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Smallpox Preparedness in LA County. Cristin Mondy, MSN/MPH, RN, PHN Bioterrorism Epidemiology & Surveillance Unit Acute Communicable Disease Control Program Los Angeles County Department of Health Services. LA Dept. of Health Services. Outline. The current threat Brief history

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smallpox preparedness in la county

Smallpox Preparednessin LA County

Cristin Mondy, MSN/MPH, RN, PHN

Bioterrorism Epidemiology & Surveillance Unit

Acute Communicable Disease Control Program

Los Angeles County Department of Health Services

LA Dept. of Health Services

  • The current threat
  • Brief history
  • Signs and symptoms of smallpox
  • Smallpox vaccine
  • LAC activities
smallpox overview
Smallpox: Overview
  • Smallpox is an acute, contagious, and sometimes fatal disease caused by the variola virus
  • Eradicated in the world in 1980
  • The use of smallpox as a biological weapon is now a possibility
  • The US government is taking precautions to deal with smallpox
smallpox overview1
Smallpox: Overview
  • Person-to-person transmission (respiratory droplets/contact)
  • Patient is contagious after rash appears
  • Death may occur in up to 30% of unvaccinated cases
smallpox overview2
Smallpox: Overview
  • Vaccination can prevent smallpox
  • No proven treatment at this time but research is ongoing
  • Vaccination within 3 days of exposure will prevent or significantly modify smallpox
  • Vaccination within 4-7 days after exposure offers some protection or modify smallpox
brief history
Brief History
  • 1949: Last case of smallpox in U.S.
  • 1972: Routine vaccination of the American public stopped
  • 1977: Last natural case occurred in Somalia
  • 1980: WHO announced eradication of smallpox worldwide
signs and symptoms
Signs and Symptoms
  • The first symptoms of smallpox usually appear 7-17 days after exposure
  • Begins with high fever, head and body aches, and sometimes vomiting (2-3 days)
  • NOT contagious during this time
signs and symptoms1
Signs and Symptoms
  • Rash follows
    • Rash can start on the mouth, face, hands, and forearms and then spread to the legs and body.
    • Rash becomes raised bumps that crust, scab and fall off after about 3 weeks, leaving a pitted scar.

The same stage of development

Mostly concentrated in face and extremities (hands and feet)

  • Spreads from contact with infected persons
  • Direct and fairly prolonged face-to-face contact is required to spread smallpox (within 6 feet)
  • May also be spread with contact through infected bodily fluids
smallpox vaccine
Smallpox Vaccine
  • Not available to the public at this time
  • If there is a smallpox outbreak, there is enough vaccine for everyone who would need it.
  • Vaccination within 3 days of exposure will prevent or significantly modify smallpox
  • Vaccination within 4-7 days after exposure offers some protection or modify smallpox
smallpox vaccine1
Smallpox Vaccine
  • Made from a live virus “vaccinia”
  • The vaccine can not spread or cause smallpox
  • Given with a bifurcated needle, not a “shot” like other vaccinations
  • The needle is used to prick the skin 3 or 15 times in a few seconds
who should not get the vaccine
Who should NOT get the vaccine?
  • Pregnant women
  • People who have or have had skin conditions (especially eczema and atopic dermatitis)
  • People with weakened immune systems
    • Those who have received a transplant
    • Those who are HIV positive
    • Those receiving treatment for cancer
    • Those taking medications (steroids) that suppresses the immune system
  • Anyone who is a household contact to any of the above
  • Anyone under the age of 18
normal vaccine reactions
Normal Vaccine Reactions
  • A red and itchy bump develops at the site in 3-4 days
  • In the first week after vaccination, the bump becomes a large blister, fills with pus, and begins to drain
  • During the second week, the blister begins to dry and a scab forms
  • The scab falls of in the third week, leaving a small scar.
vaccine reactions
Vaccine Reactions
  • Reactions are less if revaccinated
  • Mild to Moderate:
    • Mild rash (lasts 2-4 days)
    • Swelling and tenderness of armpit glands (lasts 2-4 weeks)
    • Fever of over 100oF (about 10% of adults)
    • Blisters elsewhere on the body (about 1 per 1,900)
vaccine reactions1
Vaccine Reactions

Moderate to Severe:

  • Serious eye infection or loss of vision

(<6 per 10,000)

  • Rash on entire body (1 per 4,000)
vaccine reactions2
Vaccine Reactions

Potentially Life-Threatening:

  • Severe rash on people with eczema

(1 per 26,000)

  • Severe brain reaction (encephalitis); may lead to permanent brain damage

(1 per 83,000)

  • Severe infection beginning at vaccination site (1 per 667,000, mostly those with weakened immune systems)
vaccine reactions3
Vaccine Reactions
  • Treatment is available for serious vaccine reactions
    • VIG / Cidofivir
    • Research for new treatment is ongoing
  • 14-52 people per million could have a life-threatening reaction
  • Death: 1-2 people per million
los angeles county activities

Los Angeles CountyActivities

LA Dept. of Health Services

la county smallpox plan
LA County Smallpox Plan

Elements of the Plan

  • Preparedness
  • Response
  • Recovery
  • Vaccination: Phase 1, 2, and 3
  • Surveillance
  • Smallpox Response Teams
  • Laboratory
  • Communication
  • Training
  • Management of a Suspect Case of Smallpox
  • Criteria for Activation of the Response Plan
  • Redeployment of LAC DHS Staff
  • Activation of Emergency Contract and Mutual Aid Personnel
  • Use of the Standardized Emergency Management System: ring and mass vaccination, smallpox case management, contact management, logistics, etc.
  • Criteria for Declaring the End of the Smallpox Emergency
  • Heightened Active Surveillance
  • Risk Communication
  • Evaluation and Analysis of Lessons Learned
smallpox vaccination phase 1
Smallpox Vaccination: Phase 1

Given the recent concerns that smallpox virus may be intentionally used as a bioterrorism agent, Los Angeles County has been directed to begin planning for the implementation of the Phase I Smallpox Preparedness Vaccination Program

phase i goal
Phase I: Goal

To increase the LAC’s smallpox preparedness capacity by offering vaccination safely to:

  • volunteer public health teams (including vaccinators) who will conduct investigations and outbreak control for the initial smallpox case(s)
  • volunteer health care workers who will treat and manage the initial smallpox case(s)
  • Phase 1 plans were submitted on December 9, 2002.
  • Approved by CDC on December 23
  • Immunization operations started on January 29, 2003
public health smallpox response teams
Public Health Smallpox Response Teams

In order to provide a pre-designated, highly trained, interdisciplinary team of public health personnel that will be immediately available to respond to a smallpox emergency, LAC DHS is assembling teams for rapid, scaled mobilization and deployment.

public health smallpox response teams1
Public Health Smallpox Response Teams
  • Five (5) teams from LAC DHS
    • 40 persons, as needed, per team
  • One team from Pasadena
  • One team from Long Beach
  • One team from LAX/LA Port Quarantine
smallpox health care teams
Smallpox Health Care Teams

To provide uninterrupted medical care for smallpox patients in acute care hospitals, a team of health care workers will be vaccinated so they can provide direct medical care for the initial smallpox case(s) presenting in the ER or requiring hospital admission

hospital team requirements
Hospital Team Requirements
  • Willingness to be vaccinated
  • Vaccination of all team members
  • Deliver medical care 24 / 7 for the first 7-10 days using 8-12 hour shifts
  • Experienced and competent staff
  • 45-100 employees per hospital
  • If possible, start with previously vaccinated individuals to decrease incidence and severity of systemic effects
  • Stagger same unit personnel to minimize number simultaneously out of work
  • Furlough not recommended by ACIP
administrative leave
Administrative Leave

Administrative leave is not routinely recommended unless:

  • Physically unable to work due to symptoms of illness
  • Extensive skin lesions which can not be adequately covered
  • Non-adherence to recommended infection control precautions
site care
Site care

Health care workers will need checks of sites before each shift

  • To prevent nosocomial transmission
  • Ensure bandage clean and dry
  • Reinforce importance of hand hygiene
  • Follow up on reactions, adverse events
training and education
Training and Education
  • 4 to 8 hours of training covering the smallpox vaccine, LAC’s response plan, and the vaccination clinic operations will be provided to all staff that will participate in the vaccination program.
  • Core training for all staff
  • Task oriented training based on responsibilities for each staff
community training
Community Training
  • Training on recognizing and treating adverse events after smallpox vaccination will be developed and offered to community physicians on an ongoing basis
  • Comprehensive “train-the-trainer” program will be developed to be implemented after Phase 1 to prepare for LAC’s future Phase 2 smallpox preparedness vaccination program
lac activities
LAC Activities
  • Reinstated Smallpox as a reportable disease (May 2001)
  • Established the Smallpox Planning Working Group (January 2002)
  • Developed the Draft Smallpox Preparedness, Response, and Recovery Plan (February 2002)
lac activities1
LAC Activities
  • Developed smallpox posters and disseminated to the medical community (July 2002)
  • Assessed public health workforce capacity (November 2002)
  • Developed a Plan for Phase I Smallpox Preparedness Vaccination Program (December 2002)
lac activities2
LAC Activities
  • Trained licensed public health staff on how to administer the smallpox vaccine (January 2003)
  • Started the Smallpox Vaccination Program (January 2003)
  • Trained select public health staff [Speaker’s Bureau] to give presentations to the community on smallpox (January 2003)
lac activities3
LAC Activities
  • Developed a Smallpox Public Health Response Team
  • Developed and disseminated smallpox FAQ sheets
  • Ongoing education and training activities for public health employees and the health care community
  • Ongoing updates in