Didn’t vaccinate? You still can be prepared

Post-event smallpox plan allows swift action

Baystate Medical Center in Springfield, MA, hasn’t vaccinated a single health care worker against smallpox. Yet the hospital is well-prepared for a possible smallpox event with a plan that would allow vaccination of 5,600 employees in a three-day period.

The bottom line for Baystate: "There’s more to smallpox preparedness than just vaccination," says James Garb, MD, director of occupational health and safety at the Baystate Health System.

Although the Massachusetts Department of Public Health still is promoting pre-event smallpox vaccination, it has been very supportive, he says. The agency helped train 25 Baystate employees to vaccinate others, if that should become necessary. "The emphasis has shifted from vaccinating people to having a plan like this is place."

The plan addresses the details of setting up a post-event vaccination clinic, from the number and type of employees to the location of the screening and training. For example, Garb would take over a conference facility, canceling scheduled meetings at a moment’s notice. A total of 51 employees would staff two shifts for three days to accomplish the vaccinations. "If there were smallpox, we would be called upon to do three things: Potentially take care of patients who have smallpox; vaccinate staff; and assist in vaccinating the community." The Baystate plan prepares the hospital to do that, he says.

The Joint Commission on Accreditation of Healthcare Organizations requires emergency preparedness, and the Centers for Disease Control and Prevention (CDC) advises hospitals to work with local health departments and community partners in their preparedness activities. Smallpox is an important part of the continuum of preparedness, says Deborah Levy, PhD, MPH, a senior epidemiologist with CDC and a commissioned officer with the U.S. Public Health Service.

Although Massachusetts only has vaccinated 165 health care workers, state epidemiologist Al DeMaria, MD, says vaccination is an important part of preparedness. He notes that health care workers have "less interest in getting vaccinated," but are receptive to preparedness training on smallpox and other emerging infectious diseases. Meanwhile, the state is planning a drill in the fall, testing a plan to quickly vaccinate the public if a smallpox case occurs. Participants will go through the screening process but receive the influenza vaccine, instead.

Originally, Garb planned to vaccinate a core team of health care workers who could care for a potential smallpox victim "24/7" until the rest of the staff were able to be vaccinated. "We were all set to vaccinate about 30 people. We were two or three days away from doing that when the information about the possible adverse cardiac events came out," he says. "We put that plan on hold."

As of Jan. 24, the CDC reported 16 suspected cases and five probable cases of myo/pericarditis linked to the vaccine among the 39,000 civilian health care workers vaccinated. The Department of Defense reported 72 cases of myo/pericarditis among 600,000 vaccinees.

It is impossible to quantify the risk of a smallpox event; no one knows where or when or whether it could happen. Yet world travel makes it possible for unusual diseases to appear even in remote locations. For examples, the first cases of monkeypox in the United States occurred in rural Wisconsin.

Garb contends that the very first case of smallpox anywhere in the world isn’t likely to appear in Springfield, MA. And even if it does, Garb’s vaccination plan would allow for the vaccination of employees within the three- to four-day window in which post-exposure vaccination would provide protection. "We wouldn’t make this decision in a vacuum," he says. "We would wait for direction from the Massachusetts Department of Public Health and [the CDC]."

Garb will educate employees about the plan and conduct a tabletop drill, checking for the availability of resources needed to carry it out. Annually, he will review the plan, making sure that the key personnel and resources still are available.

That is the right approach, Levy adds. "It really is not enough to just write a plan. You need to at least do a walk-through or tabletop [drill] or fold it into other [emergency preparedness] drills you’re required to do."

From triage to exit advice

When employees enter Garb’s post-event vaccination clinic, they would first encounter a triage nurse. If the first case of smallpox actually occurred in or near Springfield, the triage nurses would assess the employees for early symptoms or exposure. In general, the triage staff would identify employees who have a fever or rash and could not continue through the vaccination clinic.

Staff then would enter one of two conference rooms, where 30 people at a time would view a video about smallpox vaccination and its contraindications. They would fill out screening forms in that room and then move to the next station in the conference facility.

If staff did not check any boxes to indicate they have a contraindication, they would go directly to a vaccination station. If they checked "yes" or "maybe" to at least one question, they would undergo medical screening with a nurse practitioner or physician assistant. A physician would be on hand to consult on screening questions.

Each RN vaccinator would have an assistant to help with the documentation. Once again, the nurse would ask the employees if they have any concerns about vaccination. They could sign a declination and refuse vaccination, or they could go back to a medical screening station to discuss their concerns.

All employees who receive the vaccine would sign a consent form. In an "exit review" station, they would receive information about caring for the dressing and reporting adverse events. Employees who refused vaccination would receive information about symptoms of smallpox infection. Garb estimates that 80% of the staff of about 7,000 employees would ultimately receive the vaccine in a post-event scenario.

The plan could be adapted for other emergencies, including the need to vaccinate or provide medication for other types of outbreaks.

"If we had pandemic influenza and they were able to come up with a vaccine, this same basic plan could be used," Garb notes. "I do feel more comfortable knowing we have something."

(Editor’s note: Information on smallpox preparedness, including CDC guidelines on creating a post-event vaccination clinic, is available at www.bt.cdc.gov/agent/smallpox/response-plan/index.asp.)