3,12 Up to 97 percent of initial vaccinations are successful8; the procedure should be repeated for patients in whom the vaccine does not take.2


Figure 2
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  		Figure 2. The evolution of a primary smallpox vaccine "take," from the initial development of a papule (day 4), to a pustule surrounded by a zone of erythema (day 7), to mature scab formation (day 21). Source: Centers for Disease Control and Prevention.

 
It is estimated that vaccination taking place up to three days after exposure to the disease can prevent infection or minimize symptoms.15 The chance of success decreases with time, with previous vaccinees experiencing a better response.

The duration of immunity is not known with certainty. The CDC has stated that people who have received vaccinations are protected from infection for as little as three to five years.16 This figure may underestimate the degree of protection, however. Hammarlund and colleagues17 determined that T memory cell function against the virus tapers gradually but may persist for decades. Additionally, studies have shown that vaccinia-specific memory B lymphocytes18 and circulating antibodies18,19 can be detected more than 50 years after vaccination.

The aftermath of the 2001 anthrax attacks in the United States brought to light the country’s vulnerability to bioterrorism. One of the chief concerns was the low stockpile of licensed smallpox vaccine, which could prevent an effective public health response in the event of a subsequent smallpox attack. However, it now appears that there is enough vaccine stock to supply the U.S. population. The reserve of 15 million doses of Dryvax can be expanded through dilution by fivefold to 10-fold while still retaining its efficacy.12 Also, the existence of approximately 85 million doses of an additional smallpox vaccine derived from the same vaccinia strain as Dryvax, produced by Aventis Pasteur (Swiftwater, Pa.), was revealed in 2001. Kept frozen for many years, it also is efficacious at a 1:10 dilution.20


   CONTRAINDICATIONS TO SMALLPOX VACCINATION
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The cessation of compulsory smallpox vaccination in the United States in 19723 has created an increase in the population’s susceptibility to the disease, as immunized people account for a smaller percentage of the populace with each passing year. Complicating plans to establish another vaccination program in this country is the large number of people for whom smallpox immunization is contraindicated. In the absence of known or suspected contact with variola, vaccination should be discouraged for people who are immunosuppressed; have a history of eczema, atopic dermatitis or other inflammatory dermatoses; have an inflammatory condition of the eye; are younger than 1 year; are pregnant or breast-feeding; or are allergic to vaccine constituents.13 In addition, household contacts of those who are pregnant, immunosuppressed or who have a history of atopic dermatitis or inflammatory skin disease should not be vaccinated.13 In all, it is estimated that approximately 25 percent of the population would be deferred from vaccination owing to established contraindications and being in close contact with a person with contraindications to vaccination.21 However, in the event of a smallpox release, people who are known to have been exposed to the disease should be vaccinated regardless of contraindicatory conditions.13,14


   COMPLICATIONS
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TREATMENT OF COMPLICATIONS OF...
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There is a questionable association between smallpox vaccination and subsequent cardiac ischemia in people with underlying heart disease.22,23 At least eight civilians (all but one with a history of cardiovascular disease) of more than 36,000 who had undergone vaccination experienced myocardial infarction or angina, with symptom onset occurring a median of nine days after the procedure.22 Two patients ultimately died of myocardial infarctions. Although these occurrences are thus far rare, it has since been recommended that pre-event smallpox vaccination be withheld from people who have known cardiovascular disease or possess three or more significant predisposing conditions for heart disease, such as hypertension, diabetes and smoking.24 Interestingly, researchers examining cardiac deaths that occurred after a mass smallpox vaccination in New York in 1947 involving nearly 6.4 million people, using the same strain of vaccinia as is now used, found no increase in cardiovascular fatalities.25 It therefore is likely that the recent cardiac deaths after vaccination were the consequence of existing cardiovascular disease and occurred independent of the procedure.

Some vaccinated people may experience, in addition to the immediate mild postprocedural complications, more severe side effects from smallpox vaccination, largely involving the skin, central nervous system and heart. Early estimates of severe side effects showed an incidence of approximately 1 in 800 initial vaccinees, which declined in those receiving repeat vaccination.26 However, data from the recent U.S. military vaccination program27 and the civilian program administered by the U.S. Department of Health and Human Services (DHHS)28 to potential first responders in a bioterrorist attack (approximately 489,000) showed the incidence of such complications to be far below historically reported rates, with an incidence in the latter program of approximately 1 in 389 vaccinees. Extensive medical evaluation and education of vaccine candidates, as well as adherence to infection control procedures, may account for this reduction in adverse events.27,29 Interestingly, the incidence of severe adverse reactions in the DHHS program was higher in repeat vaccinees than in the overall study population.28 This may be attributable to the older age of those whose previous vaccinations occurred before the termination of routine childhood immunization in this country.

Inadvertent inoculation. This is the most frequent adverse consequence of smallpox vaccination.2,26 Vaccinia may be spread to a distant anatomical site should the patient touch the bare vaccination site or resultant lesion and fail to wash his or her hands immediately, leading to additional cutaneous or mucosal lesions. Most often involved are the skin of the face, including eyelids and lips, and the genital/perineum region.30 This condition typically resolves without significant morbidity.3

Generalized vaccinia. In some instances the virus can gain access to the vascular system and spread to distant anatomical sites, resulting in a focal or widespread vesicular eruption.2 This condition, usually arising six to nine days after vaccination, also tends to subside without further harm to the patient.3

Eczema vaccinatum. The nonspecific term "eczema" refers to any inflammatory disorder of the skin manifesting as erythema, swelling, pruritis or a combination thereof, potentially evolving to the development of vesicles, scaling or pigment changes.31 Eczema vaccinatum is a postvaccination disorder characterized by viral eruptions affecting regions of the skin with active or resolved eczema,2,3 in conjunction with fever and lymph node enlargement.30 Lesions may occur over large areas of the body, often coalescing with one another.30 Sequelae include secondary infection, sepsis and dehydration.30 Eczema vaccinatum is a severe complication of smallpox vaccination, with recorded fatality rates of up to 40 percent.32 Prompt administration of vaccinia immune globulin (VIG) is necessary if this condition is suspected.

Postvaccinial encephalopathy and post-vaccinial encephalomyelitis. Central nervous system vaccination sequelae are more common in young children. Their etiology is uncertain, but an underlying autoimmune process has been proposed. Postvaccinial encephalopathy (PVE) occurs in those younger than 2 years approximately six to 10 days after vaccination; postvaccinial encephalomyelitis (PVEM) is seen in children older than 2 years and shows a slightly later time of onset. Symptoms have a rapid onset and include fever, headache, malaise, changes in mental function, seizures and coma.30,33 These conditions have a 15 to 25 percent mortality rate, with many survivors experiencing long-term neurological deficits.26 VIG is not reported to be of benefit to patients with either PVE or PVEM.30 Fortunately, data compiled from the the U.S. Smallpox Vaccination Program of the Vaccine Adverse Event Reporting System (VAERS) (a cooperative program of the CDC and the Food and Drug Administration [FDA]) showed severe postvaccination neurologic sequelae to be rare.34 Most patients with neurological complications experienced mild, transient symptoms.

Progressive vaccinia. Immune-suppressed people, owing to a number of different etiologies, are susceptible to progressive vaccinia following vaccination. This uncommon26,35 event should be suspected if the lesion at the vaccination site continues to increase in size 15 days or more after the procedure.36 Early lesions may be notable for their absence of any signs of inflammation, although they may appear as the condition advances.30 As the lesion increases in radial size, it often shows central cratering and is prone to secondary bacterial infection. Bloodborne viral dissemination often results in the development and progression of new lesions in the skin, organs and bones.30 Treatment of progressive vaccinia involves VIG and rigorous supportive care. An analysis of the literature by Bray and Wright35 showed that progressive vaccinia leads to different outcomes in separate age groups. Infants with defects in cell-mediated immunity showed a striking tendency to die as a result of progressive vaccinia, while immunosuppressed adults usually survived unless they eventually succumbed to their original disease.35

Myo/pericarditis. A recently recognized consequence of smallpox vaccination, myo/pericarditis results from a nonspecific inflammation of the cardiac muscle, the mesothelium lining of the external surface of the heart or both occurring in the absence of a verifiable cause.22 As of June 2003, 21 civilians and 37 military personnel (of approximately 489,000 vaccinees) receiving pre-event smallpox vaccination developed myo/pericarditis.24,27 Clinical signs included chest pain, dyspnea, electrocardiographic and heart function alterations, and increased serum levels of cardiac enzymes.37 The diagnosis was confirmed via myocardial or pericardial biopsy and histologic evaluation. Treatment consisted largely of non-steroidal anti-inflammatory drugs and optional analgesics, with most affected people eventually recovering.37

Other complications. Smallpox vaccination may result in other complications with a range of severity. These include a mild cutaneous rash of varying morphology, pruritis, headache, fatigue, erythema multiforme, osteomyelitis and fetal vaccinia.3,28,30,34 Historical data (recorded before the onset of the AIDS epidemic) reveal a death rate of approximately 1.1 per 1 million primary vaccinees.38 Composite data from VAERS39 show a similar death rate for 27 other commonly reported vaccines in use.


   TREATMENT OF COMPLICATIONS OF SMALLPOX VACCINATION
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 VACCINATION
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 COMPLICATIONS
 TREATMENT OF COMPLICATIONS OF...
IMPLICATIONS FOR DENTISTRY
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Complications following smallpox vaccination are rare, but they can be severe and necessitate intervention to contain the resulting illness and prevent significant morbidity and/or mortality. Numerous compounds have been or are currently under investigation,40 but at this time only two, VIG and cidofovir, receive serious consideration in the treatment of systemic postvaccination adverse events.

Certain severe consequences of smallpox vaccination, such as inadvertent inoculation, generalized vaccinia, eczema vaccinatum and progressive vaccinia may be treated with VIG,13,30 although the true efficacy of this line of therapy has yet to be established with controlled trials.35 VIG represents the sterile antivaccinia antibody component taken from the serum of patients previously immunized against smallpox and is obtained through the CDC. Although its availability is limited, there was enough as of January 2003 to treat 4,000 patients.7,13,30 The use of VIG also may result in adverse events ranging from a mild erythema and pain at the injection site to anaphylaxis and alterations of kidney function. VIG once was considered appropriate to be provided simultaneously with the smallpox vaccine for people who had come in contact with the disease but for whom vaccination was otherwise contraindicated.41 At this point, however, VIG is not considered a prophylactic option for unexposed people undergoing smallpox vaccination with known contraindications, or in contraindicated people who come into contact with vaccinia but remain asymptomatic.30

Cidofovir is under investigation as a second-line agent to treat complications of smallpox vaccine administration. This medication usually is reserved for the treatment of cytomegalovirus infections in immunocompromised patients.30 Cidofovir must be administered intravenously, and it has been shown to cause significant kidney damage, with renal failure and subsequent dialysis as a possible consequence.30 Laboratory trials have shown the drug to be an effective treatment for severe vaccinia infection in mice,35 but its efficacy in humans has yet to be determined.30 The distribution of cidofovir for the treatment of post-vaccination adverse events is governed by the CDC, which restricts its use at present to patients who have complications unresponsive to VIG or who are at risk of dying as a result of postvaccination complications, or to situations in which VIG stockpiles have been depleted.30

Recent experimentation with cidofovir leads to the possibility of more effective use with limited toxicity.42 Oral administration of cidofovir complexed with lipid increases uptake of the drug within the gastrointestinal tract and decreases uptake within the kidneys, thereby reducing nephrotoxicity. Furthermore, studies in mice have shown that these experimental cidofovir-based compounds are effective in combating certain orthopoxvirus infections, including vaccinia, by controlling viral replication. In addition, these studies have shown the drug to be effective whether administered three days before or three days after viral challenge. It therefore may be possible to use this modified form of cidofovir as either a prophylaxis against variola infection or a treatment in the wake of early disease, in addition to therapy for the complications of smallpox vaccination.

New vaccine development. As mentioned above, the current vaccine has certain favorable qualities, such as high efficacy and ease of administration. Yet, drawbacks remain—namely, the possibility of severe adverse reactions, the large number of people disqualified from vaccination owing to contraindicatory conditions and the necessity of an intact immune system. New vaccines are under development that may bypass such concerns and provide a comparable level of protection to a larger segment of the population. One encouraging vaccine candidate is derived from a weakened strain known as modified vaccinia virus (MVA) Ankara.43–45 Preliminary studies have shown that in animals exposed to monkeypox virus, MVA induces a similar immune response as Dryvax but with less severe side effects.43 Other studies of experimental vaccines conducted by researchers at Acambis (Cambridge, Mass.) and DynPort Vaccine (Frederick, Md.) apparently demonstrate a decreased likelihood of severe reactions and, in research by the latter company, a protective potential similar to that of Dryvax.12

Effort also is being directed at developing antiviral drugs that will act against variola and other poxviruses.46 Intended targets for these prospective drugs are viral enzymes necessary for viral fusion and entry into the cell, DNA replication, interference with normal cell function and transport to other cells. It is anticipated that such agents could not only protect people from smallpox infection, but also treat those already infected or who are experiencing the adverse effects of smallpox vaccine.


   IMPLICATIONS FOR DENTISTRY
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 VACCINATION
 CONTRAINDICATIONS TO SMALLPOX...
 COMPLICATIONS
 TREATMENT OF COMPLICATIONS OF...
 IMPLICATIONS FOR DENTISTRY
CONCLUSION
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Although dentistry long has been recognized as a valuable resource in the investigation and management of events ranging from violent crime to manmade disasters, the emerging threat of intentional release of lethal pathogens among a susceptible population has led the profession to examine its place within the health care community in detecting, managing and containing a possible disease outbreak.

To help define the potential contribution of the dental profession in the event of a bioterrorist attack, the American Dental Association convened a workshop in June 2002 that included representatives from organized dentistry, academia, government and the military.47 The resulting consensus suggested several valuable services that dentistry could provide to the public, and the rest of the medical community, with regard to smallpox. Possible functions to be performed by dentists in the event of intentional release of biological agents include these 47–49:

– acting as an "early warning system" for the community by detecting patterns of missed or canceled appointments, or increased incidence of oral lesions suggestive of disease presence;
– discerning those exhibiting clear signs of illness from anxious but otherwise healthy people;
– directing the sick to appropriate medical care;
– directly assisting other medical personnel in the treatment of attack victims.

Some of these functions can be applied to concerns surrounding vaccination for smallpox. The need to administer the vaccine and provide other necessary medical services to a majority of the people in a community is likely to overwhelm the capacity of local hospitals, clinics and private medical practices. In such an event, dentists may be called on to lighten the burden on medical establishments by vaccinating those in need. Before performing these duties, dentists would be required to obtain training in the bifurcated-needle technique of vaccine application. In a declared national emergency, liability protection against any adverse reaction arising in the vaccine recipient is provided through the government by the Homeland Security Act of 2002, although some of this protection may be withdrawn if the health care provider is found to have operated with marked or intentional neglect or violation of the standard of care.38

In addition, as health care professionals with a base of medical knowledge, dentists can provide information about smallpox and smallpox vaccination to patients (BoxGo). Of concern is the potential for viral transmission to family members or other close contacts, particularly those for whom vaccination is contraindicated. Patients also must be counseled on proper cleaning and maintainance of the inoculation site and disposal of infected surgical dressings and scabs.14 Common adverse events and procedures to seek any necessary further medical assistance should be discussed.


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  		BOX Smallpox resources on the Internet.

 
The recent voluntary smallpox vaccination program for medical personnel and first-line responders essential to manage the initial stages of a biological attack did not specifically include dentists, concentrating instead on emergency and general care physicians and their staff members.38 A large-scale response to such an event may, however, draw dentists and dental auxiliaries into the group of health care professionals asked to manage the expected surge of patients requiring care. This, of course, would necessitate vaccination of all office staff members before exposure to the public, whereupon they could begin to assist patients.50 Of concern would be the existence of contraindications to the vaccine among the office staff and their families, as well as proper hygiene of the inoculation site. It is important that all members of the office staff be educated regarding the potential for secondary spread of vaccinia virus from the vaccination site, which could lead to adverse reactions among themselves and their close contacts. Instruction also must be given about the proper care of the vaccine site. Gauze and a semipermeable bandage or dressing must be used to isolate the area and help guard against the inadvertent inoculation of others. Staff members also should be told to cover the vaccinated area with clothing until the scab has exfoliated. Meticulous handwashing must be maintained both at home and in the dental office. It is essential to instruct staff on proper disposal of all contaminated materials.


   CONCLUSION
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 VACCINATION
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 COMPLICATIONS
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 IMPLICATIONS FOR DENTISTRY
 CONCLUSION
REFERENCES
 
The uncertainty surrounding the possible possession of lethal biological agents by terrorists necessitates the development of a planned response to a public health emergency. Although the role of the dental profession is somewhat ambiguous at this point, the potential for considerable benefit to the public relies on the dentist having current knowledge of infectious disease threats, measures to prevent them and measures to manage and treat them appropriately.


   FOOTNOTES
 

Dr. Rinaggio is an assistant professor, Department of Diagnostic Sciences, Room D-860, University of Medicine and Dentistry of New Jersey, New Jersey Dental School, 110 Bergen St., P.O. Box 1709, Newark, N.J. 07103-2400, e-mail "rinaggjo{at}umdnj.edu". Address reprint requests to Dr. Rinaggio.


Dr. Glick is a professor and the chair, Department of Diagnostic Sciences, University of Medicine and Dentistry of New Jersey, New Jersey Dental School, Newark. He also is editor of JADA.


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