Human Vaccinia Infection After Contact with a Raccoon Rabies Vaccine Bait --- Pennsylvania, 2009
Human Vaccinia Infection After Contact with a Raccoon Rabies Vaccine Bait --- Pennsylvania, 2009
"Since 2003, the U.S. Department of Agriculture's Wildlife Services has coordinated a multistate oral rabies vaccination (ORV) program for wildlife in a 15-state zone extending from Maine to Alabama and in Texas. The program seeks to enhance local control and prevent the spread of epizootic rabies among raccoons and, in Texas, among gray foxes and coyotes. The program uses baits containing liquid vaccinia-rabies glycoprotein (V-RG) recombinant virus vaccine. Because contact with ruptured baits can produce vaccinia virus infection in certain persons, surveillance for human and domestic animal contact with the baits is conducted, relying largely on reports from persons who find baits and call telephone numbers printed on them. In August 2009, during the autumn baiting campaign in western Pennsylvania, a woman aged 35 years who was taking immunosuppressive medication for inflammatory bowel disease contacted the Pennsylvania Department of Health (PADOH) after handling a ruptured bait, which had leaked liquid rabies vaccine onto a patch of abraded skin on her right hand. The patient subsequently developed vaccinia virus infection and was treated with human vaccinia immune globulin intravenous (VIGIV) and an investigational antiviral agent. This report describes this case, which was the second case of human vaccinia infection related to the ORV program. Public health agencies should educate the public, and particularly pet owners, regarding potential hazards associated with handling wildlife rabies vaccine baits and should provide guidance for persons exposed to this vaccine.
The ORV program uses an orally delivered animal vaccine, Raboral V-RG (Merial, Inc., Athens, Georgia) (1). This vaccine consists of a partially attenuated recombinant vaccinia virus (Copenhagen strain) with a gene encoding for rabies virus glycoprotein (2). Persons with immunosuppressive conditions or exfoliative dermatologic conditions are at greater risk for complications (e.g., progressive vaccinia or eczema vaccinatum) when exposed to the vaccinia virus contained in Raboral V-RG vaccine. Currently, 15 states distribute ORV baits for raccoons, and Texas distributes baits for gray foxes and coyotes. The V-RG vaccine is delivered via a bait made from a fishmeal block (or a dog food block for coyotes) encasing a sealed plastic packet containing approximately 2 mL of vaccine (Figure 1) (1). During August-September 2009, ORV bait distribution was conducted in nonresidential areas by airplane and in rural communities by hand, in parts of western Pennsylvania, Ohio, and West Virginia.
Case Report
In early August 2009, a woman aged 35 years was picking blackberries in a rural area of Pennsylvania where ORV baits recently had been distributed. Her dog picked up a bait in his mouth and punctured the bait with his teeth. After the dog dropped the bait, the woman picked it up, and V-RG vaccine dripped from the bait onto her right hand and wrist, including sites that had been abraded by blackberry thorns. Approximately 30 minutes passed before the woman was able to wash her hands. She telephoned the ORV helpline number printed on the bait, and her call was referred to PADOH. The woman had a history of inflammatory bowel disease, for which she was taking multiple immunosuppressive medications. These medications included a suppressor of T and B cell proliferation (taken daily) and a tumor necrosis factor-alpha (TNF-alpha) blocker (taken once every 6 weeks, with the last dose on July 13); she had no smallpox vaccination scar and reported no history of smallpox vaccination.
On day 1 after her exposure to the V-RG vaccine, her physician obtained a baseline serum specimen for analysis of rabies virus neutralizing antibody (by direct virus neutralization) and orthopoxirus (vaccinia) immunoglobulin IgG and immunoglobulin IgM antibodies (by enzyme-linked immunosorbent assay). In addition, photos were taken of her right hand abrasions, and she was instructed to watch for signs of infection in her hand. On day 4, she reported several red papules on her right hand. She visited a local hospital emergency department, where scrapings of the papules were obtained and submitted to the PADOH Bureau of Laboratories. The woman was discharged from the emergency department and advised to stop taking her immunosuppressant medications.
On day 5, a real-time polymerase chain reaction (PCR) assay of the scrapings tested positive for nonvariola Orthopoxvirus DNA. Subsequent testing performed at CDC confirmed the presence of vaccinia virus DNA and rabies virus G protein DNA in papule material and serologic evidence of rabies virus neutralizing antibodies. Neither Orthopoxvirus IgG nor IgM antibodies were detected.
On day 6, the papules had increased in number and size, and the patient was hospitalized. Physical examination on admission showed multiple papules on erythematous bases on the patient's right hand, wrist, and arm, including three that appeared to be early vesicles. Because of the patient's immune suppression and concerns about progressive vaccinia, she was administered a single dose (6,000 IU/kg) of VIGIV (Cangene Corporation, Winnipeg, Canada) provided by CDC. Contact precautions were utilized while the patient was hospitalized.
On day 9, she had 26 classic vaccinia virus lesions, including one on a site on her right arm that might not have been in contact with the vaccine initially....."
Continues at CDC link. Bad stuff!
This virologist's blog has an audio discussion:
TWiV 59: Dog bites virus
TWiV 59: Dog bites virus
by Vincent Racaniello on November 22, 2009
Human Vaccinia Infection After Contact with a Raccoon Rabies Vaccine Bait --- Pennsylvania, 2009
"Since 2003, the U.S. Department of Agriculture's Wildlife Services has coordinated a multistate oral rabies vaccination (ORV) program for wildlife in a 15-state zone extending from Maine to Alabama and in Texas. The program seeks to enhance local control and prevent the spread of epizootic rabies among raccoons and, in Texas, among gray foxes and coyotes. The program uses baits containing liquid vaccinia-rabies glycoprotein (V-RG) recombinant virus vaccine. Because contact with ruptured baits can produce vaccinia virus infection in certain persons, surveillance for human and domestic animal contact with the baits is conducted, relying largely on reports from persons who find baits and call telephone numbers printed on them. In August 2009, during the autumn baiting campaign in western Pennsylvania, a woman aged 35 years who was taking immunosuppressive medication for inflammatory bowel disease contacted the Pennsylvania Department of Health (PADOH) after handling a ruptured bait, which had leaked liquid rabies vaccine onto a patch of abraded skin on her right hand. The patient subsequently developed vaccinia virus infection and was treated with human vaccinia immune globulin intravenous (VIGIV) and an investigational antiviral agent. This report describes this case, which was the second case of human vaccinia infection related to the ORV program. Public health agencies should educate the public, and particularly pet owners, regarding potential hazards associated with handling wildlife rabies vaccine baits and should provide guidance for persons exposed to this vaccine.
The ORV program uses an orally delivered animal vaccine, Raboral V-RG (Merial, Inc., Athens, Georgia) (1). This vaccine consists of a partially attenuated recombinant vaccinia virus (Copenhagen strain) with a gene encoding for rabies virus glycoprotein (2). Persons with immunosuppressive conditions or exfoliative dermatologic conditions are at greater risk for complications (e.g., progressive vaccinia or eczema vaccinatum) when exposed to the vaccinia virus contained in Raboral V-RG vaccine. Currently, 15 states distribute ORV baits for raccoons, and Texas distributes baits for gray foxes and coyotes. The V-RG vaccine is delivered via a bait made from a fishmeal block (or a dog food block for coyotes) encasing a sealed plastic packet containing approximately 2 mL of vaccine (Figure 1) (1). During August-September 2009, ORV bait distribution was conducted in nonresidential areas by airplane and in rural communities by hand, in parts of western Pennsylvania, Ohio, and West Virginia.
Case Report
In early August 2009, a woman aged 35 years was picking blackberries in a rural area of Pennsylvania where ORV baits recently had been distributed. Her dog picked up a bait in his mouth and punctured the bait with his teeth. After the dog dropped the bait, the woman picked it up, and V-RG vaccine dripped from the bait onto her right hand and wrist, including sites that had been abraded by blackberry thorns. Approximately 30 minutes passed before the woman was able to wash her hands. She telephoned the ORV helpline number printed on the bait, and her call was referred to PADOH. The woman had a history of inflammatory bowel disease, for which she was taking multiple immunosuppressive medications. These medications included a suppressor of T and B cell proliferation (taken daily) and a tumor necrosis factor-alpha (TNF-alpha) blocker (taken once every 6 weeks, with the last dose on July 13); she had no smallpox vaccination scar and reported no history of smallpox vaccination.
On day 1 after her exposure to the V-RG vaccine, her physician obtained a baseline serum specimen for analysis of rabies virus neutralizing antibody (by direct virus neutralization) and orthopoxirus (vaccinia) immunoglobulin IgG and immunoglobulin IgM antibodies (by enzyme-linked immunosorbent assay). In addition, photos were taken of her right hand abrasions, and she was instructed to watch for signs of infection in her hand. On day 4, she reported several red papules on her right hand. She visited a local hospital emergency department, where scrapings of the papules were obtained and submitted to the PADOH Bureau of Laboratories. The woman was discharged from the emergency department and advised to stop taking her immunosuppressant medications.
On day 5, a real-time polymerase chain reaction (PCR) assay of the scrapings tested positive for nonvariola Orthopoxvirus DNA. Subsequent testing performed at CDC confirmed the presence of vaccinia virus DNA and rabies virus G protein DNA in papule material and serologic evidence of rabies virus neutralizing antibodies. Neither Orthopoxvirus IgG nor IgM antibodies were detected.
On day 6, the papules had increased in number and size, and the patient was hospitalized. Physical examination on admission showed multiple papules on erythematous bases on the patient's right hand, wrist, and arm, including three that appeared to be early vesicles. Because of the patient's immune suppression and concerns about progressive vaccinia, she was administered a single dose (6,000 IU/kg) of VIGIV (Cangene Corporation, Winnipeg, Canada) provided by CDC. Contact precautions were utilized while the patient was hospitalized.
On day 9, she had 26 classic vaccinia virus lesions, including one on a site on her right arm that might not have been in contact with the vaccine initially....."
Continues at CDC link. Bad stuff!
This virologist's blog has an audio discussion:
TWiV 59: Dog bites virus
TWiV 59: Dog bites virus
by Vincent Racaniello on November 22, 2009
