Smallpox Vaccination: Risk Assessment and Perspectives of the Health Care Provider, Institution, and State of Illinois
Edward P. Sloan, MD, MPH Associate Professor Dept of Emergency Medicine University of Illinois College of Medicine Chicago, IL
Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Medical Center
Some Considerations The disease The risk of an attack The public health impact of an attack The medical literature Current recommendations Questions for today
The Disease Easily spread: Most infectious disease Significant morbidity and mortality 500 million deaths in 20 th century 2 million deaths in 1967 Real morbidity
The Risk of an Attack 1980: Soviet Union starts Smallpox weapons program 1986: WHO recommends destruction of existing virus stocks 1994: Alibek defects, former deputy director of Soviet bioweapons program
The Risk of an Attack USSR producing “tons of virus” Successful weaponization of smallpox accomplished Virus transferred to a facility in Siberia Occurred concurrent with serious economic problems in Russia Might other countries might acquire the technology and weapons?
Public Health Implications of a Smallpox Attack 1972: Yugoslavia 1 case identified 11 people infected 138 people then infected 10,000 people isolated 20,000,000 people vaccinated
The Medical Literature NEJM Early release of articles Free distribution of materials Six articles Public, risk, vaccination, public health Good information for framing discussion
NEJM: Schraeder Obligation to protect public health Public health decisions “Trust our heads and our hearts”
NEJM: Blendon Public knowledge unclear Survey of 1006 adults False smallpox vaccination beliefs Need for public education
NEJM: Bozzette Scenarios of smallpox attacks Stochastic model of outcomes Risk of attack, risks of vaccination No risk: no vaccination Some risk: vaccinate HCWs High risk: vaccinate public
NEJM: Sepkowitz How contagious is vaccinia? : –12 outbreaks –85 secondary cases 75%: young children, atopic dermatitis Immunocompromise in HCWs Risk of hospital vaccinia outbreak
NEJM: Mack Alternate view of minimizing risk Vaccination & immunoglobulin best High risk of attack: immunize Otherwise, go for safer options –Facilitate rapid diagnosis –Use alternate medical facilities –Vaccinate and train 15,000 in US – Have vaccinia IgG for complications –Educate in a less inflammatory way
NEJM: Hanrahan Smallpox false alarm: case report Papulovesicular rash, same stages Centrifugal distribution Prodrome with fever, N/V CDC specimens: HSV positive Hospital test for HSV, VZV, syphillis Digital camera for to CDC
Current Recommendations CDC Advisory Committee on Immunization Practices (ACIP) June 2001: Initial recommendations June 2002: “Smallpox Health Care Teams” October 2002: 8 Specific Issues Comment: CDC HICPAC, DHHS NVAC
ACIP Recommendations Smallpox health care teams Smallpox vaccination site care Phase in: no administrative leave Screen: atopic dermatitis, pregnancy, HIV Administer other vaccinations Vaccinate the vaccinators
Questions for Today Knowns: –Risk of disease –Risk of vaccination Unknowns: –Risk of attack –Effect in society with immunocompromise –Public health value of vaccination –Need for vaccination
Questions for Today What are the risks of attack in 2003? What are the risks of vaccination? Who should get vaccinated? Who should get vaccinated first? Does prior vaccination matter? What happens after vaccination? Who assumes liability of vaccination?
Questions for Today What does the state expect of us? What are hospitals doing? Why? What are the risks of vaccination? What do we need to get it done? What are our knowledge gaps What comes next?
Our Speakers Patricia Lee, MD –Advocate IMMC –Smallpox and vaccination Dino Rumoro, DO –Rush-Pres-St Luke –Hospital perspective John Lumpkin, MD, MPH –Illinois Dept of Public Health –State public health perspective
Format & Information Three 20 minute lectures Opportunity for questions Videostreamed content Slides and lectures on internet Link from