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Urticaria, Exanthems, and Other Benign Dermatologic Reactions to Smallpox Vaccination in Adults

  1. Richard N. Greenberg1,2,
  2. Robert H. Schosser1,2,
  3. Elizabeth A. Plummer2,
  4. Sara E. Roberts2,
  5. Malissia A. Caldwell2,
  6. Dana L. Hargis2,
  7. David W. Rudy2,
  8. Martin E. Evans1,2, and
  9. Robert J. Hopkins3
  1. 1Department of Medicine, Department of Veterans Affairs Medical Center, Lexington, Kentucky
  2. 2University of Kentucky Medical School, Lexington, Kentucky
  3. 3DynPort Vaccine Company, Frederick, Maryland
  1. Reprints or correspondence: Dr. Richard N. Greenberg, Room CC444, Dept. of Medicine, University of Kentucky Medical Center, 800 Rose St., Lexington, KY 40536-0084 (RNGREE01{at}uky.edu).

  1. Presented in part: 6th Annual Conference on Vaccine Research (National Foundation for Infectious Diseases), Arlington, MD, May 2003 (abstract S12).

 
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Abstract

A phase 1 smallpox vaccine trial involving 350 adult volunteers was conducted. Of these subjects, 250 were naive to vaccinia virus vaccine (i.e., “vaccinia naive”). Volunteers received a new cell-cultured smallpox vaccine or a live vaccinia virus vaccine. Nine self-limiting rashes (3.6%) were observed in the vaccinia-naive group. None of the vaccinia-experienced patients had a rash. Rashes appeared 6–19 days after vaccination and had 5 different clinical presentations. Five volunteers had urticarial rashes that resolved within 4–15 days, 1 had an exanthem that lasted 20 days, and 1 each presented with folliculitis, contact dermatitis, and erythematous papules found only on the hands and fingers. Volunteers reported pruritus, tingling, and occasional headaches. Relief was obtained with antihistamine and acetaminophen therapy. No volunteer experienced fever or significant discomfort.

Because there is a risk that the smallpox virus will be used as a bioterrorism weapon, new cell-cultured smallpox vaccines (CCSVs) are being developed. Live vaccinia virus vaccines have been used in the past, including Dryvax (Wyeth Laboratories). Dryvax production and distribution to civilians ceased in 1983 because of lack of need. Because it was prepared from calf lymph, Dryvax can no longer be manufactured without extensive safety testing of livestock and US Food and Drug Administration approval, and only old stocks remain.

Studies are being planned or are underway that involve the use of new CCSVs in both children and adults. These studies have raised questions about the safety and adverse-event profile of the vaccine for individuals naive to vaccinia virus vaccine (hereafter, “vaccinia-naive”). Until 1971, when the Advisory Committee on Immunization Practices recommendation for vaccination ended, most American infants were routinely vaccinated. Since then, millions of Americans have never been vaccinated. Furthermore, there is a paucity of literature describing vaccinia virus vaccine—related reactions in adults who are vaccinia naive, and descriptions of adverse events are mostly limited to young children and infants.

We recently completed a phase 1 trial involving a new CCSV (DynPort Vaccine Company). One of the more impressive but non—life-threatening side effects observed in this trial was the development of benign, self-limiting rashes. The frequent occurrence of vaccinia-associated rashes has been described in the literature, but color images and descriptions of the varied range of clinical presentations in adults are limited. We describe 9 adults with benign rashes associated with live vaccinia virus vaccination (either Dryvax or a new CCSV). Our volunteers were otherwise asymptomatic, except for itching, tingling sensations, and occasional headaches. No rash was thought to be due to progressive vaccinia, eczema vaccinatum, or generalized vaccinia. These serious reactions are rare but occur at a rate of 3–5 events per 1 million primary vaccinations [1]. The purpose of this article is to alert the general practitioner to these benign rashes, which require no more than symptomatic treatment with antihistamines.

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Patients and Methods

From July 2002 through February 2003, 350 adults (⩾18 years of age) were vaccinated in a phase 1 study of a new CCSV and Dryvax. The phase 1 study was planned primarily to compare the pock take rate and adverse events of this new CCSV with that of Dryvax. A total of 250 volunteers were vaccinia naive and <31 years old, and 100 were vaccinia experienced and 32–65 years old. One hundred volunteers received Dryvax (2.5 × 105 plaque-forming units administered via 15 percutaneous punctures with a bifurcated needle), and 250 volunteers received the new CCSV (2.5 × 105 plaque-forming units or a dilution of this amount administered via 15 percutaneous punctures with a bifurcated needle). Volunteers had to be HIV antibody negative; free of immunosuppressive drugs; free of an immunosuppressive condition; free of eczema or atopic dermatitis; have normal serum levels of IgM, IgG, and IgA; hepatitis B antigen and hepatitis C antibody negative; and not pregnant. Complete blood count, liver and renal function blood testing, urine analysis, and lipid screening were performed, and uric acid level and blood sedimentation rate were measured. A physical examination was performed during the screening process, and several volunteers with severe acne, nodular skin conditions, or large areas of unhealed skin were excluded. Volunteers were observed for 180 days after vaccination, with periodic examinations performed. The presentations and pictures of the rashes were reviewed with a consulting dermatologist (R.H.S.).

CCSV used in the study was derived from the 1932 New York City Board of Health virus seed and was passed in calves until the 1960s, when Connaught Laboratories developed master seeds. Seed 17333 was provided to the US Army Medical Research Institute of Infectious Diseases in the 1980s, at which time it was plaque-purified and adapted to grow in MRC-5 cells (human diploid lung fibroblast cell line). A derivative of this, referred to as the Salk Institute (TSI) strain, was prepared as a master seed in 1989. TSI has been stored under controlled, secure conditions (<70°C) since then and is the seed strain used to produce CCSV. CCSV is made from plaque-purified TSI.

A comprehensive description of the phase 1 trial is being prepared for publication.

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Results

Volunteer 5003, a vaccinia-naive 24-year-old woman, was vaccinated with CCSV (dilution, 1 : 10) and had no symptoms until day 17 after vaccination, when she noticed several small pruritic papules on her body. By the next day, she had many edematous papules consistent with urticaria on her thighs, arms, and forearms. Some of the papular lesions were over hair follicles and resembled goose bumps, but they itched. There were a few (<20) papular lesions below the knee. She said she felt them on her feet, but none were visible. There were ∼50 lesions on each arm, 20 on each forearm, 10 on the chest, and 1 just above the upper lip. There were <10 lesions on each hand, including 1 on each palm. There were no lesions on the oropharynx. By day 20, the rash had resolved. The volunteer used diphenhydramine and loratadine, had no other systemic symptoms, and was afebrile while the rashes were present.

Volunteer 5035, a vaccinia-naive 23-year-old woman, was vaccinated with CCSV (dilution, 1 : 5) and, on day 9 after vaccination, noticed small wheals (diameter, 1–4 mm) on both hands and perioral tingling. She used diphenhydramine and ibuprofen to relieve her symptoms. By the following day, her fingers had swelled, and there were small erythematous lesions on the dorsal surfaces of her hands, extending to the wrists. Similarly, her toes had swelled, and there were comparable lesions on the dorsal surfaces of the feet that extended up to her ankles. The soles and palms appeared to be normal. The presentation was consistent with urticaria and angioedema of the fingers and toes. Bending her fingers caused a moderate amount of discomfort, as did walking (due to the swollen toes). Also, she had a red flush around her lips that was associated with a tingling sensation (figure 1). By day 12, the rash and swelling had resolved, but her feet remained mildly pruritic. The pruritus ended shortly thereafter. She did not have any other systemic symptoms and was afebrile while the rashes were present.

Figure 1
Figure 1

Rash on a volunteer who received a smallpox vaccination 10 days earlier. A and C, Swollen erythematous fingers and hand. B, Swollen erythematous toes. C, Swollen red perioral area.

Volunteer 3028, a vaccinia-naive 25-year-old man, was vaccinated with undiluted Dryvax and noted multiple red areas across his back during the evening of the ninth day after vaccination. Physical examination on day 10 found multiple urticarial lesions scattered over the left and right shoulders, upper and lower back, upper chest, neck, face, and right side of the right knee (figure 2). Some of the lesions were pressure urticaria. There was no itching, pain, or tenderness. He had a moderate headache on days 9 and 10. He used desloratadine and diphenhydramine to relieve any symptoms associated with the rash and acetaminophen or ibuprofen to treat the headache. By day 11, lesions on his face had nearly cleared, and the remaining lesions were fading. By day 15, the rash had cleared. The patient did not have a fever or any other systemic symptoms while the rashes were present.

Figure 2
Figure 2

Rash, 1 day after onset, on a volunteer who received a smallpox vaccination 10 days earlier. An erythematous urticarial reaction is present on the back and chest. Lower right, Back without the urticaria 6 days later.

Volunteer 3017, a vaccinia-naive 26-year-old woman with mitral valve prolapse, was vaccinated with undiluted Dryvax. She received prophylaxis (at the discretion of the investigator) with 875 mg/125 mg of ampicillin-clavulanate (q12h for the first 2 days following vaccination). She denied having any drug allergies. She first noticed red bumps on her hands on day 15 after vaccination. By day 16, there were 8 small, red, nonpruritic, tender papules on her fingers, but there were no other symptoms, and she was afebrile (figure 3A). Because of a concern for subacute bacterial endocarditis, 3 sets of blood cultures were taken; none had growth. By day 21, the lesions on the fingers had faded; they were gone by day 24 after vaccination. She was healthy during the subsequent 6-month period. The consulting dermatologist could not determine the relationship of the papules to vaccination.

Figure 3
Figure 3

Lesions on 4 different volunteers. A, Two-millimeter erythematous papular lesion on the proximal interphalangeal joint of the ring finger (arrow) of volunteer 3017. B, Diffuse erythematous pruritic papular rash 3 mm in diameter on both hands of volunteer 5076. C, Arm of volunteer 5089, who received a smallpox vaccination 28 days earlier, with multiple abrasions that resulted from scratching. D, Pruritic erythematous papular body rash on volunteer 5051, who received a smallpox vaccination 21 days earlier.

Volunteer 5076, a vaccinia-naive 21-year-old man, was vaccinated with CCSV (dilution, 1 : 50) and, on day 19 after vaccination, first noticed an itchy rash on his hands. On day 22, physical examination found numerous small wheals up to 3 mm in diameter limited to the bilateral dorsal surfaces of the hands and both elbows (figure 3B). The rash was consistent with urticaria. By day 27, the rash had resolved. He was afebrile while the rashes were present.

Volunteer 5089, a vaccinia-naive 21-year-old man, was vaccinated with undiluted CCSV and, on day 16 after vaccination, reported having an itching sensation over his entire body. On day 17, he noticed small red bumps on his hands, arms, stomach, legs, and back, with continued itching. Physical examination on day 18 revealed >30 erythematous maculae and wheals consistent with urticaria on his arms, hands, stomach, back, and legs (figure 3C). His eyes felt scratchy but were not dry or watery, and his vision was not impaired. He had no oral lesions. On day 21, the volunteer reported more red bumps on his arms and upper legs and worsened itching. He took loratadine and diphenhydramine for relief of symptoms. On day 28, an examination found pruritic erythematous eruptions similar to what was seen earlier, but with the addition of excoriations on the arms. The knee lesions were resolving. The pruritic eruption resolved by day 30. He was afebrile and had no other symptoms while the rashes were present.

Volunteer 5051, a vaccinia-naive 19-year-old man, was vaccinated with CCSV (dilution, 1 : 5) and, in the evening of day 15 after vaccination, noticed an itchy rash on his body. Physical examination on day 18 revealed a diffusely pruritic macular erythematous eruption on his face, chest, back, abdomen, arms, hands, and lower legs. Perifollicular papules were evident. He took diphenhydramine and loratadine for relief of the itching. By day 21, the rash had faded and was no longer papular; however, some areas continued to itch (figure 3D). On day 28, physical examination found that the rash had completely resolved. The subject was afebrile and had no other symptoms while the rashes were present. The consulting dermatologist mentioned that the rash was similar in appearance to Malassezia (formerly known as Pityrosporum) folliculitis.

Volunteer 5047, a vaccinia-naive 24-year-old woman, was vaccinated with CCSV (dilution, 1 : 25) and on day 9 after vaccination, small red spots erupted over her entire body except for the face, palms, and soles; they were associated with a tingling sensation over her body. The generalized eruption was characterized by small blanching erythematous papules 1–4 mm in diameter. There was no itching, pain, or other systemic symptoms. The volunteer took diphenhydramine as needed to relieve the tingling sensation. On day 10, the redness of the spots had increased in intensity, especially over the axillae, thighs, and buttocks. Because of the dramatic increase in redness of the spots, she initiated fexofenadine therapy while continuing to receive diphenhydramine. By day 13, the rash on her upper body (back, stomach, chest, and arms) had begun to fade, but it remained unchanged over her lower extremities (figure 4); the tingling continued. Physical examination on day 28 found that the rash had completely resolved; she had discontinued her antihistamine therapy before the examination. While the rash was present, she was afebrile and noted no other symptoms related to the rash. The consulting dermatologist considered the rash to be consistent with a classical drug-induced exanthem.

Figure 4
Figure 4

An intense exanthem on the legs and abdomen of a volunteer who received a smallpox vaccination 13 days earlier. The rash resolved 28 days after vaccination.

Volunteer 5108, a vaccinia-naive 24-year-old man, was vaccinated with CCSV (dilution, 1 : 10) and showed no symptoms until day 6 after vaccination, when he noticed generalized pruritic erythematous papules on his body, except for his face, hands, and feet. He took loratadine for the next 3 days. On day 10, a 90 × 65–mm red and scaly circular area was noted over the left lateral arm, near the vaccination site (figure 5). The rash did not fluoresce under a Wood's lamp, and lesion scrapings in KOH did not show fungus. Empirical treatment with 1% econazole cream was initiated because of the suggestive appearance of the rash. The consulting dermatologist considered the red and scaly circular area to possibly be a contact dermatitis due to the bandage adhesive, which may have leaked onto the vaccination site. The dermatologist also believed that the entire presentation could be consistent with that diagnosis. By day 14, the erythematous papules on the body were fading, and the scaly circular lesion was resolving. The papules resolved by day 21, and the scaly area resolved by day 24. During the period of the rash, the volunteer was afebrile and had no other systemic symptoms.

Figure 5
Figure 5

Rash on a volunteer who received a smallpox vaccination 14 days earlier. A fading erythematous eruption on the calf and thigh and a large scaly lesion (possibly a contact dermatitis from the bandage adhesive) just beneath the vaccination site on left arm are evident.

Table 1 lists the time to rash presentation, the time to rash clearance, and total rash duration for the 9 volunteers. Rashes initially presented a mean of 13 days after vaccination and lasted for a mean of 11 days. The first 7 volunteers described in table 1 did not have exanthems or contact dermatitis, and their rashes lasted for a mean duration of 9 days. The rashes—an exanthem and a contact dermatitis—seen in the other 2 volunteers, lasted much longer, with a mean duration of 20 days.

Table 1
Table 1

Characteristics of rash in 9 volunteers who received smallpox vaccine.

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Discussion

In this study of 350 carefully screened adult volunteers, there were no serious adverse events (e.g., death, cancer, or hospitalization) related to either CCSV or Dryvax. However, 9 volunteers had rashes that were self-limited, benign, and associated mostly with pruritus, tingling, and occasional headaches. Eight of the rashes did not have any pustular components; only volunteer 5051 had folliculitis. None of the rashes had mucosal surface lesions. None of the volunteers had any systemic symptoms other than pruritus and occasional headaches. The volunteers obtained relief from itching with antihistamine treatment.

Five of the rashes were thought to be urticarial. Urticaria has been reported after vaccination with vaccinia virus and after inoculation with many other vaccines, including varicella vaccine, pneumococcal vaccine, meningococcal polysaccharide vaccine, Japanese encephalitis vaccine, Haemophilus type b vaccine, and influenza vaccine [2–7]. The cause of urticaria in such cases often remains unknown, but the possibility of an unexpected allergy to a component of the vaccine must always be considered. In 2 instances, urticaria was thought to be due to the gelatin component in the varicella vaccine. Intradermal testing with gelatin resulted in a wheal and flare reaction in both children tested [2]. Urticaria after vaccinia vaccination is uncommon [8] and, in our study, occurred in 5 (1%) of 350 volunteers (250 vaccinia-naive and 100 vaccinia-experienced individuals).

Four of the rashes were not urticarial. One of them was an exanthem. The exanthem took more time to resolve than did the urticarial rashes (20 days vs. 6 days). The single exanthem was extensive, with large, confluent areas of erythema, but it was also distinguished by a lack of associated symptoms. One rash was possibly a contact dermatitis due to the bandage adhesive, with both a localized rash and a generalized rash present. Another rash appeared to be folliculitis. Finally, 1 rash that presented as self-limiting erythematous papules localized to the hands remains unusual and unexplained.

The rashes appeared during the second week after vaccination and resolved a mean of 11 days later. The rashes occurred in 2 (4%) of 50 vaccinia-naive adults who received Dryvax, in 7 (3.5%) of 200 vaccinia-naive adults who received CCSV, in 0 of 50 vaccinia-experienced adults who received CCSV, and in 0 of 50 vaccinia-experienced adults who received Dryvax.

Neff et al. [9] mention that, in their national survey of complications of smallpox vaccination in the United States during 1963—including 765,000 primary vaccinees who were >10 years of age (total survey population of 14 million)—they found 12 patients with a generalized maculopapular rash that appeared 4–10 days after vaccination, all of whom recovered. No more than 2 of these patients were vaccinia-naive adults, and none were vaccinia-experienced adults. Neff et al. [9] found that complications, such as eczema vaccinatum, generalized vaccinia, and others (including benign rashes), occurred much more often among primary vaccinees than among revaccinees, and that the persons at highest risk were <1 year of age. The most common complication was generalized vaccinia, with a prevalence of 20.8 cases per million primary vaccinations.

A 4-state survey from 1963 describes 20 cases (in 600,000 vaccinations) of a generalized maculopapular rash of short duration that occurred ∼1 week after vaccination [10]. Results of a national survey reported in 1968 included no specific mention of adults with benign rashes. It is possible that some of the benign rashes were considered to be generalized vaccinia- or erythema multiforme–like rashes [11]. A 10-state survey also conducted in 1968 made no specific mention of benign rashes [12]. These reports provide very little description of benign vaccine-associated rashes.

Frey et al. [13] studied 680 vaccinia-naive adults aged 18–32 years in their trials of Dryvax dilutions. They describe hand lesions that were similar to those seen on volunteer 3017 and a generalized erythematous lesion that was seen in 5 of our subjects. They mention that 37 (5.4%) of 680 volunteers had rashes that appeared on days 7–9 after vaccination and that, for another 67 subjects (10.1%), rashes appeared on days 10–12, for an overall rate of 14.3%. Pustular and vesicular rashes were most common in their study, and rashes were mostly on the chest and back. All rashes resolved spontaneously. Their study suggests that benign rashes with Dryvax are relatively common; however, they did not suggest a cause for the rashes.

In a 148-volunteer study involving vaccinia-naive adults, Talbot et al. [14] report 4 participants (2.7%) who developed generalized eruptions and 11 (7.4%) who developed focal eruptions after vaccination with 1 of 3 dilutions (undiluted and dilutions of 1 : 5 and 1 : 10) of the Aventis Pasteur smallpox vaccine. Viral cultures of lesion biopsy specimens did not grow vaccinia. A skin biopsy sample obtained from a volunteer with a generalized rash revealed suppurative folliculitis without any evidence of a viral infection. All lesions resolved without scarring.

At the time of writing, there is only speculation that some of these rashes may represent a form of vasculitis that is the result of a host response to vaccination. It is possible that some of the rashes could be mild cases of generalized vaccinia. Generalized vaccinia is a syndrome resulting from the viremic spread of virus from the vaccination site. Lesions are similar to those associated with primary vaccination but are usually smaller and rapidly evolve to scarring [1]. None of the rashes described in our volunteers resembled the primary pock lesion. However, no diagnostic tests were conducted as part of this phase 1 trial. Additional studies will be needed to define the cause of these rashes.

Our report focuses on a variety of self-limiting skin reactions to vaccinia vaccination. Our findings are important because of the description of the variety of presentations as well as the course of the rashes. The study volunteers were selected after a rigorous screening process and represented an otherwise healthy population of adults. In such a population, there will be a small number of self-limited rashes, such as urticaria and exanthems. Urticarial rashes resolve <1 week after appearance, whereas exanthems may last >3 weeks and can be extensive.

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Acknowledgments

We thank Dr. Sandy Geile and Dr. Lloyd Mayer (University of Kentucky Medical School, Lexington), and the University of Kentucky Clinical Research Office, for their assistance with the patients, and Dr. Robert Malone, for reviewing the article in manuscript.

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Footnotes

  • Financial support: DynPort Vaccine Company, which financed the vaccine trial; the US Department of Defense Joint Vaccine Acquisition Program (DAMD 17-98-C-8024); and the University of Kentucky (GCRC grant number M01-RR-02602).

  • Conflict of interest: R.J.H. is employed by DynPort Vaccine Company; none of the other authors has any financial interest in this company.

  • Received September 29, 2003.
  • Revision received December 1, 2003.
  • Accepted March 15, 2004.
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References

  1. ↵
    1. Fulginiti VA,
    2. Papier A,
    3. Lane JM,
    4. Neff JM,
    5. Henderson DA
    . Smallpox vaccination: a review, part II. Adverse events. Clin Infect Dis 2003;37:251-71.
    Abstract/FREE Full Text
  2. ↵
    1. Singer S,
    2. Johnson CE,
    3. Mohr R,
    4. Holowecky C
    . Urticaria following varicella vaccine associated with gelatin allergy. Vaccine 1999;17:327-9.
    CrossRefMedlineWeb of Science
    1. Holdiness MR
    . Rare systemic dermatologic reaction after pneumococcal vaccine administration. South Med J 2003;96:64-5.
    CrossRefMedlineWeb of Science
    1. Ball R,
    2. Braun MM,
    3. Mootrey GT
    . Safety data on meningococcal polysaccharide vaccine from the Vaccine Adverse Event Reporting System. Vaccine Adverse Event Reporting System Working Group. Clin Infect Dis 2001;32:1273-80.
    Abstract/FREE Full Text
    1. Berg SW,
    2. Mitchell BS,
    3. Hanson RK,
    4. et al
    . Systemic reactions in US Marine Corps personnel who received Japanese encephalitis vaccine. Clin Infect Dis 1997;24:265-6.
    Abstract/FREE Full Text
    1. Humphreys F
    . Acute urticaria and angio-edema following haemophilus influenzae b vaccination. Br J Dermatol 1994;131:582-3.
    CrossRefMedlineWeb of Science
  7. ↵
    1. Horowitz L
    . Urticaria subsequent to administration of influenza vaccine. South Med J 1979;72:1334-5.
    MedlineWeb of Science
  8. ↵
    1. Lane JM,
    2. Goldstein J
    . Adverse events occurring after smallpox vaccination. Semin Pediatr Infect Dis 2003;14:189-95.
    CrossRefMedline
  9. ↵
    1. Neff JM,
    2. Lane JM,
    3. Pert JH,
    4. Moore R,
    5. Millar JD,
    6. Henderson DA
    . Complications of smallpox vaccination. 1. National survey in the United States, 1963. N Engl J Med 1967;276:125-32.
    MedlineWeb of Science
  10. ↵
    1. Neff JM,
    2. Levine RH,
    3. Lane JM,
    4. et al
    . Complications of smallpox vaccination United Stated 1963. II. Results obtained by four statewide surveys. Pediatrics 1967;39:916-23.
    Abstract/FREE Full Text
  11. ↵
    1. Lane JM,
    2. Ruben FL,
    3. Neff JM,
    4. Millar JD
    . Complications of smallpox vaccination, 1968: national surveillance in the United States. N Engl J Med 1969;281:1201-8.
    MedlineWeb of Science
  12. ↵
    1. Lane JM,
    2. Ruben FL,
    3. Neff JM,
    4. Millar JD
    . Complications of smallpox vaccination, 1968: results of ten statewide surveys. J Infect Dis 1970;122:303-9.
    MedlineWeb of Science
  13. ↵
    1. Frey SE,
    2. Couch RB,
    3. Tackett CO,
    4. et al
    . Clinical responses to undiluted and diluted smallpox vaccine. National Institute of Allergy and Infectious Diseases Smallpox Vaccination Study Group. N Engl J Med 2002;346:1265-74.
    CrossRefMedlineWeb of Science
  14. ↵
    1. Talbot TR,
    2. Bredenberg HK,
    3. Smith M,
    4. LaFleur BJ,
    5. Boyd A,
    6. Edwards KM
    . Focal and generalized folliculitis following smallpox vaccination among vaccinia-naive recipients. JAMA 2003;289:3290-4.
    Abstract/FREE Full Text
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  1. Clin Infect Dis. (2004) 38 (7): 958-965. doi: 10.1086/382360
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