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Procedure: Vaccination of staff working with vaccinia virus

Purpose

To inform staff and students of the requirements for working with vaccinia virus.

Procedure

  1. University staff and students working with vaccinia virus are to be vaccinated against the virus, in accordance with Australian recommendations.
  1. A researcher’s OGTR licence conditions may require vaccinia vaccination of all relevant persons.
  2. The University recommends that the decision to be vaccinated should be made by the individual involved, after receiving detailed advice and counselling.
  3. Staff and students who are not vaccinated will have restricted duties in relation to vaccinia viruses.
  4. Staff are currently advised to receive revaccination every 10 years.
  5. Currently the University engages Professor Stephen Kent, an infectious disease expert from Melbourne, to provide counselling and administration of the vaccinia (smallpox) vaccination where appropriate. Post vaccination follow-up is provided 10 days after the vaccination, by Professor Kent via video conferencing link. Follow-up may also be sought from infectious diseases experts located at The Canberra Hospital or by another health provider such as Medibank Health Solutions.
  6. Exemptions

Vaccination against Vaccinia is not recommended for people who;

  • have skin conditions (e.g. eczema),
  • are immune-compromised,
  • have heart problems, or
  • are pregnant or breastfeeding.
  1. University staff and students working with highly attenuated strains of vaccinia virus are not required to receive vaccination with vaccinia vaccine. However receiving counselling and information (from a medical officer) is recommended.

Strains of Vaccinia

  1. Various strains of vaccinia virus are used in the laboratory for experimental purposes. A risk assessment of the work must be undertaken and the advantages and disadvantages of vaccination considered.
  2. Standard and recombinant vaccinia strains are capable of replicating in human cells, and thus can cause illness in humans. Examples of these strains include: Copenhagen, Lister, NYCBOH, Wyeth and WR [1]. Laboratory-acquired infections with standard and recombinant vaccinia strains have been reported in the literature [2-6].
  3. Some strains of poxviruses have been developed that are highly attenuated; host restricted and replicate either not at all or poorly in human cells. Examples of these strains include: MVA and NYVAC [1]. These highly attenuated strains of poxvirus do not result in productive infection in humans.
  4. For further information on strains of vaccinia, see Appendix 1.

Vaccinia Vaccine and Side Effects

  1. The current vaccinia vaccine used in Australia is a live virus that is capable of replicating in human cells and causing a usually mild illness. The vaccine confers immunity to other viruses in the genus Orthopoxvirus (e.g. monkeypox, cowpox, smallpox) [1].
  2. Side effects and adverse reactions to the vaccine are wide ranging in type and severity.
  3. Some of the more common and less severe reactions may be [1]:
  1. Most frequently, inadvertent inoculation at other sites of the body can occur. This happens when the person touches the vaccination site and then touches, for example, their eye.
  2. A fever – this is less common among adults than children.

Moderate and severe adverse reactions occur less commonly. These may include: Eczema vaccinatum – a localised or systemic dissemination of vaccinia, occurring most commonly in people with a history of eczema or some other skin conditions. Generalised vaccinia – a generalised rash that can vary in extent and is generally self-limiting except in those who may have underlying immunodeficiency. Progressive vaccinia – progressive necrosis in the vaccination area, which may spread to other areas of the body. Very serious, however occurs almost exclusively among those with an underlying immunodeficiency. Post-vaccinial encephalitis – mainly affects primary vaccinees.

  1. These complications are rare, and their occurrence is more frequent among those receiving their first vaccination, and younger children [1]. Fatal complications are very rare, and occur at a rate of approximately 1 death/million primary vaccinations, and 0.25 deaths/million revaccinations [1].
  • Further basic information on side effects from the vaccination and contraindications is available in the information sheet: ‘Smallpox vaccine, what you need to know’ [14] produced by the Centre for Disease Control in America.
  1. There is a list of contraindications for vaccination, including skin, heart or immune system problems, and pregnancy.
  2. Some research [12] has indicated that smallpox vaccination does not increase risk of heart related complications. However it is still recommended to exclude anyone with pre-existing heart problems from vaccination unless there are compelling reasons for vaccination.

Emergency Procedures for Vaccinia Exposure

  1. Research groups handling vaccinia need to have in place emergency procedures, including sufficient quantities of saline to effectively flush eyes or mucous membranes where necessary.
  2. In the event of a skin exposure or needle-stick injury of live vaccinia virus:
  • Wash the wound thoroughly with soap and water (not ethanol or antiseptic)
  • Do not squeeze the wound or encourage bleeding
  • In the event of a splash to the eye or mucous membranes with live vaccinia virus:
  • Flush the eye vigorously with saline eye wash
  • If saline is not immediately to hand, water may be used

Responsibilities

  1. Responsibilities for those dealing with vaccinia virus are detailed below.

Research group leader

  1. The research group leader is responsible for:
  • Considering the risks involved with their research and undertaking a documented risk assessment (as per ANU WHS Policy [15]),
  • Clearly stating when advertising for jobs and student positions that handling of and vaccination for vaccinia virus is required,
  • Discussing vaccinia handling and vaccination with a potential employee or student during pre-employment interviews and the possibility of medical screening,
  • Commencing the vaccination process for new staff as soon as practical after the employment contract is signed/accepted, and;
  • Not employing a person who is medically contraindicated for vaccination, or does not wish to receive the vaccination for a position that handles standard or recombinant live vaccinia virus or animals infected with the virus.
  • Restricting duties of staff and students involving handling of standard and recombinant live vaccinia virus, or animals infected with the virus if those (current) staff and students are medically advised against being vaccinated. A non-vaccinated staff member or student cannot be subjected to an unacceptable health risk or cause a breach of licence conditions.

The implications of a laboratory-acquired infection with vaccinia virus in a person who is medically contraindicated from vaccination could be severe. This group of people could be at risk for the most serious complications of infection.

  • Restricting the duties of unvaccinated staff and students from working with recombinant strains of vaccinia virus until they have been vaccinated.
  • Restricting the duties of unvaccinated staff and students from undertaking high risk activities with standard strains of vaccinia (such as injection of the virus) until they have been vaccinated.
  • Organising for staff and students working directly with standard and recombinant strains of vaccinia virus cultures and vaccinia virus infected animals to; receive mandatory counselling by a doctor approved by the local budget unit, and; then if appropriate be offered the vaccinia vaccine.
  • The current doctor undertaking vaccinations for ANU is Dr Stephen Kent from the University of Melbourne. Local area safety officers or the WHS Branch can be contacted for details.
  • Notifying staff and students who work with highly attenuated strains of vaccinia virus that they are not required to receive vaccination with vaccinia vaccine, however they may still receive counselling and information (from a medical officer) if requested.
  • Providing staff and students with the following documents from the CDC for their information prior to being sent for counselling and potentially vaccination: ‘Smallpox Vaccine – What you need to know’ [13], 'Smallpox Vaccine and Heart Problems' [14]. The staff member should read these documents before their appointment for counselling so that they are prepared to raise any questions or concerns. The counselling appointment is generally also when the vaccination is administered as required. Ideally this documentation should be initially provided at interview stage. The applicant should sign off to indicate they have none of the documented contraindications to vaccination before they are employed.
  • Arranging for a booster vaccination to be offered to staff after 10 years.
  • Documenting safe operating procedures, including; Details of the action to be taken in the event that a worker is accidentally exposed. Immediate post-incident procedures should be detailed, such as the flushing of an eye exposure. There should also be consultation with a doctor or health service (e.g. Medibank Health Solutions, or the ANU Occupational Physician) who are available to be the first point of contact for advice and treatment post-incident. Depending on the circumstances the affected person may be referred on to other experts, such as those in the Infectious Diseases Unit at The Canberra Hospital. Ensuring that workers are aware of the risks of contamination of surfaces when handling concentrated stocks of virus. Such contamination may present risk to staff who are not vaccinated. There have also been documented cases of orthopox viruses cross-contaminating other cultures in a laboratory resulting in accidental infection of unvaccinated workers [17,18]. Ensuring workers are aware of the symptoms of vaccinia virus infection and that they know to mention they work with vaccinia if they need medical care for an undiagnosed illness. Symptoms and incubation period of a laboratory acquired infection may not always be the same as those of a naturally acquired infection or a medical vaccination. Reporting any incident or possible exposure involving vaccinia virus using the University’s online incident notification system.

Supervisor of animal workers

  1. Supervisors of animal workers are responsible for:
  • Determining (with advice from experts) when support staff may need to be offered vaccination.
  • Organising for support staff to receive vaccination where it is deemed necessary.

Support staff such as animal workers who are not working directly with the standard and recombinant strains of vaccinia virus do not require vaccination.

Animal care staff who work with animals infected with standard and recombinant vaccinia strains do not generally need to be vaccinated as this is not considered a high risk situation [advice from Professor Stephen Kent December 2011].

Human Resources Manager, Business Manager or Safety Officer

  1. The local area Human Resources manager, business manager or safety officer is responsible for:
  • Creating and maintaining a record of; those staff who handle vaccinia that have received counselling for the vaccination and; whether or not they were subsequently vaccinated.
  • Obtaining feedback in writing from the treating doctor as to which staff were or were not vaccinated. Reasons for staff not being vaccinated should not be requested, as this would breach patient confidentiality.
  • Formalising an agreement between the ANU budget unit and the doctor who administers the vaccination. This agreement should set out the details of the procedure for counselling and vaccination, along with follow-up procedures.

Staff and Students

  1. Staff and students working with vaccinia virus are responsible for:
  • Wearing protective eyewear whenever handling viable virus or animals infected with the virus. Reading glasses are not considered protective eyewear.

One of the most serious potential incidents involving laboratory staff and vaccinia virus is contamination of the eye leading to an eye infection and potentially blindness. It is possible that even vaccinated individuals may become infected in this situation, so eye protection is mandatory for all staff handling the live virus, or handling animals infected with the virus.

  • Covering any breaks in skin integrity with a waterproof dressing in addition to wearing gloves.
  • Undertaking work with vaccinia virus only where a documented risk assessment and safe operating procedure is in place prior to work being started (as per ANU WHS Policy [15]).
  • Reporting any incident or possible exposure involving vaccinia virus using the University’s online incident notification system.

References

  1. Vaccinia (Smallpox) Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity and Mortality Weekly Report, June 22, 2001 / Vol. 50 / No. RR-10.
  2. Openshaw, Alwan, Cherrie, and Record. Accidental infection of laboratory worker with recombinant vaccinia virus. – Letter – The Lancet, Vol 338, August 17, 1991.
  3. Pike. Laboratory-associated infections: summary and analysis of 3,921 cases. Health Lab Sci, 1976; 102:105-14.
  4. Jones, Ristow, Yilma and Moss. Accidental human vaccination with vaccinia virus expressing nucleoprotein gene. – Letter – Nature, Vol 319, p. 543, 13 February 1986.
  5. Moussatche, et al. Accidental Infection of Laboratory Worker with Vaccinia Virus. Emerging Infectious Diseases, Vol. 9, No. 6, p 724 – 726, June 2003.
  6. Loeb, et al. Laboratory-acquired vaccinia infection. Canada Communicable Diseases Report, Vol 29-15, 1 August 2003.
  7. Australian Immunisation Handbook (9th Edition 2008). http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home - accessed online 29/3/12.
  8. AS/NZS 2243.3 2010 Safety in laboratories Part 3: Microbiological Aspects and Containment Facilities.
  9. Wenzel and Nettleman. Smallpox vaccination for investigators using vaccinia recombinants. – Letter – The Lancet, September 9, 1989, p. 630.
  10. Hammarlund, Lewis, Hansen, Strelow, Nelson, Sexton, Hanifin and Slifka. Duration of antiviral immunity after smallpox vaccination. Nature Medicine, published online 17 August 2003; doi: 10.1038nm917.
  11. Slifak. Immunological memory to viral infection. Commentary. Current Opinion in Immunology, 2004. 16:443-450.
  12. Frieden, Mostashari, Schwartz, Thorpe, et al. Cardiac deaths after a mass smallpox vaccination campaign – New York City 1947. MMWR 2003, Vol.52; Iss. 39; p. 933.
  13. Centre for Disease Control, Vaccine Information Sheet, ‘Smallpox vaccine, what you need to know’: http://www.bt.cdc.gov/agent/smallpox/vaccination/pdf/smallpox-vis.pdf - accessed online 29/3/12.
  14. Centre for Disease Control, Interim Smallpox Fact Sheet, ‘Smallpox vaccine and heart problems’: http://www.bt.cdc.gov/agent/smallpox/vaccination/pdf/heartproblems.pdf - accessed online 29/3/12.
  15. ANU WHS Policy: https://policies.anu.edu.au/ppl/document/ANUP_000432 - accessed online 27/6/13
  16. Laboratory-Acquired Vaccinia Exposures and Infections – United States, 2005 – 2007. Morbidity Mortality Weekly Report – April 18, 2008 / 57(15);401-404 - http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5715a3.htm - accessed online 9/8/12
  17. Laboratory-Acquired Vaccinia Virus Infection – Virginia, 2008. Morbidity Mortality Weekly Report, July31, 2009 / 58(29);797-800
  18. Investigation of the First Laboratory-Acquired Human Cowpox Virus Infection in the United States. The Journal of Infectious Diseases (2012) 206(1):63-68.

Appendix 1

  1. Australian information and recommendations on vaccinia virus vaccination can be found in the Australian Immunisation Handbook [7], and AS/NZS 2243.3 [8]. The Immunisation Handbook recommends that the only current indication for vaccination with vaccinia/smallpox vaccine in Australia is for laboratory workers using live vaccinia virus. AS/NZS 2243.3 reinforces this by also recommending vaccination in these circumstances. The Australian recommendations do not differentiate between the more virulent and the highly attenuated strains of vaccinia.
  2. In the USA, the Advisory Committee on Immunisation Practices (ACIP) has written a document [1] on the use of vaccinia vaccine. This document includes information on use of the vaccine to protect laboratory workers who handle vaccinia virus. The ACIP recommends vaccinia vaccine for ‘laboratory workers who directly handle a) cultures or b) animals contaminated or infected with, non-highly attenuated vaccinia virus … or other Orthopoxviruses that infect humans’ [1]. This publication indicates that laboratory workers who handle only highly attenuated strains of vaccinia virus, do not require routine vaccination.
  3. International opinion is divided as to the necessity and usefulness of vaccination of laboratory workers using vaccinia. There has been speculation that even in a vaccinated worker an exposure through, for example, a splash to the eye or a needle-stick injury, may still result in a local infection [2,9]. In the documented cases of laboratory acquired vaccinia infection [2-6] no deaths have been recorded. Vaccination may reduce the severity of any accidental infection.[16]
  4. The advice to re-vaccinate workers every 10 years has been closely questioned, and there has been much international discussion on the usefulness of revaccination. Some papers [10,11] have questioned the necessity of revaccination, citing older examples that indicate that smallpox immunity after a single vaccination is long lasting, possibly for decades. A booster vaccination may be of some assistance however if the initial vaccination is suboptimal [11]. Most adverse effects from vaccination occur during the primary vaccination; booster vaccinations have a much lower rate of side effects [1].

Information

Printable version (PDF)
Title Vaccination of staff working with vaccinia virus
Document Type Procedure
Document Number ANUP_005001
Version 7
Purpose To inform staff and students of the requirements for working with vaccinia virus.
Audience Staff
Category Administrative
Topic/ SubTopic Health, Safety & Environment - Occupational Health & Safety
 
Effective Date 25 Jul 2013
Review Date 25 Jul 2016
 
Responsible Officer Director, Human Resources
Approved By: Chief Operating Officer
Contact Area Human Resources Division
Authority