Guest guest Posted February 1, 2003 Report Share Posted February 1, 2003 > How contagious is vaccinia? > > > Friends, > To view the tables intact in the below article, go to the actual URL. To > contact the article's author, write: sepkowik > Jock > > http://content.nejm.org/cgi/content/short/348/5/439?query=TOC > > Volume 348:439-446 January 30, 2003 Number 5 > > How Contagious Is Vaccinia? > Kent A. Sepkowitz, M.D. > > The Department of Health and Human Services is finalizing plans for a U.S. > vaccination program against smallpox. As more vaccinia virus vaccine has > become available, the debate over how many persons to vaccinate has centered > on two issues: the safety of the live vaccine and the transmissibility of > vaccinia virus from a recently vaccinated person to a susceptible host. > The issue of safety has received substantial attention, given that a > predictable number of adverse events will occur among vaccine recipients. > Furthermore, an extensive literature has established credible estimates of > the complication rates.1,2,3,4 The risk of secondary transmission, however, > is discussed much less, perhaps because relatively little is known. A report > on vaccine-related deaths in the United States during the 1960s found that > 12 > of the 68 deaths occurred in unvaccinated persons exposed to recently > vaccinated family members or friends, a finding that demonstrates the > potential gravity of the problem.5 A recent reconsideration of the > transmission rates during the 1960s concluded that spread is remarkably > infrequent; this finding is quite reassuring for immunocompetent persons in > the general population.4 > However, the finding of infrequent transmission may not apply to hospitals, > where large numbers of workers will be vaccinated, many for the first time. > There is a large concentration of immunocompromised patients in hospitals, a > situation distinctly unlike that in 1947, the last time a mass vaccination > campaign was mounted in the United States. The prospect that a series of > decisions might unwittingly introduce a live, transmissible, and potentially > lethal virus into hospitals has dampened the enthusiasm of many for > widespread vaccination. > In this article, I review the literature on the secondary transmission of > vaccinia virus, including transmission in hospitals, among families, and in > other circumstances. Many of the older articles would not pass modern peer > review. However, the information they contain cannot be obtained elsewhere — > a fact that makes them, however limited, of real value. > Nosocomial Spread > Nosocomial spread of vaccinia virus has been reported at least 12 times, > from > 1907 through 1975, and has resulted in 85 secondary > cases6,7,8,9,10,11,12,13, > 14,15,16,17 (Table 1). Several additional outbreaks of Kaposi's > varicelliform > eruption unrelated to vaccinia virus have also been described. The cause of > this diffuse skin eruption, whose name is often incorrectly used > interchangeably with eczema vaccinatum (a known complication of vaccinia > virus vaccination), was debated till the middle of the 20th century. Experts > argued whether herpes simplex or vaccinia was the more likely cause; current > thinking accepts both these and other viruses as etiologic agents. Studies > that clearly demonstrated herpes simplex to be the cause of a patient's > Kaposi's varicelliform eruption are therefore not discussed in this > article.18 > ,19,20 > About three fourths of the cases of secondary vaccinia infection occurred in > young children with a dermatologic disorder, usually eczema (currently > referred to as atopic dermatitis). These children had eczema vaccinatum, a > syndrome of diffuse dermatitis with open vesicles, fever, regional or > generalized adenopathy, and (rarely) encephalitis. Vaccinia could easily be > cultured from the lesions. Many patients in whom eczema vaccinatum develops > have active eczema at the time; the others have only a history of the > condition.4,21 Those without active lesions may have a less severe form of > eczema vaccinatum.4 Other skin conditions that may predispose a patient to > secondary acquisition of vaccinia virus include seborrheic dermatitis, > impetigo, scabies, burns, and pemphigus foliaceus. Reports of > non–outbreak-related disease have described secondary transmission to areas > of acne and accidental skin abrasion.12 > The incidence of secondary transmission of vaccinia virus is not easily > calculated. In Glasgow, Scotland, after a three-year-old girl with eczema > vaccinatum was hospitalized, all 11 children on her ward and 4 on an > adjoining ward had generalized disease.7 Smaller series from Germany,6 > Sweden, > 9 Philadelphia,10 and São Paulo, Brazil,15 demonstrated transmission to 16 > of > 27 susceptible patients (59 percent). In a single outbreak involving adults > at a hospital in Brazil where vaccination was given to several patients with > pemphigus foliaceus, 16 unvaccinated persons developed secondary disease.16 > However, because many patients on the ward were vaccinated simultaneously, > the opportunity for exposure increased. Furthermore, the denominator was not > clearly defined but may have included 187 patients whose vaccine history was > unknown, yielding an incidence of secondary vaccinia of about 9 percent. > A single French report examined the contribution of the duration of exposure > to the risk of vaccinia virus transmission. An infant presented in the > daytime with eczema vaccinatum, was hospitalized on an eczema ward, and by > evening was transferred to isolation.13 Despite this, four secondary cases > occurred in children on the eczema ward, though none had close contact with > the index case. > The exact route of transmission is also uncertain. In the above study,13 all > of the children were confined to cribs and were too ill to interact. In > another, after hospitalization of the index patient, several cases of > disease > occurred in an adjoining ward.7 Although the affected children did not mix, > they were cared for by the same professional staff. A sore throat developed > in three treating nurses, one of whom had several " pustular bullae " on the > forearms, but none were formally evaluated.7 In a carefully studied case of > transmission from an adult with disseminated vaccinia to a woman with active > mycosis fungoides in California, investigators remained uncertain how the > virus moved from the isolation room to the woman, whose room was some 25 m > (75 ft) away.17 They suggested that perhaps health care workers carried the > virus or that the two patients occupied the same hall area for several > hours, > resulting in fomite-based spread. The studies also raise the possibility of > aerosol transmission of vaccinia virus.7,8,13 Any of these potential methods > of spread has substantial implications for infection-control teams that may > be called on to isolate and care for a patient with eczema vaccinatum. > Yet another route of transmission was demonstrated by a unique outbreak in > Italy, where vaccinia was spread by a contaminated urinary catheter.14 After > her older brother received vaccine, a 13-month-old girl had initially > undiagnosed genital lesions and dysuria resulting from vaccinia infection. > At > the hospital, she was catheterized, and the catheter was then placed in a > pan > of Citrosil solution for sterilization. Several other urinary catheters were > soaking in the same pan. Within a five-week period, there were 23 secondary > cases with vulvar–urethral vaccinia; each of the patients had been > catheterized with one of the contaminated catheters. About half had high > fevers, and some had gross hematuria. Virus was cultured from the urine of > several children. > Two reports have clearly defined the epidemic curve of vaccinia virus > infection. In the 1935 outbreak in Glasgow, all secondary cases occurred > between 8 and 18 days after exposure.7 Examination of patients treated at an > infectious-disease hospital in Brooklyn, New York, after the 1947 mass > vaccination in New York City found an average incubation period of 10.6 days > (range, 5 to 19).11 > Nine of the 85 reported patients (11 percent) died. Worsening severity of > disease with each generation of transmission was seen in one outbreak in > Germany.8 In another report, from Scotland, those in whom disease developed > later tended to have milder symptoms.7 Death was typically due to > encephalitis or the development of secondary bacterial pneumonia. Treatment > included antibacterial agents and, for several, vaccinia immune globulin. > Spread within Families > Numerous reports have described the spread of vaccinia virus within > families. > The majority are instances of single transmission, usually from a recently > vaccinated child to an unvaccinated younger sibling.22,23,24,25 However, two > or more secondary cases have been reported in at least eight reports of > family outbreaks published from 1931 to 198126,27,28,29,30,31,32,33 (Table 2 > ). Many of the reports describe severe, sometimes fatal eczema vaccinatum in > the first family member with secondary disease and substantially milder > local > inoculation disease in the rest of the family. These latter infections might > have been overlooked had medical attention not been sought for the severe > case. > These eight reports describe transmission to 27 family members. Only five > (19 > percent) had previously received vaccine; these persons invariably had > milder > disease. Of 19 whose skin examination results were noted, 6 had current or > previous eczema, including the 3 (11 percent) with fatal disease, none of > whom had previously received vaccinia virus vaccine. Death was invariably > from fulminant disease, occurring before vaccinia immune globulin could be > administered. > In many of the family outbreaks,27,28,29,30 sharing close quarters was a > significant factor, suggesting the need for sustained, intimate contact to > transmit vaccinia between intact hosts. In one outbreak, a bed was shared by > three persons in whom disease developed, further supporting this notion.27 > An > unusual aspect of the family outbreaks of vaccinia was the apparent tendency > for lesions to be present in similar anatomical areas in all secondary > cases, > including the mouth32 and the face.33 > Other Transmission > Scattered reports detail other cases of secondary transmissions of vaccinia, > exclusively by inadvertent inoculation.34,35,36,37,38,39,40 Eyelids, lips, > nose, and vulva were most commonly reported.32 Humphrey found 70 cases of > vulvar vaccinia in the literature,37 including the 24 catheter-related cases > described above,14 many due to auto-inoculation and several from sexual > transmission.31,34 The mucosa may be involved because vaccinia can penetrate > more easily into this tissue than into skin. Alternatively, vaccinia may > have > a tropism for mucosal surfaces. This phenomenon may be important, since many > currently hospitalized patients, such as those receiving chemotherapy, have > substantial mucosal abnormalities and therefore may be at higher risk for > acquisition of secondary vaccinia virus infection. > Occupational spread to the hands of those working with vaccinia virus > vaccine > has been described, and many workers have repeated local infection despite > previous vaccination.41 A sustained outbreak occurred among 22 farm workers > and 450 cows on a dairy farm in El Salvador.42 One of the workers had > received vaccine and resumed milking cows before his lesions had resolved, > thereby spreading the virus to cows and thence to coworkers, including the > woman who washed the towels used by the milkers. In all 22 affected workers, > lesions were confined to the hands and genitals. > Implications for Vaccination Policy > The rate of adverse events after vaccinia virus vaccination is being > carefully scrutinized as a national vaccination policy is developed.1,2,3,4 > Relatively little is known, however, about the risk of secondary > transmission > of this live virus in the hospital setting.4 A review of the literature > indicates that nosocomial transmission does occur and that the outcome may > be > fatal in up to 11 percent of cases. Nosocomial outbreaks seem to require > relatively minor contact with a source case, whereas spread in the home > appears to occur only with sustained, intimate exposure, perhaps owing to > immunologic and dermatologic differences among the persons exposed. > Information regarding secondary transmission is particularly important for > health care facilities, which will need to vaccinate workers while ensuring > patients' safety. The composition of hospitalized patients in the 21st > century is dramatically different from that in the mid-20th century. > Patients > treated before the 1950s were very unlikely to be immunosuppressed: cancer > chemotherapy was just beginning; transplantation had not yet been performed; > the human immunodeficiency virus (HIV) was unheard of; and corticosteroid > therapy had only recently been introduced. > Now, approximately 506,154 persons in the United States are known to be > living with HIV43; 1.2 million new non-skin cancers are diagnosed > annually44; > 2.1 million persons have rheumatoid arthritis and receive therapy with > corticosteroids or other immunosuppressive agents45; and more than 14 > million > have asthma, many of whom require intermittent steroid use.46 Thousands of > solid-organ and bone marrow transplantations are performed each year and > tens > of thousands of transplant recipients are alive and still receiving > immunosuppressive therapy. Atopic dermatitis is also more common, with > prevalence among children ranging from 6.8 percent to 17.2 percent.47 > Finally, there are tens of thousands of patients in intensive care units and > newborn nurseries. Current expert opinion recommends that vaccination of > such > persons should be avoided.48 Vaccination can be avoided, but contact with a > recent vaccinee probably cannot. > Of equal importance are the differences in the modern population of health > care workers, some of whom are themselves immunocompromised. Previously, > hospitals were staffed with workers who had received at least one vaccinia > virus vaccine. Such persons were therefore unlikely to initiate or propagate > an outbreak. In contrast, most current health care workers are susceptible > to > smallpox and vaccinia and so might play a dangerous supporting or even lead > part in any nosocomial outbreak. > Both the rate and route of vaccinia transmission remain unknown. The > incidence derived from the cited studies (9 to 59 percent) is certainly an > overestimation of current risk, owing to erratic infection-control practices > in past decades, differences in the virulence of the vaccinia virus used, > and > a substantial reporting bias. The current plan for an occlusive dressing at > the vaccination site and other now-routine infection-control procedures, > including hand hygiene and isolation for any patient with unexplained fever > and rash, should effectively limit potential spread.49 Equally important is > the need to ensure that the vaccine program develops slowly, with > flexibility > and ample time to make any necessary adjustments. > The actual route of transmission is not revealed by these outbreaks, but it > may include several different paths.7,8,13,14,17 First, health care workers > may carry virus on their clothes, on their hands, or even in the > nasopharynx. > Other evidence suggests transmission by fomites,17 and the widespread > transmission from contaminated urinary catheters14 emphasizes the need for > rigorous cleaning of any item that comes into contact with a recently > vaccinated person. There is also the possibility of transmission of vaccinia > virus by the aerosol route, since some secondary cases have occurred on the > same hospital floor as a bedbound source patient.7,8 > Other than those with underlying skin conditions, it is not known which > patients are at high risk for secondary disease. Dozens of reports have > described progressive vaccinia (also referred to as vaccinia necrosum and > vaccinia gangrenosa) in immunocompromised patients, particularly those with > hematologic neoplasms (especially chronic lymphocytic leukemia), > hypogammaglobulinemia, or defects in cellular immunity.50,51,52,53,54,55 > These infections, which are often fatal, may last for months and may respond > poorly to frequent doses of vaccinia immune globulin.50 Progressive vaccinia > in a newly vaccinated soldier with advanced, previously undiagnosed HIV > infection has also been described.56 These studies demonstrate that vaccinia > may be easily transmitted to hosts with severe dermatologic disorders, with > substantial mortality in the absence of appropriate infection-control > measures. > An additional important finding from these articles is the observation that > secondary disease is manifested exclusively as eczema vaccinatum or contact > inoculation. No secondary cases of the most severe complications — > progressive vaccinia and postvaccination encephalitis (except in those with > overwhelming eczema vaccinatum) — have been reported. Thus, the danger of > nosocomial spread, though alarming, is mitigated by the limited range of > clinical manifestations in secondary disease. > Because of the risk of secondary transmission of vaccinia, many hospitals > remain uncomfortable with the recent recommendation against the provision of > administrative leave for newly vaccinated health care workers.56 Also, the > advisability of immunocompromised workers' remaining on the job while > colleagues receive vaccine has not been determined. Until these > controversies > are settled, hospitals must be certain that the rush to vaccinate health > care > workers does not result in a self-inflicted epidemic — not of smallpox, but > of infection with the live, potentially lethal virus, vaccinia. > Supported in part by a grant (K24 AI052239-01) from the National Institutes > of Health. > I am indebted to Linda Han and Sara Tuttle for research assistance, and to > Johan Herrlin, Roman Tuma, Gregoire Lauvau, Matthias Frank, and Svetolik > Djurkovic for help in translating the articles cited. > > Source Information > From the Infectious Disease Service, Memorial Sloan-Kettering Cancer Center, > New York. > > This article was published at www.nejm.org on December 19, 2002. > Address reprint requests to Dr. Sepkowitz at the Infectious Disease Service, > Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021, > or at sepkowik. > > References > 1. Waddington E, Bray PT, Evans AD, Richards IDG. Cutaneous complications > of > mass vaccination against smallpox in South Wales 1962. Trans St Johns Hosp > Dermatol Soc 1964;50:22-42. > 2. Conybeare ET. Illness attributed to smallpox vaccination during 1951-60. > Mon Bull Minist Health Public Health Lab Serv 1964;23:126-133. > 3. Haim M, Gdalevich M, Mimouni D, Ashkenazi I, Shemer J. Adverse reactions > to smallpox vaccine: the Israel Defense Force experience, 1991 to 1996: a > comparison with previous surveys. Mil Med 2000;165:287-289.[iSI][Medline] > 4. Neff JM, Lane JM, Fulginiti VA, Henderson DA. Contact vaccinia -- > transmission of vaccinia from smallpox vaccination. JAMA 2002;288:1901-1905. > [iSI][Medline] > 5. Lane JM, Ruben FL, Abrutyn E, Millar JD. Deaths attributable to smallpox > vaccination, 1959 to 1966, and 1968. JAMA 1970;212:441-444.[Medline] > 6. Danziger F. Ueber Vaccina generalisata. Munch Med Wochenschr > 1907;54:1583-1585. > 7. McLachlan AD, Gillespie M. Kaposi's varicelliform eruption: an epidemic > of sixteen cases. Br J Dermatol Syphilol 1936;48:337-56. > 8. Nimpfer T. Über Variola-Vaccinainfektion brandwunden im Verlaufe einer > Stationsinfektion. Arch Dermatol Syph 1936;174:518-24. > 9. Bergman R, Lindahl J. Eczema vaccinatum in connection with 12 cases. > Nord > Hyg Tidskr 1941;22:257-280. > 10. Strickler A. Kaposi's varicelliform eruption: a report of five cases, > all > in children. Urol Cutaneous Rev 1944;48:340-1. > 11. Fries JH, Borne S, Barnes HL. Varicelliform eruption of Kaposi due to > vaccinia virus complicating atopic eczema. J Pediatr 1948;32:532-542.[iSI] > 12. Sommerville J, Napier W, Dick A. Kaposi's varicelliform eruption: record > of an outbreak. Br J Dermatol 1951;63:203-214.[iSI] > 13. Pierret R, Huriez C, Breton A, Desmons F, Fontaine G. Severe vaccinia > epidemic in eczematous infants. Bull Soc Fr Dermatol Syph 1956;63:409-12. > 14. Toscano F, Angela G. Considerazioni su di una epidemia di vaccinosi > vulvare da cateterismo. Minerva Pediatr 1953;5:987-990. > 15. Angulo JJ, Flores MR, de Salles-Gomes LF. Spread of vaccinia in a > dermatological infirmary. Hospital (Rio J) 1966;69:179-186.[Medline] > 16. Magaldi-Jordao FB, de Salles-Gomes LF, Rabello SI, Amorosino A, Angulo > JJ. Outbreaks of vaccinia in a Pemphigus foliaceus hospital. Arch Dermatol > 1962;85:533-538.[iSI] > 17. Johnson RH, Krupp JR, Hoffman AR, Koplan JP, Nakano JH, Merigan TC. > Nosocomial vaccinia infection. West J Med 1976;125:266-270.[iSI][Medline] > 18. Barton RL, Brunsting LA. Kaposi's varicelliform eruption: review of the > literature and report of two cases of its occurrence in adults. Arch Derm > Syphilol 1944;50:99-104. > 19. Brain RT, Dudgeon JA, Philpott MG. Kaposi's varicelliform eruption. Br J > Dermatol Syphilol 1950;62:203-12. > 20. Landtman B, Halonen P, Ahvenainen EK, Valanne EH, Vuorinen SR. Kaposi's > varicelliform eruption. Ann Paediatr Fenn 1954;1:61-73. > 21. Copeman PWM, Wallace HJ. Eczema vaccinatum. BMJ 1964;2:906-908.[iSI] > 22. Chaudhuri AK, Cassie R, Douglas WS. Contact vaccinia from recently > vaccinated British soldiers. Br Med J (Clin Res Ed) 1981;282:1797-1797. > [Medline] > 23. Contact spread of vaccinia from a recently vaccinated Marine -- > Louisiana. MMWR Morb Mortal Wkly Rep 1984;33:37-38.[Medline] > 24. Martin HA. A most rare, possibly unique, case of general eruption of > vaccinia. Med Rec 1882;21:393-6. > 25. Birrer RB, Laude TA. Vaccinia reaction in a sibling. N Y State J Med > 1981;81:774-775.[iSI][Medline] > 26. Ellis FA. Eczema vaccinatum: its relation to generalized vaccinia: > report > of 2 cases. JAMA 1935;104:1891-1894. > 27. Gray FG. A familial spread of vaccinia with one death: isolation and > identification of the virus. Bull Johns Hopkins Hosp 1948;82:538-49. > 28. Whittle CH, Lyell A, Miles JAR, Stoker MGP. Kaposi's varicelliform > eruption, with virus studies. Br J Dermatol 1950;62:195-203. > 29. Horwitz MS, Solomon P. A family epidemic of vaccinia. J Pediatr > 1966;68:308-310.[iSI] > 30. Vaccinia outbreak -- Indiana. MMWR Morb Mortal Wkly Rep 1968;17:336-336. > 31. Andreev VC, Lachapelle JM, Rook AJ. An outbreak of accidental vaccinia > in > a family. Dermatol Int 1969;8:5-9.[Medline] > 32. Greer KE, Sheap CN. A family outbreak of oral accidental vaccinia. Arch > Dermatol 1974;110:107-108.[iSI][Medline] > 33. Vaccinia outbreak -- Newfoundland. MMWR Morb Mortal Wkly Rep > 1981;30:453-455.[Medline] > 34. Willcox RR. Montine vaccinia. Br J Clin Pract 1957;11:925-925. > 35. Fiumara NJ. Inoculation vaccinia -- a hazard of the conjugal bed. N Engl > J Med 1973;288:324-325. > 36. Haim S. Accidental vaccinia of the vulva. Cutis > 1976;17:308-309.[Medline] > 37. Humphrey DC. Localized accidental vaccinia of the vulva: report of 3 > cases and a review of the world literature. Am J Obstet Gynecol > 1963;86:460-469.[iSI] > 38. Ayo C, Braley AE. Accidental vaccinial infection of the nose: review of > the literature and report of a case of laboratory infection. Arch > Otolaryngol > 1942;36:556-559. > 39. Brav A. Accidental vaccinia of the eyelid with disciform keratitis. Arch > Ophthalmol 1945;33:67-67.[iSI] > 40. Vaccinia. BMJ 1971;1:121-121. > 41. Horgan ES, Haseeb MA. Some observations on accidental vaccinations on > the > hands of workers in a vaccine lymph institute. J Hyg (Lond) 1944;43:273-274. > 42. Lum GS, Soriano F, Trejos A, Llerena J. Vaccinia epidemic and epizootic > in El Salvador. Am J Trop Med Hyg 1967;16:332-338.[iSI][Medline] > 43. HIV/AIDS surveillance report. Vol. 13. No. 2. Atlanta: Centers for > Disease Control and Prevention, 2001:7. > 44. Cancer facts & figures 2002. Atlanta: American Cancer Society, 2002. > (Accessed January 7, 2003, at > http://www.cancer.org/eprise/main/docroot/stt/stt_0.asp.) > 45. Questions and answers about arthritis and rheumatic diseases. Bethesda, > Md.: National Institute of Arthritis and Musculoskeletal and Skin Diseases, > February 2002. (Accessed January 7, 2003, at > http://www.niams.nih.gov/hi/topics/arthritis/artrheu.htm.) > 46. Data fact sheet: asthma statistics. Bethesda, Md.: National Heart, Lung, > and Blood Institute, January 1999. (Accessed January 7, 2003, at > http://www.nhlbi.nih.gov/health/prof/lung/asthma/asthstat.htm.) > 47. Laughter D, Istvan JA, Tofte SJ, Hanifin JM. The prevalence of atopic > dermatitis in Oregon schoolchildren. J Am Acad Dermatol 2000;43:649-655. > [iSI][Medline] > 48. Breman JG, Henderson DA. Diagnosis and management of smallpox. N Engl J > Med 2002;346:1300-1308.[Full Text] > 49. Centers for Disease Control and Prevention. Summary of October 2002 ACIP > smallpox vaccination recommendations (updated October 21, 2002). (Accessed > January 7, 2003, at > http://www.bt.cdc.gov/agent/smallpox/vaccination/acip-recs-oct2002.asp.) > 50. Hall GFM, Cunliffe AC, Dudgeon JA. Prolonged generalized vaccinia. J > Pathol Bacteriol 1953;66:25-38.[iSI] > 51. Kozinn PJ, Sigel MM, Gorrie R. Progressive vaccinia associated with > agammaglobulinemia and defects in immune mechanism. Pediatrics > 1955;16:600-608.[Abstract] > 52. Erichson RB, McNamara MJ. Vaccinia gangrenosa: report of a case and > review of the literature. Ann Intern Med 1961;55:491-498.[iSI] > 53. O'Connell CJ, Karzon DT, Barron AL, Plaut ME, Ali VM. Progressive > vaccinia with normal antibodies: a case possibly due to deficient cellular > immunity. Ann Intern Med 1964;60:282-289.[iSI] > 54. Fulginiti VA, Kempe CH, Hathaway WE, et al. Progressive vaccinia in > immunologically deficient individuals. Birth Defects Orig Artic Ser > 1968;4:129-145. > 55. Dixon MF. Progressive vaccinia complicating lymphosarcoma. J Pathol > 1970;100:53-67.[iSI][Medline] > 56. Redfield RR, Wright DC, James WD, Jones TS, Brown C, Burke DS. > Disseminated vaccinia in a military recruit with human immunodeficiency > virus > (HIV) disease. N Engl J Med 1987;316:673-676.[iSI][Medline] > > The New England Journal of Medicine is owned, published, and copyrighted © > 2003 Massachusetts Medical Society. All rights reserved. > > > > Jock Doubleday > Director > Natural Woman, Natural Man, Inc. > A California Nonprofit Corporation > P.O. Box 1794 > Ojai, CA 93024 > http://www.gentlebirth.org/nwnm.org > jockdoubleday > > The information contained in this email is not a substitute for professional > caregiver advice. > > Jock Doubleday is the author of Spontaneous Creation: 101 Reasons Not To > Have > Your Baby in a Hospital. He is also active in the international endeavor to > bring the dangers of vaccination to light. > > > " The study of the evolution of disease patterns provides evidence that > during > the last century doctors have affected epidemics no more profoundly than did > priests during earlier times. Epidemics came and went, imprecated by both > but > touched by neither. They are not modified any more decisively by the rituals > performed in medical clinics than by those customary at religious shrines. " > Ivan Illich > Limits to Medicine, page 15 > > > > > > ******************************** > > Paranormal_Research - Scientific Data & Health Conspiracies > Paranormal_Research > Subscribe:... Paranormal_Research- > Quote Link to comment Share on other sites More sharing options...
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