Hospital Issues and Smallpox Vaccine

1. Hospital Issues and Smallpox Vaccine Lisa G. Kaplowitz, M.D., M.S.H.A. Deputy Commissioner Emergency Preparedness and Response Virginia Department of Health

2. VDH Emergency Preparedness and Response (EP&R) • All hazards approach to emergency preparedness • Responsible for CDC grant to enhance public health infrastructure and ability to respond to public health emergencies • Partnership with VHHA for HRSA grant to enhance hospital emergency preparedness

3. VDH EP&R Programs • National Pharmaceutical Stockpile (NPS) distribution and management – • Close collaboration with Virginia Department of Emergency Management (DEM) • Pre and post event smallpox vaccination plans • State, regional and local plans • District health departments (35) responsible for development and implementation of plans at local level

4. Smallpox vaccination • Dec, 2002: President Bush announced plan to vaccinate civilian response teams and military personnel • Pre-event smallpox vaccination • Stage 1: Hospital and public health response teams • Stage 2: Other health care providers, first responders • Stage 3: Offer to general public when enough licensed vaccine available

5. Hospital Participation in Smallpox Vaccination Plan • Voluntary for both hospitals and individuals • Pre-event vaccination of team to provide care to smallpox patients in first 7-10 days of a smallpox event • Assure that a certain number of health care providers will be comfortable providing care for persons with smallpox until others are vaccinated

6. Suggested Hospital Team Members • Physicians – ER,ICU, general medical, specialists (ID, dermatology, others) • Nurses - ER, ICU, medical • Infection Control Practitioners (ICPs) • Respiratory therapists • Transportation • Laboratory technicians • Housekeeping

7. Smallpox Vaccine Issues • Live virus vaccine – vaccinia • Contraindications pre-event • Immunosuppression: disease or medications • Eczema or history of eczema • Family member with immunosuppression or eczema • Pregnancy • Breastfeeding • Allergy: any vaccine components

8. Complication Primary Vaccination Revaccination Inadvertent Autoinoculation 529 42 Generalized Vaccinia 242 9 Eczema Vaccinatum 39 3 Progressive Vaccinia 1.5 3 Postvaccinal Encephalitis 12 2 Total 1254 108 Complication Rates of VaccinationRates (per million vaccinations) Following Smallpox Vaccination – U.S., 1968 (ten state survey)

9. Pre-Clinic Screening of Vaccination Candidates • Health care workers volunteering for vaccination will be identified • Volunteers will be given a packet of information to review at home prior to vaccination day • Contraindications • Complications • Precautions • Information about HIV, pregnancy testing • Volunteers will be allowed to withdraw without stating a specific reason

10. Screening for HIV Infection • Vaccine should NOT be administered to those with HIV infection or AIDS • Educate staff regarding risk of vaccine for those with HIV/AIDS • Mandatory HIV testing not required • HIV testing recommended for persons who have history of risk factor and do not know status • Anyone wishing HIV testing can be referred to health department for free confidential or anonymous testing

11. Screening for Pregnancy • In pre-event setting, should NOT be given to: • pregnant women • women trying to become pregnant • Educate women of child-bearing age about fetal vaccinia • Advise avoidance of pregnancy for 4 weeks following vaccination • If concerned, administer home test for pregnancy

12. Smallpox VaccinationHealth Department Responsibilities • Education and training, including providing education materials • Contraindications • Complications • Vaccine site management • Responsible for vaccine and vaccine administration • Collect information and report on adverse vaccine events

13. Adverse Events • Notify health department • Clinical assessment by patient’s provider, with assistance by appropriate specialists (ID, dermatology) • VIG in limited supply, management of many severe complications • Only available from CDC, through health department • Cidofovir not licensed for vaccinia complications

14. Hospital Responsibilities After Vaccination • Daily assessment of vaccine site for anyone involved in direct patient care • Vaccine site coverage for anyone involved in patient care: gauze, dressing, clothing • Dressing change as necessary, with appropriate disposal of dressings • Assessment of vaccine take at 7 days

15. Hospital Issues • Do not need to place HCWs on leave, unless: • Physically unable to work due to systemic signs and symptoms • Extensive skin lesions or vaccination site that can not be covered • HCWs do not adhere to infection control precautions and recommendations • No requirement for staff reassignment after vaccination

16. Vaccination Site Care • Virus can be recovered at site from time of papule until scab separates • Site should be kept dry • Normal bathing can occur if covered by waterproof bandage • Contact precautions most important – vaccinia virus IS NOT aerosolized

17. Vaccination Site Care • HCWs should keep site covered • Use gauze or similar absorbent material • Cover this with semi-permeable dressing • Wear long sleeves to further limit contact with vaccine site

18. Other Post Vaccine Issues • Defer blood donation for 21 days after scab falls off • Appropriate care with dressing change • Handwashing • Disposal of dressings in ziplock bag • Disposal of dressing in red bag in hospital, trash at home