1. DMC HVSH Guidelines for Suspected Smallpox Vaccine Adverse Events Evaluation Confirm that individual is smallpox vaccinee (should have PVN card) Those with contraindications to smallpox vaccine should not care for patient - Local Reaction: -Robust Take -Normal Variant Response -Satellite lesions -Lymphangiitis -Regional lymphadenopathy -Erythema (viral cellulitis) -Adhesive tape reactions Toxic Appearance or Signs of Other Serious Reaction: -Erythema Multiforme (EM) -Stevens Johnson Syndrome (SJS) -Generalized Vaccinia -Progressive Vaccinia -Eczema Vaccinatum -Post-vaccinial Encephalitis (PVE)  Adhere to “Prevention of Contact Vaccinia Guidelines” (see pp. 2 & 3)  Refer to HVSH Employee Health during normal hours  Refer to ED after hours. (ED should contact house supervisor @ pager 248-527-8598 and discuss with HAP* on call)  Pt. may benefit from NSAIDS and/or po anti-pruritics  OHS should be notified by the next day and employee should not be returned to work until seen by OHS Presenting Signs/Symptoms (refer to “ CDC Smallpox Vaccination Methods and Reactions” brochure/poster in ED or www.bt.cdc.gov/training/smallpoxvaccine/reactions/SmallpoxVaccinationGuide.pdf ) www.bt.cdc.gov/training/smallpoxvaccine/reactions/SmallpoxVaccinationGuide.pdf  Adhere to “Prevention of Contact Vaccinia Guidelines” (see pp. 2 & 3)  Adhere to Airborne and Universal Precautions (details on p. 3)  Place patient in airborne isolation * EM, SJS, PVE are not infectious, but patient may be placed in isolation until dx. is confirmed  Contact on-call HAP* * HAP=Hospital Assigned Physician (see p. 3) 1

2. DMC Central Region Guidelines for Suspected Smallpox Vaccine Adverse Events Evaluation Confirm that individual is smallpox vaccinee (should have PVN card) Those with contraindications to smallpox vaccine should not care for patient - Local Reaction: -Robust Take -Normal Variant Response -Satellite lesions -Lymphangiitis -Regional lymphadenopathy -Erythema (viral cellulitis) -Adhesive tape reactions Toxic Appearance or Signs of Other Serious Reaction: -Erythema Multiforme (EM) -Stevens Johnson Syndrome (SJS) -Generalized Vaccinia -Progressive Vaccinia -Eczema Vaccinatum -Post-vaccinial Encephalitis (PVE)  Adhere to “Prevention of Contact Vaccinia Guidelines” (see pp. 2 & 3)  Refer to Employee Health (4K UHC) during normal hours. Phone: 745-4522  Refer to DRH ED after hours  Pt. may benefit from NSAIDS and/or po anti-pruritics  ED Clinical Coordinator should notify OHS at above # by the next day and employee should not be returned to work until seen by OHS Presenting Signs/Symptoms (refer to “ CDC Smallpox Vaccination Methods and Reactions” brochure/poster in ED or www.bt.cdc.gov/training/smallpoxvaccine/reactions/SmallpoxVaccinationGuide.pdf ) www.bt.cdc.gov/training/smallpoxvaccine/reactions/SmallpoxVaccinationGuide.pdf  Adhere to “Prevention of Contact Vaccinia Guidelines” (see pp. 2 & 3)  Adhere to Airborne and Universal Precautions (details on p. 3)  Place patient in airborne isolation * EM, SJS, PVE are not infectious, but patient may be placed in isolation until dx. is confirmed  Contact on-call HAP* * HAP=Hospital Assigned Physician (see p. 3) 1

3. DMC NW Region Guidelines for Suspected Smallpox Vaccine Adverse Events Evaluation Confirm that individual is smallpox vaccinee (should have PVN card) Those with contraindications to smallpox vaccine should not care for patient - Local Reaction: -Robust Take -Normal Variant Response -Satellite lesions -Lymphangiitis -Regional lymphadenopathy -Erythema (viral cellulitis) -Adhesive tape reactions Toxic Appearance or Signs of Other Serious Reaction: -Erythema Multiforme (EM) -Stevens Johnson Syndrome (SJS) -Generalized Vaccinia -Progressive Vaccinia -Eczema Vaccinatum -Post-vaccinial Encephalitis (PVE)  Adhere to “Prevention of Contact Vaccinia Guidelines” (see pp. 2 & 3)  Refer to Employee Health during normal hours  Refer to SG ED after hours and contact HAP*  Pt. may benefit from NSAIDS and/or po anti-pruritics  OHS should be notified by the next day and employee should not be returned to work until seen by OHS Presenting Signs/Symptoms (refer to “ CDC Smallpox Vaccination Methods and Reactions” brochure/poster in ED or www.bt.cdc.gov/training/smallpoxvaccine/reactions/SmallpoxVaccinationGuide.pdf ) www.bt.cdc.gov/training/smallpoxvaccine/reactions/SmallpoxVaccinationGuide.pdf  Adhere to “Prevention of Contact Vaccinia Guidelines” (see pp. 2 & 3)  Adhere to Airborne and Universal Precautions (details on p. 3)  Place patient in airborne isolation * EM, SJS, PVE are not infectious, but patient may be placed in isolation until dx. is confirmed  Contact on-call HAP* * HAP=Hospital Assigned Physician (see p. 3) 1

4. Prevention of Contact Vaccinia Guidelines Avoid any contact with the vaccination site. During normal business hours, refer employee to employee health for local reactions. Good Hand Hygiene is the most important measure for preventing inadvertent implantation and contact transmission from vaccinia virus. This includes: Handwashing with soap and water for at least 15 seconds. Alcohol hand rubs may be used. Thorough hand hygiene after direct contact with vaccinee or the vaccination site. Thorough hand hygiene after contact with items that might be contaminated with live virus, such as bandages, clothing, or linen in contact with the vaccination site. Site covering for on-duty health care worker vaccinees: The vaccination site must be covered with a gauze, then covered with a secure Tegaderm or Opsite dressing. The vaccinee must wear long sleeves. BOTH of the above measures must be used until the scab has separated and the underlying skin has healed. Waste Disposal Any items in direct contact with the vaccination site are considered medical waste, including gauze, bandages, tape, Tegaderm or Opsite dressings. These must be immediately disposed into a biohazard container. Linen Clothing, towels or sheets in contact with the vaccination site can be decontaminated with routine laundering in hot water. Immediately bag these items and place into soiled utility. 2

5. Isolation The patient will require isolation initially until the diagnosis is confirmed. Place in negative pressure room, if available, or private room Keep door closed Wear N95 respirator to enter room Use Universal Precautions at all times Gowns and gloves for all direct patient contact Dressings, bandages, etc. = biohazardous waste Soiled linen = standard laundry procedures Discontinue isolation once smallpox**, Eczema Vaccinatum, Generalized Vaccinia, & Progressive Vaccinia have been ruled out (post-consultation with HAP) Maintain Universal Precautions ** Smallpox cannot be acquired from the smallpox vaccine, but is in the differential diagnosis HOSPITAL ASSIGNED PHYSICIAN NOTIFICATION ROSTER Central & Northwest Regions Jack Ebright, MD: DMC pager 2492 Tammy Lundstrom, MD: DMC pager 4052 Suzanne White, MD: pager 313-796-7778 Children’s Hospital of Michigan Basim Asmar, MD: DMC pager 4094 HVSH 1) Jim Gordon, MD: mobile 248-417-5157 3