Smallpox Vaccination:Smallpox Vaccination:Risk Assessment and Risk Assessment and

Perspectives of the Perspectives of the Health Care Provider, Health Care Provider,

Institution, and State of IllinoisInstitution, and State of Illinois

Edward P. Sloan, MD, MPHEdward P. Sloan, MD, MPH

Associate ProfessorAssociate ProfessorDept of Emergency MedicineDept of Emergency Medicine

University of Illinois

College of Medicine

Chicago, IL

Attending Physician Attending Physician Emergency MedicineEmergency Medicine

University of Illinois Hospital

Our Lady of the Resurrection

Medical Center

Some ConsiderationsSome Considerations

• The disease

• The risk of an attack

• The public health impact of an attack

• The medical literature

• Current recommendations

• Questions for today

The DiseaseThe Disease

• Easily spread: Most infectious disease

• Significant morbidity and mortality

• 500 million deaths in 20th century

• 2 million deaths in 1967

• Real morbidity

The Risk of an AttackThe Risk of an Attack

• 1980: Soviet Union starts Smallpox weapons program

• 1986: WHO recommends destruction of existing virus stocks

• 1994: Alibek defects, former deputy director of Soviet bioweapons program

The Risk of an AttackThe Risk of an Attack

• USSR producing “tons of virus” • Successful weaponization of smallpox

accomplished• Virus transferred to a facility in Siberia• Occurred concurrent with serious

economic problems in Russia• Might other countries might acquire the

technology and weapons?

Public Health ImplicationsPublic Health Implicationsof a Smallpox Attackof a Smallpox Attack

• 1972: Yugoslavia

• 1 case identified

• 11 people infected

• 138 people then infected

• 10,000 people isolated

• 20,000,000 people vaccinated

The Medical LiteratureThe Medical Literature

• NEJM

• Early release of articles

• Free distribution of materials

• Six articles

• Public, risk, vaccination, public health

• Good information for framing discussion

NEJM: Schraeder NEJM: Schraeder

• Obligation to protect public health

• Public health decisions

• “Trust our heads and our hearts”

NEJM: BlendonNEJM: Blendon

• Public knowledge unclear

• Survey of 1006 adults

• False smallpox vaccination beliefs

• Need for public education

NEJM: BozzetteNEJM: Bozzette

• Scenarios of smallpox attacks

• Stochastic model of outcomes

• Risk of attack, risks of vaccination

• No risk: no vaccination

• Some risk: vaccinate HCWs

• High risk: vaccinate public

NEJM: Sepkowitz NEJM: Sepkowitz

• How contagious is vaccinia?

• 1907-1975: –12 outbreaks

–85 secondary cases

• 75%: young children, atopic dermatitis

• Immunocompromise in HCWs

• Risk of hospital vaccinia outbreak

NEJM: Mack NEJM: Mack

• Alternate view of minimizing risk• Vaccination & immunoglobulin best• High risk of attack: immunize• Otherwise, go for safer options–Facilitate rapid diagnosis–Use alternate medical facilities–Vaccinate and train 15,000 in US– Have vaccinia IgG for complications–Educate in a less inflammatory way

NEJM: Hanrahan NEJM: Hanrahan

• Smallpox false alarm: case report

• Papulovesicular rash, same stages

• Centrifugal distribution

• Prodrome with fever, N/V

• CDC specimens: HSV positive

• Hospital test for HSV, VZV, syphillis

• Digital camera for email to CDC

Current RecommendationsCurrent Recommendations

• CDC Advisory Committee on Immunization Practices (ACIP)

• June 2001: Initial recommendations • June 2002: “Smallpox Health Care

Teams”

• October 2002: 8 Specific Issues

• Comment: CDC HICPAC, DHHS NVAC

ACIP RecommendationsACIP Recommendations

• Smallpox health care teams

• Smallpox vaccination site care • Phase in: no administrative leave

• Screen: atopic dermatitis, pregnancy, HIV

• Administer other vaccinations

• Vaccinate the vaccinators

Questions for TodayQuestions for Today

• Knowns:–Risk of disease

–Risk of vaccination

• Unknowns:–Risk of attack

–Effect in society with immunocompromise

–Public health value of vaccination

–Need for vaccination

Questions for TodayQuestions for Today• What are the risks of attack in 2003?

• What are the risks of vaccination?

• Who should get vaccinated?

• Who should get vaccinated first?

• Does prior vaccination matter?

• What happens after vaccination?

• Who assumes liability of vaccination?

Questions for TodayQuestions for Today• What does the state expect of us?

• What are hospitals doing? Why?

• What are the risks of vaccination?

• What do we need to get it done?

• What are our knowledge gaps

• What comes next?

Our SpeakersOur Speakers• Patricia Lee, MD–Advocate IMMC–Smallpox and vaccination

• Dino Rumoro, DO–Rush-Pres-St Luke–Hospital perspective

• John Lumpkin, MD, MPH– Illinois Dept of Public Health–State public health perspective

Format & InformationFormat & Information• Three 20 minute lectures

• Opportunity for questions

• Videostreamed content

• Slides and lectures on internet

• www.FERNE.org

• Link from www.ICEP.org