Is it smallpox? When panicked patients storm the ED, nurses will be the refuge

Take steps now to prevent major problems later

Are you ready to isolate a case of suspected smallpox, cope with potentially serious side effects from the vaccine, and answer questions from panicked patients? There is no time to hesitate — these are things you will have to do soon, because hospitals nationwide have received the official go-ahead to vaccinate staff for smallpox.

"This is on everyone’s mind, as emergency staff are among the first groups to be phased into the plan to receive the vaccination," says Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, director of emergency and trauma at University of California-Irvine Medical Center in Orange.

In emergency departments (EDs) across the country, there is a new sense of urgency in getting prepared to confront a possible smallpox outbreak, says Karen G. Ketchie, RN, EMT-P, disaster preparedness manager at Shands Jacksonville (FL) Medical Center. "We now have clear guidelines," she says. "Now that we have that information, we can begin to implement our plans at the direction of the health department."

Ketchie’s facility has been asked to provide a list of personnel who have volunteered to receive inoculation to the state department of health. Before that step can be accomplished, staff members need to be educated, prescreened, and given the opportunity to ask questions so they can make an informed decision, she says. "We are beginning an educational blitz immediately," Ketchie reports. She says that the materials used are from the Centers for Disease Control and Prevention (CDC) and the hospital’s infectious disease specialists. It is inevitable that some problems will arise, Ketchie says. "That will happen at every hospital, due to the sheer volume of people being inoculated," she says.

Here are items to consider when planning for the smallpox vaccine:

• Be ready to answer questions.

Be ready to field all types of questions about the vaccine from concerned colleagues and worried patients, says Bradley. "ED nurses must have a very comprehensive awareness about smallpox and the vaccine since they will be on the front lines," she underscores. "You will be sought out for advice and treatment of the vaccine side effects." You must understand the disease, CDC recommendations, risks of the vaccine, vaccine alternatives, contraindications, side effects, screening, reporting, and monitoring, Bradley says.

ED nurses at Ketchie’s facility will be educated with inservices, town hall meetings, a designated site on the hospital’s intranet system, departmental staff meetings, question-and-answer sessions, and printed information. "We will get out as much information as we possibly can," she says. "Our staff will be provided the information required to make an informed decision, for them and their family."

Ask yourself whether you are truly well informed, Bradley advises. "ED nurses must be comfortable with their knowledge in this area, because it is for certain they will be challenged," she warns. Be ready to address questions from patients who ask about receiving the vaccine, says Bradley. "Assure them that their opportunity will come much later in time and that their risk is much lower than that of the health care worker," she says.

• Have a high index of suspicion for smallpox and side effects from the vaccine.

If a patient develops a rash, febrile illness, or eye drainage within one month of receiving the smallpox vaccine, you should suspect a vaccine-related complication, says Eric Lavonas, MD, FACEP, an ED physician and toxicology fellow at Carolinas Medical Center in Charlotte, NC. If you suspect vaccine-related side effects, Lavonas suggests asking the following question: Have you or anyone in your household been recently vaccinated for smallpox? "Remember that vaccinia is primarily spread by touch," he says. For a suspected vaccinia case, he recommends decontaminating the patient’s chair and medical equipment as you would with a blood contamination.

According to the CDC, hospitalization of patients with adverse events should be based on the degree of severity and infectiousness.1 Patients with severe and extensive inoculation vaccinia, progressive vaccinia, and post-vaccinial encephalitis almost always require hospital care, according to the agency. In the hospital, these patients must be isolated, the CDC says. You must separate all materials used in their care, and you should treat such materials as infectious waste, the agency says. (For more information, visit the "Preventing Contact Transmission" page on the CDC web site, Noninfectious patients do not need to be hospitalized unless serious disease is present, such as Stevens Johnson syndrome, the agency says. Most patients with generalized vaccinia do not need to be hospitalized, the agency says; in fact, avoid hospitalization to minimize intrahospital spread, the CDC recommends.

• Consider using only vaccinated nurses for triage.

Ideally, nurses should be vaccinated as a condition of accepting the role of triage nurse, Bradley argues. However, she acknowledges that this requirement could be potentially problematic, because some experienced triage nurses may have contraindications or decline the vaccine. This particular issue is fraught with controversy, and experts disagree as to whether triage nurses should be required to be vaccinated.

"Triage nurses should ask themselves, What are the odds that I, personally, will be the first American nurse to see a patient with smallpox since 1949?’" says Lavonas. "Unless there is an outbreak, nobody’s job should be affected by their desire to receive or decline the smallpox vaccine."

Even in a worst-case scenario, smallpox vaccination is effective if received within 48 hours of exposure, so an exposed triage nurse should be able to receive the vaccine in plenty of time, Lavonas notes. "Patients with smallpox develop a pretty dramatic rash on the face at about the same time that they become contagious," he adds.

In addition to the education given to all ED staff, triage nurses at Bradley’s facility will receive more comprehensive training that will include special isolation procedures, she says. (For more information on isolation procedures, go to the CDC web site and click on "Diagnosis/Evaluation.") "If, in fact, we are at risk for a smallpox event, the triage nurse would be first to see it," she explains.

• Make sure you understand contraindications.

A significant number of nurses won’t be able to receive the vaccine, notes Ketchie. "The first big hurdle is to rule out nurses with contraindications," she says. Protecting family members is a key consideration for staff, Ketchie adds. "Many of the contraindications not only apply to the person receiving the vaccine, but to any of their immediate household members," she notes. At Ketchie’s facility, staff members are being prescreened before they even get to the health department to receive the inoculation, where they will be screened again, she reports.

If you choose not to receive the vaccine, your colleagues should respect your decision, says Bradley, emphasizing the voluntary nature of the program. "You should not be required to disclose the reason for your decision," she underscores.

• Have a plan in place to address side effects.

Triage nurses will need to recognize the side effects of vaccination, Ketchie says. "You need to understand what the side effects may be from the day of inoculation until the day the scab falls off, so there are no surprises," she says. She says that 30% of vaccinated individuals experience enough flulike symptoms that they feel they are unable to work for a day or two. Symptoms and side effects could last up to three weeks, with peaking during the second week after inoculation, Bradley notes. "This will present a hardship on staffing when the staff become ill," she says. She also predicts increased visits to the ED as a result of inpatient staff getting sick from the vaccine.

• Establish a system to address concerns of vaccinated staff.

Since many vaccinated staff will become sick, you must have an effective way to answer questions and concerns, advises Ketchie. Ketchie’s facility has set up a telephone number for staff to call if they still have questions after receiving the training session and reading an information packet. Staff members are instructed to leave their contact information on a recording, and a nursing educator or infectious disease specialist who can address their concerns promptly contacts them. "Staff always will be instructed to follow up with their physician for any medical questions they are unsure of," Ketchie says.

• Avoid inadvertent transmission of the virus.

A primary concern for ED nurses at Ketchie’s facility is to avoid inadvertent transmission of the virus, and she stresses the importance of following universal precautions. "The biggest safety concern is transmitting this live virus to family, patients, or co-workers," she says.

However, this should not be a problem, so long as proper precautions are followed, says Lavonas. "Vaccinia virus is present in the eschar and drainage at the vaccination site on the upper arm," he says. According to the CDC recommendations, the site should be loosely covered with a porous bandage, and the vaccinated person should wear a long-sleeved shirt to cover the site.


1. Centers for Disease Control and Prevention. "Adverse Reactions." Accessed at


For more information on the smallpox vaccine, contact:

Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, Director Emergency/Trauma Services, University of California-Irvine Medical Center, 101 The City Drive, Route 128, Orange, CA 92868-3298. Telephone: (714) 456-5248. Fax: (714) 456-5390. E-mail:

Karen G. Ketchie, RN, EMT-P, Disaster Preparedness Manager, Shands Jacksonville Medical Center, 655 W. Eighth St., Jacksonville, FL 32209. Telephone: (904) 244-2598. Fax: (904) 244-4285. E-mail:

Eric Lavonas, MD, FACEP, Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Blvd., Charlotte, NC 28203. Telephone: (704) 355-4212. Fax: (704) 355-8356. E-mail:

Here is a partial listing of educational resources available at no charge the Atlanta-based Centers for Disease Control and Prevention web site (

  • Under "Frequently Requested," click on "Smallpox Vaccine Administration Video" to review common reactions following vaccination, screening for contraindications, administering the vaccine, and caring for the vaccination site.
  • Under "Frequently Requested," click on "Vaccination & Adverse Events Training Module" for information on the smallpox vaccine, method of vaccination, and vaccination reactions.
  • Under "Frequently Requested," click on "Response Plan & Guidelines (including updated forms) for guidance for responding to a smallpox emergency.
  • For preparedness information from recent web casts, under "Featured Links," click on "Webcast: Smallpox Preparedness: Considerations for Response Team Volunteers," "Webcast: CDC Bioterrorism Update: Smallpox Preparedness," and "Q&A for public health & clinical personnel planning for vaccination."