Vulvar Vaccinia Infection May Follow Sexual Contact With a Smallpox Vaccinee
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May 4, 2007 — Vulvar vaccinia infection may follow sexual contact with a smallpox vaccinee, according to a case report in the May 4 issue of the Morbidity and Mortality Weekly Report.
On October 10, 2006, an otherwise healthy woman presented to a public health clinic in Alaska with vaginal tears that had become increasingly painful over 10 days, after having sex with a new male partner between September 22 and October 1, 2006. Her partner consistently used condoms, but a condom broke during vaginal intercourse on October 1.
An isolate from a labial swab specimen was identified by the U.S. Centers for Disease Control and Prevention (CDC) as a vaccine strain of vaccinia virus, and it came to light that the woman’s new sex partner was a U.S. military-service member who had been vaccinated for smallpox 3 days before beginning his relationship with the woman.
“Health-care providers should be aware of the possibility of vaccinia infection in persons with clinically compatible genital lesions who have had recent contact with smallpox vaccines,” write J. McLaughlin, MD, from the Alaska Section of Epidemiology, and colleagues.
The woman told health-care providers that she had not seen penile ulcers or other skin lesions on her partner; that she had no history of genital ulcers or sexually transmitted infections; and that her vaginal tears did not result from sexual violence or abuse. She had tested negative for human immunodeficiency virus approximately 3 months earlier, and she had no fever, itching, or dysuria.
Examination showed 2 shallow ulcerations — 1 on the upper left labia minora measuring 5 mm and the other on the lower right labia minora measuring 3 mm — mild bilateral labial erythema and induration, and vaginal discharge. Lymph nodes, cervix, uterus, adnexa, and anus appeared normal. Tests for gonorrhea and Chlamydia trachomatis infection were negative, and the presumed diagnosis was sexually transmitted infection. She was treated with an over-the-counter medication for secondary vulvovaginal candidiasis.
After 2 days of increased redness, swelling, and burning of the labia minora, she was diagnosed with cellulitis on October 10. The over-the-counter medication was discontinued, and she was prescribed a 7-day course of oral cephalexin. Her labial redness, induration, and pain resolved, and the ulcers healed completely by October 19.
Immunofluorescent antibody staining was negative for herpes simplex virus, and subsequent staining of the viral isolate was negative for herpes simplex virus and cytomegalovirus. The viral isolate was submitted on November 22 to a second reference laboratory, where it remained unidentified 1 month later; it was sent to CDC on January 9, 2007.
Two pathogen-discovery strategies — a pan-herpes virus polymerase chain reaction (PCR) test and a deoxyribonuclease sequence-independent single-primer amplification (DNase-SISPA) — were performed at CDC. Although the pan-herpes virus PCR assay was negative, DNase-SISPA produced unique and prominent DNA fragments in the unknown isolate but not in the control cells, and 8 of 9 sequenced clones of the bands matched vaccinia virus sequences. Additional PCR testing by the CDC Poxvirus Laboratory identified the isolate as being consistent with a vaccine strain of vaccinia virus.
On January 30, 2007, CDC notified the Alaska State Virology Laboratory of the results, which were immediately relayed to the Alaska Section of Epidemiology.
An accompanying editorial notes that unintentional transfer of vaccinia virus can occur from a vaccination site to a second site on the vaccinee (inadvertent autoinoculation) or to a close contact (contact transmission), particularly to the face, nose, mouth, lips, genitalia, anus, and eye.
“To prevent transfers, health-care providers should educate vaccinees regarding proper hand washing after bandage changes or other contact with the vaccination site,” the editorial states. “This general recommendation remains the most effective way to prevent genital vaccinia infections. Persons with any new genital lesion, including lesions suspected to have been caused by vaccinia infection, should avoid sexual contact and consult a health-care provider.”
Since March 8, 2007, CDC and the U.S. Department of Defense have received 4 reports of nongenital contact vaccinia transmitted by recently vaccinated service members, including 2 cases from Indiana and 1 case each from Alabama and New Mexico.
“Health-care providers and public health professionals should ask about any contact with recent smallpox vaccinees when evaluating patients with vesicular lesions compatible with vaccinia,” the editorial concludes. “Early identification of such contact can guide diagnostic tests, allow for timely contact tracing and clinical intervention, and facilitate prompt patient counseling to prevent further transmission of the virus.”
MMWR Morb Mortal Wkly Rep. 2007;56(17):417-419.
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On October 10, 2006, an otherwise healthy woman presented to a public health clinic in Alaska with vaginal tears that had become increasingly painful over 10 days, after having sex with a new male partner between September 22 and October 1, 2006. Her partner consistently used condoms, but a condom broke during vaginal intercourse on October 1.2006年10月10日，一位不同于正常健康的女性患者因为性交时阴道撕裂，疼痛逐渐加重到阿拉斯加健康中心就诊。他是在2006年9月22日与一个新的性伴侣性交时出现的阴道撕裂，同时男性性交时所带的避孕套也破裂。
An isolate from a labial swab specimen was identified by the U.S. Centers for Disease Control and Prevention (CDC) as a vaccine strain of vaccinia virus, and it came to light that the woman’s new sex partner was a U.S. military-service member who had been vaccinated for smallpox 3 days before beginning his relationship with the woman. 该患者阴唇的单独的病理擦拭标本在美国疾病预防控制中心鉴定，结果显示标本内有天花疫苗病毒。调查发现该患者的新性伴侣在美国军队服役，在与患者发生关系的前三天接种了天花疫苗。
“Health-care providers should be aware of the possibility of vaccinia infection in persons with clinically compatible genital lesions who have had recent contact with smallpox vaccines,” write J. McLaughlin, MD, from the Alaska Section of Epidemiology, and colleagues.阿拉斯加流行病学部的 J. McLaughlin博士和他的同志们认为，卫生保健者应该清醒的认识到，接种天花疫苗同时出现临床上的阴道损伤，可能导致天花感染。
The woman told health-care providers that she had not seen penile ulcers or other skin lesions on her partner; that she had no history of genital ulcers or sexually transmitted infections; and that her vaginal tears did not result from sexual violence or abuse. She had tested negative for human immunodeficiency virus approximately 3 months earlier, and she had no fever, itching, or dysuria. 该患者告诉卫生保健工作者她没有发现他的性伴侣阴茎有破损或者溃疡，她也没有阴道溃疡史和性传播疾病。她的阴道撕裂不是因为性暴力和虐待导致的。大概3个月前，她的人类免疫缺陷病毒检查阴性，同时她没有发烧、皮肤瘙痒和排尿困难。
Examination showed 2 shallow ulcerations — 1 on the upper left labia minora measuring 5 mm and the other on the lower right labia minora measuring 3 mm — mild bilateral labial erythema and induration, and vaginal discharge. Lymph nodes, cervix, uterus, adnexa, and anus appeared normal. Tests for gonorrhea and Chlamydia trachomatis infection were negative, and the presumed diagnosis was sexually transmitted infection. She was treated with an over-the-counter medication for secondary vulvovaginal candidiasis.检查发现两处浅表型溃疡，一个在小阴唇的左上侧，直径5mm，另一个在小阴唇的右下方，直径3mm。在小阴唇的两面都有红斑和硬化，并且有阴道流出物，淋巴结、子宫颈、子宫附件、子宫和肛门正常。可能的诊断为性传播疾病，而淋球菌和衣原体检查阴性。所以该患者以女性念珠菌感染的次要疾病进行治疗。
After 2 days of increased redness, swelling, and burning of the labia minora, she was diagnosed with cellulitis on October 10. The over-the-counter medication was discontinued, and she was prescribed a 7-day course of oral cephalexin. Her labial redness, induration, and pain resolved, and the ulcers healed completely by October 19. 两天内患者的小阴唇的红、肿和热加重，在10月10日诊断为蜂窝组织炎。对患者进行了间断的药物治疗，口服头孢立新口服7天。在10月19日患者的小阴唇红斑和硬化消失，溃疡痊愈。
Immunofluorescent antibody staining was negative for herpes simplex virus, and subsequent staining of the viral isolate was negative for herpes simplex virus and cytomegalovirus. The viral isolate was submitted on November 22 to a second reference laboratory, where it remained unidentified 1 month later; it was sent to CDC on January 9, 2007. 抗体免疫荧光检测法检测单纯疱疹病毒阴性，单纯疱疹病毒和巨细胞病毒分离培养阴性，在11月22日在上级实验室进行了第二次分离培养，结果阴性。标本与2007年1月9日被送往传染病中心。
Two pathogen-discovery strategies — a pan-herpes virus polymerase chain reaction (PCR) test and a deoxyribonuclease sequence-independent single-primer amplification (DNase-SISPA) — were performed at CDC. Although the pan-herpes virus PCR assay was negative, DNase-SISPA produced unique and prominent DNA fragments in the unknown isolate but not in the control cells, and 8 of 9 sequenced clones of the bands matched vaccinia virus sequences. Additional PCR testing by the CDC Poxvirus Laboratory identified the isolate as being consistent with a vaccine strain of vaccinia virus. 在传染病中心采用总疱疹病毒聚合酶链反应和DNase-不依赖序列的单一引物核酸扩增技术，总疱疹病毒PCR分析阴性，但是DNase-不依赖序列的单一引物核酸扩增技术扩增出与对照细胞相比唯一显著的未知DNA，9个序列中的8个与痘病毒序列相匹配，传染病中心痘病毒实验室PCR试验发现该序列与痘病毒疫苗菌株序列相同。
On January 30, 2007, CDC notified the Alaska State Virology Laboratory of the results, which were immediately relayed to the Alaska Section of Epidemiology. An accompanying editorial notes that unintentional transfer of vaccinia virus can occur from a vaccination site to a second site on the vaccinee (inadvertent autoinoculation) or to a close contact (contact transmission), particularly to the face, nose, mouth, lips, genitalia, anus, and eye. 2007年1月30日，传染病中心通告阿拉斯加州病毒实验室结果，阿拉斯加州病毒实验室把结果转给阿拉斯加州流行病学部，同时发表评论，接种的牛痘病毒可以从接种者的接种位点转移到接触接种位点另一个位点，或者是临近的位点，特别是脸、鼻子、嘴、嘴唇、阴道、肛门和眼睛。
“To prevent transfers, health-care providers should educate vaccinees regarding proper hand washing after bandage changes or other contact with the vaccination site,” the editorial states. “This general recommendation remains the most effective way to prevent genital vaccinia infections. Persons with any new genital lesion, including lesions suspected to have been caused by vaccinia infection, should avoid sexual contact and consult a health-care provider.” 为了阻止这种传播，卫生保健工作者应该教育牛痘的接种者在更换绷带和接触接种位点后正确的洗手方式。编者说这是阻止阴道感染最有效的方法。有生殖器损伤的人，包括因注射牛痘病毒而导致的感染，都应避免性生活，与卫生保健工作者联系。
Since March 8, 2007, CDC and the U.S. Department of Defense have received 4 reports of nongenital contact vaccinia transmitted by recently vaccinated service members, including 2 cases from Indiana and 1 case each from Alabama and New Mexico. 2007年3月8日，传染病中心和美国预防部又收到牛痘疫苗服务成员的报告，有4例非阴道接触感染病理，2例来自印度，1例来自阿拉巴马，另一例来自墨西哥。
“Health-care providers and public health professionals should ask about any contact with recent smallpox vaccinees when evaluating patients with vesicular lesions compatible with vaccinia,” the editorial concludes. “Early identification of such contact can guide diagnostic tests, allow for timely contact tracing and clinical intervention, and facilitate prompt patient counseling to prevent further transmission of the virus.” 卫生保健的工作者和公共健康专家在评估与牛痘苗一致的小水疱时应该询问最近是否有天花疫苗的接触史。编者认为早期证明天花疫苗的接触史可以帮助诊断，及时的进行跟踪调查和临床干预，给患者提供及时的咨询并且阻止病毒的进一步传播。
一位不同于正常健康的女性患者因为性交时阴道撕裂，疼痛逐渐加重到阿拉斯加健康中心就诊。他是在2006年9月22日与一个新的性伴侣性交时出现的阴道撕裂，同时男性性交时所带的避孕套也破裂。该患者阴唇的单独的病理擦拭标本在美国疾病预防控制中心鉴定，结果显示标本内有天花疫苗病毒。调查发现该患者的新性伴侣在美国军队服役，在与患者发生关系的前三天接种了天花疫苗。阿拉斯加流行病学部的 J. McLaughlin博士和他的同志们认为，卫生保健者应该清醒的认识到，接种天花疫苗同时出现临床上的阴道损伤，可能导致天花感染。该患者告诉卫生保健工作者她没有发现他的性伴侣阴茎有破损或者溃疡，她也没有阴道溃疡史和性传播疾病。她的阴道撕裂不是因为性暴力和虐待导致的。大概3个月前，她的人类免疫缺陷病毒检查阴性，同时她没有发烧、皮肤瘙痒和排尿困难。检查发现两处浅表型溃疡，一个在小阴唇的左上侧，直径5mm，另一个在小阴唇的右下方，直径3mm。在小阴唇的两面都有红斑和硬化，并且有阴道流出物，淋巴结、子宫颈、子宫附件、子宫和肛门正常。可能的诊断为性传播疾病，而淋球菌和衣原体检查阴性。所以该患者以女性念珠菌感染的次要疾病进行治疗。两天内患者的小阴唇的红、肿和热加重，在10月10日诊断为蜂窝组织炎。对患者进行了间断的药物治疗，口服头孢立新口服7天。在10月19日患者的小阴唇红斑和硬化消失，溃疡痊愈。抗体免疫荧光检测法检测单纯疱疹病毒阴性，单纯疱疹病毒和巨细胞病毒分离培养阴性，在11月22日在上级实验室进行了第二次分离培养，结果阴性。标本与2007年1月9日被送往传染病中心。在传染病中心采用总疱疹病毒聚合酶链反应和DNase-不依赖序列的单一引物核酸扩增技术，总疱疹病毒PCR分析阴性，但是DNase-不依赖序列的单一引物核酸扩增技术扩增出与对照细胞相比唯一显著的未知DNA，9个序列中的8个与痘病毒序列相匹配，传染病中心痘病毒实验室PCR试验发现该序列与痘病毒疫苗菌株序列相同。 2007年1月30日，传染病中心通告阿拉斯加州病毒实验室结果，阿拉斯加州病毒实验室把结果转给阿拉斯加州流行病学部，同时发表评论，接种的牛痘病毒可以从接种者的接种位点转移到接触接种位点另一个位点，或者是临近的位点，特别是脸、鼻子、嘴、嘴唇、阴道、肛门和眼睛。为了阻止这种传播，卫生保健工作者应该教育牛痘的接种者在更换绷带和接触接种位点后正确的洗手方式。编者说这是阻止阴道感染最有效的方法。有生殖器损伤的人，包括因注射牛痘病毒而导致的感染，都应避免性生活，与卫生保健工作者联系。传染病中心和美国预防部又收到牛痘疫苗服务成员的报告，有4例非阴道接触感染病理，2例来自印度，1例来自阿拉巴马，另一例来自墨西哥。卫生保健的工作者和公共健康专家在评估与牛痘苗一致的小水疱时应该询问最近是否有天花疫苗的接触史。编者认为早期证明天花疫苗的接触史可以帮助诊断，及时的进行跟踪调查和临床干预，给患者提供及时的咨询并且阻止病毒的进一步传播。
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