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To the Editor: In their discussion of the risk of contact vaccinia spread from individuals who receive smallpox vaccine, Dr Neff and colleagues¹ only briefly discussed the risk to patients from health care workers who have been recently vaccinated. Scrupulous hand hygiene among vaccine recipients will be important in preventing vaccinia transmission; however, it is not clear that this would entirely negate the risk of transmission.

Enveloped lipophilic viruses such as vaccinia are more readily inactivated by alcohol and other disinfectants than are nonenveloped viruses.² There are only sparse data, however, about inactivation by topical antiseptics or nonmedicated soaps of enveloped intracellular viruses that might be encountered at the site of smallpox vaccination. Fifteen seconds of contact between an alcohol-based hand rinse product is virucidal for cell-free orthopoxvirus, leading to a 10 000-fold reduction in viral infectivity, irrespective of the presence of proteinaceous material.³ Fifteen seconds of contact between cell-free recombinant vaccinia virus and nonmedicated soap, in the absence of added proteinaceous material, leads to a 1000-fold reduction in viable vaccinia.⁴ Sixty seconds of contact between intracellular vaccinia virus and nonmedicated soap has no significant effect on recombinant vaccinia virus viability.⁴

The efficacy of alcohol-based antiseptic products for hand hygiene in rapidly eradicating intracellular vaccinia virus is unclear. Use of alcohol-based antiseptic products improves health care workers' compliance with hand hygiene. This is why it has been recommended as a standard in US hospitals if hands are not visibly dirty or contaminated with proteinaceous material.⁵

Thus, it is now important to test currently marketed alcohol-based topical antiseptics to determine which, if any, are rapidly virucidal against intracellular vaccinia in the presence of serum or erythrocytes and albumin likely to be present at the site of smallpox vaccination. This is important since nonmedicated soaps used in many hospitals are ineffective at inactivating such viruses.⁴ Thus, gloves should always be worn any time there is a risk of contact with the vaccine site. Once gloves are removed, hands should be cleansed with the most effective topical antiseptic.

Leonard A. Mermel, DO, ScM
Division of Infectious Diseases
Rhode Island Hospital
Providence

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. Ali Y, Dolan MJ, Fendler EJ, Larson EL. Alcohols. In: Block SS, ed. Disinfection, Sterilization, and Preservation. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001:229-253. 3. Kamph G, Rudolf M, Labadie JC, Barrett SP. Spectrum of antimicrobial activity and user acceptability of the hand disinfectant agent sterillium gel. J Hosp Infect. 2002;52:141-147. FULL TEXT | ISI | PUBMED 4. Jonczy EA, Daly J, Kotwal GJ. A novel approach using an attenuated recombinant vaccinia virus to test the antipoxviral effects of handsoaps. Antiviral Res. 2000;45:149-153. FULL TEXT | PUBMED 5. Boyce JM, Pittet D, Farr BM, et al. Guidelines for hand hygiene in healthcare settings. MMWR Recomm Rep. 2002;51(RR-16):1-45.

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

JAMA. 2003;289:844-845.

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