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Hospital Smallpox Vaccination Perspective Dino P. Rumoro, D.O., F.A.C.E.P. Clinical Chairman Assistant Professor Department of Emergency Medicine January.

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Presentation on theme: "Hospital Smallpox Vaccination Perspective Dino P. Rumoro, D.O., F.A.C.E.P. Clinical Chairman Assistant Professor Department of Emergency Medicine January."— Presentation transcript:

1 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

2 Center of Excellence: Bioterrorism Preparedness Supported by a grant from the Chicago Department of Public Health

3 ©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?

4 ©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

5 ©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

6 ©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)

7 ©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)

8 ©2002 Rush-Presbyterian-St. Luke’s Medical Center What Are the Chances…? History is against us!

9 ©2002 Rush-Presbyterian-St. Luke’s Medical Center 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

10 ©2002 Rush-Presbyterian-St. Luke’s Medical Center Domestic Bioterrorism Attacks 2001 Anthrax laden letters

11 ©2002 Rush-Presbyterian-St. Luke’s Medical Center Ask Yourself…? Did you really think there was ever a chance of an anthrax attack?

12 ©2002 Rush-Presbyterian-St. Luke’s Medical Center Smallpox

13 ©2002 Rush-Presbyterian-St. Luke’s Medical Center History of U.S. Smallpox Vaccine Recommendations 1940’s: Last US case of smallpox 1971:Discontinued routine vaccination of the public 1976:Discontinued vaccination of healthcare workers 1989:Discontinued vaccination of the military 2003:Voluntary vaccination for first responders to a case of smallpox

14 ©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

15 ©2002 Rush-Presbyterian-St. Luke’s Medical Center What is the Current Risk? Logically, some degree of risk must exist!

16 ©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?

17 ©2002 Rush-Presbyterian-St. Luke’s Medical Center Knowledge is Power Know the Facts!

18 ©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

19 ©2002 Rush-Presbyterian-St. Luke’s Medical Center Bifurcated Needle

20 ©2002 Rush-Presbyterian-St. Luke’s Medical Center 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

21 ©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

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23 ©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

24 ©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

25 ©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

26 ©2002 Rush-Presbyterian-St. Luke’s Medical Center Potential Vaccine Side Effects  Symptoms usually occur about 1 week after vaccination  soreness  inflamed red ring around vaccination site  generalized weakness  swollen lymph nodes (25-50%)  fever > 100 F (2-16%)  muscle aches, headache, chills, nausea (0.3 – 37%)  fatigue  satellite lesions

27 ©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

28 ©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

29 ©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

30 ©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

31 ©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 patientimmediately thus minimizing further exposures

32 ©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

33 ©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

34 ©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

35 ©2002 Rush-Presbyterian-St. Luke’s Medical Center RPSLMC Hospital Response Team Physicians Emergency6 ID: Adult3 ID: Peds1 Critical Care: Adult6 Critical Care: Peds1 Psychiatrist1 Other7 _______________________ Total25

36 ©2002 Rush-Presbyterian-St. Luke’s Medical Center RPSLMC Hospital Response Team Nurses Emergency20 Critical Care: Adult20 Critical Care: Peds2 Infection Control3 Other10 _______________________ Total55 _______________________ Grand Total80

37 ©2002 Rush-Presbyterian-St. Luke’s Medical Center RPSLMC Hospital Response Team Miscellaneous Site Care Team5 Respiratory2 Security5 HVAC Technician1 Radiology2 Housekeeping4 Mortuary1 _______________________ Total20 _______________________ Grand Total100

38 ©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

39 ©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

40 ©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

41 ©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

42 ©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

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44 ©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

45 ©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

46 ©2002 Rush-Presbyterian-St. Luke’s Medical Center Resources www.bt.cdc.gov/training/www.bt.cdc.gov/training/smallpoxvaccine/reactions/ default.htm Rush specific information email:


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