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To the Editor: The US government recently announced a program to offer smallpox immunization to hospital health care workers (HCWs). The vaccine contains live vaccinia virus and carries a risk of significant adverse events for vaccinees and their close contacts. From experience in the 1960s, for every 100 000 primary vaccinees, there would be an expected 2 to 6 transmissions of virus to unvaccinated contacts, with 1 to 2 cases of eczema vaccinatum.¹ Individuals at high risk of serious complications from contact vaccinia (CV) include immunocompromised contacts, those with chronic dermatologic conditions, and children younger than 5 years.¹ In the past, most transmission occurred in the home setting and rarely as a result of hospital-related contact. However, because hospital transmission to patients has been documented,¹ vaccinating HCWs may expose patients to undue risk. The number of patients currently at increased risk in hospitals is unknown, but is certainly higher than in the 1960s.

Methods
We estimated the proportion of hospitalized patients at increased risk for serious complications from CV by analyzing the New York State hospital discharge file for 2001. This file includes all nonfederal, nonpsychiatric inpatient hospital discharges. We selected one group having primary or secondary discharge diagnoses that are contraindications for smallpox vaccination (high-risk conditions), as well as a second group having lower-risk conditions. These included diagnoses suggestive of possible immunocompromise or debility (conditions often treated with steroids, diabetes mellitus, etc) or skin conditions that increase risk of complications from CV.

Results
During 2001, there were 1 107 173 hospital discharges in New York City, of which 228 043 (21%) received International Classification of Diseases, Ninth Revision codes for high-risk conditions and 398 342 (36%) received codes for lower-risk conditions (Table 1). In the rest of New York State (upstate), 240 170 (19%) of the 1 294 287 total hospital discharges received codes for high-risk conditions and 470 739 (36%) received codes for lower-risk conditions. The rate of hospitalization for these conditions was 74 per 1000 population in New York City (population: 8 008 278) and 61 per 1000 population in upstate (population: 10 968 179). The mean (6 days) and median (3 days) lengths of stay for these conditions were similar to hospitalizations for all conditions, suggesting that at any point in time more than 50% of inpatients have 1 or more of these conditions.

View this table: [in this window] [in a new window] Table. Hospital Discharges by Selected Conditions in New York, 2001

Comment
Our estimates are crude since the actual health status of these patients was not validated by medical chart review. Our numbers may be overestimates because we included conditions (eg, chronic obstructive pulmonary disease) that do not always require immunosuppressive therapy. On the other hand, we were unable to identify all patients who underwent surgery, which compromises skin integrity (approximately 469 371 in New York City and 637 337 upstate), and bone marrow and solid organ transplants (795 in New York City and 1238 upstate).

The US Centers for Disease Control and Prevention (CDC) has published recommendations against placing HCWs on leave after receiving smallpox vaccination.² The finding that half of hospitalized patients in New York State may be at increased risk for CV complications points out the need for strict adherence to infection control guidelines for vaccinated HCWs. The CDC recommends daily inspection and covering of the vaccine site with a semipermeable dressing over absorbent material, meticulous hand washing after contact with the site, and administrative leave for HCWs if complications of vaccination develop. Successful implementation of this policy will require the complete cooperation of every vaccinated HCW to avoid complications among vulnerable hospital patients.

Perry F. Smith, MD; Hwa-Gan Chang, MS
New York State Department of Health
Albany

Kent A. Sepkowitz, MD
Memorial Sloan-Kettering Cancer Center
New York, NY

1. Neff JM, Lane JM, Fulginiti VA, Henderson DA. Contact vaccinia: transmission of vaccinia from smallpox vaccination. JAMA. 2002;288:1901-1905. FREE FULL TEXT 2. US Centers for Disease Control and Prevention. Recommendations for using smallpox vaccine in a pre-event vaccination program: supplemental recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2003. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/m2d226.htm. Accessibility verified March 5, 2003.

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;289:1512-1513.

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