on february 23 , 2010 , a military service member preparing for deployment received smallpox vaccination and was counseled by the us department of defense about postvaccination care and infection control . on february 27 , the index patient wrestled 2 persons in a semiprofessional match , during which the dressing covering the vaccination site was detached . within 3 days , skin lesions developed in both contacts . one of these 2 wrestlers participated in another wrestling match on march 5 , exposing a third person in whom lesions on the chest developed . a fourth contact , a household member of a wrestler from the february 27 match , had lesions develop on the face . all were examined , and test results of specimens were negative for vacv ( figure 1 ) . * timeline of investigation of secondary and tertiary transmission of vaccinia virus from a us military service member , new york , usa , 2010 . nysdoh , new york state department of health ; ph , public health ; vig , varicella immune globulin ; pmd , private physician ; derm , dermatologist . on march 11 , a 26-year - old male wrestler with no noteworthy medical history visited a dermatologist after being referred by his private physician who had prescribed trimethoprim / sulfamethoxazole for presumed methicillin - resistant staphylococcus aureus from lesions on his face , neck , and chest ( figure 2 ) . molluscum contagiosum and impetigo were included in the differential diagnosis , and a culture was sent to a local laboratory to test for methicillin - resistant s. aureus . the dermatologist notified the local health department of the patient s possible exposure to vacv . a nysdoh public health physician evaluated the patient on march 12 . on examination , he had clinically compatible vacv lesions , including papular , umbilicated lesions with overlying vesicles and a few pustules . vaccinia lesions in patients with secondary and tertiary cases , new york , usa , 2010 . top row , case - patient 1 ; bottom row , case - patient 3 . on march 11 , a 24-year - old male wrestler with no noteworthy medical history was contacted by the nysdoh because he was a wrestling contact of the vaccinee . he reported lesions on his face , neck , chin , and left eye that developed several days after the wrestling event and were associated with substantial pruritus , exudate , and erythema . at his public health evaluation on march 12 , he had numerous papular lesions that were umbilicated with overlying vesicles , several of which were draining serous fluid , and vacv was clinically diagnosed . he received slit - lamp examination by a local ophthalmologist , who after consultation with cdc and nysdoh , treated him with trifluridine ophthalmic solution ( 4 ) . the blepharitis and eyelid erythema resolved within 48 hours after initiation of trifluridine . on march 10 , a 25-year - old male wrestler and roommate of the vaccinee sought treatment for vesicular lesions on his trunk and chest . he reported that several pruritic papules had developed 2 days after wrestling case - patient 1 . the physician thought the lesions appeared to be molluscum contagiosum , but given the patient s history , consulted an infectious disease physician , who observed lesions compatible with vacv . at the public health clinical evaluation on march 12 , the patient had grouping of vesicular lesions with central umbilication on mildly erythematous bases on his trunk ( figure 2 ) , with a solitary lesion near his left areola and on the volar aspect of his right forearm . vacv was clinically diagnosed . on march 9 , lesions developed along the mandible of the 29-year - old household contact of case - patient 1 . on march 11 , she was evaluated by a dermatologist , who performed a punch biopsy for suspected herpes . over the next several days , she was seen by the nysdoh public health physician on march 16 , and vacv was clinically diagnosed . the most plausible route of exposure was a shared hand towel with case - patient 1 . over the next several days , her lesions started draining and became substantially more erythematous and painful . after consultation between her physician , nysdoh , and cdc , varicella immune globulin was released from the strategic national stockpile for administration because of the new mucosal involvement ( 5 ) . varicella immune globulin was administered with no complications on march 19 at a local hospital . samples were obtained by unroofing vesicles , collecting the tissue , performing slide touch preps of the unearthed base of each vesicle , and obtaining viral swabs by using pox collection kits that had been distributed through nysdoh . all patient specimens were tested at the nysdoh wadsworth center ( albany , ny , usa ) by real - time pcr , and preliminary results indicated vacv . vacv subsequently was confirmed in all 4 patients by real - time pcr at the nysdoh wadsworth center . the complete hemagglutinin gene was sequenced by cdc for 3 of the samples ( cases 1 , 3 , 4 ) and was identical to that of acam2000 ( 6 ) . nysdoh provided appropriate transmission precautions and wound care instructions to all 4 case - patients ( 7 ) . on march 11 , a 26-year - old male wrestler with no noteworthy medical history visited a dermatologist after being referred by his private physician who had prescribed trimethoprim / sulfamethoxazole for presumed methicillin - resistant staphylococcus aureus from lesions on his face , neck , and chest ( figure 2 ) . molluscum contagiosum and impetigo were included in the differential diagnosis , and a culture was sent to a local laboratory to test for methicillin - resistant s. aureus . the dermatologist notified the local health department of the patient s possible exposure to vacv . a nysdoh public health physician evaluated the patient on march 12 . on examination , he had clinically compatible vacv lesions , including papular , umbilicated lesions with overlying vesicles and a few pustules . vaccinia lesions in patients with secondary and tertiary cases , new york , usa , 2010 . top row , case - patient 1 ; bottom row , case - patient 3 . on march 11 , a 24-year - old male wrestler with no noteworthy medical history was contacted by the nysdoh because he was a wrestling contact of the vaccinee . he reported lesions on his face , neck , chin , and left eye that developed several days after the wrestling event and were associated with substantial pruritus , exudate , and erythema . at his public health evaluation on march 12 , he had numerous papular lesions that were umbilicated with overlying vesicles , several of which were draining serous fluid , and vacv was clinically diagnosed . he received slit - lamp examination by a local ophthalmologist , who after consultation with cdc and nysdoh , treated him with trifluridine ophthalmic solution ( 4 ) . on march 10 , a 25-year - old male wrestler and roommate of the vaccinee sought treatment for vesicular lesions on his trunk and chest . he reported that several pruritic papules had developed 2 days after wrestling case - patient 1 . the physician thought the lesions appeared to be molluscum contagiosum , but given the patient s history , consulted an infectious disease physician , who observed lesions compatible with vacv . at the public health clinical evaluation on march 12 , the patient had grouping of vesicular lesions with central umbilication on mildly erythematous bases on his trunk ( figure 2 ) , with a solitary lesion near his left areola and on the volar aspect of his right forearm . on march 9 , lesions developed along the mandible of the 29-year - old household contact of case - patient 1 . on march 11 , she was evaluated by a dermatologist , who performed a punch biopsy for suspected herpes . over the next several days , she was seen by the nysdoh public health physician on march 16 , and vacv was clinically diagnosed . the most plausible route of exposure was a shared hand towel with case - patient 1 . over the next several days , her lesions started draining and became substantially more erythematous and painful . after consultation between her physician , nysdoh , and cdc , varicella immune globulin was released from the strategic national stockpile for administration because of the new mucosal involvement ( 5 ) . varicella immune globulin was administered with no complications on march 19 at a local hospital . samples were obtained by unroofing vesicles , collecting the tissue , performing slide touch preps of the unearthed base of each vesicle , and obtaining viral swabs by using pox collection kits that had been distributed through nysdoh . all patient specimens were tested at the nysdoh wadsworth center ( albany , ny , usa ) by real - time pcr , and preliminary results indicated vacv . vacv subsequently was confirmed in all 4 patients by real - time pcr at the nysdoh wadsworth center . the complete hemagglutinin gene was sequenced by cdc for 3 of the samples ( cases 1 , 3 , 4 ) and was identical to that of acam2000 ( 6 ) . nysdoh provided appropriate transmission precautions and wound care instructions to all 4 case - patients ( 7 ) . in 2003 , members of the military , selected health care workers , public health personnel , and first responders began receiving smallpox vaccinations as part of bioterrorism preparedness ( 8) . although smallpox vaccination campaigns directed toward health care workers and public health officials ended in january 2008 ( 9 ) , smallpox vaccinations continue for military service members . this case report illustrates the need to ensure that military vaccinees understand the risk associated with contact transmission . regions with active military smallpox vaccination programs need to maintain awareness among community medical providers , health departments , and laboratories to facilitate recognition , correct diagnosis , and appropriate response to inadvertent inoculation of vaccinia virus to help limit further transmission . especially in areas with ongoing smallpox vaccination programs , finally , updates are needed on identification of vacv cases , along with the notification and involvement of public health .
during february and march 2010 , the new york state department of health investigated secondary and tertiary vaccinia contact transmission from a military vaccinee to 4 close contacts . 
 identification of these cases underscores the need for strict adherence to postvaccination infection control guidance to avoid transmission of the live virus .