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Tennessee Prepares for the Threat of Smallpox
by Pauline S. McIntyre, RN, CNM
Smallpox, once the most devastating of all infectious diseases and killer of millions, is reemerging as a threat to mankind. recent intelligence reports indicate that a number of countries may have stockpiles of the virus and there is a growing concern about its potential for use as a biological weapon.
Terrorists could use many biological agents, but few have the ability to cause such illness and panic that may completely overwhelm existing medical and public health systems. Since most people are no longer immune from this deadly and disfiguring disease, we have to take steps to prepare. This article discusses smallpox and Tennessee‘s preparedness response.
The last case of smallpox in the United States occurred in 1949. routine smallpox vaccination in the United States was discontinued in 1972, and the last case of naturally acquired smallpox in the world was in Somalia in 1977.
in 1980, the World Health Organization (WHO) declared the world to be free of naturally occurring smallpox. At that time, WHO recommended that all countries cease vaccination and that all laboratories destroy their stocks of variola (smallpox) virus or transfer them to one of two WHO reference laboratories – the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, or the Institute of Virus Preparations in Moscow, Russia. Thus it was that smallpox became the first, and thus far the only, disease to be completely eradicated from the earth, an unprecedented accomplishment for public health.
Smallpox is an acute, contagious, and sometimes fatal disease caused by the variola virus (an orthopoxvirus) and marked by fever and a distinctive progressive skin rash. Transmission is through close person-to-person contact or by direct contact with contaminated body fluids, clothing or bed linens. Clinical symptoms include the sudden onset of a high fever (>1020F), malaise, severe headache, backache, abdominal pain or vomiting. A rash, the result of virus replication on the skin, erupts and evolves through stages of papules, vesicles and pustules, which eventually scab over.
initially, the lesions appear on the oral mucosa, and later, concentrate on the face and extremities (centrifugal), all lesions evolving at the same rate. They are deep, firm, and well circumscribed (resulting in the marked skin pitting/scarring of smallpox survivors) and may be confluent or umbilicated. Patients are contagious from the time the rash first appears until all the scabs of all the lesions have separated.
The public health strategy for containing a smallpox outbreak includes isolation of confirmed and suspected smallpox cases, together with tracing, vaccination and close surveillance of all contacts. Vaccination is effective in preventing infection if given in advance, or within three days of exposure.
The mass pre-event smallpox voluntary vaccination plan, initiated in January 2003, includes three separate phases whereby vaccination will be offered to: 1) volunteer vaccinators, health care workers, and those on public health smallpox response teams; 2) first responders (police, firefighters, and ambulance crews), and all health care workers and public health staff; and 3) the general public (although the federal government is not currently recommending this final phase).
In preparation for Phase 1 of the plan, I was one of five nurses selected from Tennessee to attend the national CDC smallpox-training course held in Atlanta in December. We spent an intensive day learning about vaccine clinic operations and management, vaccine administration (including practical demonstration and opportunity for perfecting our vaccine administration technique), medical screening and contraindications, post vaccination site care and “take“ evaluation.
objectives of the training were to: a) train the nursing leadership in each state and provide tools for them to implement training at the local level; and b) insure that resources were immediately available in order to initiate post-event vaccinations should a smallpox case occur. We then set about developing a similar training for key public health staff throughout the state, and they, in turn, implemented training at the local level. We also developed a medical protocol for smallpox vaccination and guidelines for site care. In less than a month, we were ready to start vaccinating.
The first element of the program was the identification of eight public health investigation response teams geographically located so that one team could be mobilized to any part of the state within a one-and-a-half-hour time frame. Each six-person team is headed by a health department physician and includes at least two physicians, two nurses and two team members who are experienced in outbreak investigation. Their role is to investigate suspected cases of smallpox and to immediately initiate the post-event smallpox plan should it be needed.
The Tennessee Department of Health identified 136 acute care hospitals in the state. Each facility was asked to designate staff willing to be vaccinated that would serve on hospital smallpox health care response teams. These teams will provide medical care for the first smallpox patients requiring hospital admission and evaluate/manage patients presenting at the emergency room with suspected smallpox. Seven cities were selected as vaccination sites based on their proximity to the greatest number of the state‘s larger hospitals. Intensive education and pre-screening of potential volunteers were completed.
Careful screening is required prior to voluntary vaccination in order to identify persons at the greatest risk for serious side effects from the smallpox vaccine. In a pre-event situation, individuals who have, or live with someone who has, eczema or other exfoliated skin conditions, weakened immune system or pregnancy should not receive the smallpox vaccine. Additionally, individuals should not receive the smallpox vaccine if they are allergic to any component of the vaccine, are younger than 18 or older than 65, have a moderate or severe short-term illness, are breastfeeding or using steroid drops in their eyes. pending further evaluation of a possible causal relationship between the smallpox vaccine and cardiac disease, the CDC also recommends a temporary medical deferral of smallpox vaccination for those persons: a) previously diagnosed with heart disease (coronary artery disease or myocardial disease such as angina, a history of a heart attack, congestive heart failure, or any kind of cardiomyopathy); b) having three or more known major cardiac risk factors (including hypertension, diabetes, hypercholesterolemia, and smoking); or c) having an immediate family member who has had onset of a heart condition before the age of 50. there are no vaccine contraindications if an individual is actually exposed to a case of smallpox.
Mild side effects from the vaccine include lymph node swelling, tenderness around the vaccination site, low-grade fever, rash, body aches and fatigue. People at greatest risk for serious and potentially life-threatening reactions (eczema vaccinatum, progressive vaccinia, and postvaccinal encephalitis) are those with immunocompromising conditions, atopic dermatitis or eczema.
The smallpox vaccine, which is made from the live vaccinia virus (related to, but distinct from, the smallpox virus), is administered using a unique percutaneous method whereby a droplet of the reconstituted vaccine is held between the prongs of a birfurcated needle and is instilled through multiple punctures into the skin over the deltoid muscle. The punctures should form a small circular area of approximately 5 mm in diameter and be vigorous enough to allow a trace of blood to appear after 15-20 seconds. A successful “take“ or “major reaction“ indicating successful vaccination is confirmed (day 6-8) by the presence of a pustular lesion or an area of definite induration or congestion surrounding a central lesion, which can be a scab or an ulcer.
live virus is shed from the vaccination site; therefore strict hand washing and appropriate site care is essential. This is especially critical during the time the vaccinee is in direct contact with patients when a semi-permeable dressing must be used. Careful disposal of contaminated dressing materials is required, as well as laundering of clothing/linens (hot water, detergent, and/or bleach) that may have had direct contact with the vaccination site.
the goal of Tennessee‘s pre-event voluntary vaccination program is to prepare for possible cases of smallpox by vaccinating those who would be caring for or investigating the initial case(s) of smallpox, as well as staff responsible for vaccinating others. Volunteer public health vaccinators were vaccinated beginning January 30, 2003, and hospital volunteers February 10, 2003. clinics were held on designated days during February and March, and as of April 11, 2003, Tennessee has vaccinated a total of 2,429 individuals, placing us third in the nation, once again proving that Tennessee is truly the “volunteer state.”
As of May 2, the total number of persons vaccinated throughout the United States is 35,903 and although major adverse events have been limited, the CDC continues to monitor for potential health concerns that may be identified. Phase 2 of the voluntary pre-event vaccination plan is not scheduled to begin until further evaluation of Phase 1 has been completed.
Should the United States experience a smallpox bioterrorism attack, a post-event voluntary vaccination plan is already in place that will assure voluntary vaccinations are provided both safely and rapidly. In accordance with instructions from the CDC, all Tennesseeans (without contraindications) will be offered smallpox vaccinations over a 10-day period. Individuals with contraindications having contact with a smallpox case will be immunized also. This will involve the establishment of one clinic per 50,000 population or 117 clinics statewide. clinics would operate two eight-hour shifts per day for 10 consecutive days and serve 5,000 patients each day. The staffing plan will include more than 200 public health staff and volunteers for each clinic (100 per shift), for a total of 25,000 clinic workers statewide. Since there are only 4,500 public health employees statewide, we are relying heavily on a volunteer workforce.
The Department is working to educate the general public and the medical community about smallpox planning and recruiting and training volunteers. We are also developing a mechanism to track and contact clinic volunteers and staff. It should be noted that the infrastructure that is being developed to provide for smallpox mass vaccination could readily be adapted to respond to other bioterrorism or disaster events that might affect the state such as the need for large-scale distribution of antibiotics.
Concurrently with the health department‘s effort towards preparedness for mass post-event vaccination clinics, the Tennessee Department of Health is also working with hospitals to prepare them for acts of bioterrorism. An advisory Committee for Hospital Preparedness has been established and regional meetings held to begin the process of developing a hospital bioterrorism preparedness plan. The focus of the plan is to prepare for the needs of 500 casualties in terms of facilities, staffing and personnel management, communication issues and associated operations. Upon completion of the statewide hospital bioterrorism plan, tabletop exercises will be conducted.
One case of smallpox anywhere in the world would constitute an international public health emergency. Both the United States and the state of Tennessee must prepare for such an event. A deliberate and careful approach to screening and vaccinating health care and public health workers provides a safe and effective method of preparation. We cannot prepare in a vacuum; teamwork is critical. Hospitals, public health, emergency management and first responders must form partnerships. The time to meet your partners and plan is now; we cannot afford to wait for that late night phone call.
Both the CDC and the Public Health Foundation provide smallpox related materials that can be used by health care providers. The CDC‘s website can be accessed at www.cdc.gov/smallpox. The public Health Foundation has produced a video, “Smallpox: What Every Clinician Should Know.” The videotape is available from the Foundation at (301) 665-773, by email at [email protected], or it can be viewed on the Internet. continuing education credits will be offered through the remainder of 2003. The CDC has also produced a poster “Evaluating Patients for Smallpox: Acute Generalized Vesicular or Pustular Rash Protocol.” It is useful for differentiating varicella from smallpox and presents common conditions that might be confused with smallpox. Copies can be obtained by calling the CDC at (404) 639-3632. The National Immunization Program website is www.cdc.gov/nip. The CDC‘s hotline number for public information is (888) 246-2675. If you have questions about the smallpox vaccination program please call your local health department or the Tennessee Department of Health at (615) 741-7247.
Pauline S. McIntyre, RN, CNM, currently serves as the Acting State Director of Nursing for the Tennessee Department of Health. McIntyre spent 20 years as a maternal and child health nursing consultant for the Department before assuming the role of Assistant State Director of Nursing in 1995. McIntyre holds a Bachelor of Arts degree in health care administration and is certified in nurse midwifery, ophthalmology and trauma medicine. Her primary responsibilities include coordinating nursing practice and management activities with special emphasis on the development of public health nursing protocols. Most recently, she has been actively involved with the planning and implementation of Tennessee’s smallpox preparedness plan.
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