Allison L. Naleway, PhD; Edward A. Belongia, MD; Robert T. Greenlee, PhD, MPH; Burney A. Kieke Jr, MS; Robert T. Chen, MD, MA; David K. Shay, MD, MPH
Acknowledgments: The authors thank Drs. John Melski, Scott Norton, and Cynthia Henry for their advice on study design and case definition; Kathy Brecke, Theresa Esser, Nancy Gilge, Juanita Herr, Deborah Hilgemann, Debra Kempf, Tina Kollmansberger, Jacklyn Salzwedel, and Sonia Weigel for their assistance with data collection; Lorelle Benetti, Marilyn Bruger, Jaime Elliott, and Donna Wittman for their assistance with data entry and data management; and Carol Beyer for assistance with manuscript preparation.
Grant Support: By the Vaccine Safety Datalink, contract 200-95-0957 (task order 57) from the Centers for Disease Control and Prevention.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Edward A. Belongia, MD, Epidemiology Research Center, Marshfield Clinic Research Foundation, 1000 North Oak Avenue-Mailstop ML2, Marshfield, WI 54449; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Naleway, Belongia, and Greenlee and Mr. Kieke: Epidemiology Research Center, Marshfield Clinic Research Foundation, 1000 North Oak Avenue-Mailstop ML2, Marshfield, WI 54449.
Drs. Chen and Shay: Immunization Safety Branch, National Immunization Program, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E-61, Atlanta, GA 30333.
Author Contributions: Conception and design: A.L. Naleway, E.A. Belongia, R.T. Greenlee, R.T. Chen, D.K. Shay.
Analysis and interpretation of the data: A.L. Naleway, E.A. Belongia, R.T. Greenlee, B.A. Kieke.
Drafting of the article: A.L. Naleway, E.A. Belongia, R.T. Greenlee, R.T. Chen, D.K. Shay.
Critical revision of the article for important intellectual content: A.L. Naleway, E.A. Belongia, R.T. Greenlee, R.T. Chen, D.K. Shay.
Final approval of the article: A.L. Naleway, E.A. Belongia, R.T. Greenlee, R.T. Chen, D.K. Shay.
Statistical expertise: B.A. Kieke.
Obtaining of funding: R.T. Chen, D.K. Shay.
Administrative, technical, or logistic support: R.T. Chen, D.K. Shay.
Collection and assembly of data: A.L. Naleway, R.T. Greenlee.
Persons with atopic dermatitis or eczema, regardless of disease severity or activity, may develop eczema vaccinatum if they or their close contacts receive the smallpox vaccine. According to current recommendations, a preexposure vaccination program should identify these persons and exclude them from participating.
To determine the prevalence of diagnosed atopic dermatitis and eczema in a defined population and assess the sensitivity of screening questions to identify patients who have received these diagnoses.
Population-based prevalence survey and telephone interview.
14 ZIP code regions in Wisconsin.
Persons given a diagnosis of atopic dermatitis or eczema in 2000 and 2001 were identified from a population-based cohort. Persons with a history of atopic dermatitis diagnosed since 1979 were eligible for the telephone survey.
Prevalence of diagnosed atopic dermatitis or eczema; proportions of respondents able to recall a past diagnosis of atopic dermatitis, eczema, or recurrent rash.
The prevalence of atopic dermatitis or eczema diagnosis in 2000 or 2001 was 0.8%. At least 2.4% of the cohort would be ineligible for smallpox vaccination because of active skin disease in themselves or household members. Among 94 adult respondents with atopic dermatitis, 55 (59%) correctly self-reported skin disease. Seventy-nine (60%) of 133 household contacts of adults with atopic dermatitis correctly reported the presence of skin disease in a household member. Parental recall of skin disease in children with atopic dermatitis was 70% (123 of 177).
Identifying dermatologic contraindications to smallpox vaccination by relying only on a self-reported history of rash illnesses is likely to miss a substantial proportion of individuals who should not receive smallpox vaccine in a preexposure vaccination campaign.
People with a history of atopic dermatitis or eczema in themselves or their close contacts should not receive preexposure smallpox vaccination because of the risk for eczema vaccinatum.
This population-based study suggests that about 40% of people would not correctly report that they or a close contact has these skin conditions even though medical records confirm that they do.
Relying on patient self-report about dermatologic contraindications to smallpox vaccination would miss a substantial proportion of people with true contraindications.
Table 1. Prevalence of Atopic Dermatitis or Eczema in the Marshfield Epidemiologic Study Area on 31 December 2001, Based on Diagnoses in 2000 and 2001
Sampling and response from telephone interview with parents or guardians of children with atopic dermatitis, adult patients with atopic dermatitis, and adult household contacts of adult patients with atopic dermatitis.
Table 2. Recall of Dermatologic Diagnoses and Symptoms by Parents or Guardians of Children with Atopic Dermatitis, Adult Patients with Atopic Dermatitis, and Adult Household Contacts of Adult Patients with Atopic Dermatitis
Predicted recall of dermatologic diagnoses and rash by time since last diagnosis.
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Naleway AL, Belongia EA, Greenlee RT, et al. Eczematous Skin Disease and Recall of Past Diagnoses: Implications for Smallpox Vaccination. Ann Intern Med. 2003;139:1–7. doi: 10.7326/0003-4819-139-1-200307010-00006
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Published: Ann Intern Med. 2003;139(1):1-7.
Bioterrorism Infectious Agents, Infectious Disease, Prevention/Screening, Vaccines/Immunization.
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