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Myopericarditis Following Smallpox Vaccination Among Vaccinia-Naive US Military Personnel

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Myopericarditis Following Smallpox Vaccination Among Vaccinia-Naive US Military Personnel ORIGINAL CONTRIBUTION Myopericarditis Following Smallpox Vaccination Among Vaccinia-Naive US Military Personnel Jeffrey S. Halsell, DO Context In the United States, the annual incidence of myocarditis is estimated at 1 James R. Riddle, DVM, MPH to 10 per 100000 population. As many as 1% to 5% of patients with acute viral in- J. Edwin Atwood, MD fections involve the myocardium. Although many viruses have been reported to cause myopericarditis, it has been a rare or unrecognized event after vaccination with the Pierce Gardner, MD currently used strain of vaccinia virus (New York City Board of Health). Robert Shope, MD Objective To describe a series of probable cases of myopericarditis following small- Gregory A. Poland, MD pox vaccination among US military service members reported since the reintroduction of vaccinia vaccine. Gregory C. Gray, MD, MPH Design, Setting, Participants Surveillance case definitions are presented. The cases Stephen Ostroff, MD were identified either through sentinel reporting to US military headquarters surveillance Robert E. Eckart, DO using the Defense Medical Surveillance System or reports to the Vaccine Adverse Event Reporting System using International Classification of Diseases, Ninth Revision. The cases Duane R. Hospenthal, MD, PhD occurred among individuals vaccinated from mid-December 2002 to March 14, 2003. Roger L. Gibson, DVM, PhD Main Outcome Measure Elevated serum levels of creatine kinase (MB isoenzyme), John D. Grabenstein, RPh, PhD troponin I, and troponin T, usually in the presence of ST-segment elevation on elec- trocardiogram and wall motion abnormalities on echocardiogram. Mark K. Arness, MD, MTM&H Results Among 230734 primary vaccinees, 18 cases of probable myopericarditis af- David N. Tornberg, MD, MPH ter smallpox vaccination were reported (an incidence of 7.8 per 100000 over 30 days). and the Department of Defense No cases of myopericarditis following smallpox vaccination were reported among 95622 Smallpox Vaccination Clinical vaccinees who were previously vaccinated. All cases were white men aged 21 years to Evaluation Team 33 years (mean age, 26.5 years), who presented with acute myopericarditis 7 to 19 days following vaccination. A causal relationship is supported by the close temporal cluster- E REPORT THE FIRST 18 ing (7-19 days; mean, 10.5 days following vaccination), wide geographic and temporal cases of probable myo- distribution, occurrence in only primary vaccinees, and lack of evidence for alternative pericarditis following etiologies or other diseases associated with myopericarditis. Additional supporting evi- smallpox vaccination dence is the observation that the observed rate of myopericarditis among primary vac- cinees is 3.6-fold (95% confidence interval, 3.33-4.11) higher than the expected rate Wamong otherwise healthy, young adult among personnel who were not vaccinated. The background incidence of myopericar- members of the US military who were ditis did not show statistical significance when stratified by age (20-34 years: 2.18 ex- vaccinated between mid-December pected cases per 100000; 95% confidence interval [CI], 1.90-2.34), race (whites: 1.82 2002 and March 14, 2003 (N=326356; per 100000; 95% CI, 1.50-2.01), and sex (males: 2.28 per 100000; 95% CI, 2.04-2.54). 230734 primary vaccinees and 95622 Conclusion Among US military personnel vaccinated against smallpox, myopericar- revaccinees). Despite decades as the ditis occurred at a rate of 1 per 12819 primary vaccinees. Myopericarditis should be standard vaccine for US civilian and considered an expected adverse event associated with smallpox vaccination. Clini- military populations, the New York City cians should consider myopericarditis in the differential diagnosis of patients present- Board of Health (NYCBOH) strain of ing with chest pain 4 to 30 days following smallpox vaccination and be aware of the vaccinia virus (Dryvax, Wyeth Labo- implications as well as the need to report this potential adverse advent. ratories, Marietta, Pa) has only rarely JAMA. 2003;289:3283-3289 www.jama.com See also pp 3278, 3290, 3295, Author Affiliations are listed at the end of this article. Skyline Six, Suite 682, 5111 Leesburg Pike, Falls Church, and 3306. Corresponding Author and Reprints: James R. Riddle, VA 22041-3206 (e-mail: [email protected] DVM, MPH, Armed Forces Epidemiological Board, .army.mil). ©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, June 25, 2003—Vol 289, No. 24 3283 Downloaded From: https://jamanetwork.com/ on 09/25/2021 MYOPERICARDITIS FOLLOWING SMALLPOX VACCINATION AMONG US MILITARY PERSONNEL dividual’s longitudinal health record, Box. Myopericarditis Following Smallpox Vaccination: which was maintained as part of the De- Adverse Event Surveillance Case Definitions fense Medical Surveillance System 25 Confirmed Myopericarditis Following Vaccination (DMSS). This system integrates data from sources worldwide in a continu- Patient with acute myocarditis* with or without pericarditis with symptom onset 4 to 30 days after vaccinia exposure and absence of another causal infection, dis- ously expanding relational database that ease or toxic agent and, virus culture or detection† of vaccinia DNA by polymer- documents the military and medical ex- ase chain reaction identification of vaccinia virus infection from myocardial tis- periences of service members through- sue or pericardial fluid (detection of viral nucleic acid in the myocardium is regarded out their careers. The DMSS allows as indicative of virus infection) nearly instantaneous assessments of the Probable Myopericarditis Following Vaccination morbidity experiences of service mem- Patient with acute myocarditis* with or without pericarditis with symptom onset bers who share common characteris- 4 to 30 days after vaccinia exposure and absence of another causal infection, dis- tics, such as vaccination. Statistical ease, or toxic agent analysis was performed using SAS ver- *Clinical diagnosis of myocarditis is confirmed by detection of elevated serum levels of cre- sion 8.02 (SAS Institute, Cary, NC). atine kinase (MB isoenzyme), troponin I, and troponin T, usually in the presence of ST- segment elevation on electrocardiogram and abnormal findings on echocardiogram. Case Identification †Whether vaccinial myopericarditis is a direct viral cytopathogenic effect or an immune- The cases presented herein were iden- mediated disease remains unclear. tified either through sentinel report- ing to military headquarters and/or to the VAERS or through diagnostic sur- been associated with myopericarditis December 2002.24 To detect adverse veillance among vaccinees at military following vaccination. Only 5 cases events after vaccination, the Depart- treatment facilities using International were reported in the medical litera- ment of Defense and the US Coast Guard Classification of Diseases, Ninth Revi- ture between 1955 and 1986.1-8 require reporting to the Vaccine Ad- sion (ICD-9)26 coded diagnoses (420.90, Myocarditis and pericarditis follow- verse Event Reporting System (VAERS) 420.99, other and unspecified acute ing vaccination have been reported more using established guidelines. Addition- pericarditis; 422.90, 422.91, other and commonly with other vaccinia virus ally, the Department of Defense encour- unspecified acute myocarditis; and strains,9-17 may be associated with other ages clinicians to report all other clini- 429.0 myocarditis unspecified) ob- adverse events following vaccination,2 cally relevant adverse events after tained from the DMSS. Fifteen cases and may be asymptomatic.10,18-20 In 1968, administration of any vaccine or medi- were first identified from surveillance Price and Alpers14 noted that minor car- cation to VAERS or MedWatch (US Food of military treatment facilities, and only diac complications after smallpox vac- and Drug Administration Safety Infor- 3 cases were first identified from the cination may be more common than is mation and Adverse Event Reporting VAERS. The cases were classified based generally reported. Six years earlier, Program). To heighten awareness of po- on surveillance case definitions shown MacAdam and Whitaker21 reported 3 tential adverse events, including car- in the BOX. Clinical diagnosis of myo- cases of cardiac complications 5 to 14 diac events, clinicians were provided ex- carditis was based on detection of el- days following smallpox vaccination and tensive education and vaccinees were evated serum levels of creatine kinase suggested that cardiac complications had individually counseled and provided (MB isoenzyme), troponin I, and tro- been previously overlooked. In 1983, the educational material. An Internet site ponin T, usually in the presence of ST- incidence of myocarditis following vac- providing access to a comprehensive ar- segment elevation on electrocardio- cination among Finnish military con- ray of materials and ongoing program gram and wall motion abnormalities on scripts who were hospitalized with mild status was established (http://www echocardiogram. myocarditis following vaccination with .smallpox.army.mil/). the Finnish strain of smallpox had been A 3-pronged approach was imple- RESULTS estimated to be as high as 1 per 10000.22 mented for surveillance and patient Clinical and diagnostic details for the 18 As early as 1953, Mathieu and Hadot23 safety following vaccination, as de- cases of probable myopericarditis fol- recommended screening for cardiac risk scribed by Grabenstein and Winken- lowing smallpox vaccination reported factors before
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