hospital smallpox vaccination perspective dino p. rumoro, d.o., f.a.c.e.p. clinical chairman...
TRANSCRIPT
Hospital Smallpox Vaccination Perspective
Dino P. Rumoro, D.O., F.A.C.E.P.
Clinical Chairman
Assistant Professor
Department of Emergency Medicine
January 10, 2003
Center of Excellence:Bioterrorism Preparedness
Supported by a grant from the
Chicago Department of Public Health
©2002 Rush-Presbyterian-St. Luke’s Medical Center
What You Must Be Asking Yourself:
Questions•Why?…Is this important•What?..Is the risk of an outbreak•What?..Is the risk of the vaccine•How?…Do I proceed
•DO I PROCEED?
©2002 Rush-Presbyterian-St. Luke’s Medical Center
History of Bioterrorism
6th Century B.C.•Solon of Athens poisoned water with skunk cabbage during the siege of Krissa
184 B.C.•During a naval battle against King Eumenes of Pergamon,
Hannibal hurled pots of snakes
1346•During the siege of Kaffa, the Tartar army catapulted its plague
infected dead over the city walls
©2002 Rush-Presbyterian-St. Luke’s Medical Center
History of Bioterrorism
15th Century•Pizarro gave South American natives clothing infected with
smallpox
1914-1917•WWI: Germany allegedly tried to spread cholera in Italy and
plague in St. Petersburg
1936•Unit 731 formed - Japanese biowarfare team responsible for
thousands of deaths
©2002 Rush-Presbyterian-St. Luke’s Medical Center
History of Bioterrorism
1941-1943•US army develops biological agent R&D unit
1960’s•Vietcong use fecally contaminated spear traps
1978•Bulgarian exile, Georgi Markov, dies after assassin injects ricin
pellet from an umbrella
1979•USSR Military Compound 19 explodes and releases an agent
that kills 40-1000 (anthrax)
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Who is Manufacturing Bioweapons?
Iran, Iraq, Libya, Syria, North Korea, Taiwan, Israel, Egypt, Vietnam, Laos, Cuba, Bulgaria, India, South Korea, South Africa, China, Russia
(Based on a 1995 Office of Technology Assessment Report)
©2002 Rush-Presbyterian-St. Luke’s Medical Center
What Are the Chances…?
History is against us!
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Domestic Bioterrorism Attacks
1984•Salmonella Poisoning in Oregon
•Bhagwan Shree Rajneesh of the Rajneeshee religious cult
•750 people infected, 40 hospitalized
•Purpose was to influence a local election
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Domestic Bioterrorism Attacks
2001•Anthrax laden letters
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Ask Yourself…?
Did you really think there was ever a chance of an anthrax attack?
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Smallpox
©2002 Rush-Presbyterian-St. Luke’s Medical Center
History of U.S. Smallpox Vaccine Recommendations
1940’s: Last US case of smallpox1971: Discontinued routine vaccination of the
public1976: Discontinued vaccination of healthcare
workers1989: Discontinued vaccination of the military2003: Voluntary vaccination for first responders to
a case of smallpox
©2002 Rush-Presbyterian-St. Luke’s Medical Center
History and Significance
•Endemic smallpox was declared eradicated in 1980 by the WHO
•2 WHO approved repositories of Variola virus
•CDC in Atlanta
•Institute for Viral Preparations in Moscow–Extent of clandestine stockpiles in other parts of the world
remains unknown–Japan considered the use of smallpox as a bioweapon in WW II
©2002 Rush-Presbyterian-St. Luke’s Medical Center
What is the Current Risk?
Logically, some degree of risk must exist!
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Before You Say No, Consider This...
Military Personnel
•Vaccination program has begun•Reservists currently working in hospitals may be
vaccinated soon•How will their patient care activities be monitored?•What if they become ill?•Who will care for a case of Vaccinia?
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Knowledge is Power
Know the Facts!
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Smallpox Vaccine
Contains live Vaccinia virus•does not contain smallpox virus
Dryvax (Wyeth) vaccine•produced using calf lymph
•vaccine used in the 1960’s
•FDA licensed specific lots in October 2002
•only available from CDC
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Bifurcated Needle
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Vaccine Administration
Scarification •multiple punctures with a bifurcated needle to inoculate the
superficial layers of the skin with Vaccinia
•virus multiplies and causes the body to produce an immune response to Vaccinia
–immunity to Vaccinia is cross-protective against smallpox
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Clinical Response to Vaccination
1. Papule forms (day 3-4)
2. Vesicle forms (day 5-6)–fluid filled blister
3. Pustule forms (day 7-9)–purulent fluid filled blister
4. Scab forms (day 12-17)
5. Scab falls off (day 18-28)
*The site is infectious until the scab falls off
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Development of Immunity
•95% of primary vaccinees develop antibodies within 1-2 weeks–protection begins to fade after 5 years
•Those previously vaccinated may have residual immunity, but need to be revaccinated
–does not offer full protection from smallpox
–may be protective against severe disease or death
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Clinical Response to Vaccination
•Major reaction – “take”•indicates viral replication has occurred and the vaccination was successful
•considered to be protective
•Equivocal reaction •anything other than a major reaction
•indicates incorrect vaccination technique or impotent vaccine
•requires revaccination
–can be revaccinated 7 days after initial vaccination
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Vaccination Complications
•Most benign, even if frightening in appearance•Some serious, but treatable•Few, which are rare, can be life threatening or fatal
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Potential Vaccine Side Effects
Symptoms usually occur about 1 week after vaccinationsorenessinflamed red ring around vaccination sitegeneralized weaknessswollen lymph nodes (25-50%)fever > 100 F (2-16%)muscle aches, headache, chills, nausea (0.3 – 37%)fatigue satellite lesions
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Accidental Implantation(inadvertent inoculation)
•Transfer of Vaccinia virus to other body parts or unimmunized close contacts
•Common site are mucocutaneous borders (eyes, mouth, nose, rectum)
•Young children at greatest risk•Lesion progression usually follows the same course as the
vaccination site•Treatment usually not necessary
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Supportive Therapy
•Today’s medical treatments are improved from the ones available prior to 1971
–cidofovir as IND
•No evidence exists, but these treatments may help to improve the outcomes of smallpox vaccine
complications
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Pre-Event ACIP Recommendations
Phase I: Hospital and public health response teams•vaccination for hospital response teams and public health response teams
Phase II: Other first responders - fire/police/EMS
Phase III: General public? Wait for new Acambis vaccine
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Pre-Event Vaccination Program
•Not meant to be a full scale response•Meant to be scalable if cases would occur
–quick response and scale up of numbers of vaccinees
•No further CDC guidelines for phase II or III plans•Plans must be flexible
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Smallpox Healthcare Teams
•Each hospital identify a group of healthcare workers who would be vaccinated
•First 7-10 days, this team would be hospital based and provide care 24 hrs/day (8-12 hour shifts)
•Would enable care of the first few cases presenting to a hospital
•Would be able to care for the patient immediately thus minimizing further exposures
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Order of Vaccination
•First: Public Health Response Team–Will perform all vaccinations
•Second: Hospital Site Care Team–Several member team to monitor the status of the Hospital
Response Team Members and their vaccination sites
•Third: Hospital Response Team
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Hospital Response Team:Recommended Members
•Emergency staff•Intensive care staff•General medicine staff•Medical house staff•Medical sub-specialty staff•Infection control•Phlebotomy•Respiratory therapy•Security•X-ray techs•Housekeeping and laundry
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Hospital Response Teams
Hospital Response Team makeup:•vaccination of health care staff for purpose of caring for
patients, NOT for protecting all healthcare workers
•vaccinees have a responsibility to provide care if a case occurs
•total hospital vaccinees expected: 50-100/hospital
©2002 Rush-Presbyterian-St. Luke’s Medical Center
RPSLMC Hospital Response Team
Physicians•Emergency 6•ID: Adult 3•ID: Peds 1•Critical Care: Adult 6•Critical Care: Peds 1•Psychiatrist 1•Other 7
_______________________
Total 25
©2002 Rush-Presbyterian-St. Luke’s Medical Center
RPSLMC Hospital Response Team
Nurses•Emergency 20•Critical Care: Adult 20•Critical Care: Peds 2•Infection Control 3•Other 10
_______________________
Total 55
_______________________
Grand Total 80
©2002 Rush-Presbyterian-St. Luke’s Medical Center
RPSLMC Hospital Response Team
Miscellaneous•Site Care Team 5•Respiratory 2•Security 5•HVAC Technician 1•Radiology 2•Housekeeping 4•Mortuary 1
_______________________
Total 20
_______________________
Grand Total 100
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Key to a Safe Vaccination Program
•Thorough screening for contraindications to eliminate individuals who are ineligible to
receive the vaccine
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Contraindications in a Pre-Event Setting
•Pregnancy or breast feeding•Immunodeficiency
–HIV/AIDS–cancer
•Immunosuppressive therapies–cancer treatment–organ transplant maintenance–long-term steroid therapy
•prednisone: 2 mg/kg/day or 20 mg/day for 14 days or longer
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Contraindications in a Pre-Event Setting
•Eczema / atopic dermatitis–healed or active
•Vaccine component allergy–neomycin–streptomycin–polymyxin–tetracycline
•Eye disease of conjunctiva or cornea–pruritic lesions–florid inflammation
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Contraindications in a Pre-Event Setting
•Extensive skin diseases
(until the condition resolves)–acne–burns–wounds–recent incisions–impetigo–contact dermatitis
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Contraindications in a Pre-Event Setting
Household Contact with Contraindication
•Risk of accidental inoculation of household contacts exists until the scab falls off
–immunocompromised–eczema
•Infants <1 year (under evaluation)•Should defer immunization in pre-event setting
Rush Presbyterian-St. Luke’s Medical CenterSmallpox Response Team
Prescreening Tool
Introduction: President Bush has recently announced the smallpox vaccination plan forthe United States. In the initial phase, members of the military and smallpox responseteams would be vaccinated. The City of Chicago has asked each hospital in the city toprovide plans for a smallpox response team for their hospital. The Rush SmallpoxResponse team would consist of approximately 100 select hospital personnel who wouldbe vaccinated for smallpox and be involved in caring for the first potential cases ofsmallpox seen at Rush. Personnel successfully vaccinated for smallpox are immune fromacquiring smallpox infection.
Instructions: This document is not a consent for smallpox vaccination, rather it is a toolto determine how many of our key employees might be eligible and willing to receivesuch vaccination. Please complete this tool even if you are unwilling or unable to receivevaccination. Your responses are confidential. This is a two-page form.
Please print:
Department: _____________________ Position (MD, RN, RT, Security etc)______________
Do you have clinical experience with (circle one): adults children both
Last Name: _______________________ First Name:_____________________Age:_____
Employee ID Number:_______________ Are you (circle one): full time part time
Work phone:______________pager:__________________Home phone:_________________
Please check the appropriate box:
Have you ever been vaccinated for smallpox? ? yes ? no ?unsure
Are you (or household member) currently pregnant ? yes ? no ?unsure or trying to become pregnant?
Do you have children in your home less then 1 year old? ? yes ? no ?unsure
Do you have eczema, or have you ever had eczema? ? yes ? no ?unsure
Has anyone in your home ever had eczema? ? yes ? no ?unsure
Have you ever had an allergic reaction to smallpox vaccine? ? yes ? no ? unsure
Are you allergic to polymyxin B, streptomycin, ? yes ? no ? unsure Tetracycline, neomycin, or phenol?
Are you immunosuppressed from cancer treatment, ? yes ? no ? unsure organ transplant or other condition? Describe:________________________
Is anyone in your home immunosuppressed from cancer ? yes ? no ? unsure treatment or organ transplant?
Are you currently breastfeeding? ? yes ? no ? unsureDo you believe that you might have any other medical
contraindications for receiving smallpox vaccination? ? yes ? no ? unsureDescribe:______________________________________________
In the coming weeks you will be receiving additional education related to the benefits and risksof smallpox vaccination. Members of the Rush Smallpox Response Team will all be volunteers.Rush will not require any employee to be vaccinated. Rush will provide free screening forHIV, and pregnancy if requested. Employees will not be required to utilize any PTO time toparticipate in this effort.
Based on what you currently know, please complete the following:
? I would like to be considered for participation in the Smallpox Response team, whichincludes vaccination with smallpox.
? I am not interested in being part of a Smallpox Response Team.
If you would like to discuss any components of this form prior to completing it, you maycontact any of the following:
Gordon Trenholme, MD 2-5865Stacy Pur, Infection Control 2-3056Stephanie Black, MD 2-4451John Segreti, MD 2-5865
Please return this form to Stacy Pur, 143 Ac Fac in the envelope provided.
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Logistics
Hospital Response Team phase-in•designate a small proportion (20-30%) for first round to gain
experience in post-vaccination management•stagger HCW within an individual unit by ~three weeks
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Hospital Responsibilities
•Participating hospitals will need to: •provide pre-program education•identify their hospital response team•evaluation and treatment of adverse events•pre-shift, daily management of vaccination site until scab off
–assess dressings, change dressing as needed–assess site for local reactions and for vaccine take
•evaluation of vaccination ‘takes’ and reporting to public health authorities
©2002 Rush-Presbyterian-St. Luke’s Medical Center
Resources
www.bt.cdc.gov/training/smallpoxvaccine/reactions/default.htm
Rush specific information email: