579 KB/36 slides
Transcript of 579 KB/36 slides
![Page 1: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/1.jpg)
Post-Vaccinial EncephalitisDiagnostic and Management
None for specific diagnosis of PVE Diagnosis of exclusion – Consider other
infectious or toxic etiologies 15-25% mortality rate 25% varying neurological deficits VIG not recommended
![Page 2: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/2.jpg)
Fetal Vaccinia
![Page 3: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/3.jpg)
Fetal Vaccinia
![Page 4: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/4.jpg)
Associating the Condition with the Vaccine
•Know Chronology of immunization and adverse event
•Corresponds to those previously associated
•Biologic plausibility
•Lab result confirms association
•Recurs on re-administration
•Controlled clinical or epi trial shows association
![Page 5: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/5.jpg)
Revaccination of Those with History of AE
In absence of smallpox, do NOT revaccinate Defer those not vaccinated from response teams
![Page 6: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/6.jpg)
Prophlyaxis of High-Risk Groups Accidentally Exposed
VIG NOT recommended Vigilant clinical follow-up Do NOT administer VIG with smallpox vaccine Exclude those with contraindications
![Page 7: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/7.jpg)
Laboratory Diagnosis
![Page 8: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/8.jpg)
Laboratory DiagnosisRule Out Testing
Varicella Herpes Zoster Herpes Simplex Enteroviruses
![Page 9: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/9.jpg)
Laboratory DiagnosisTests Available
Electron Microscopy (EM) - Orthopoxvirus PCR – Gene Amplification Viral Culture – Identify vaccinia
May be available through LRN Consult with CDC for testing advice
![Page 10: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/10.jpg)
Specimen Collection
Contact state health department CDC Interim Smallpox Response Plan, Guide D
www.cdc.gov/smallpox
![Page 11: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/11.jpg)
Treatments
![Page 12: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/12.jpg)
Vaccinia Immune Globulin
Immunoglobulin fraction of plasma Antibodies to vaccinia from vaccinated donors Previously-licensed IM product (Baxter)
Contains 0.01% thimerosal New IV products in production Obtain as IND product through CDC and DoD
![Page 13: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/13.jpg)
VIG IndicationsIndications
Eczema vaccinatum Progressive vaccinia Vaccinia necrosum Generalized vaccinia – severe cases
![Page 14: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/14.jpg)
Vaccinia Immune GlobulinIndications
Recommended Inadvertent Inoculation - severeEczema vaccinatumGeneralized vaccinia – severe or underlying illnessProgressive vaccinia
Not Recommended
Inadvertent Inoculation – Not severeGeneralized vaccinia – mild or limitedNon-specific rashes, EM, SJSPost-vaccinial encephalitis
Consider Ocular complications
![Page 15: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/15.jpg)
Vaccinia Immune GlobulinSide Effects - Mild
Local Pain Tenderness Swelling Erythema From few hours to 1 or 2 days
![Page 16: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/16.jpg)
Joint Pain Diarrhea Dizziness Hyperkinesis Drowsiness Pruritis Rash Perspiration Vasodilation
Vaccinia Immune GlobulinSide Effects - Moderate
![Page 17: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/17.jpg)
Hypotension Anaphylaxis Renal Dysfunction Aseptic Meningitis Syndrome (AMS)
Vaccinia Immune GlobulinSide Effects - Serious
![Page 18: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/18.jpg)
Vaccinia Immune Globulin Contraindications
Allergic reaction to thimerosal History of severe reaction with IG preparations IgA Deficiency Vaccinia keratitis, except in some cases Pregnancy Theoretical risks as with all human plasma
![Page 19: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/19.jpg)
VIG Administration
VIG-IM 0.6ml/kg IM, preferably in buttock or anterolateral aspect
of thigh Divide doses > 5ml Refer to package insert
![Page 20: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/20.jpg)
Cidofovir
Nucleotide analogue of cytosine Some antiviral activity against orthopoxviruses Administer under IND protocol, only Released by CDC and DoD if:
No response to VIG Patient near death All inventories of VIG exhausted
![Page 21: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/21.jpg)
Cidofovir Side Effects
Renal toxicity Neutropenia Proteinuria Decreased intraocular pressure Anterior uveitis/iritis Metabolic acidosis
![Page 22: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/22.jpg)
Cidofovir Admin
5 mg/kg IV over 60 minute period Consider 2nd dose one week later if no response Adjust dose for renal function Assess baseline and post-admin renal function IV hydration (1L of 0.9% saline IV) 3 doses oral probenicid (25 mg/kg per dose)
![Page 23: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/23.jpg)
Obtaining VIG and Cidofovir
Civilian Medical Facilities CDC Smallpox Vaccinee Adverse Events Clinical
Team
Military Facilities USAMRIID (301) 619-2257 or 888-USA-RIID
![Page 24: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/24.jpg)
Consultation
![Page 25: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/25.jpg)
Consultation
State and Territories establish program Hospitals assign physicians with expertise Provide 24/7 access to vaccinees and affected
contacts CDC Provider Information Line
![Page 26: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/26.jpg)
ConsultationInformation to Have
Thorough vaccination history Physical Examination of patient High-resolution digital photographs of
dermatologic manifestations Contact state health department, first
![Page 27: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/27.jpg)
Smallpox Adverse Event Reporting
![Page 28: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/28.jpg)
VAERS Reporting
Secure web-based reporting
https://secure.vaers.org/VaersDateEntryintro.htm
Downloadable form
http://www.vaers.org/pdf/vaers_form.pdf Fax to:
1-877-721-0366
![Page 29: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/29.jpg)
Additional Information
CDC Smallpox Website
www.cdc.gov/smallpox
Adverse Events Training Module
www.bt.cdc.gov/training/smallpoxvaccine/reactions
![Page 30: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/30.jpg)
Infection Control
Documented rarely in healthcare settings Primarily after direct contact with site May occur with other infected body sites Indirect transmission possible, but never
documented
![Page 31: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/31.jpg)
Ocular Vaccinial Infections and Therapy
![Page 32: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/32.jpg)
Treatment of Ocular Infections
Previous experience with older antivirals Not done by today’s standards Currently available topical opthalmic antivirals
not studied with vaccinia Animal studies
![Page 33: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/33.jpg)
Animal studies, rabbit model of vaccinial keratitis Topical vidarabine or trifluridine Virologic and clinical improvement Early use might reduce complications Not approved by FDA for vaccinia disease
Treatment of Ocular InfectionsTopical Opthalmic Anti-Virals
![Page 34: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/34.jpg)
No evidence effective Might increase scarring after vaccinial keratitis Rabbit studies used increased doses
Treatment of Ocular InfectionsVaccinia Immune Globulin
![Page 35: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/35.jpg)
Manage in consult with ophthalmologist Consider off-label use of topical ophthalmic
trifluridine or vidarabine Balance with risk of drug toxicity Continue until periocular and/or lid lesions heal
and scabs fall off
Treatment of Ocular InfectionsGuidance for Clinicians
![Page 36: 579 KB/36 slides](https://reader035.fdocuments.net/reader035/viewer/2022081504/556cb27ed8b42ab70c8b4c26/html5/thumbnails/36.jpg)
Consider VIG when keratitis NOT present Useful with severe blepharitis or
blepharoconjunctivitis Weigh risks and benefits if keratitis present Use VIG for other severe vaccinia disease, even
if keratitis present Consider prophylaxis against bacterial infection Enroll in studies
Treatment of Ocular InfectionsGuidance for Clinicians