Vigilant monitoring will protect HCWs, patients

EHPs to join skin-care teams in daily checks

After health care workers receive the smallpox vaccine, employee health professionals will assist with the most important vaccination role: monitoring reactions and protecting patients and others from vaccinia.

A pustule forms from the live vaccinia (cowpox) virus in the vaccine, and until the scab separates from the skin about 21 days after vaccination, the injection site is infectious. Those who are vaccinated inadvertently can inoculate themselves in another part of the body, such as the eyes; or vaccinia can be transmitted to other people through contaminated hands or clothing.

The Healthcare Infection Control Practices Advisory Committee (HICPAC), an expert advisory panel, has developed a protocol for protecting and monitoring the injection site. It includes the following recommendations:

• Use a semipermeable clear dressing with absor-bent, nonadherent gauze, such as Opsite or Tegaderm.

• If the health care worker is allergic to the semipermeable dressing, use a hydropolymer adhesive waterproof dressing with nonadherent absorbent pad such as Allevyn or Tielle.

• Keep the initial dressing in place for one to four days following vaccination unless there is fluid around the edge of the gauze in the clear products or discoloration of the other products.

• Cover the dressing with plastic wrap when showering.

• At the start of each work shift, vaccinated employees should report to a skin-care team, which may include employee health nurses. The team will check that the dressing is intact, change the dressing as needed, and ask about signs or symptoms of adverse reactions. Team members should change gloves between removing the old dressing and applying the new. They should use good hand hygiene, which can include alcohol-based gels.

• Advise vaccinated employees to use good hand hygiene and contact the team if any problems develop at home.

• Discard dressings and scab as regulated medical waste.

By taking those precautions, hospitals can pro-tect patients from any potential risk, according to William Scheckler, MD, hospital epidemiologist at St. Mary’s Hospital Medical Center in Madison, WI, and a HICPAC member.

"The data are quite good that [such precautions] will contain the virus," he says. "It’s a perfectly safe way to take care of patients."

Placing vaccinated health care workers on administrative leave until the scab separates would not be a practical plan, particularly in light of the current nursing shortage, says Jane D. Siegel, MD, professor of pediatrics at Southwestern Medical School of the University of Texas in Dallas and chair of the HICPAC bioterrorism working group. "That would be an incredible crisis for health care delivery," she says.

Daily monitoring of the injection site also provides an opportunity for hospitals to monitor adverse reactions. The monitoring team will be asked to collect data on:

  • the days of heaviest drainage for takers of vaccine;
  • fever, chills, fatigue, headaches, lymphadenopathy;
  • days off work;
  • severity of pain/pruritis;
  • presence of oral lesions;
  • lesions outside of vaccination site;
  • secondary infections.

The Clinical Immunization Safety Assessment system will provide a national hotline for questions about adverse events. Physicians knowledgeable about the smallpox vaccine will provide consultation and referral, and vaccine immune globulin and cidofovir will be available to treat more severe adverse events.