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Mass Vaccination
After over a month of politely insisting upon seeing a copy of Idaho’s smallpox mass
vaccination plan, it was finally received.
Attention activists:
After over a month of politely insisting upon seeing a copy of Idaho’s smallpox mass
vaccination plan, it was finally received. First, a FAXed copy from a local newspaper
reporter who was noticeably upset by the contents of the plan, arrived Dec. 30, 2002. And
then, finally, without a note or anything else attached, the Idaho Department of Health
& Welfare (IDHW) Bureau of Health Policy and Vital Statistics forwarded a clean copy
of the 34-page plan that arrived January 2, 2003. The following is a scanned version of
that “official” copy from the IDHW.
Though a few mistakes may still appear in the 16,755-word plan, great care has been taken
to correct scanning errors and reproduce the document exactly as it appears on paper. All
boldface and italics are taken from the original. The plan is below in the body of this
message.
From the Table of Contents one can see the gravity
of what is being proposed with this mass vaccination plan. Though the plan below is
specific to Idaho, the plans submitted to the CDC by every state are no doubt similar as
they, like Idaho, are modeled on Centers for Disease Control and Prevention (CDC)
recommendations that were forwarded to the several states Sept. 22, 2002.
Pandemic preparedness plans have been under construction since President Ford ordered that
the Federal Guidebook to Pandemic Preparedness be drafted in 1973 after the swine
flu mass vaccination disaster. The guidebook was still in draft form when President
Clinton ordered it be completed in 1993. By 1998, cities and counties all over the nation
began adopting emergency powers ordinances that would trigger the implementation of
martial law in the event of a declared state of emergency. By Nov. 1, 2001, the CDC had
released its Model State Emergency Health Powers Act (MEHPA), which, if adopted by the
several states, would give governors the power to suspend the constitutions and declare
states of medical martial law.
Detailed descriptions of MEHPA are available at http://www.vaclib.org
Both Vaccination Liberation and The Idaho Observer have been studying the
history of pandemic preparedness in the U.S. and have been monitoring its snowballing
evolution since 1998. Just close your eyes and imagine the logistics of feeding a machine
that will vaccinate, within a few days time, at least 80 percent of the people in a
mid-sized town close to you. Once you fully understand the resources, manpower and
police-state controls that will be in place locally to accomplish that seemingly
impossible task, broaden your perspective to encompass vaccinating some 80 percent of
America’s 280,000,000 people within 10 days. This is not a matter to be taken
lightly. Every city, county and state in the nation is actively preparing for mass
vaccination while we wonder if they will ever manufacture the public health emergency to
justify such a campaign.
Though we finally received most of the state plan (notice that the section relating to the
transition to mass vaccinating the public is not available to the public), the local plans
are “confidential” and are also unavailable to the public.
It is our belief that decades of preparation make the eventual implementation of medical
martial law inevitable. The American public has been prepped for medical martial law by
being taught to fear diseases and believe that vaccines are the only way to prevent them.
We will not go into the details of 50 years of disease-scare in America at this time. We
will, however, preface the following plan by stating without reservation that FRAUD is the
engine driving the national mass smallpox vaccination plan.
The following plan perpetuates several smallpox “myths” to justify mass
vaccination.
2.
3.
4.
5.
The list of inaccuracies regarding the epidemiological potential of smallpox and the
medical illogic perpetually cited as appropriate public health policy goes on and on. But,
they intend to vaccinate us all anyway. That is why Vaccination Liberation and The
Idaho Observer published Smallpox Alert!an eight-page, publication of
historical an contemporary truth regarding smallpox. Smallpox Alert! is an
interesting, engaging read designed to prompt people to question the intelligence of
blindly accepting a poison needle.
If we are to derail this plan, which will likely result in a public health disaster of
cataclysmic proportions, it is going to come from educating ourselves, friends, family and
the various human components of the mass vaccination machinery--police, doctors, nurses,
elected officials--to the point they resist participating in this lunacy.
On a personal note, I have been an opposition publisher since 1995. A lot of things have
happened in America since that time. The end result to most things that happen is the
federal government grows in both size and authority. Increasing numbers of people are
becoming concerned that the federal government will not stop usurping power until it
controls everything there is to control. We can clearly see the federal octopus now and
that bigger it gets the less likely we, as Americans, will be able to stop it with
petitions and organized non-violent civil disobedience.
It has become obvious the federal government, which has clearly left the confines of its
constitutional straightjacket, will eventually clash with those who intend to put it back
into its constitutional place. What would come of such a confrontation is the stuff from
which daydreams and movies are made. In my own daydreams, as various scenarios have played
themselves out in my mind, it never occurred to me that we would end up this way.
To think that our country could be destroyed because our people have become so accepting
of their slave status they would climb over one another with their sleeves rolled
up--begging for the poisoned needle. How pathetic. How dishonorable. How undignified. Free
people will not allow government to inject poison into their bodies under the guise of
public health.
One last comment before you begin to read the “plan” your government has for
you. Go to Revelations 16:1-2. The King James Version is best for our purposes because the
language used is amazing for the subject of this post. It may be that God is using the
Bush administration to accomplish a task and that mass vaccination against smallpox is
inevitable. What remains to be seen, however, is who will succumb to the “vials”
of God’s wrath. That, it seems, is totally dependent upon each of us and our
relationship with God.
Good luck to us all in 2003. We have a lot of work to do. Our mission is not to change the
government which, unfortunately is a mirror image of ourselves as a nation, but to change
the hearts and minds of our countrymen. If we can do that, our government will have little
choice but to be a reflection of our better selves.
No matter what,
Don Harkins
The Idaho Observer
PS: Should you decide to help change the hearts and minds of those in your community, Smallpox
Alert! ordering information can be found at the end of this post.
**********************************************************************************
I. Executive Summary
II. Criteria for implementation of CDC and Idaho Smallpox Plans
III. Notification Procedures for Suspected Smallpox Cases
IV. Outline of CDC and State/Local Responsibilities
V. CDC Vaccine Deployment
VI. CDC Personnel Mobilization and Deployment for Assistance
Guide A - Surveillance, Contact Tracing, and Epidemiological Investigations Guidelines
10
1. Pre-event rash surveillance
2. Smallpox clinical presentations and differential diagnosis
3. Smallpox case definitions
4. Epidemiological (case and outbreak) investigation
5. Surveillance following an outbreak
6. Contact identification, tracing and surveillance
7. List of Forms
Guide B - Vaccination Guidelines
l. Vaccination strategies
2. Source of CDC Guidelines on:
Indications for vaccination; Contraindications for vaccination;
Reconstitution,
administration, and storage of vaccine; Recognition of expected
vaccine reactions/take;
Recognition of adverse reactions; indications and guidelines for
VIG administration;
Contingencies for re-sterilization of bifurcated needles
Guide C - Isolation Guidelines
1. Isolation Measures
4. Quarantine
Guide D - Specimen Collection and Transport Guidelines
Guide E - Communications Plans and Activities
Guide F - Decontamination Guidelines
1. Reusable medical equipment
2. Medical waste
3. Surfaces
4. Protective clothing, bedding, linens, etc.
5. Facility/Rooms
6. Transportation vehicle
Guide G - Transition to Mass Vaccination - Official Public Health Use Only
[Please note that page numbers in table of contents correspond with the hardcopy
documented as forwarded to Vaccination Liberation by the state of Idaho and will not
necessarily be reflected in the scanned electronic version of the state plan to follow
~DWH).
I. Executive Summary
These guidelines were written to help coordinate an organized plan for preparing for,
and
responding to, cases or suspect cases of smallpox, or suspected exposures to smallpox, in
Idaho. They are designed to be used together with the Center for Disease Control and
Prevention's Interim Smallpox Response Plan and Guidelines (CDC ISPR). It is recommended
that anyone referring to this plan for guidance also view the CDC ISPR. Some information
from
the CDC ISPR is duplicated here, but many sections were not repeated in order to make the
Idaho guidelines as streamlined as possible, while still containing enough general
information to
be helpful to a user without access to the CDC ISPR.
The CDC ISPR is being updated at the time of this writing. The most current version is
available
at the website: http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp
If an outbreak of smallpox were to occur, several factors could contribute to a more
rapid spread
of smallpox than was routinely seen before this disease was eradicated.
These factors include:
1. Virtually non-existent immunity to smallpox in the absence of naturally occurring
disease and
the discontinuation of routine vaccination in the U. S. in the early 1970's,
2. Delayed recognition of smallpox by health personnel unfamiliar with the disease, and
3. Increased mobility and crowding of the population.
Because of these factors, a single case of smallpox would require an immediate and
coordinated
public health and medical response to contain the outbreak.
Smallpox
Variola virus is the etiological agent of smallpox. The only known reservoir for the
virus during the
smallpox era was humans; there were no known animal or insect reservoirs or vectors. The
most
frequent mode of transmission is person-to-person spread via direct deposit of infective
droplets
onto the nasal, oral, or pharyngeal mucosal membranes, or the alveoli of the lungs from
close,
face-to-face contact with an infectious individual. Indirect spread (not requiring
face-to-face
contact with an infectious individual) via fine-partide aerosols or fomites containing the
virus has
been reported but is less common. In most cases, symptoms of disease begin within 12 - 14
days (range 7 - 17) following the exposure of a susceptible person to the virus. A 2 - 3
day
prodrome of high fever, malaise, and prostration with severe headache and backache is
followed
by a maculopapular rash (eruptive stage) that progresses to papules (1 - 2 days after
appearance
of rash), vesicles (4 - 5th day), pustules (by 7th day), and finally scab lesions (14th
day). The rash
generally appears first on the oral mucosa, face, and forearms, then spreads to the trunk
and
legs. Lesions are also seen on the palms of the hands and soles of the feet. The skin
lesions of
smallpox are deeply embedded in the dermis and feel like firm round objects embedded in
the
skin. As the skin lesions heal and the scabs separate, pitted scarring gradually develops.
Smallpox patients are most infectious during the first week of the rash when the oral
mucosa
lesions ulcerate and release large amounts of virus into the saliva and are less
infectious once
the lesions have scabbed over. A patient is no longer infectious once all the scabs have
separated (usually 3 - 4 weeks after the onset of the rash). The overall mortality rate
associated
with smallpox was approximately 30%. Other less common but more severe forms of smallpox
can occur (See the CDC ISPR for a more complete discussion of smallpox).
Smallpox Vaccine
Smallpox vaccine is a highly effective immunizing agent. It is a live-virus vaccine
composed of
vaccinia virus, an orthopoxvirus that induces antibodies that also protect against
smallpox. Its use
in focused ring vaccination campaigns that utilized intensive surveillance and contact
tracing
during the smallpox eradication program helped bring about the global eradication of
smallpox.
Smallpox vaccine production ceased in the early 1980's and current supplies of smallpox
vaccine
are limited ~15.4 million doses in the U.S.A. as of 12/2712001). However, it is expected
that new
cell-culture grown smallpox vaccines will become available for use within the next few
years.
Although smallpox vaccine is considered a safe vaccine, post-vaccination adverse events
can
occur. These adverse events and their rates as determined in a 1968 10-state survey
include:
1. Inadvertent inoculation (529,2/million primary vaccinations),
2. Generalized vaccinia (241,5/million primary vaccinations),
3. Eczema vaccinatum (38.5/million vaccinations),
4. Progressive vaccinia (1.5/million primary vaccinations), and
5. Post-vaccinial encephalitis (12.3/million primary vaccinations),
6. Death (one per million primary vaccinations -- usually a result of
progressive
vaccinia, post-vaccinial encephalitis, or severe eczema vaccinatum).
Several groups have been identified as having a higher risk for developing
post-vaccination
complications. These include:
1. Persons with eczema (including a history of eczema) or
other forms of chronic
dermatitis,
2. Persons with altered immune states (e.g. HIV, AIDS,
leukemia, lymphoma,
immunosuppressive drugs, etc.),
3. Pregnant women,
4. Children under 1 year of age, older adolescents or young
adults receiving primary
vaccination may also have a greater risk of
post-vaccination complications.
Note that in the case of a known exposure to smallpox, these contraindications are not
absolute,
and vaccination should be strongly considered due to the high risk of disease and death
from
smallpox. Vaccinia Immune Globulin (VIG) is used to treat certain vaccine adverse
reactions,
however, supplies of VIG are limited.
CDC Interim Smallpox Response Plan (CDC ISPR) and Guidelines
The CDC ISPR is a working document that is updated regularly. It is recommended that
each
Idaho district health department have printed copies of the forms from Guide A in the plan
available, and bookmark the Internet site listed above, which will contain updated
versions of the
plan. The CDC ISPR is operational and would be implemented should a smallpox emergency
occur. The Idaho Interim Plan will be updated if significant changes in the CDC ISPR
require
adjustments to the state plan, or if new information becomes available which changes
elements
of the planned public health response.
General Strategy and Priority Activities for Smallpox Outbreak Containment
The first and foremost public health priority during a smallpox outbreak is control of
the epidemic.
The following activities would be essential to accomplishing this goal.
Ring (aka "Focused") Vaccination
According to CDC, any vaccination strategy for containing a smallpox outbreak should
utilize the
ring vaccination concept. This includes:
1. Isolation of confirmed acid suspected smallpox cases,
2. Tracing, vaccination, and close surveillance of contacts of cases, and
3. Vaccination of household contacts of the contacts.
Vaccinating and monitoring a "ring" of people around each case and contact will
help to protect
those at the greatest risk for contracting the disease as well as form a buffer of immune
individuals to prevent the spread of disease. According to CDC, this strategy would be
more
desirable than an indiscriminate mass vaccination campaign for the following reasons:
1. Focused contact tracing and vaccination combined with extensive surveillance and
isolation of
cases was successful in stopping outbreaks of smallpox during the eradication program
without
the need for indiscriminate vaccination.
2. Adverse events would be expected to be higher in an indiscriminate vaccination campaign
due
to vaccination of persons with unrecognized contraindications (e.g. undiagnosed
immunosuppressive disorders such as H1V or AIDS). Careful screening for contraindications
to
vaccination would also be more difficult in a large-scale vaccination campaign. The risks
vs.
benefits of vaccination ratio would be higher in such a campaign because of the inevitable
vaccination of persons with high risk of adverse events and a low risk of smallpox.
3. Current supplies of VIG would not be sufficient to treat the number of expected adverse
events
that would occur with a large, indiscriminate vaccination campaign.
4. Current supplies of smallpox Vaccine would be exhausted quickly if an indiscriminate
campaign
was utilized, potentially leaving no vaccine for use if smallpox cases continued to occur
5. Mass, indiscriminate vaccination of a large population would require a very large
number of
health-care/public health workers to perform vaccination and deal with the higher number
of
adverse events
6. Utilization of mass vaccination may lead to improper reliance on this strategy to
control the
outbreak with less focus on other essential outbreak control measure such as careful
surveillance, contact tracing, and isolation of cases. This could also lead to inadequate
supplies
of vaccine for areas with the greatest need and potentially prolong the epidemic instead
of
controlling it. The size of the vaccinated "ring" of individuals surrounding a
case or contact may
be expanded or contracted, depending upon:
1. the option for outbreak control that is selected,
2. the size of the outbreak,
3. personne/resources,
4. effectiveness of other outbreak control measures, and
5. vaccine availability.
However, the ring vaccination concept should be maintained overall. The determination of
the
initial vaccination ring size or alteration of subsequent vaccination ring sizes will be
made jointly
by Federal and State health officials.
Identification of Priority Groups
The following are considered high risk groups and should be prioritized for
vaccination in a
smallpox outbreak:
1. Face-to-face close contacts within 6.5 feet, or household contacts of smallpox
patients after
the onset of the smallpox patient's fever. (Although individuals with smallpox are not
infectious
until the onset of rash, vaccinating contacts from the time of the onset of fever helps
provide a
buffer and assures that contacts who may have been exposed at the early onset of rash,
when
the rash may have been faint and unrecognized, have been vaccinated.)
2. Persons exposed to the initial release of the virus (if the release was discovered
during the first
generation of cases and vaccination may still provide benefit).
3. Household members (without contraindications to vaccination) of contacts of
smallpox patients
(to protect household contacts should smallpox case contacts develop disease while under
fever
surveillance at home). Household members of contacts who have contraindications to
vaccination
should be housed separately from the other vaccinated household members until the
vaccination
site scab has separated (~ 2 weeks) to prevent inadvertent transmission of vaccinia virus.
They
should be also be housed separately from the contact until the incubation period for
smallpox has
passed and the contact is released from surveillance.
4. Persons involved in the direct medical care, public health evaluation, or
transportation of
confirmed or suspected smallpox patients. This includes personnel whose public health
activities
involve direct patient contact such as case interviewing.
5. Laboratory personnel involved in the collection and/or processing of clinical specimens
from
suspected or confirmed smallpox patients.
6. Other persons who have a high likelihood of exposure to infectious materials (e.g.
personnel
responsible for hospital waste disposal and disinfection).
7. Personnel involved in contact tracing and vaccination, or quarantine/isolation or
enforcement,
or law-enforcement interviews of suspected smallpox patients.
8. Persons permitted to enter any facilities designated for the evaluation, treatment, or
isolation of
confirmed or suspected smallpox patients (only essential personnel should be allowed to
enter
such facilities). Only personnel without contraindications to vaccination should be
chosen
for activities that would require vaccination for their protection. Personnel with
contraindications should not perform duties that would place them at risk for smallpox
exposure
and should otherwise only be vaccinated if an exposure has already occurred.
9. Persons present in a facility or conveyance with a smallpox case if fine particle
aerosol
transmission was likely during the time the case was present (e.g. hemorrhagic smallpox
case
and/or case with active coughing). Evaluation of the potential risk for aerosol
transmission and
initiation of vaccination for nondirect contacts will be done by CDC, state, and local
public health
officials. The decision to offer vaccination to non-direct contacts of smallpox cases will
be made
jointly by Federal, State and district health officials.
Additional Groups that May Be Considered for Voluntary Vaccination
Federal, State, and Local response personnel not involved in direct patient or contact
evaluation
or care but whose uninterrupted support of response activities is deemed essential may be
considered for voluntary vaccination. Vaccination of these personnel will be dependent
upon the
size of the outbreak, availability of vaccine, the assessed risk for unintentional or
unrecognized
contact with smallpox cases, and a careful assessment of the benefits vs, the risks of
vaccination.
Personnel within these non-patient contact groups who have no contraindications
will be considered for vaccination. Persons within these groups with contraindications
should not
be vaccinated. The decision to offer voluntary vaccination to non-patient contact
personnel will be
made by the Director of CDC. These groups include, but are not limited to:
1. Public health personnel in the area involved in surveillance and epidemiological data
analysis
and reporting whose support of these public health activities must remain unhindered
2. Logistics/resource/emergency management personnel whose continued support of response
activities must remain unhindered
3. Law enforcement, fire, and other personnel involved in other non-direct patient care
response
support activities such as crowd control, security, law enforcement, and firefighting or
rescue
operations
II. Criteria for Release of Smallpox Vaccine and implementation of the CDC ISPR
The CDC Director may authorize the release of all or portions of the smallpox vaccine
stockpile
and implement all or portions of the CDC ISPR according to guidelines set in their plan.
The
CDC Director will notify the Surgeon General and other federal agencies prior to the
release of
smallpox vaccine.
III. Notification Procedures for Suspected Smallpox Cases - For Official Public
Health Use
ONLY:
District public health staff and health care workers
should notify the Idaho
Department of Health and Welfare (IDHW) Epidemiology Program
immediately for any of
the following:
1. A suspected case of smallpox with request for clinical
specimen testing
2. An outbreak of illness that is clinically compatible with
smallpox
3. A request to test an environmental sample, package,
distribution device, or other
device associated with potential human exposure for smallpox
virus
Contact numbers at the IDHW:
Epidemiology: Monday
through Friday, 8am - 5pm MST: 208-334-5939
24-hour emergency line
(after hours, or during working hours if no
immediate response to
above number): 1-800-632-8000. Public health will
be paged.
Although telephone reporting is preferred, redundant mechanisms should be utilized for
reporting,
including fax and email, should telephone contact not be immediately established. In
addition,
plans for alternate reporting should phone lines be down or power be lost should be made
(e.g.,
through the local 911 system to the State Communications Center).
State public health authorities will notify CDC immediately of any suspected smallpox case
or
exposure. One of the following CDC offices will be notified:
1. Bioterrorism Preparedness and Response Program
a. Daytime telephone: 404-639-24~8 or
404-639-0385
b. Night, weekends, and holidays:
770-488-7100
2. Poxvirus Section, Division of Viral and Rickettsial
Diseases, NCID, CDC
a. Daytime telephone: 404-639-2184 or
404-639-4931 ~laboratory),
or 404639-3532 (branch), or 404-639-3311
(division)
b. Night, weekends, and holidays:
770-488-7100
3. Emergency Preparedness and Response Branch
All times: 770-488-7100
IV. CDC, State and District Health Responsibilities and Actions in the Event of a
Smallpox
Outbreak
CDC Responsibilities and Actions (from the CDC ISRP)
1. Delivery or standby readiness for delivery of smallpox vaccine and
vaccination components.
2. Initial laboratory confirmation of smallpox infection and establishment of
laboratory protocols
for confirmation in surge capacity laboratories.
3. Coordination with state/local health officials to establish communications and
implement
federal-state response plans.
4. Immediate mobilization and deployment of CDC personnel to assist local and state public
health officials with epidemiologic investigations, surveillance, implementation of case
isolation
protocols, contact identification, vaccine administration. adverse events monitoring, and
vaccine
inventory monitoring.
5. Development of vaccination strategies and prioritization.
6. Distribution of guidelines for surveillance, contact identification and tracing,
vaccination,
isolation strategies, specimen collection and transport, public/media communications,
decontamination, and smallpox patient medical care guidelines.
7. Provision of technical assistance to the national authority responsible for
coordinating the
overall federal efforts for managing the event.
8. Coordination with federal law enforcement agencies conducting the criminal
investigation
9. Provide recommendations on quarantine needs that supercede the capabilities of local
and
state authorities and statutes.
10. Coordination with state/local authorities for public and media communications.
11. Tracking and reporting of national surveillance information regarding outbreak.
12. Coordinate between states for contact tracing and monitoring.
State Public Health Responsibilities and Actions
1.Activation of state emergency response plans for bioterrorism and smallpox.
2. Designation of state leads for the following activities:
-- case surveillance and isolation,
-- contact tracing and monitoring.
-- epidemiologic investigation,
-- vaccine administration,
-- adverse events monitoring,
-- coordination with CDC response team, FEMA, and other
state agencies
-- coordination with local, state and federal law
enforcement agencies conducting the
criminal investigation.
3. Designation, in concert with the affected district health department(s), of
sites/clinics for
vaccine administration.
4. Designation, in concert with the affected district health department(s), of sites for
patient
isolation.
5. Designation, in concert with the affected district health department(s), of sites for
contact
isolation if initiated.
6. Utilization of state public health statues and resources for implementation and
enforcement of
isolation and quarantine within the state.
7. Coordination with federal authorities for public and media communications.
District Public Health Responsibilities and Actions
1. Activation of local emergency response plans for bioterrorism and/or smallpox
outbreaks
2. Designation of district leads for the following activities:
-- case surveillance and isolation,
-- contact tracing and monitoring,
-- epidemiologic investigation,
-- vaccine administration,
-- adverse events monitoring,
-- coordination with CDC response team
-- coordination with local. state and federal law
enforcement agencies conducting the
criminal investigation.
3. Mobilization of local public health resources to conduct epidemiological
investigations,
surveillance, implementation of case isolation protocols. contact identification, vaccine
administration, and adverse events monitoring
4. Designation, in concert with the state health department, of sites for vaccine
administration,
5. Staffing and management of sites/clinics for vaccine administration
6. Designation, in concert with the state health department, and management of sites for
patient
isolation
7. Designation, in concert with the state health department, and management of sites for
contact
isolation if initiated
8. Utilization of local public health statutes and resources for implementation and
enforcement of
isolation and quarantine within the local jurisdiction
9. Coordination with other local and state law enforcement agencies conducting the
criminal investigation
10. Coordination with other local and state authorities for public and media
communications
V. Vaccine Mobilization and Deployment
The state immunization program manager or state health officer will request vaccine
immediately
if a case of smallpox is suspected, or if Idaho citizens are determined to be at risk of
exposure to
smallpox due to a release of the virus. The National Pharmaceutical Stockpile (NPS) may be
activated, following the state and federal NPS plan. Initial deployment of smallpox
vaccine and
vaccine components will occur once approval for release has been obtained from the
Director of
CDC. Criteria for release are detailed in the CDC ISRP.
VI. CDC Personnel Mobilization and Deployment
Once an outbreak of smallpox has been identified, the Director of CDC will initiate
mobilization of
personnel to satisfy their responsibilities outlined in section [V, above. Details are
outlined in the
CDC ISRP. If personnel needs extend beyond CDC staffing capabilities, the Director of CDC
will
seek the assistance of other Federal agencies.
Should this plan be activated, the state
epidemiologist or designee will coordinate overall
case surveillance and epidemiological investigation activities for the state. This person
will work closely with Federal and district health agencies on all aspects of the
epidemiological investigation, surveillance and contact tracing.
Note: activities and actions described within this section may be altered depending
upon the size
and characteristics of the outbreak. If this occurs, information regarding the new
procedures to
follow or actions to take will be communicated to local health department personnel by the
state
epidemiologist or health officer, and federal health authorities.
Outbreak Definition: because smallpox no longer exists as a naturally occurring
disease,
an outbreak of smallpox is defined as a single laboratory confirmed case.
This section will cover the following topics:
1. Pre-event rash surveillance
2. Clinical presentations and differential diagnosis
3. Case definitions
4. Epidemiological (case and outbreak) investigation
5. Surveillance following an outbreak
6. Contact identification, tracing and surveillance
PRE-EVENT RASH SURVEILLANCE
Idaho is in the process of establishing enhanced pre-event surveillance for
generalized febrile
vesicular-pustular rash illness. An algorithm and protocol for evaluating patients with
febrile
vesicular-pustular rash illness has been developed by CDC (see CDC ISRP Annex 4).
CLINICAL CASE DESCRIPTION AND DIFFERENTIAL DIAGNOSIS
Smallpox is characterized by both an enanthem with lesions in the mouth and posterior
pharynx
and an exanthem (rash). Constitutional symptoms prior to onset of rash (exanthem) include
fever
(100%), which generally occurs about 1-3 days before rash onset, headache (90%). backache
(90%), chills (60%), and vomiting (50%). Less common symptoms include pharyngitis and
severe
abdominal pain. The hallmark of the ordinary (or classic) type of smallpox is a
generalized
vesiculopustular rash with lesions found more densely on the face and extremities
(centrifugal),
including the palms and soles. All lesions on any one part of the body are at a similar
stage of
development and are approximately the same size. Rash progresses from sparse macules (day
1), to papules (day 2), vesicles (days 3-4), pustules (days 5 to approximately 12), and
scabs
(days 13-18) for a total duration of 2-3 weeks. Less common presentations of the smallpox
rash
include flat, or hemorrhagic lesions. A rash that progresses through the stages more
rapidly and
has fewer lesions characterizes modified smallpox. which occurs more commonly among
previously vaccinated persons. Infection via cutaneous inoculation also has a shorter
course with
appearance of one or several vesicles at the site of inoculation after about 3 days.
Asymptomatic
cases are very uncommon and their role in transmission is unclear but likely to be
minimal.
Because routine childhood vaccination in the U. S. stopped in 1971, persons currently
< 30
years of age are generally totally susceptible to smallpox and if exposed, are expected to
exhibit classic or atypical presentations. Persons aged 30 years or more may have been
vaccinated during childhood or as adolescents or adults for travel or occupational
reasons.
Vaccination of health care workers and persons traveling overseas continued until the
late 1970s and military personnel were vaccinated until 1990. Epidemiological studies have
shown that an increased level of protection against smallpox persists for < 5 years
after primary
vaccination and substantial but waning immunity can persist for ~ 10 years. Antibody
levels after
revaccination can remain high longer, conferring a greater period of immunity than occurs
after
primary vaccination alone. Although it is assumed that adults ~ 30 years in the U. S. may
have
little or no immunity to smallpox, there is evidence that vaccination during infancy
results in long
term reduction in mortality. Therefore, it is possible that if smallpox virus were
introduced into the
U.S. population. some vaccinated adults -- especially those who have received 2 or more
doses
of smallpox vaccine -- may develop modified smallpox following exposure and that mortality
would be markedly lower than unvaccinated persons. The most likely condition to consider
in the
differential diagnosis of vesiculopustular rash is varicella (see box below).
Major
distinguishing
features
Other
distinguishing
features
part of the body
days.
Other differential diagnoses:
In herpes tester, lesions are usually localized to 1 or 2 dermatomes, but can become
generalized, especially among immunocompromised persons. The lesions in localized herpes
zoster are painful and could likely be differentiated from smallpox based on their
appearance.
Other diagnoses to consider include drug eruptions, erythema multiforme, impetigo,
disseminated
herpes simplex, enteroviral infections associated with a vesicular rash, and others.
CASE DEFINITIONS AND CASE CLASSIFICATION
These preliminary case definitions are from the CDC ISRP, and will be followed
exactly in Idaho.
Preliminary case definitions may require revision by public health personnel conducting
the
epidemiological investigation depending upon the specifics of the epidemic.
a. Clinical Case Definition
An illness with acute onset of fever > 101º F followed by a rash characterized by
firm, deep seated
vesicles or firm pustules in the same stage of development without other apparent cause.
b. Laboratory Criteria for Confirmation* (to be conducted in Level C or D
laboratories only)
1. Isolation of smallpox (variola) virus from a clinical specimen (Level D
laboratory only), or
2. Polymerase chain reaction (PCR) identification of variola DNA in a
clinical specimen, or
3. Negative stain electron microscopy (EM) identification of variola virus in
a clinical
specimen (Level D laboratory or approved Level C laboratory)
*Level D laboratories include the CDC and USAMRIID. Initial confirmation of a smallpox
outbreak
requires testing in a Level D laboratory. Level C laboratories will assist with testing of
clinical
specimens following initial confirmation of an outbreak by CDC.
c. Case Classification
· Confirmed: A case of smallpox that is laboratory confirmed.
· Probable: A case that meets the clinical case definition that is
riot laboratory confirmed but
has an epidemiological link to another confirmed or probable case.
· Suspected: A case that meets the clinical case definition but is
not laboratory confirmed
and does not have an epidemiological link to a confirmed or probable case of
smallpox, OR
a case that has an atypical presentation that is not laboratory confirmed but
has an
epidemiological link to a confirmed or probable case of smallpox. Atypical
presentations of
smallpox include a) hemorrhagic lesions OR b) flat, velvety lesions not
appearing as typical
vesicles nor progressing to pustules.
d. Definition of Contact: A person who has had contact with a suspected, probable,
or
confirmed case of smallpox during the contagious period, which will be considered from
fever
onset until scabs have all separated for this document. (Note that although a person is
not
contagious until rash onset, at times the oral enanthem, which is less obvious on physical
examination, may precede the external exanthem; the oral lesions do spread disease by
respiratory droplet nuclei. For this reason, the onset of fever is used in this document
as the
beginning of "exposure time", even though in many cases, the person will not
have become
contagious until several days later.) A contact's risk of contracting smallpox increases
with close
contact, increasing length of exposure to a case and the stage and severity of clinical
case. Thus.
close contact is defined as any face-to-face contact (< 6.5 feet) with a smallpox case
and duration
of contact should be quantified, if possible.
The importance of case confirmation using laboratory diagnostic tests differs depending on
the
epidemioiogical situation. Laboratory confirmation is important for a first case in a
geographic
area, reading to release of Vaccine as part of a response. In a setting where multiple
cases are
identified, laboratory capacity may soon be overwhelmed. In such instances, priority for
laboratory
resources will include 1) clinical or environmental specimens that will provide
information about a
potential source of exposure, facilitating law enforcement activities and case detection;
and 2)
clinical specimens from cases with an unclear presentation but who are suspected as cases
following expert consultation (see above).
POST-EVENT RESPONSE: EPIDEMIOLOGICAL INVESTIGATION
When this plan is activated, the state epidemiologist or designee will coordinate the
epidemiological investigation in collaboration with federal health authorities. An
estimate of the
number and kind of personnel necessary for performing these functions will be made and
additional assistance requested as needed. The lead state and federal staff will
coordinate all
aspects of the investigation with relevant district, state and federal authorities
including the FBI,
police, quarantine officials, and others.
All personnel designated for case interviews must be vaccinated prior to initiating
their
first face-to-face interview with a suspected, probable or confirmed smallpox case.
The purpose of the case investigations are:
· To establish the diagnosis and case classification;
· To identify contacts for tracing, vaccination and
surveillance;
· To impose isolation of confirmed, probable and suspected
cases;
· To identify the most likely source of initial exposure
for the case;
· To monitor clinical course and outcome of cases; and
· To monitor the epidemiology of the outbreak for analysis
and communications
purposes.
Case investigation forms (CDC ISRP Forms 2-4) prepared by CDC will be used for initial
case
investigations. Once person-to-person transmission is ongoing, shorter case surveillance
forms
(CDC ISRP Forms 5A and 5B) may be used together with the contact identification module
(CDC
ISRP Form 3). Much of the epidemiological investigation may be performed in conjunction
with
identification and evaluation of potential smallpox cases. However, because of the urgency
of the
outbreak, adequate personnel must be available to collect and analyze data that would
allow
rapid:
1. Identification of persons who have had close contact with the smallpox case since
date of
onset of fever. Since smallpox is a contagious disease, once a case is confirmed, the
highest
priorities for public health officials are to reduce risk of ongoing transmission by
immediately
identifying and vaccinating close contacts of cases and isolating the cases.
2. Identification of the most likely source of initial exposure (hopefully within 24
hrs of the first
confirmation of smallpox). This may require extensive trace-back capabilities if the
initial
recognition and confirmation of smallpox occurred later than the first generation of
disease in the
outbreak.
3. Identification or estimation of the population at risk. To the extent possible. the
population at
risk should be identified. Exposure could be due to an infected persons present at a
specified
location; use of a specified of mode of transportation; or presence at a location of
suspected
smallpox virus release. These persons should be placed under surveillance; public health
action
to consider would include offering smallpox vaccine to the exposed population and to their
household contacts.
4. Identification of any unexpected epidemiological features of the outbreak (e.g.,
unusual
presentation, morbidity, mortality, incubation period, transmission, affected population)
5. Evaluation of characteristics and extent of the outbreak to develop the most effective
containment strategies.
Expected epidemiological features of smallpox and varicella are outlined in the CDC ISRP.
POST-EVENT SURVEILLANCE
Once a confirmed case(s) of smallpox has been identified, the district public health
staff will
initiate immediate active surveillance for additional suspected, probable and confirmed
cases,
with assistance from the IDHW epidemiology staff. Detailed guidelines provided in the CDC
ISRP
will be followed. and will include these general areas:
1. Distribution of clinical case definitions and case classifications for suspected,
probable and
confirmed cases.
2. Distribution of reporting forms from the CDC ISRP.
3. Daily contact with major reporting sources to encourage timely reporting.
Reporting
(See section III, above, for contact numbers).
A computer system for data entry and analysis of all the collected case investigation and
surveillance information will be provided by federal health authorities and will be
managed and
maintained at the state IDHW for all confirmed, probable, and suspected cases. Methods
will be
established to follow up on laboratory results and epidemiological links for probable and
suspect
cases. The data management system will provide a daily tracking form (such as CDC ISRP
Form
6) for monitoring such cases.
Case information will be immediately shared by the agency initially receiving the report
to
surveillance partners at the appropriate district, state, and federal (CDC) health
departments. If
possible, personnel should prioritize the risk of contacts and sites based on closeness
and
duration of contact and stage of the illness.
Confirmed contact lists will be given to personnel responsible for tracing, vaccinating
and
following up on contacts. If resources permit, personnel assigned to verify cases, travel
histories,
contacts, and conduct the epidemiological investigation may also participate in contact
tracing.
Out-of-state contacts or places of travel will be immediately reported to the CDC
Coordination
Group, which will assist with notification of the appropriate health authorities in
affected states.
Surveillance data will be reported on a daily basis to the CDC Coordination Group. This
group will
be responsible for maintaining the national surveillance database and helping with
notification of
out of state contacts. Mechanisms for reporting to CDC including the data format (Excel
file,
Access file, etc.) will be distributed to surveillance personnel at the time of the
outbreak.
Methods for enhanced hospital-based surveillance
Once a case of smallpox has been confirmed in the community, patients with febrile
rash
illnesses will be directed to seek evaluation and care at a small number of facilities
(clinics,
hospitals) where physicians and health professionals familiar with smallpox and similar
rash
illnesses will see. diagnose and triage patients. If vaccinated smallpox response teams
are
available in the affected community, they will be utilized to triage ill persons and care
for the case
until others can be successfully vaccinated.
Precautions to prevent spread of possible smallpox will be implemented by infection
control
practitioners. In addition, other area hospitals will be asked to initiate active
surveillance for cases
to identify patients admitted with compatible illnesses. Idaho Department of Health and
Welfare,
and the district health departments. are contracting and working with the Idaho Hospital
Association to form hospital coalitions to make emergency plans for large outbreaks.
including the
evaluation of sizeable numbers of patients with rash illnesses.
Active Surveillance in Hospitals
1. Each hospital in the active surveillance network will identify one person
~preferably an infection
control practitioner (ICP) who will be responsible for daily active surveillance at that
institution.
Patients will be evaluated and assigned a risk category: high, medium or low. The ICP will
notify
the district health department immediately of any high-risk patient for transfer to the
designated
type C facility for isolation of smallpox cases. All patients identified as medium risk
will be notified
to the district health department and transferred to a type X facility. In the event that
there are no
suspected smallpox patients, a report will still be sent to notify the district health
department that
surveillance was conducted and has not yielded suspect patients ("zero
reporting"). Smallpox
surveillance forms will be completed on all suspect cases. This information will be given
to the
district and state health department's epidemiology programs on a daily basis. Line lists
will be
maintained and updated daily by the district and state health departments, with daily
contact
between the agencies to ensure consistency and accuracy, and will include both new
patients
and previously reported patients until smallpox is ruled out.
2. Prospective surveillance: Active surveillance for possible cases of smallpox currently
hospitalized will be performed prospectively from the time of first report of an index
case in the
emergency department, (and any other unit that could accept patients directly without
having ED
evaluation), intensive care units, pathology and laboratory departments. Whenever
possible,
potential cases will be seen by an infectious disease consultant, dermatologist or
smallpox
consultant to clarify the diagnosis. Surveillance in each department is described below.
3. Retrospective surveillance: In order to identify cases that may have been admitted
before the
outbreak was recognized but once transmission in the community was theoretically possible,
retrospective screening of patients admitted with compatible syndromes will be conducted
from
the date determined by district health department personnel. If resources are available,
records
will be reviewed for all patients who were seen in the emergency department and discharged
home, admitted, or transferred to another hospital. Charts of patients with a non-lab
confirmed
diagnosis of varicella, or generalized herpes roster or HSV, or those described to have a
diffuse vesicular or pustular rash with fever and no lab-confirmed diagnosis will be
reviewed
to determine if the illness may have been smallpox. Patients currently in the hospital
will be
evaluated, and those transferred to another facility, discharged or expired will be
reported to the
district health department for follow-up.
Classification of evaluated patients
High Risk (epi-linked):
1) Patients epidemiologically linked to a confirmed case of smallpox who
have a history of a
febrile prodrome and on examination had a maculopapular rash with
predominantly
face/distal extremity distribution OR involvement of the palms and/or soles.
2) Patients epidemiologically linked to a confirmed case of smallpox who have
a viral
syndrome with fever 2101 and systemic symptoms (prostration, headache,
backache, chills,
vomiting, or abdominal pain) for <4 days but who do not have a generalized
rash on
examination.
High Risk (not epi-linked):
Patients with a severe prodromal illness consisting of temperature >
101 º F 1-4 days before
rash onset, AND at least one of the following. prostration, headache,
backache, chills,
vomiting, or abdominal pain AND
1) Generalized rash of acute onset that is either: comprised of deep, round,
dermal lesions
characteristic of smallpox; maculo-papular rash involving the palms and/or
soles OR
distributed more densely on the face and distal extremities than the trunk
AND no other lab-
confirmed diagnosis that would adequately explain the illness
2) Prostration or shock AND either maculo-papular rash, hemorrhagic rash, or
rash with flat,
velvety lesions that may be confluent AND no other lab-confirmed diagnosis
that would
adequately explain the illness.
Moderate Risk (not epi-linked):
Patients with no known contact, brief or uncertain contact to a smallpox
case with a
prodromal illness consisting of temperature >201 º F and at least one of
the following:
prostration, headache, backache, chills, vomiting, or abdominal pain AND a
generalized rash
of acute onset that is atypical for smallpox (e.g. lesions on oral mucosa
only, maculo-papular
rash with localized distribution to face, or face and forearms,
hemorrhagic/petechial rash)
AND no other lab-confirmed diagnosis that would adequately explain the
illness
Low Risk (not epi-linked):
Patients who are not epidemiologically linked to a smallpox case AND
1) Lack a history of a febrile prodrome
2) Do not have classic smallpox lesions, OR
3) Have a laboratory confirmed non-smallpox diagnosis compatible with their
illness
Strategies for Conducting Active Surveillance (refer to CDC ISRP for details).
Surveillance in hospitals should cover the following areas:
1)ER/ICUs/Wards
2) Pathology Department, in hospitals where autopsies are performed
3) Laboratories
4) Lists of high risk, and moderate risk cases should be maintained and continually
updated.
6. CONTACT IDENTIFICATION, TRACING, VACCINATION, AND SURVEILLANCE
All personnel designated for case
interviews or contact-tracing activities must be
vaccinated prior to initiating their first face-to-face interview with a suspect, probable
or
confirmed case or contact tracing activities.
Identification of Contacts
A single person will be designated by Director of the affected District Health
Department to
coordinate overall onsite contact identification, tracing, vaccination assurance and
surveillance
activities. Additional state and federal resources will be provided to assist with these
activities.
Personnel designated for contact identification and determination of case travel history
should
perform the tasks listed below. Additional staff will be assigned for tracing,
interviewing, arranging
vaccination and surveillance of contacts, The following general activities should be
covered:
1. Using CDC ISRP Forms 3 and 3A-D, interview each suspected, probable, or confirmed case
to
get detailed name and contact information for all persons with whom case had face-to-face
contact (defined in the CDC ISRP) since onset of fever until the time of the interview.
2. Seek detailed information on places visited since fever onset.
3. If possible, interview the patient's family, close friends, and work associates to
verify his/her
travel and contact history since onset of fever.
4. If only contacts in one state are involved, give all the information obtained to the
appropriate
district epidemiologist and state epidemiology program staff. The names of the contact and
household members of contacts should be provided to personnel or clinics responsible for
completing contact information and vaccination of contacts. If out-of-state contacts or
travel are
identified, state epidemiology staff will give the information to the CDC Coordination
Group.
5. Once all contacts are listed, allocate them to priority categories for vaccination
based on
duration of exposure according to the CDC ISPR guidelines.
Determination of source
The case or suspect case will be interviewed to determine possible exposure
mechanisms. If this
is an index case, appropriate law enforcement personnel will be notified of the suspected
case,
and information regarding the suspected exposure scenario will be shared with law
enforcement.
Tracing and interviewing of contacts
A single person will be designated by the state epidemiologist to coordinate tracing,
interviewing,
arranging for vaccination and the surveillance of contacts in the state. A single person
will be
designated by the Director of the affected District Health Department to coordinate
tracing,
interviewing, arranging for vaccination and the surveillance of contacts in the district.
Additional
personnel will be provided from state resources as needed. Personnel assigned to trace
contacts
will receive names and any (known address, telephone number(s), or other locating
information for
these contacts from case investigation personnel. The number of contacts for each case may
require a very large number of personnel be identified, trained and available for contact
tracing
and follow-up activities. For details on contact tracing procedures, see the CDC ISRP.
Surveillance (monitoring) of health status and vaccine "take" of contacts
Contacts who do not have fever or rash at the time of interview must remain under
active
surveillance for 18 days after their last contact with the smallpox case, or 14 days
following
successful vaccination. Procedures for contact tracing will follow the CDC ISRP.
Forms for Guide A can be found in the CDC ISRP.
Forms 1-4 Detailed case investigation 4 modules*
Form 1 Patient, medical history and clinical case information
Form 2 Laboratory form
Form 3 Contact identification module (used as module in detailed case investigation
and as
required module for surveillance) includes the following forms:
Form 3A Household contact Form for listing all household contacts of case
Form 3B Non-household contact Form for listing all named non-household contacts
plus duration
of exposure
Form 3C Contact site list for listing sites where unnamed contacts may have been
exposed to case
Form 3D Contact transportation list for listing sites (cities, states, countries)
where case
traveled during infectious period and modes of transportation
Form 4 Source of exposure module, which includes the following forms:
Form 4A Exposure source site form for listing sites visited during period of
possible exposure
Form 4B Exposure source transportation form for listing sites (cities, states,
countries) where
case traveled during period of exposure and modes of transportation
*Note: The modules represented by the series of forms 1-4 are intended to be used in the
initial
stages of a smallpox outbreak investigation. The investigation will require 2 or 3 staff
working
concurrently; using forms 1 and 2, a medical epidemiologist should abstract information
from
admitting medical record or ER record while another epidemiologist/PHA interviews the case
(or
family member/friend if case is too ill for the interview) starting with forms 3 (contact
identification
module) and then forms 4 (source of exposure module). Information needed for form 1 that
is not
available from the medical record should be obtained from the case or a close family
member or
friend.
Forms 5A & 58 Surveillance short forms; these forms will replace forms 1 -4
once cases
are more common and detailed case investigations, especially to determine source of
exposure,
are not needed. Note: must continue to use Forms 3: contact ID module with forms 5.
Form 6 Daily tracking case status form, used for updating case information that
affects case
classification e.g. lab results, epi linkage
Form 7 Hospital surveillance tracking form
Form 8 Form for interviewing each contact and identifying household contacts of
contacts
Form 9 Form for referral of Contacts and Household Members For Vaccination to a
fixed site
Form 10 Individual contact surveillance form to record vaccine "take" and
serious adverse events
for vaccinated household members of contacts (for use by contact tracer)
Form 11 Master form for daily tracking of contact list
Forms still under development
Form 12 Form for contact to record daily temperatures, health status, vaccine take and
serious
vaccine adverse events and Vaccine take and serious Vaccine adverse events of household
contacts (this could be the same form as form 10 or with minor modifications)
Form 13 Daily master form to summarize contacts found/not found. symptoms
of contacts, disposition of found contacts (vaccinated/referred for vaccination, referred
for illness
evaluation, isolated if fever or rash develops, status of contacts not found, number of
contact's
household members and those vaccinated or referred for vaccination. (this may not need
to be a
form but rather a computer generated report from contact form data.)
NOTE: UPDATED FORMS WILL BE USED BASED ON CHANGES TO THE CDC ISRP.
The state health officer will assign a person or
persons to assume organizational
responsibilities for state and local resources for vaccine administration during a
smallpox
outbreak. This person will work with Federal and other state emergency management
authorities to implement vaccine administration strategies.
Detailed vaccination guidelines are available in the CDC ISRP, Guide B. Only general
principles are outlined here.
Overall Vaccination Strategy
According to the CDC, focused vaccination of close contacts is the mainstay of
smallpox outbreak
control as it assures the administration of vaccine to those with the greatest risk of
developing
disease and limits the number of unnecessary vaccinations in those individuals with little
risk of
disease. Judicious use of the Vaccine by establishing priority vaccination of those
individuals who
have the greatest risk of disease must also be exercised to effectively utilize the
currently limited
supplies of smallpox vaccine. Vaccination of those at low risk for disease will decrease
the
number of vaccine doses available for necessary outbreak control activities and may
seriously
compromise the chance for outbreak containment.
Once a smallpox outbreak has been confirmed, vaccination efforts will focus on:
1. contacts of cases
2. household contacts of those identified as contacts of cases
3. non-contact high-risk personnel
The following activities must also take place to support vaccination administration in a
smallpox
emergency:
1. Establish controlled, non-hospital vaccination sites for contacts or other broader
public
vaccination campaigns that may be implemented. Sites must have:
a. appropriate vaccine storage capabilities (vaccine stored at 2-8º C)
b. space for screening, vaccination, and education of vaccine recipients
c. communication capabilities including at least telephone and fax
capabilities
d. adequate security to provide safe storage of vaccine and protection for
personnel
e. equipment needed for re-sterilization of needles if required
2. Establish controlled, non-hospital vaccination sites for medical, public health, or
other
designated responders.
3. Establish a system for vaccine adverse events tracking and reporting
Primary Vaccination Strategy: Contact Identification and Vaccination
If contacts can be vaccinated within 4 days of their contact with the smallpox case,
they may be
protected from developing the disease or may develop a less severe illness. Since smallpox
is
usually transmitted by close contact, people with face-to-face or household contact with a
smallpox case are the ones at greatest risk for developing the disease and should be
prioritized
for vaccination. Individuals most likely to come into contact with an asymptomatic contact
to a
smallpox case (i.e. household members of a contact) should also be vaccinated to prevent
infection of those individuals, should the initial smallpox contact later develop the
disease. In
addition, contagious individuals must be isolated to prevent contact with nonvaccinated or
susceptible individuals during their period of infectiousness (from onset of fever or rash
until all
scabs have fallen off), further limiting the opportunity for disease transmission.
Intensive
surveillance for other contacts and potential cases in the area will help to quickly
identify other
groups for focal vaccination and isolation.
Smallpox vaccination strategies in an outbreak will be based on the following 6
principles:
1. Quickly identifying and isolating smallpox cases.
2. Identifying and vaccinating their close contacts.
3. Monitoring the vaccinated contact and isolating the contact if fever develops.
4. Vaccinating household members of contacts without contraindications to vaccination in
order to
protect them if the contact develops smallpox. Household members of contacts who cannot be
vaccinated due to contraindications should avoid the contact until the incubation period
for the
disease has passed (18 days) or 14 days following successful vaccination of the contact.
5. Vaccinating health-care and public health workers (physicians, nurses, EMTs, etc.) who
will be
directly involved in evaluating, treating, transporting, or interviewing potential
smallpox cases
6. Vaccinating other emergency, law enforcement, or military response personnel who have a
reasonable probability of contact with smallpox patients or infectious materials.
Procedures for Vaccination follow-up to confirm vaccine take will utilize a vaccine site
reaction
recognition card given to vaccine recipients at the time of vaccination. if personnel
resources
permit. vaccine takes should be confirmed and recorded by health personnel 7 days
following
vaccination. if personnel resources do not permit direct follow-up for vaccine take
confirmation,
recipients will have instructions to call for evaluation if the Vaccine site does not look
similar to
that depicted on the card at day 7.
Supplemental Strategy (See Guide G for transition to Mass Plan)
A broader vaccination campaign to increase community immunity to smallpox may be
instituted
by Federal public health authorities in addition to continuing contact tracing and
vaccination
activities under the following conditions:
i. The initial number of smallpox cases or identified locations of smallpox outbreaks is
considered
too large to allow contact tracing with vaccination to be effective as the only
vaccination strategy
for outbreak containment.
2. New cases fail to show a decline after 2 or more generations from initially identified
case(s).
3. Initial outbreak control measures fail to show a decline in the number of new cases
after
approximately 30% of the current stores of vaccine have been utilized.
As of this writing, Idaho strategies will be heavily dependent upon CDC actions,
including
release of the vaccine, recommendations, and status of the CDC ISRP at the time of
activation of the Idaho plan. Therefore, specific vaccination strategies as of this
writing
follow the CDC plan exactly. Refer to the CDC ISRP, Guide B, "Vaccination Guidelines
for
State and Local Health Agencies" for current guidelines on:
Use of Diluted Vaccine
Indications for Vaccination, During a Smallpox Emergency
Contraindications for Vaccination of Non-Contacts During a Smallpox Emergency
Reconstitution, Administration, and Storage of Vaccinia Vaccine
Recognition of Expected Vaccine Reactions/Take
Recognition of Adverse Reactions
Indications and Guidelines for Vaccinia Immune Globulin (VIG) Administration,
and
CDC Recommendations for Handling, Cleaning and Sterilizing Bifurcated
Immunization
Needles in Healthcare Settings
The state health officer will designate a person or
persons to coordinate with federal authorities
all activities related to isolation or quarantine and care of the specific groups listed
below.
The IDHW and the district health department directors are granted authority to isolate
under certain conditions
Idaho Code permits quarantine authority (see Idaho Code TI'TLE 46-1008) once the
governor declares a disaster emergency. State legal statutes are proposed to be modified
in the 2003 legislative session to allow public health intervention and implementation of
the isolation and quarantine measures outlined in this section.
CDC isolation Guidelines as outlined in the CDC ISRP Guide C will be followed.
Preparation activities that are in progress or need to be initiated in Idaho in order to
implement
the recommendations of the CDC ISRP Guide C include:
1. Identification of personnel responsible for local/state coordination of isolation and
quarantine
activities.
2. Identification of appropriate facilities to be utilized for isolation and care of
smallpox patients
and febrile contacts as outlined and establishment of procedures for activating them.
3. Identification of appropriate law enforcement entities to enforce isolation and
quarantine
orders.
4. Identification of appropriate personnel to maintain and staff facilities.
5. Establishment of procedures for monitoring and controlling access to facilities.
6. Establishment of procedures for appropriate disposal of medical waste when using a
nonmedical facility.
7. Establishment of laundry service arrangements (on-site if possible) and appropriate
disposal of
medical waste.
8. Arrangement for food service support for facility occupants.
9. Establishment of procedures for monitoring health status of facility staff and plans
for referral to
appropriate care.
SECTION 1: ISOLATION MEASURES. See CDC ISRP Guide C.
Note that Standard, Contact, and Airborne precautions are recommended for smallpox
patients in a healthcare facility.
For guidelines for handling bodies after death from smallpox, see CDC ISRP Guide D,
under "Autopsy specimens".
SECTION 2: QUARANTINE MEASURES AS PART OF THE RESPONSE TO A SMALLPOX
EMERGENCY
A. State Quarantine Laws
In recent years, while quarantine has not been widely employed by states as an
infection control
measure, Idaho does have current experience with legal isolation through its application
to limited
numbers of patients with tuberculosis. The Idaho attorney general's office has reviewed
state
laws regarding quarantine and emergency response to identify gaps. The legislature will
consider
a proposal in 2003 to strengthen legal authority for quarantine and isolation by public
health
officials in Idaho.
A summary of the public health powers needed for adequate response to a bioterrorism event
is
listed in the CDC ISPR Guide C and is summarized below.
Public Health Powers Needed by a Health Officer in a Bioterrorism Event
Collection of Records and Data: Reporting of diseases, unusual clusters, and
suspicious events,
Access to hospital and provider records, Data sharing with law enforcement
agencies,Veterinary
reporting, Reporting of workplace absenteeism, Reporting from pharmacies
Control of Property: Right of access to suspicious premises, Emergency closure of
facilities,
Temporary use of hospitals and ability to transfer patients, Temporary use of hotel rooms
and
drive-through facilities, Procurement or confiscation of medicines and vaccines, Seizure
of cell
phones and other "walkie-talkie" type equipment, Decontamination of buildings,
Seizure and
destruction of contaminated articles
Management of Persons: Identification of exposed persons, Mandatory medical
examinations,
Collection of lab specimens and performance of tests, Rationing of medicines, Tracking and
follow-up of persons, Isolation and quarantine, logistical authority for patient
management,
Enforcement authority through police or National Guard, Suspension of licensing authority
for
medical personnel from outside jurisdictions, Authorization of other doctors to perform
functions
of medical examiner
Access to Communications and Public Relations: Identification of public health
officers, e.g.
badges, Dissemination of accurate information. rumor control, 1-800 number, Establishment
of a
command center, Access to elected officials, Access to experts in human relations and
post-
traumatic stress syndrome, Diversity in training, cultural differences, dissemination of
information
in multiple languages
Related Idaho Law:
In addition of the state and district powers of quarantine listed above, the
Governor's explicit
powers during a disaster, including the authority to restrict movement of persons, are
outlined in
the Idaho Code: Title 46 "Militia and Military Affairs", Chapter 20, "State
Disaster Preparedness
Act", section 46-1008, "The Governor and Disaster Emergencies".
B. Federal Assistance in Enforcement of State Quarantine. See CDC ISRP.
C. Federal Intervention When State Response is Inadequate. See CDC ISRP.
The Idaho Bureau of Laboratories, Division of
Health, in Boise will soon be receiving the
technology and training to rapidly test for (varicella) chickenpox by PCR methods. This
technology will hopefully be useful in diagnosing chickenpox rapidly in cases where
smallpox may
be in the differential diagnosis. For details, contact the Bureau of Laboratories Virology
Program:
208-334-2235.
CDC has laboratory facilities for testing clinical samples for smallpox.
No laboratory in Idaho is set up to safely handle clinical smallpox specimens at this
time;
therefore, all suspect samples must be sent to CDC for testing.
Approval must be obtained prior to the shipment of potential smallpox patient clinical
specimens
to CDC. The district or state health department's epidemiology program should be notified
immediately if any sample is being collected for smallpox testing; the epidemiology
program will
assist in obtaining CDC approval for the shipment of samples.
See the CDC ISRP Guide D for details on specimen collection and shipping. Note that chain
of
custody documentation may be a critical part of the specimen handling procedures.
Specific directions regarding the transportation method for the packaged specimens to CDC
will
be given at the time of consultation.
Shipping address at CDC:
Centers for Disease Control and Prevention
1600 Clifton Road NE
ATTN: DASH (forward to Dr. Rich Meyer)
Atlanta, GA 30333
For shipping questions relating to sending specimens to the CDC, contact
(404) 639-0075 weekdays/business hours
(404) 639-4931 - weekdays/business hours
(770) 488-7100 nights/weekends/holidays
To address public questions, false rumors and
misinformation, it is imperative that public hearth
officials acknowledge the seriousness of a smallpox outbreak and provide accurate, timely
information to the public through the media. Government agencies, including CDC, the Idaho
Department of Health and Welfare, and the district health departments, need to respond to
media
inquiries immediately, and work to maintain effective relationships. The public must
perceive that
federal, state, and local health officials are effectively responding to the smallpox
emergency.
Together, they must convey a strong impression the public health system is responding in a
sound manner and fashion.
This communications plan is based on the CDC plan found in Guide E of the CDC ISRP, and is
grounded in the guidelines that communication experts have recommended for effectively
addressing public concerns and fears. These principles of "crisis communication
include:
· Adopting a policy of full disclosure about what is and is not known.
· Recommending specific steps that people can or should take to protect themselves.
·Avoiding speculation.
· Avoiding the issuance of statements or information that is at conflict with that being
provided by other government agencies.
· Delivering information in a non-patronizing manner.
In the event of an outbreak or highly suspected case, a smallpox Communications
Command
Center would be immediately established at CDC to help manage communications to the media,
health care providers, public health partners, and the general public. This Center will
direct all
CDC smallpox communications activities, including communications strategy deve~opment, key
message development, web site development and management, materials development and
dissemination, national media relations, media monitoring and all other national
communications
components. Similarly, the Idaho Department of Health and Welfare would designate a staff
member to be the point person for media inquiries, and to spearhead message development.
Overall Smallpox Communication Objectives
1. Instill and maintain public confidence in the nation's public health system--and
its ability to
respond to, and manage, a smallpox outbreak--by providing accurate, rapid, and complete
information to calm fears and maintain a sense of order.
2. Minimize, as much as possible, public panic and fears related to smallpox.
3. Rapidly provide the public, health care providers, policymakers, and the media access
to
accurate, consistent, and comprehensive information about smallpox, smallpox vaccine, and
the
management of the situation.
4. Address, as quickly as possible, rumors, inaccuracies, and misperceptions.
5. Provide accurate, consistent, and highly accessible information and materials through
the
coordination of communication efforts with other federal, state, and local partners.
Guiding Principles - Smallpox communication plans and activities should be guided
by the
following primary principles:
· Effective communications require preparing and disseminating messages and materials
right
now that will increase public, health care professional, policymaker, media, and key
partner
knowledge and understanding about smallpox, smallpox vaccine, and health strategies
related to
smallpox. For example, the public should be educated about smallpox disease containment
strategies, such as quarantine and isolation, so that such approaches are understood and
accepted.
· The first suspected or confirmed case of smallpox wilt generate immediate,
intense, and
sustained public, health care provider, media, and policymaker concern, interest,
and demand
for information. The reaction will exceed that generated by the first recently reported
case of
anthrax. It will take an enormous amount of preparation and effort to effectively respond
to an
enormous public, media, policymaker, and health care provider demand for information and
guidance. The public will immediately need to be given information that will help
people
minimize their risk.
· The city in which the first confirmed case of smallpox takes place will
experience a tremendous
amount of media attention, interest, and coverage. The media will nock to the site
of the first
outbreak. And the public is likely to flock to area hospitals, physicians' offices, and
public
health offices/agencies. Managing the media demands. along with assisting local
hospitals and
health care providers in responding to public, practitioner, and media inquiries, will
necessitate
the deployment of at least two or three communications specialists to the area.
· A great deal of the initial media, public. health care provider, and policymaker
interest and
attention will be on the source of the infection--that is, who is infected, how and when
did that
person get infected, and who else may have been infected. The Idaho public health
system
needs to be prepared to immediately address these questions related to the source of the
initial case and provide guidance to the public regarding disease susceptibility,
diagnosis,
treatment, and immunization. Further, the number of cases, confirmed, suspected, and
potential, will constantly need to be placed into context.
· Effective smallpox communications encompasses more than media management and
relations.
Communication centers must also communicate, and address the needs of, state and local
health
departments, local health care providers and hospitals, and key partner organizations
(e.g.,
professional medical organizations). We need to be able to provide physicians and
other
health care providers the detailed information they need to identify and treat suspected
or
confirmed cases of smallpox.
· To reduce public fear and minimize the spread of rumors, inaccuracies, and
misinformation, it is
imperative that timely, accurate, and comprehensive information be available immediately
in the
event of a confirmed smallpox case or outbreak. The public and media must perceive
that the
public health system is prepared and working.
· CDC plans on dispatching at least two CDC communications experts to any
community that has
a confirmed case of smallpox, to coordinate all communications and media relations
activities at
the field site and to coordinate communications with public and private sector health care
providers and agencies. However, it is likely that in the event of a case of smallpox
outside of
Idaho, no specific aid would be available to the Idaho public health system, and the
communications staff from the IDHW will be primarily responsible for message development.
· Developing. before a confirmed case of smallpox, information resources and materials
that can
be quickly and broadly disseminated to the media, health care providers, state and local
health
departments. and other key partners through a wide variety of distribution channels, is
critical.
Further, authorities for reviewing and clearing smallpox-related messages and
materials
needs to be established now--prior to a smallpox outbreak.
· Websites need to be used as a central component to managing the flood of information
requests
from the public. Strategically-designed websites should be used to organize and quickly
provide information, updates, fact sheets, frequently-asked question documents, health
care
provider resources, including patient and public education materials, and media materials
to a
range of audiences. Much of the work on these websites should be done before a reported
case
of smallpox (e.g., created and housed on development web servers that could be activated
when
needed). In addition, a targeted distribution plan that directs information and education
materials
will be implemented to help address the needs of health care providers and local health
officials.
· The CDC's National Immunization information Hotline will be utilized to immediately
provide
information to the public. Specific regional information about clinic locations and,
quarantine
guidelines will be available through the hotline. Hotline staff will access website
information to
help them address public questions. The hotline also will be used to provide ongoing
guidance to
communication staff about new messages and materials that need to be developed to respond
to
public needs. NIIH Numbers: 1-800-232-2522 or 1-800-232-0233 (Spanish).
·A toll-free Hotline will be established to provide consultation with district and state
health
departments and refer the public to clinic locations. Hours of the Hotline may be expanded
as
needed during the crisis.
· Systems and methods for rapidly identifying, tracking, and responding to public, health
care
provider, and media concerns and questions should be established in the pre-event planning
phase. This includes contracts for initiating or adding telephone information lines to the
Idaho
Careline, preparing e-mail response systems, and putting in place Joint Information
Centers
(JIC) for factual and consistent distribution of information.
· A portfolio of communication, information, and education sources and materials need to
be in
place on a range of topics, including: characteristics of the disease, diagnosis (clinical
and
laboratory), vaccine management and administration (storage and handling, administering
the
vaccine, contraindications and adverse events) and vaccination and containment strategies
(household contacts, case investigation etc) and vaccine safety (e.g., Vaccine Information
Statements, adverse event recognition, management and reporting), roles and
responsibilities of
different agencies (e.g., CDC, FDA, state health departments, local health departments,
health
care providers, etc.).
· Recognized and trusted health officials, smallpox experts, and health communications
experts
should be identified and consulted during the planning and preparation phases to assist in
the
development of effective messages and materials, including the delivery of public health
information to the mass media.
Pre-Event Communication Objectives (i.e., before a confirmed case of smallpox)
1. Identify public and health care provider knowledge, understanding, and beliefs
related to smallpox, smallpox immunization, and other smallpox-related public health
issues, such
as quarantine and isolation, vaccine safety, and disease transmission.
2. Increase public, health care provider, public health official, policy maker, media and
key partner
knowledge and understanding of smallpox disease, smallpox immunization, and the general
approaches/concepts that will be used should there be a confirmed case or outbreak of
smallpox;
this includes quarantine and isolation, immunization strategies, and vaccine
administration.
Ideally, communications and education will help "de-mystify" smallpox and
increase knowledge
and understanding of isolating and quarantining smallpox patients.
3. Identify and develop messages and materials that address public, health care provider,
public
health official, policy maker, and key partner needs, knowledge gaps, and interests
related to
smallpox disease, smallpox vaccine(s), and smallpox-related public health strategies.
4. Increase the range and type of smallpox materials available to the public, health care
providers, policy makers, and the media from the IDHW and the district health departments.
5. Help prepare and establish appropriate public, health care provider, policy maker, and
media
responses to a smallpox case or outbreak. including an understanding of how the public
health
system will respond, roles and responsibilities of the different sectors involved, and
reasonable
expectations regarding the scope and effects of public health actions.
6. Establish the protocols that would be used to communicate the specific data that would
need to
be reported daily after a confirmed smallpox case (e.g., morbidity and mortality figures;
geographic location of cases; number of persons in quarantine; location of immunization
clinics;
number of persons vaccinated, number of doses of vaccine used and available, etc.).
Event/Post-Event Activities (e.g., after a likely or confirmed case)
Idaho Smallpox Communications Command Post
1. Once smallpox has been verified anywhere in the U.S., full-scale communications
activities at
the Idaho Communications Command Post should be activated. Staffing assessment will be
made and personnel will begin staffing the command post for extended hours and days.
2. Implement at least two dedicated telephone lines to the Idaho Smallpox Communications
Command Post so that public health staff can have immediate access. Implement
another community phone line for health care providers and public persons who have been
quarantined. All other calls will be directed to the CDC's National Immunization
Information
Hotline.
3. Activate the emergency "Smallpox" website and bring the website up.
4. Contact toll free Hotline number and provide them with the Idaho smallpox web site
address for
information .
5. Contact state and local government agency partners and provide them with materials that
will
enable them to respond to media, public, and health care provider inquiries. Implement
twice-a-
day briefings with these partners.
6. Create and disseminate a media advisory that provides information regarding the
situation, the
major actions being taken. information about smallpox, public guidance, and resources.
7. Rumor control will be the main concern for the first few hours and days, until the
organism is
definitely identified and confirmed, thus it will be imperative to immediately issue
information
updates and to correct, as much as possible, errors and misperceptions.
8. All media and public materials should be posted to the Idaho smallpox website and all
Idaho
smallpox printed information should provide the website address. The Idaho smallpox
websites
should be used heavily for most of the media updates related to Idaho smallpox activities.
It is important that in all contacts with the media, that IDHW's role in this response is
made clear.
Prior to press briefings, interviews. teleconferences, etc., it should be explained that
our primary
focus is "to identify the public health threat and take actions to protect the
public." IDHW
will gladly answer questions concerning smallpox and the actions we are taking to contain
it.
Questions concerning the source of the smallpox, how it was dispersed, who dispersed it
and
why, should be directed to the law enforcement officials involved in the investigation
(personnel
dealing with the media will be trained on the types of questions they should answer and
the types
of questions that should be directed elsewhere). IDHW must establish that we are the
source
for public health information only-- and cannot address questions related to bio-terrorism
activities.
9. Implement daily routines for informing, and responding to, the media, health care
provider, partner, and public inquiries.
a. The Idaho Smallpox Communications Command Post will establish teams
patterned along
the same lines as pre-outbreak activities (i.e., media, website, public
education, health care
provider and partner communications). Each team will have a team leader, who
will report to
the Smallpox Communications Command Post director.
b. The teams will meet twice daily--at the beginning of a work shift. and at
the middle of a
shift--for briefings, updates, and to share information and materials.
c. Should smallpox be affecting Idaho directly (cases or contacts in the
state, persons in the
state recommended to Set vaccine, etc), public health updates should be
posted twice daily
to the Idaho smallpox website and sent to appropriate partner organizations
~morning and
late afternoon).
d. The CDC ISRP states they will be planning daily or twice daily
teleconferences, preferably
around 10 a.m. and 4 p.m.. The briefings will be characterized as public
health response
updates (not bioterrorism updates) to reinforce the CDC's role in the
response. Ideally, the
same CDC experts will conduct the media briefings. If necessary, these daily
activities can
be extended.
e. Personnel responding to media calls or local community calls from health
care providers
or quarantined individuals should take notes that enable identification and
tracking types of
questions and concerns, and as frequently as possible:
1. post questions and answers to smallpox website,
2. send to any and all relevant information services (e.g., Hotline and
e-mail services). and
3. state and local health departments and appropriate external partner
organizations.
f. The smallpox content management team at the home base CDC Atlanta will
begin
identifying and creating new messages and materials that address the emerging
questions
and concerns of the media. public, health care providers, policy makers, and
others. As
appropriate and feasible, field team communications staff will tailor
smallpox education and
communication materials to community needs. IDHW Communications Center staff
will work
with CDC partners as needed to maintain consistency and accuracy in public
health
information .
Role of CDC in Communications
The interaction between the Idaho Communications Center and the CDC Communications
team
will vary greatly depending on the nature of the incident, whether it is affecting
multiple states or
only one state, and whether Idaho is directly involved. The following notes are based on
the CDC
ISRP regarding the anticipated role of CDC Communications in a smallpox event.
CDC On-Site Communications Operations
CDC will establish an on-site JIC in addition to the centralized communications
command center
located in Atlanta. If an event occurred in Idaho, a JIC would be established here. The
Idaho
Public Health Preparedness program staff will designate a person or persons to coordinate
communication and media activities related to notification of the news media for the local
and
state health departments, and to work with the CDC field communications liaison (FCL).
The CDC FCL Media objectives include:
· Working with state and local officials to instill and maintain public confidence;
· Facilitating the effective management of local communication efforts and the on-site
communications center;
· Facilitating the provision and management of accurate, timely, and relevant information
to the
public and media;
· Assisting in the management of public expectations;
· Facilitating timely and appropriate responses to errors and misinformation;
· Enhancing and increasing state and local communication efforts (e.g., helping to obtain
or verify
information or facts, prepare and debrief subject matter experts, obtain needed
information, etc.);
· Communicating with law enforcement officials to assure a safe and orderly public health
and
community environment.
The CDC FCL Media Person will:
1. Serve as the principal CDC media advisor in the field, and assist the CDC Smallpox
Response
Team leader in serving, as appropriate, as a media spokesperson. It is essential that the
FCL
Media person be included as a part of the decision-making team. This means meeting with
CDC,
State/local health officials, and law enforcement meetings on a regular basis, attending
all staff
meetings, and being included in all meetings involving issues that will result in media
coverage or
have an impact on public knowledge, perceptions, opinions, and behavior(s). Once on-site,
the FCL should immediately begin to assist in the creation, provision, and management of
the
flow of information and the coordination of local contacts.
2. Assist state and local officials in preparing statements and materials to 1) inform the
public that
there is a suspected (or confirmed) case of smallpox in the city and State, 2) state that
health
officials are working with CDC to confirm or rule-out the diagnosis (or to prevent further
transmission), and 3) assure the public that measures to prevent the spread of the disease
are
being implemented. An initial key message is likely to be: "Only unvaccinated persons
who were
in close contact (face-to-face) to a person with smallpox are at risk of contracting the
disease.
These persons should get vaccinated as soon as possible.
3. Work with the CDC Smallpox Communications Command Post to determine the most
appropriate messages and timing for the notification of the news media and general public,
and to
assure proper clearances for messages and materials. This includes developing and
utilizing
short fact sheets and question-and-answer documents.
4. Coordinate with Joint Information Centers (JIC) for factual and consistent distribution
of
information as well as identification of information needs (e.g., frequently asked
questions). The
JIC will be operational at the beginning of the federal response to the outbreak and will
consist of
representatives from all local, state, and federal agencies involved in the response to
the
outbreak. The following information will be coordinated and distributed through the JIC
once it is
operational :
· Progress reports / updated information on the latest developments
· Requests for locating spokespeople and key subject matter experts
· General disease and vaccination information
· Public health announcements related to the outbreak
· Other information requests related to the outbreak which require distribution to the
media and
general public.
Once a JIC is operational, all media contacts and information should be handled through
this center to assure consistent and accurate information distribution. This includes:
· Establishing a "news desk operation" to coordinate and manage media
relations activities (e.g.,
handle media requests and inquiries);
· Providing a place for the CDC, HHS, state, and local communications and emergency
response
personnel to meet and work side-by-side in handling media inquiries, writing media
advisories
and briefing documents, providing access to appropriate subject matter experts and
spokespeople, etc.
· Responding to routine (i.e., frequently occurring) media questions with established
fact sheets,
talking points, and question-and-answer documents.
· Issuing media credentials
· Developing, coordinating, and managing local websites
5. Help develop a list of "authorized" public health spokespeople, and assist in
directing local
media to previously identified reliable state and local smallpox subject matter experts
(e.g., local
health officers, infectious disease physicians).
6. Assist state and local officials in preparing for media interviews, developing media
materials,
scheduling and managing media interviews, and other arrangements as necessary. This
includes
assisting in logistics, such as arranging for tables and chairs, media telephone lines,
staff
telephones, audio-visual equipment, etc.
7. Work with the General Services Administration (GSA) to lease space for briefing rooms
or
media response offices and media workspace.
8. Provide regular updates to the CDC Smallpox Communications Command Center regarding
local developments, concerns, and issues. This includes breaking news, frequently asked
questions, and local communications and media strategies.
9. Help arrange and publicize state and local smallpox information resources, such as
websites
and toll-free information numbers. It will be important to direct routine
inquiries concerning state or local programs to the appropriate local program
personnel or authorized spokesperson.
10. Assist in preparing bulletins, Frequently Asked Questions, and Question-and-
Answers pertaining to information on the disease, contact tracing, recommendations
for vaccination, disease transmission, surveillance activities, laboratory testing, etc.
Field Communications Media Liaison Initial Actions
During the initial phase the on-site FCL will establish CDC and HHS as credible
sources of
information. Messages will convey that CDC and local health officials are effectively
addressing
the public health issues and their approaches are reasonable, professional, scientific and
caring.
Upon arriving at the affected community, the FCL should:
· Meet with local health Public Information Officer(s) (PIOs) to assess staffing needs,
develop
media lists, discuss local political sensitivities, assign duties, determine briefing room
location,
and determine media needs.
· Set-up an emergency communications center for the media.
· Work with GSA to lease space for briefing room and media response offices (if not
available
through local health department or other local means) and media work space.
· Work with state and local officials to develop a list of authorized government
spokespeople and
subject matter experts.
First contacts should include:
· Public affairs directors or information officers from local and state health
departments (e.g.,
NPHIC members).
· City and state government public affairs offices (i.e., mayor and governor).
· Local congressional delegation and offices
· Local police and fire departments and emergency management officials
· Regional HHS Health Officers and Regional Office of Emergency Preparedness
· Local hospital public relations/affairs departments
· State and local Emergency Operations Center Coordinators
Field Communications Liaison Guidelines and Suggestions
CDC field staff should remember that it is impossible for any one person to handle all
aspects of
media relations in the event of a smallpox outbreak. A joint information center is the
best way to
coordinate and manage media relations activities. Public information officers from a wide
range of
federal, state, and local agencies (e.g., CDC, HHS, state and local health departments,
and law
enforcement) will need to work side-by-side handling media inquires, writing releases,
providing
information on their agencies and other duties as appropriate.
The FCL should establish a daily routine for coordinating and communicating with the
various
contacts outlined above (especially state and local officials) on media briefings and
media
materials. Arrange personal briefings. At these briefings, remind those attending that
this is
confidential information and any public or media release of information should be done
through
appropriate spokespeople and channels (e.g., media briefings). If people do not respect
media
guidelines or information embargoes. caution should be exercised when providing them
additional
information. Cooperation and understanding among all the involved agencies will greatly
enhance
the success of the media operation. The FCL should work closely with communications staff
and officials from focal and state health departments as well as law enforcement agencies.
Together, these groups will create and manage the flow of information to the media. It
will also be important to work closely with mayoral. governor, and Congressional media
and communication staff. State and local health department public information officers
can offer valuable insights into crucial issues in the state and local community, as well
as
guidance in dealing with local media. In addition, they can provide information about
media contacts, outlets, directories, and telephone and fax numbers to facilitate
distribution of
information to the media. They may also have facilities and infrastructure for briefings.
Don't
overlook local hospital media offices. They generally have good relationships with the
media, as
does the local fire department P1O. In most communities, fire departments deal on a daily
basis
with the local media and can be one of the FCL's most valuable resources.
CDC Field Communications Community Liaison (FCCL)
The CDC field Communications Community Liaison will serve as the principal CDC community
relations advisor in the field, and assist the CDC smallpox response team leader in
serving as the
principal contact point to local hospitals, infectious disease specialists, National Guard
officials,
and health departments. Once on-site, the FCCL should.
1. Attend all CDC response team meetings and provide updates to the CDC
team leader and Media Communications Liaison on community outreach and education
activities.
This should include detailing any encountered or anticipated barriers or problems as well
as
suggested actions.
2. Immediately meet with lead local health officials and identify key community partners.
Develop
and maintain a contact list of key community and state partners. Establish regular
briefings with
key community and state partners on a daily basis, including members of health care and
law
enforcement agencies.
3. Work with the immunization services team members and law enforcement officials to
assist in
identifying, communicating and safely securing places for "first responders" to
receive smallpox
vaccine. Key personal identified in first immunization wave include selected local service
providers that provide essential non-medical services to quarantined households.
4. Establish a community phone line to assist in responding to the questions and concerns
of
state and local health care providers, pharmacists, law enforcement personnel, and any
quarantined members of the community.
Provide national materials and work with key partners to implement a follow up resource
and
referral list for phone center staff.
5. Work with CDC Response team members and local partners to coordinate communication and
health education activities by identifying needs, tracking progress and reporting to the
CDC
smallpox response team leader on key communication and health education activities planned
and executed. These activities may include: 1) information campaigns for the affected
community,
e.g. planned immunization activities, quarantine information, and/or clinic information,
2) health
care provider education campaigns and activities, including first responders, 3) education
and
communication with state and community people involved in meeting community needs or
community actions designed to prevent the spread of the disease, and 4) helping to assure
quarantined persons have access to essential information on how to obtain needed supplies
or
services .
6. Tailoring, as appropriate and feasible, communication and education services and
messages
to the affected community. This will likely include meeting with community and state
partners to
identify specific community resources that can be utilized and secured. In addition, the
field
communications community liaison will work with quarantine teams to customize materials to
community and disseminate information and materials to quarantined individuals. Specific
issues
to be addressed in the materials should include local phone numbers for assistance, along
with
information for quarantined individuals on how to obtain food, medical care, emergency
home care needs (plumbing; electricity), and even recreation services.
7. Develop a list of key health care facilities in the community and doctors offices for
information
dissemination purposes and for health education activities. Coordinate with CDC medical
team
staff in initiating contact with health care providers. Cross train key partners to assist
in education
and outreach efforts.
8. Obtain and track information daily on numbers and location of new cases; number and
location
of new quarantine cases; number and location of immunization efforts, and number of doses
of
smallpox vaccine used and available. Utilize these reports to prioritize community
outreach and
education efforts.
9. Work with the CDC Smallpox Communications Command Post to determine the most
appropriate messages and timing for the notification of the community, and to assure
proper
clearances for messages and materials. This includes working with partners in rapidly
identifying
community needs, communicating these needs to appropriate program staff and developing
information distribution plans.
10. Provide feedback to and coordinate with the Joint Information Center (JIC) for factual
and
consistent distribution of information as well as identification of information needs
(e.g., frequently
asked questions).
11. Assist in tailoring messages and materials to the affected community (e.g., Frequently
Asked
Questions documents and information materials on the disease, contact tracing,
recommendations for vaccination. disease transmission, surveillance activities, laboratory
testing,
quarantine, etc.).
On-Site Media Briefings and Teleconferences
Generally, media briefings should be no longer than 30 to 45 minutes. The FCL or
state/local
public information officer should moderate the briefing, as well as begin and end it. The
moderator should set ground rules, announce times of future briefings and make
housekeeping
announcements - for example, asking for contact numbers or email addresses so reporters
can
be quickly notified of breaking events. Before beginning, the moderator should make sure
the
television camera operators as well as reporters are ready. The moderator will release
general
facts - number of cases, deaths (before releasing names, make sure you have family
approval),
and provide other updated statistics. Do not release any personal information without
prior written
approval. All interview requests involving victims or victim family members should be
coordinated
through the FCL or other appropriate public health information officer.
The moderator should briefly introduce each panel member. including name and spelling,
title,
agency, expertise, and briefly explain what the panel member will discuss. Each panel
member
should speak for 3 to 5 minutes on issues related to his/her area of expertise. All
questions
should be held until all panel members have spoken. Questions should be directed to the
moderator, who will either answer the question or refer it to the appropriate panel
member. The
moderator should conclude the briefing after about 30 minutes by reminding reporters of
the next
briefing. Following the conclusion of the briefing, all spokespeople should leave.
Spokespeople
should be advised to avoid participating in individual media interviews with panel members
following briefing. The FCL should be notified immediately of any potential issues,
including new
questions that need to be answered. identified during media briefings. This can include
inaccurate
information or reports of rumors in the community.
General Guidelines for Working with the Media
Establishing credibility and a working relationship with the media is critical.
· All media requests should go through communications and public affairs personnel.
People
handling media calls should take the reporter's name, number and affiliation, as well as
ask what
information they are seeking and what their deadline is.
· Communications and public affairs personnel handling media inquiries should, as much as
possible, assume full responsibility for assisting the reporters--avoid referring the
members of
the media to other communications staff.
· Ideally, media calls should be handled by a live voice within 30 minutes, if possible.
· All media personnel should be treated with the same respect and
professionalism-irrespective
of the size and scope of the medium's audience. While there is often a greater urgency and
priority associated with national media, that urgency should not translate into actions
that are
disrespectful to smaller media, especially local media. It is important to remember that
CDC will
be guests in the community, and any slight to local media or local officials can have a
long-lasting
negative effect. Always be polite and diplomatic.
· Questions related to criminal investigations or activities should be directed to law
enforcement
agency personnel. Law enforcement agencies are specifically trained to respond to
questions
concerning crimes and ongoing investigations. Inappropriate responses in a public
setting or
to the media can jeopardize criminal investigations or subsequent trials.
· Spokespeople should have media experience or training.
· Spokespeople and public affairs staff should be quick, factual, and consistent in
dealing with,
and responding to, media inquiries.
· Provide the media with information about what the public and/or health care providers
should
expect or do. Use media interviews as a way to give advice and guidance to the public and
health
care providers.
· Respond promptly to all media calls. Be aware of deadlines. An answer after deadline is
as bad
as no answer at all.
· Reply to questions accurately, but avoid providing more information than is requested.
Know the
key messages and talking points and communicate them frequently.
· Don't speculate. If you don't know an answer, don't be afraid of saying you don't have
that
information, but will try to find an answer.
· Never discuss programs of other agencies beyond what is contained in approved fact
sheets or
news releases.
· Repeat the key facts about events. Publicize additional sources of information (e.g.,
web sites,
hotlines, partner organizations).
· When possible, provide the media with written materials and resources (including
websites).
· Be prepared to describe what is being done, the number of CDC personnel involved, and
their
general activities and responsibilities.
· In general, references or referrals to other agencies or programs should not be made
without
prior approval or notification.
· Avoid the phrase "No comment." It often is interpreted in a negative light,
irrespective of the
speaker's intent. Effective alternatives include: "I can't answer that question until
we have more
complete information." "I don't have that information. But I will try to find
and answer for you.
"I'm not qualified to answer questions on that topic. I will have someone get back
with you." "We
will have a statement on that shortly.
· Eliminate obstacles whenever possible. Obstacles imply to reporters that there is an
untold
story; that something is being hidden from the public. if there is something that cannot
be
discussed in a public forum, say so. Most reporters will understand.
· Use judgment when releasing information to the media. Consider possible consequences,
and
remember to put numerical information into a context. It is important to respond to the
media. but
always consider the public to be your primary audience.
· Don't intentionally mislead the media.
Only vaccinated personnel should perform the
following decontamination procedures. Protective
clothing including, gowns, gloves, shoe covers, caps, and masks should be worn.
Ideally, all disposable protective clothing worn by decontamination personnel should be
placed in
biohazard bags and autoclaved or incinerated before disposal. However, if needed due to
shortages of protective clothing, re-useable protective clothing that can be laundered may
be
transported to the laundry in biohazard bags, then laundered using hot water (71º C) and
bleach
according to the standard proportions recommended by the manufacturer. The contaminated
clothing should be wetted before sorting by laundry personnel to help prevent the
aerosolization
of contaminated particles during sorting. (see Fenner, F, Henderson DA, Arita I, Jelek Z,
Ladnyi
ID. Smallpox and its eradication. Geneva, Switzerland: World Health Organization; 1988:
p.194,
and Henderson DA, Inglesby TA, Bartlett JG, et al. Smallpox as a biological weapon;
medical and
public health management. JAMA. 1999; 281(22): 2127-2137).
Re-useable materials should be laundered on site and all personnel handling laundry must
be
recently vaccinated (within 3 years). Decontamination personnel should immediately shower
with
soap and water after the contaminated protective clothing is removed.
A. Reusable medical equipment
Reusable medical equipment should be cleaned with a 5% aqueous solution of a phenolic
germicidal detergent or other EPA-approved germicidal detergent per manufacturer's
recommendations, then decontaminated using one of the following methods. The method
selected should be based on manufacturer recommendations for decontamination of the
equipment.
1. Autoclave decontamination- Manufacturers standard protocols for autoclave
decontamination
may be used.
2. Ethylene oxide decontamination Equipment that must be decontaminated using this method
should be bagged in plastic bags that are permeable to gaseous ethylene oxide. Humidify
the
material to be sterilized by injecting water into the plastic-bagged material to produce a
relative
humidity of 50 - 70%. Place the bags into an ethylene oxide sterilizer and allow an
exposure of
at least 24 hours at a concentration of at least 800 mg per liter ethylene oxide.
The equipment should be allowed to fully aerate after ethylene oxide decontamination.
3. Solution soak decontamination - Soak equipment in a 5% aqueous solution of a phenotic
germicidal detergent (e.g. industrial strength Lysol or Amphyl, )for at least 1 hour. APIC
recommends decontamination should be done with an EPA-approved germicide per
manufacturer's recommendations.
B. Medical waste
Medical waste should be bagged in appropriately marked biohazard bags and incinerated
or
autoclaved on-site if possible. Alternatively, if on-site autoclaving and incineration is
not possible,
medical waste may be transported to an appropriate facility for autoclaving or
incineration. If
incineration takes place in an area other than the facility, the outside of the bag should
be
sprayed with a suitable disinfectant (e.g. Lysol, household bleach) prior to
transportation to the
area for incineration. All personnel involved in handling, transportation, and disposal of
medical
waste from facilities where confirmed or potential smallpox patients are housed must have
recent
vaccination (within 3 years).
C. Surfaces
Contaminated horizontal surfaces may be decontaminated using a 5% aqueous solution of
a
phenolic germicidal detergent (e.g. industrial strength Lysol, Amphyl, or other commercial
decontamination solution). APIC recommends using EPA-approved hospital-grade germicidal
detergent per manufacturer's recommendations. All surfaces should be thoroughly wet with
the
solution. Allow the solution to stand for at least 20 minutes then wet vacuum or wipe with
clean
cloths or disposable wipes. If a wet vacuum is not available or practical and mops are
used,
disposable mop heads should be used for no more than 500 sq. ft. of floor area. The cloths
or
disposable wipes, mop heads, vacuum cleaner contents, and protective clothing worn by the
decontamination personnel should be bagged and incinerated or autoclaved. If needed
because
of material shortages, re-useable protective clothing and cleaning materials that can be
laundered
may be bagged then laundered using hot water (71º C) and bleach as outlined above. The
vacuum cleaner should also be disinfected with EPA-approved hospital-grade germicide per
manufacturer's recommendations after use to further disinfect the non-disposable parts of
the
vacuum cleaner (nozzle, hose, etc.).
D. Protective clothing, bedding, linens, etc.
Contaminated protective clothing should be bagged immediately after removal and then
incinerated or autoclaved. However, if needed due to shortages of protective clothing,
reuseable
protective clothing that can be laundered may be bagged then laundered using hot water
(710C)
and bleach as outlined above. Bedding, linens, clothing, or other reusable cloth materials
may be
autoclaved or laundered using hot water (71º C) and bleach as outlined above, Mattresses
and
pillows should be cleaned with EPA-approved hospital-grade germicide per manufacturer's
recommendations.
E. Room/facility
Facilities or rooms that were used to house smallpox patients should be decontaminated
once
they are no longer used to house such patients. All disposable items should be bagged and
incinerated or autoclaved.
1.All horizontal surfaces, furniture, fixtures, and walls should be decontaminated as
outlined in C
above.
2. All mattress covers, curtains, clothing, and other removable cloth items should be
bagged and
autoclaved, incinerated, or laundered in hot water (71º C) and bleach as described.
3. Items that should not be autoclaved or incinerated should be bagged and decontaminated
using EPA-approved hospital-grade germicide per manufacturer's recommendations as outlined
above.
If smallpox patients are housed in their own homes, at a minimum, the following
decontamination
procedures should be performed:
1. All disposable items that came into contact with the smallpox patient should be bagged
and
incinerated. If incineration takes place in an area other than the home where the patient
was
housed, the outside of the bag should be sprayed with a suitable disinfectant (e.g. Lysol,
household bleach) prior to transportation to the area for incineration.
2. Bedding, linens, clothing, curtains, or other cloth material that came into contact
with the
smallpox patient should be transported in biohazard bags to be laundered using hot water
I710C)
and bleach or incinerated (see step 2 above).
3. Surfaces, furniture, fixtures, and walls should be thoroughly cleaned with a 5% aqueous
solution of a phenolic germicidal detergent (e.g. Lysol, Amphyl).
4. Carpets and upholstery should be cleaned using an EPA-approved hospital-grade germicide
per manufacturer's recommendations.
F. Vehicles (e.g, ambulance)
Ambulances should be decontaminated after transporting a smallpox patient(s) before
re-use to
transport non-smallpox patients. Wet decontamination and cleaning of the entire passenger
compartment and all door handles should be done as outlined below:
1. All items that can be incinerated or autoclaved should be bagged and processed by one
of
these methods.
2. Heat-sensitive, reusable items should be sterilized using ethylene oxide as outlined
above.
3. Larger items such as the stretcher should be decontaminated at the same time as the
ambulance.
4. Spray the entire interior of the ambulance heavily (until the solution runs off) with a
5%
aqueous solution of a phenolic germicidal detergent (e.g. Lysol, Amphyl). Personnel
performing
this step should wear respiratory protection.
5. Allow the solution to stand on all surfaces for at least 20 minutes.
6. Wet vacuum or wet clean with clean cloths, disposable wipes, or mops with disposable
mop
heads, all surfaces inside the ambulance and all outside door handles
7. Vacuum cleaner contents, cloths or disposable wipes, mop heads, and protective clothing
worn
by the decontamination personnel should be bagged and incinerated, autoclaved, or
laundered
as outlined above.
8. The vacuum cleaner should be disinfected with EPA-approved hospital-grade germicide per
manufacturer's recommendations after use. The above procedures may not be possible for
private vehicles used to transport smallpox patients. At a minimum, the following
decontamination
procedures should be performed:
1. All disposable items in the vehicle should be bagged and incinerated.
2. All surfaces in the vehicle should be thoroughly wiped down with EPA-approved
hospital-grade
germicide per manufacturer's recommendations.
3. Carpets and upholstery should be cleaned using EPA-approved hospital-grade germicide
per
manufacturer's recommendations. The solution should be allowed to remain on the carpets
and
upholstery for at least 20 minutes before being wiped off. Cloth upholstery should be
allowed to
completely dry before use.
4. All outside door handles should be thoroughly cleaned using EPA-approved hospital-grade
germicide per manufacturer's recommendations.
5. All cloths used to wipe down the inside of the vehicle should be laundered using hot
water
(71º C) and bleach or bagged and incinerated (see above).
[End, 34 pages total, 16,755 words]
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