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James Magner, M.D.
East Carolina University
Greenville, NC 27858-4354
References
In 1962, before the main U.S. military escalation in Vietnam and before the fall of the Diem regime, a civilian physician from the U.S. Operations Mission and I were dispatched in a convoy through the jungles to verify reports of a smallpox outbreak among Montagnard villagers.
What we found at the end of our journey was a small village with half a dozen fresh graves (allegedly of smallpox victims, but during war, who knows?). Of the villagers who came out to greet us, fully 40 percent looked exactly like the patient in Dr. Herron's photographs. However, there was a major difference. Questioning revealed that a French medical team had been through the area nine days earlier and had inoculated one third of the villagers, using the old French method of scarification. Drops of smallpox vaccine were placed on the upper arm and scarified with the tip of a lancet, so that the skin was cut and blood appeared in the X-shaped scar through each droplet.
In those days, French textbooks described the technique for "vaccination anti-variolique" as follows: "Scarification must be epidermal; it is necessary to avoid reaching the dermis and causing bleeding. . . . A simple linear incision 3 to 5 mm long is sufficient."1
Despite the warning, the result in Vietnam was iatrogenic generalized vaccinia in most patients. The resultant shedding of the virus generated numerous secondary cases throughout the village, thus increasing the overall herd immunity.
According to Henderson:
Generalized vaccinia represents a secondary eruption resulting from bloodborne dissemination of vaccinia virus. Almost all cases occur after primary vaccination. The lesions become evident between six and nine days after vaccination. The number of lesions may range from a few to a generalized involvement of the skin. It is a self-limited illness, and complete recovery occurs without a specific therapy.2
Benenson also notes that the vesicles of generalized vaccinia appear 5 to 10 days after vaccination and that the condition is benign and self-limited.3
It seems to me that the information on timing, as well as the clinical description accompanying the photographs, may well be consistent with the above description.
John P. Maher, M.D., M.P.H.
Chester County Health Department
West Chester, PA 19382-4542
References
Is it a coincidence that you published this image on nearly the same day, though 200 years later, that Edward Jenner performed the famous inoculation of cowpox virus into the young James Phipps, on May 14, 1796?
The successful eradication program is based on Jenner's experiments and on his lifelong promotion of vaccine inoculation. In 1801 he summarized his experiences with cowpox inoculation (Figure 1) and stated, "The numbers who have partaken of its benefits throughout Europe and other parts of the Globe are incalculable: and it now becomes too manifest to admit of controversy, that the annihilation of the Small Pox, the most dreadful scourge of the human species, must be the final result of this practice."1 He got it right, 200 years later. The most recent Swedish textbook of infectious diseases does not even mention smallpox.
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Andreas Aly, M.D., Ph.D.
Sophia Aly
Ersta Hospital
S-116 91 Stockholm, Sweden
References
ek Z, Ladnyi ID. Smallpox and its eradication. Geneva: World Health Organization, 1988.
Andrew J. Larner, M.R.C.P.
National Hospital for Neurology and Neurosurgery
London WC1N 3BG, United Kingdom
To the Editor: It is possible that the generalized disease shown in my photographs is vaccinia rather than variola, but it is not very likely. The patient had been exposed to an unvaccinated person, known to have smallpox, before the onset of her rash and before her vaccination. The period between exposure and the onset of the rash was appropriate for an incubation period. The source case was the penultimate in a chain of transmission of well-documented smallpox cases among unvaccinated persons over a two-month period.1
Although the transmission of smallpox to unvaccinated contacts occurred at rates of 60 to 90 percent,2 generalized vaccinia due to vaccination is extremely rare. Two large surveys documented attack rates of only 20.8 cases3 and 23.4 cases4 per million persons who had undergone primary vaccinations. These contrasting probabilities definitely favor variola over vaccinia as the diagnosis in the patient I described.
Dr. Maher's comments imply that extra-vigorous vaccination (two scarification strokes rather than one, and the initiation of bleeding at the vaccination site) led to high rates of generalized vaccinia in vaccine recipients, with secondary transmission to contacts, resulting in an incidence rate of about 40 percent in his village sample. Dixon, however, in discussing the incidence of generalized vaccinia, concluded that it "does not appear to be related to more vigorous technique" and "is exceedingly rare" regardless of the technique used.5 The data he cites indicate that the syndrome occurs at a rate of about 48 cases per million persons of all ages who have undergone primary vaccination. He does note a "more common" occurrence after subcutaneous, rather than intradermal, introduction of vaccinia virus, but the rate cited was only 3 cases per 10,000, with the numerator probably including cases of isolated metastatic lesions, as well as generalized disease. Generalized vaccinia acquired from another person's vaccination is also rare, with only 2 cases reported by Lane et al. among contacts of 5,594,000 vaccine recipients.4
The apparent attack rate in Dr. Maher's village sample is unbelievably high for generalized vaccinia. This high rate, along with the report of six fatal cases in the first wave of illness, suggests that the disease he found among the Montagnards is much more likely to have been smallpox than vaccinia, so the similarity to my photograph is not at all surprising.
Charles A. Herron, M.D.
10014 Edgewater Dr.
Cleveland, OH 44102
References
Some of our readers are exceptionally observant. Two years ago, readers noticed that we published an Image in Clinical Medicine on primary syphilis on page 1492, a number corresponding to the year Columbus came to the New World.1 (It was only a coincidence.)
In today's correspondence, Larner and Aly and Aly note that when we published the image of smallpox on May 16, we missed the 200th anniversary of Jenner's cowpox inoculation by a mere two days. It may seem a little spooky, but it is just another coincidence.
Jerome P. Kassirer, M.D.
References
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Related Letters:
Syphilis and Coincidence
Carter R. L., Spiers A. S.D., Lewin P. K., Robbins D. A., Kassirer J. P.
Extract |
Full Text
N Engl J Med 1995;
332:1175-1176, Apr 27, 1995.
Correspondence
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