Address risks of staff who get smallpox vaccine

Even if your ED staff are not being vaccinated for smallpox, you’ll need to address transmission risks if reservists receive the vaccine due to military call-ups. "The reservist and military issue is why everyone needs a policy," says Robert E. Suter, DO, FACEP, senior consultant at Texas Emergency Physicians in Dallas. "You cannot simply hide and avoid the issues surrounding the vaccination program. They can come to you regardless." (For more information on smallpox, see "Don’t miss smallpox/plague outbreaks: Adapt strategies to track bioterrorism," ED Management, January 2002, p. 1.)

There are three items that are essential to consider:

• Survey staff about their vaccination status. At Inova Health System in Fairfax, VA, nurse managers regularly inquire as to whether staff have been vaccinated as part of the military vaccination campaign, reports Dan Hanfling, MD, FACEP, director of emergency management and disaster medicine. "Those who have are being asked to report this to their supervisors, and to undergo evaluation of their bandage covering prior to participating in their health care-related activities," he says. The bandage is being evaluated for proper placement and integrity, he says. "We are assuming the vaccine recipient will be responsible for following the progress of their own vaccine reaction, and [they] will be asked to notify their physician of any unexpected findings," adds Hanfling.

• Remind staff to ask if patients have been vaccinated. "We are emphasizing to our ED staff that any patients who present with fever and rash, either localized or generalized, should be asked if they or a close contact have recently been vaccinated with the smallpox vaccine," Hanfling says. Vaccinia virus, which causes rash, fever, and head and body aches, can be spread from the vaccination site by touching the site before it has healed or by touching contaminated bandages or clothing, according to the Atlanta-based Centers for Disease Control and Prevention (CDC) guidelines.

• Address risks of transmission. Because some ED staff will be vaccinated from other sources regardless of your policy, you’ll need to address this problem even if your ED staff weren’t vaccinated at your facility, Suter says. "The best defense is to give leave to those who are vaccinated until they are noninfectious," he says. If this is not possible, Suter says the following are recommended:

  • Wear a gauze bandage covered with a semipermeable dressing as an additional barrier.
  • Wear long sleeves over the dressing site.
  • Give assignments which minimize patient care duties to those who are still potential transmitters.

The key recommendation is to wash hands, especially after touching the vaccination site or bandages, clothing or anything else that might have come in contact with the vaccination site, Hanfling says.

Review and implement CDC guidelines to avoid transmission to patients, staff, and visitors at increased risk, advises Bettina Stopford, RN, a member of the Des Plaines, IL-based Emergency Nurses Association Disaster Planning Workgroup. (The guidelines can be accessed at no charge at Click on "ACIP Recommendations: Smallpox Vaccine in a Pre-Event Vaccination Program.") Encourage staff who receive the vaccine to work with their hospital infection control professional to prevent any transmission, Stopford says.

According to the CDC guidelines, newly vaccinated staff can safely care for patients, Hanfling says. "With [more than] 300,000 vaccine recipients to date in the U.S., there have been no reported transmissions of vaccinia from vaccine recipient to patients," he says. "The Israeli vaccination experience also did not demonstrate any cases of vaccinia amongst hospitalized patients," he says.

However, a California adult recently became infected with the same virus used in the military’s smallpox vaccination program. The patient had been in close contact with someone who was recently inoculated, although it is unclear exactly how the virus was transmitted. "While this is not known to be a case of transmission from a health care worker, it reminds us all that it can happen," Suter says. Health care workers will be expected to exercise caution and diligence to prevent transmission, he emphasizes. "Those who don’t can expect the legal community to be a step away from filing a lawsuit," Suter says.

To avoid this scenario, promote basic infection control practices such as good hand washing and appropriate site coverage to reduce the likelihood of such transmission, Hanfling advises. "We are also working with our staff to avoid the situation whereby a known immune-compromised patient is cared for by a recently vaccinated health care worker," he says. Many ED patients may have immunocompromised status that you are unaware of, he acknowledges. "Whenever possible, we are going to avoid patient care contact with those most obviously immunocompromised, such as those with neutropenia or recently transplanted, as an added precaution," Hanfling says.


For more information on reducing risks of inadvertent transmission of the smallpox vaccine, contact:

Dan Hanfling, MD, FACEP, Director, Emergency Management and Disaster Medicine, Inova Health System, 3300 Gallows Road, Falls Church, VA 22042. Telephone: (703) 698-3002. Fax: (703) 698-2893. E-mail:

Bettina Stopford, RN, Senior Program Analyst, SAIC, Homeland Security Group, 8301 Greensboro Drive, MS E-1-6, McLean, VA 22102. Telephone: (703) 676-6348. E-mail:

Robert E. Suter, DO, FACEP, Senior Consultant, Texas Emergency Physicians, 5926 Saint Marks Circle, Dallas, TX 57230-4048. Telephone: (214) 739-2776. Fax: (214) 739-0658. E-mail: