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This report supplements the 2001 statement by the Advisory Committee on Immunization Practices (ACIP) (CDC. Vaccinia [smallpox] vaccine: recommendations of the Advisory Committee on Immunization Practices [ACIP], 2001. MMWR 2001;50[No. RR-10]:1-25). This supplemental report provides recommendations for using smallpox vaccine in the pre-event vaccination program in the United States.To facilitate preparedness and response, smallpox vaccination is recommended for persons designated by public health authorities to conduct investigation and follow-up of initial smallpox cases that might necessitate direct patient contact. ACIP recommends that each state and territory establish and maintain >/=1 smallpox response team. ACIP and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that each acute-care hospital identify health-care workers who can be vaccinated and trained to provide direct medical care for the first smallpox patients requiring hospital admission and to evaluate and manage patients who are suspected as having smallpox. When feasible, the first-stage vaccination program should include previously vaccinated health-care personnel to decrease the potential for adverse events. Additionally, persons administering smallpox vaccine in this pre-event vaccination program should be vaccinated.Smallpox vaccine is administered by using the multiple-puncture technique with a bifurcated needle, packaged with the vaccine and diluent. According to the product labeling, 2-3 punctures are recommended for primary vaccination and 15 punctures for revaccination. A trace of blood should appear at the vaccination site after 15-20 seconds; if no trace of blood is visible, an additional 3 insertions should be made by using the same bifurcated needle without reinserting the needle into the vaccine vial. If no evidence of vaccine take is apparent after 7 days, the person can be vaccinated again.Optimal infection-control practices and appropriate site care should prevent transmission of vaccinia virus from vaccinated health-care workers to patients. Health-care personnel providing direct patient care should keep their vaccination sites covered with gauze in combination with a semipermeable membrane dressing to absorb exudates and to provide a barrier for containment of vaccinia virus to minimize the risk of transmission; the dressing should also be covered by a layer of clothing. Dressings used to cover the site should be changed frequently to prevent accumulation of exudates and consequent maceration. The most critical measure in preventing contact transmission is consistent hand hygiene. Hospitals should designate staff to assess dressings for all vaccinated health-care workers. When feasible, staff responsible for dressing changes for smallpox health-care teams should be vaccinated; all persons handling dressings should observe contact precautions. Administrative leave is not required routinely for newly vaccinated health-care personnel, unless they are physically unable to work as a result of systemic signs and symptoms of illness; have extensive skin lesions that cannot be adequately covered; or if they are unable to adhere to the recommended infection-control precautions. Persons outside the patient-care setting can keep their vaccination sites covered with a porous dressing; hand hygiene remains key to preventing inadvertent inoculation.FDA has recommended that recipients of smallpox vaccine be deferred from donating blood for 21 days or until the scab has separated. Contacts of vaccinees, who have inadvertently contracted vaccinia, also should be deferred from donating blood for 14 days after complete resolution of their complication.In the pre-event vaccination program, smallpox vaccination is contraindicated for persons with a history or presence of eczema or atopic dermatitis; who have other acute, chronic, or exfoliative skin conditions; who have conditions associated with immunosuppression; are aged <1 year; who have a serious allergy to any component of the vaccine; or who are pregnant or breastfeeding. ACIP does not recommend smallpox vaccination for children and adolescents aged <18 years during the pre-event vaccination program. Pre-event vaccination also is contraindicated among persons with household contacts who have a history or presence of eczema or atopic dermatitis; who have other acute, chronic, or exfoliative skin conditions; who have conditions associated with immunosuppression; or who are pregnant. For purposes of screening for contraindications for pre-event vaccination, household contacts include persons with prolonged intimate contact (e.g., sexual contacts) with the potential vaccinee and others who might have direct contact with the vaccination site. Persons with inflammatory eye disease might be at increased risk for inadvertent inoculation as a result of touching or rubbing the eye. Therefore, deferring vaccination is prudent for persons with inflammatory eye diseases requiring steroid treatment until the condition resolves and the course of therapy is complete.Eczema vaccinatum, a serious form of disseminated vaccinia infection, can occur among persons with atopic dermatitis and other dermatologic conditions. Potential vaccinees should be queried regarding the diagnosis of atopic dermatitis or eczema in themselves or any member of their household, or regarding the presence of chronic or recurrent rashes consistent with these diagnoses. Persons reporting such a rash in themselves or household members should not be vaccinated, unless a health-care provider determines that the rash is not eczema or atopic dermatitis.Before vaccination, women of childbearing age should be asked if they are pregnant or intend to become pregnant during the next 4 weeks; women who respond positively should not be vaccinated. Any woman who thinks she might be pregnant or who wants additional assurance that she is not pregnant should perform a urine pregnancy test on the day scheduled for vaccination. If a pregnant woman is inadvertently vaccinated or if she becomes pregnant within 4 weeks after smallpox vaccination, she should be counseled regarding concerns for the fetus. Vaccination during pregnancy should not ordinarily be a reason to terminate pregnancy. CDC has established a pregnancy registry to prospectively follow the outcome of such pregnancies and facilitate the investigation of any adverse pregnancy outcome among pregnant women who were inadvertently vaccinated. For enrollment in the registry, contact CDC at 404-639-8253.Smallpox vaccine should not be administered to persons with human immunodeficiency virus infection (HIV) or acquired immunodeficiency syndrome (AIDS) as part of a pre-event program because of their increased risk for progressive vaccinia. HIV testing is recommended for persons who have any history of a risk factor for HIV infection or for anyone who is concerned that he or she might have HIV infection. HIV testing should be available in a confidential or anonymous setting, in accordance with local laws and regulations, with results communicated to the potential vaccinee before the planned date of vaccination.Smallpox vaccine can be administered simultaneously with any inactivated vaccine. With the exception of varicella vaccine, smallpox vaccine can be administered simultaneously with other live-virus vaccines. To avoid confusion in ascertaining which vaccine might have caused postvaccination skin lesions or other adverse events, varicella vaccine and smallpox vaccine should be administered >/=4 weeks apart. Health-care workers scheduled to receive an annual purified protein derivative (PPD) skin test for tuberculosis screening should not receive the skin test until >/=1 month after smallpox vaccination.Persons with progressive vaccinia, eczema vaccinatum, and severe generalized vaccinia or inadvertent inoculation might benefit from therapy with VIG or cidofovir, although the latter has not been approved by FDA for this indication. Suspected cases of these illnesses or other severe adverse events after smallpox vaccination should be reported immediately to state health departments. VIG and cidofovir are available from CDC under Investigational New Drug protocols. Clinically severe adverse events after smallpox vaccination should be reported to the Vaccine Adverse Event Reporting System. Reports can be made online at https://secure.vaers.org/VaersDataEntryintro.htm, or by postage-paid form, which is available by calling 800-822-7967 (toll-free).ACIP will review these recommendations periodically as new information becomes available related to smallpox disease, smallpox vaccines, the risk of smallpox attack, smallpox vaccine adverse events, and the experience gained as recent recommendations are implemented. Revised recommendations will be developed as needed. [ABSTRACT FROM AUTHOR]

These revised recommendations regarding vaccinia (smallpox) vaccine update the previous Advisory Committee on Immunization Practices (ACIP) recommendations (MMWR 1991;40; No. RR-14:1-10 ) and include current information regarding the nonemergency use of vaccinia vaccine among laboratory and health-care workers occupationally exposed to vaccinia virus, recombinant vaccinia viruses, and other Orthopoxviruses that can infect humans. In addition, this report contains ACIP's recommendations for the use of vaccinia vaccine if smallpox (variola) virus were used as an agent of biological terrorism or if a smallpox outbreak were to occur for another unforeseen reason. [ABSTRACT FROM AUTHOR]

These recommendations concern the use of aluminum hydroxide adsorbed cell-free anthrax vaccine (Anthrax Vaccine Adsorbed [AVA], BioPort Corporation, Lansing, MI) in the United States for protection against disease caused by Bacillus anthracis. In addition, information is included regarding the use of chemoprophy-laxis against B. anthracis. [ABSTRACT FROM AUTHOR]

The article presents an update to an article in the November 2007 issue where New York State Department of Health officials notified the U.S. Centers for Disease Control and Prevention of possible exposures to a vaccine strain of Brucella abortus RB51 which is used to vaccinate cattle against brucellosis in several clinical laboratories which participated in a Laboratory Preparedness Survey (LPS) proficiency test. As of January 14, 2008, no cases of brucellosis related to these exposures had been reported to the center. Exercises such as LPS which are designed to test skills and procedures in laboratories are one of the few that tests a laboratory's response to bioterrorism agents.

On August 29, 2021, the United States government oversaw the emergent establishment of Operation Allies Welcome (OAW), led by the U.S. Department of Homeland Security (DHS) and implemented by the U.S. Department of Defense (DoD) and U.S. Department of State (DoS), to safely resettle U.S. citizens and Afghan nationals from Afghanistan to the United States. Evacuees were temporarily housed at several overseas locations in Europe and Asia* before being transported via military and charter flights through two U.S. international airports, and onward to eight U.S. military bases, † with hotel A used for isolation and quarantine of persons with or exposed to certain infectious diseases. § On August 30, CDC issued an Epi-X notice encouraging public health officials to maintain vigilance for measles among Afghan evacuees because of an ongoing measles outbreak in Afghanistan (25,988 clinical cases reported nationwide during January-November 2021) (1) and low routine measles vaccination coverage (66% and 43% for the first and second doses, respectively, in 2020) (2)., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

In January 2020, with support from the U.S. Department of Homeland Security (DHS), CDC instituted an enhanced entry risk assessment and management (screening) program for air passengers arriving from certain countries with widespread, sustained transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). The objectives of the screening program were to reduce the importation of COVID-19 cases into the United States and slow subsequent spread within states. Screening aimed to identify travelers with COVID-19-like illness or who had a known exposure to a person with COVID-19 and separate them from others. Screening also aimed to inform all screened travelers about self-monitoring and other recommendations to prevent disease spread and obtain their contact information to share with public health authorities in destination states. CDC delegated postarrival management of crew members to airline occupational health programs by issuing joint guidance with the Federal Aviation Administration.* During January 17-September 13, 2020, a total of 766,044 travelers were screened, 298 (0.04%) of whom met criteria for public health assessment; 35 (0.005%) were tested for SARS-CoV-2, and nine (0.001%) had a positive test result. CDC shared contact information with states for approximately 68% of screened travelers because of data collection challenges and some states' opting out of receiving data. The low case detection rate of this resource-intensive program highlighted the need for fundamental change in the U.S. border health strategy. Because SARS-CoV-2 infection and transmission can occur in the absence of symptoms and because the symptoms of COVID-19 are nonspecific, symptom-based screening programs are ineffective for case detection. Since the screening program ended on September 14, 2020, efforts to reduce COVID-19 importation have focused on enhancing communications with travelers to promote recommended preventive measures, reinforcing mechanisms to refer overtly ill travelers to CDC, and enhancing public health response capacity at ports of entry. More efficient collection of contact information for international air passengers before arrival and real-time transfer of data to U.S. health departments would facilitate timely postarrival public health management, including contact tracing, when indicated. Incorporating health attestations, predeparture and postarrival testing, and a period of limited movement after higher-risk travel, might reduce risk for transmission during travel and translocation of SARS-CoV-2 between geographic areas and help guide more individualized postarrival recommendations., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

The 2015 Middle East respiratory syndrome (MERS) outbreak in the Republic of Korea (ROK) is an example of an infectious disease outbreak initiated by international travelers to a high-income country. This study was conducted to determine the economic impact of the MERS outbreak on the tourism and travel-related service sectors, including accommodation, food and beverage, and transportation, in the ROK. We projected monthly numbers of noncitizen arrivals and indices of services for 3 travel-related service sectors during and after the MERS outbreak (June 2015 to June 2016) using seasonal autoregressive integrated moving average models. Tourism losses were estimated by multiplying the monthly differences between projected and actual numbers of noncitizen arrivals by average tourism expenditure per capita. Estimated tourism losses were allocated to travel-related service sectors to understand the distribution of losses across service sectors. The MERS outbreak was correlated with a reduction of 2.1 million noncitizen visitors corresponding with US$2.6 billion in tourism loss for the ROK. Estimated losses in the accommodation, food and beverage service, and transportation sectors associated with the decrease of noncitizen visitors were US$542 million, US$359 million, and US$106 million, respectively. The losses were demonstrated by lower than expected indices of services for the accommodation and food and beverage service sectors in June and July 2015 and for the transportation sector in June 2015. The results support previous findings that public health emergencies due to traveler-associated outbreaks of infectious diseases can cause significant losses to the broader economies of affected countries.

In response to the largest recognized Ebola virus disease epidemic now occurring in West Africa, the governments of affected countries, CDC, the World Health Organization (WHO), and other international organizations have collaborated to implement strategies to control spread of the virus. One strategy recommended by WHO calls for countries with Ebola transmission to screen all persons exiting the country for "unexplained febrile illness consistent with potential Ebola infection." Exit screening at points of departure is intended to reduce the likelihood of international spread of the virus. To initiate this strategy, CDC, WHO, and other global partners were invited by the ministries of health of Guinea, Liberia, and Sierra Leone to assist them in developing and implementing exit screening procedures. Since the program began in August 2014, an estimated 80,000 travelers, of whom approximately 12,000 were en route to the United States, have departed by air from the three countries with Ebola transmission. Procedures were implemented to deny boarding to ill travelers and persons who reported a high risk for exposure to Ebola; no international air traveler from these countries has been reported as symptomatic with Ebola during travel since these procedures were implemented.

This report describes the first case of naturally acquired inhalation anthrax in the United States since 1976. The patient's clinical course included adjunctive treatment with human anthrax immunoglobulin. Clinical correlation of serologic assays for the lethal factor component of lethal toxin and anti-protective antigen immunoglobulin G are also presented.

Much progress has been made in recent years to strengthen local, state, national and international capacities to detect and respond to bioterrorism events and naturally occurring outbreaks of disease. New tools and systems are available to estimate the potential impact of a biological event and predict resource needs for effective response, enable earlier detection of an attack or outbreak, enhance diagnostic capacity and facilitate rapid intervention to mitigate the impact of an event on a community. These advances have required new approaches to preparedness, planning and surveillance, as well as new partnerships and collaborations across a range of disciplines. We examine some of these developments, discuss potential uses and limitations of these approaches, and identify priorities for the future.

A retrospective cohort study was conducted among troops training at Fort Chaffee, Arkansas, from May through June 1997, to identify infections caused by tick-borne pathogens. Serum samples were tested by IFAs for antibodies to selected Rickettsia and Ehrlichia species and by an investigational EIA for spotted fever group Rickettsia lipopolysaccharide antigens. Of 1,067 guardsmen tested, 162 (15.2%) had antibodies to one or more pathogens. Of 93 guardsmen with paired serum samples, 33 seroconverted to Rickettsia rickettsii or spotted fever group rickettsiae (SFGR) and five to Ehrlichia species. Most (84.8%) of the personnel who seroconverted to SFGR were detected only by EIA, and seropositivity was significantly associated with an illness compatible with a tick-borne disease. In addition, 34 (27%) of 126 subjects with detectable antibody titers reported a compatible illness. The primary risk factor for confirmed or probable disease was finding > 10 ticks on the body. Doxycycline use and rolling up of long sleeves were protective against seropositivity. The risk of transmission of tick-borne pathogens at Fort Chaffee remains high, and use of the broadly reactive EIA suggests that previous investigations may have underestimated the risk for infection by SFGR. Measures to prevent tick bite and associated disease may require reevaluation.

The release of nerve gas in a Tokyo subway and attempted releases of biological agents by the Aum Shinrikyo cult have demonstrated the willingness and ability of modern-day terrorists to use unconventional weapons. Unlike explosive weapons, the use of biologic weapons may only become apparent once people become ill. The detection and response to these man-made outbreaks will occur initially at the medical and public health levels. Therefore, the Centers for Disease Control and Prevention and its partners are strengthening their response, disease detection, diagnostic, and communication capabilities to better protect the nation's citizens against biological or chemical terrorism.

During May 1998, we conducted a case-control study of 357 participants from 60 households during an outbreak of acute bartonellosis in the Urubamba Valley, Peru, a region not previously considered endemic for this disease. Blood and insect specimens were collected and environmental assessments were done. Case-patients (n = 22) were defined by fever, anemia, and intra-erythrocytic coccobacilli seen in thin smears. Most case-patients were children (median age = 6.5 years). Case-patients more frequently reported sand fly bites than individuals of neighboring households (odds ratio [OR] = 5.8, 95% confidence interval [CI] = 1.2-39.2), or members from randomly selected households > or = 5 km away (OR = 8.5, 95% CI = 1.7-57.9). Bartonella bacilliformis isolated from blood was confirmed by nucleotide sequencing (citrate synthase [g/tA], 338 basepairs). Using bacterial isolation (n = 141) as the standard, sensitivity, specificity, and positive predictive value of thin smears were 36%, 96%, and 44%, respectively. Patients with clinical syndromes compatible with bartonellosis should be treated with appropriate antibiotics regardless of thin-smear results.

Objective: To identify common elements of large-scale human exposures to rabid or presumed rabid animals in the United States from 1990 to 1996., Design: Retrospective study., Procedure: Health departments in 50 states and the District of Columbia were contacted regarding episodes of large-scale human exposures to rabid animals occurring between 1990 and 1996. A large-scale exposure was defined as administration of postexposure prophylaxis (PEP) to 25 or more people after an exposure to a rabid or presumed rabid animal or littermates. Incident-specific information was obtained through questionnaires sent to states reporting episodes. Data are reported as medians., Results: Fifteen of 51 (29.4%) health departments reported 22 episodes; 72.7% involved companion animals or livestock. Twenty-six animals were involved in these 22 episodes, including 10 (38.5%) dogs, 4 (15.4%) livestock, 4 (15.4%) raccoons, 3 (11.5%) cats, 3 (11.5%) bats, and 2 (7.7%) ferrets. Schools (36.4%) and public places (22.7%) were the most common settings for exposures. Reportedly, 1,908 people received PEP. The cost for 10 episodes was $61,547/episode (range, $14,199 to $1,500,000). An episode-specific written algorithm for recommending PEP had been developed for use in only 4 (18.2%) episodes., Clinical Implications: Large-scale exposures most commonly involved a single companion animal. Exposures attributable to improper handling of wildlife and unrestricted access of animals in schools and public areas can be potentially remedied by targeted education. Use of an episode-specific algorithm to determine need for PEP may also reduce the number of unnecessary treatments.

Vibrio vulnificus has been associated with three main clinical syndromes; primary septicemia; wound infection, and gastroenteritis. This organism has increased virulence for persons with underlying medical conditions that predispose to iron overload or an impaired immune system. Since the organism proliferates more readily in warm, coastal waters, such infections are more commonly found in those regions. Infection can result from the ingestion of contaminated, undercooked seafood; contact of a wound with seawater; or a puncture wound sustained from a contaminated surface. Vibrio infections rarely occur in inland areas, but when they do occur, they are usually a result of the contact of wounds with contaminated, brackish water or the ingestion of raw shellfish. Because infections with this organism occur less frequently in non-coastal regions, the diagnosis may not be suspected initially in susceptible individuals and a delay of treatment may result. We present a case of V. vulnificus sepsis occurring in a man with underlying liver disease and a history of row oyster consumption in Oklahoma and discuss the clinical manifestations of primary sepsis with this organism as well as prevention strategies.