Hospital Issues and Smallpox Hospital Issues and Smallpox VaccineVaccine

Lisa G. Kaplowitz, M.D., M.S.H.A.Lisa G. Kaplowitz, M.D., M.S.H.A.

Deputy CommissionerDeputy Commissioner

Emergency Preparedness and ResponseEmergency Preparedness and Response

Virginia Department of HealthVirginia Department of Health

VDH Emergency Preparedness VDH Emergency Preparedness and Response (EP&R)and Response (EP&R)

All hazards approach to emergency All hazards approach to emergency preparednesspreparedness

Responsible for CDC grant to enhance Responsible for CDC grant to enhance public health infrastructure and ability to public health infrastructure and ability to respond to public health emergenciesrespond to public health emergencies

Partnership with VHHA for HRSA grant to Partnership with VHHA for HRSA grant to enhance hospital emergency enhance hospital emergency preparednesspreparedness

VDH EP&R ProgramsVDH EP&R Programs

National Pharmaceutical Stockpile (NPS) National Pharmaceutical Stockpile (NPS) distribution and management – distribution and management – – Close collaboration with Virginia Department of Close collaboration with Virginia Department of

Emergency Management (DEM)Emergency Management (DEM)

Pre and post event smallpox vaccination Pre and post event smallpox vaccination plansplansState, regional and local plansState, regional and local plansDistrict health departments (35) responsible District health departments (35) responsible for development and implementation of plans for development and implementation of plans at local levelat local level

Smallpox vaccinationSmallpox vaccination

Dec, 2002: President Bush announced Dec, 2002: President Bush announced plan to vaccinate civilian response teams plan to vaccinate civilian response teams and military personneland military personnelPre-event smallpox vaccinationPre-event smallpox vaccination– Stage 1: Hospital and public health response Stage 1: Hospital and public health response

teamsteams– Stage 2: Other health care providers, first Stage 2: Other health care providers, first

respondersresponders– Stage 3: Offer to general public when enough Stage 3: Offer to general public when enough

licensed vaccine availablelicensed vaccine available

Hospital Participation in Smallpox Hospital Participation in Smallpox Vaccination PlanVaccination Plan

Voluntary for both hospitals and individualsVoluntary for both hospitals and individuals

Pre-event vaccination of team to provide Pre-event vaccination of team to provide care to smallpox patients in first 7-10 days of care to smallpox patients in first 7-10 days of a smallpox eventa smallpox event

Assure that a certain number of health care Assure that a certain number of health care providers will be comfortable providing care providers will be comfortable providing care for persons with smallpox until others are for persons with smallpox until others are vaccinated vaccinated

Suggested Hospital Team MembersSuggested Hospital Team Members

Physicians – ER,ICU, general medical, Physicians – ER,ICU, general medical, specialists (ID, dermatology, others)specialists (ID, dermatology, others)Nurses - ER, ICU, medicalNurses - ER, ICU, medicalInfection Control Practitioners (ICPs)Infection Control Practitioners (ICPs)Respiratory therapists Respiratory therapists TransportationTransportationLaboratory technicians Laboratory technicians HousekeepingHousekeeping

Smallpox Vaccine IssuesSmallpox Vaccine Issues

Live virus vaccine – vacciniaLive virus vaccine – vacciniaContraindications pre-eventContraindications pre-event– Immunosuppression: disease or medicationsImmunosuppression: disease or medications– Eczema or history of eczemaEczema or history of eczema– Family member with immunosuppression or Family member with immunosuppression or

eczemaeczema– PregnancyPregnancy– BreastfeedingBreastfeeding– Allergy: any vaccine componentsAllergy: any vaccine components

Complication Rates of VaccinationComplication Rates of VaccinationRates (per million vaccinations) Following Smallpox Vaccination – U.S., 1968 Rates (per million vaccinations) Following Smallpox Vaccination – U.S., 1968

(ten state survey)(ten state survey)

10810812541254TotalTotal

221212Postvaccinal Postvaccinal EncephalitisEncephalitis

331.51.5Progressive VacciniaProgressive Vaccinia

333939Eczema VaccinatumEczema Vaccinatum

99242242Generalized VacciniaGeneralized Vaccinia

4242529529Inadvertent Inadvertent AutoinoculationAutoinoculation

RevaccinationRevaccination

PrimaryPrimary

VaccinationVaccinationComplicationComplication

Pre-Clinic Screening of Vaccination Pre-Clinic Screening of Vaccination CandidatesCandidates

Health care workers volunteering for vaccination Health care workers volunteering for vaccination will be identifiedwill be identifiedVolunteers will be given a packet of information Volunteers will be given a packet of information to review at home prior to vaccination dayto review at home prior to vaccination day– ContraindicationsContraindications– ComplicationsComplications– PrecautionsPrecautions– Information about HIV, pregnancy testingInformation about HIV, pregnancy testing

Volunteers will be allowed to withdraw without Volunteers will be allowed to withdraw without stating a specific reason stating a specific reason

Screening for HIV InfectionScreening for HIV Infection

Vaccine should NOT be administered to those Vaccine should NOT be administered to those with HIV infection or AIDSwith HIV infection or AIDSEducate staff regarding risk of vaccine for those Educate staff regarding risk of vaccine for those with HIV/AIDSwith HIV/AIDSMandatory HIV testing not requiredMandatory HIV testing not requiredHIV testing recommended for persons who have HIV testing recommended for persons who have history of risk factor and do not know statushistory of risk factor and do not know statusAnyone wishing HIV testing can be referred to Anyone wishing HIV testing can be referred to health department for free confidential or health department for free confidential or anonymous testinganonymous testing

Screening for PregnancyScreening for Pregnancy

In pre-event setting, should NOT be given to:In pre-event setting, should NOT be given to:– pregnant womenpregnant women– women trying to become pregnantwomen trying to become pregnant

Educate women of child-bearing age about fetal Educate women of child-bearing age about fetal vacciniavaccinia

Advise avoidance of pregnancy for 4 weeks Advise avoidance of pregnancy for 4 weeks following vaccinationfollowing vaccination

If concerned, administer home test for pregnancyIf concerned, administer home test for pregnancy

Smallpox VaccinationSmallpox VaccinationHealth Department ResponsibilitiesHealth Department Responsibilities

Education and training, including providing Education and training, including providing education materialseducation materials– ContraindicationsContraindications– ComplicationsComplications– Vaccine site managementVaccine site management

Responsible for vaccine and vaccine Responsible for vaccine and vaccine administrationadministrationCollect information and report on adverse Collect information and report on adverse vaccine eventsvaccine events

Adverse EventsAdverse Events

Notify health departmentNotify health department

Clinical assessment by patient’s provider, with Clinical assessment by patient’s provider, with assistance by appropriate specialists (ID, assistance by appropriate specialists (ID, dermatology)dermatology)

VIG in limited supply, management of many VIG in limited supply, management of many severe complicationssevere complications– Only available from CDC, through health departmentOnly available from CDC, through health department

Cidofovir not licensed for vaccinia complicationsCidofovir not licensed for vaccinia complications

Hospital Responsibilities After Hospital Responsibilities After VaccinationVaccination

Daily assessment of vaccine site for Daily assessment of vaccine site for anyone involved in direct patient careanyone involved in direct patient care

Vaccine site coverage for anyone involved Vaccine site coverage for anyone involved in patient care: gauze, dressing, clothingin patient care: gauze, dressing, clothing

Dressing change as necessary, with Dressing change as necessary, with appropriate disposal of dressingsappropriate disposal of dressings

Assessment of vaccine take at 7 daysAssessment of vaccine take at 7 days

Hospital IssuesHospital Issues

Do not need to place HCWs on leave, unless:Do not need to place HCWs on leave, unless:– Physically unable to work due to systemic signs Physically unable to work due to systemic signs

and symptomsand symptoms

– Extensive skin lesions or vaccination site that Extensive skin lesions or vaccination site that can not be coveredcan not be covered

– HCWs do not adhere to infection control HCWs do not adhere to infection control precautions and recommendationsprecautions and recommendations

No requirement for staff reassignment after No requirement for staff reassignment after vaccinationvaccination

Virus can be recovered at site from Virus can be recovered at site from time of papule until scab separatestime of papule until scab separates

Site should be kept drySite should be kept dry

Normal bathing can occur if covered Normal bathing can occur if covered by waterproof bandageby waterproof bandage

Contact precautions most important – Contact precautions most important – vaccinia virus IS NOT aerosolizedvaccinia virus IS NOT aerosolized

Vaccination Site CareVaccination Site Care

Vaccination Site CareVaccination Site Care

HCWs should keep site coveredHCWs should keep site covered

Use gauze or similar absorbent materialUse gauze or similar absorbent material

Cover this with semi-permeable dressingCover this with semi-permeable dressing

Wear long sleeves to further limit contact Wear long sleeves to further limit contact with vaccine sitewith vaccine site

Other Post Vaccine IssuesOther Post Vaccine Issues

Defer blood donation for 21 days after scab Defer blood donation for 21 days after scab falls offfalls off

Appropriate care with dressing changeAppropriate care with dressing change– HandwashingHandwashing– Disposal of dressings in ziplock bagDisposal of dressings in ziplock bag– Disposal of dressing in red bag in hospital, trash at Disposal of dressing in red bag in hospital, trash at

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