1. Exit Review Area  Objective Understand Your Role in the Exit Review Area Understand Your Role in the Exit Review Area

2. Job Description of Exit Review Area Personnel (Majority of Counseling Will Be Showing Where in Patient’s Package) Knowledge of All Materials in the Patient’s Package (May need to read information to the patient) Knowledge of All Materials in the Patient’s Package (May need to read information to the patient) Knowledge of & Ability to Answer Any Questions on: Knowledge of & Ability to Answer Any Questions on: Contraindications of Vaccine Contraindications of Vaccine Normal Side Effects Normal Side Effects Care of Vaccine Site Care of Vaccine Site “Take” “Take” Adverse Events Adverse Events 1-800 # to call for Questions 1-800 # to call for Questions How to Deal With an Immediate Emergency

3. Supplies For Exit Review Area  Table & Chairs  CDC Smallpox Vaccination Pamphlet  Extra Forms of: CDC/VIS on Vaccination Site Appearance And Care CDC/VIS on Vaccination Site Appearance And Care CDC/VIS on Reaction After Vaccination CDC/VIS on Reaction After Vaccination  May Need Ammonia, 2x2 Gauze, Tape

4. Vaccine “Takes”, Normal Vaccine Side Effects, and Site Care  Job Description: Exit Review Personnel Knowledge of all materials in the Patient’s information package Knowledge of all materials in the Patient’s information package Knowledge of/ability to answer any questions on: Knowledge of/ability to answer any questions on: Contraindications of vaccineContraindications of vaccine Normal Side EffectsNormal Side Effects Care of Vaccine SiteCare of Vaccine Site “Take”“Take” Adverse EventsAdverse Events How to deal with an immediate emergency How to deal with an immediate emergency

5. Clinical Response to Vaccination* Symptom/sign Papule Pustule Maximum erythema Scab Scab separation Time after Vacc 2-5 days 7-10 days 8-10 days 14 days 21 days * typical response in a nonimmune person

6. Normal Response To Smallpox Vaccination First dose Booster dose Day 0Day 3Day 7Day 10Day 14 First Dose Booster Dose Day 0Day 3Day 7Day 10Day 14

7. Progression of smallpox vaccination site in a non-immune person

8. TAKE VERSUS NON-TAKE  Major reaction and take: area of definite induration/congestion surrounding a central pustule about day 7 – 8 indicates a take.  Equivocal – Erythema and a small, temporary papule that resolves quickly. Revaccination is required.  No reaction at all. Revaccination is required.

9.  Virus can be recovered at site from time of papule until scab separates  Site should be covered until scab falls off (approximately 3 weeks)  Site should be kept dry  Normal bathing can occur if covered by waterproof bandage Vaccination Site Care

10.  Hand hygiene immediately after handling dressing or contact with site CRITICAL to preventing spread  Clothing over site (long sleeves when sleeping)  May place gauze with tape over vaccine site, allowing site to “breathe”

11. Site Care at Home  Change dressing if gauze becomes saturated (wet, soiled, or loose)  If drainage gets on clothes or linens, wash in hot water (160°) separately  If bandage removed/changed at home, place in ziploc bag and discard in regular trash (also scabs)  Avoid placing ointments or ice on vaccination site

12. Normal Side Effects of Smallpox Vaccine  Pain, swelling, erythema at vaccination site (40 -47% have pain)  Regional lymphadenopathy (21-38%) Begins 3-10 days after vaccination Begins 3-10 days after vaccination Can persist for 2-4 weeks after vaccination site heals Can persist for 2-4 weeks after vaccination site heals

13. Reaction Rates among adults  Elevated temperature 7 to 12 days post vaccination: 17% >100 o F 17% >100 o F 1.4% >102 o F 1.4% >102 o F  Systemic symptoms (malaise, myalgias) 8 – 10 days post vaccination  20 - 36% sufficiently ill to miss work, school, or recreational activities or had trouble sleeping

14. Normal Variants of Vaccine Reaction  Local edema at vaccination site  Lymphangitis  Regional lymphadenopathy (nonfluctuant)  Satellite lesions (Incidence of 2.4 – 6.6%)

15. Lymphangitis following smallpox vaccination

16. Satellite lesions

17. Local Reactions Following Smallpox Vaccine  Allergic reactions to bandage and tape adhesives  Large primary vaccination reactions (“robust primary takes” – RPT)  Secondary bacterial infection

18. Allergic reaction to tape

19. Local Reactions to Adhesive  Erythema corresponds to placement of adhesive tape  No systemic symptoms  Treat with antihistamines, NSAIDs, frequent bandage/tape change  Steroid treatment not recommended

20. Robust Primary Takes (RPT)  Expected variant of normal reaction  >3 inches of erythema with induration, pain, warmth  Occur in 5%-15% of recipients  Peak at day 8-10 post-vaccination  May resemble bacterial infection (“viral cellulitis”)

21. Robust primary take

22. Robust Primary Takes (RPT)  Observe carefully  Supportive therapy Rest affected limb Rest affected limb Analgesia (non-aspirin) Analgesia (non-aspirin) NSAIDs NSAIDs  Usually improve in 24-48 h

23. Secondary bacterial infection of vaccination site

24. Secondary Bacterial Infection  More common among children than adults  Usually Staphylococcus aureus or Group A beta hemolytic Streptococci  Anaerobic and mixed infections may occur  Evaluate with gram stain and culture  Antibiotic therapy based on culture

25. Rashes Following Smallpox Vaccine (Erythema multiforme, roseola vaccinia, toxic erythema, postvaccinial urticaria)  Flat, erythematous, macular, or urticarial lesions  Usually do not become vesicular  Do not appear to involve viral multiplication or systemic dissemination of vaccinia virus  Occur approximately 10 days after vaccination  Resolve spontaneously within 2 to 4 days

26. Erythema multiforme following smallpox vaccination

27. Inadvertent Inoculation  Transfer of vaccinia virus from vaccination site to another site on the body, or to a close contact  Most frequent complication of smallpox vaccination (about ½ of all complications)  Occurred 25-529 cases per million primary vaccinations  Most common sites are face, eyelid, nose, mouth, genitalia, rectum  Lesions contain vaccinia virus

28. Inadvertent Inoculation  Uncomplicated lesions require no therapy, self-limited, resolve in ~3 weeks  VIG may speed recovery if extensive or painful genital involvement  Hand washing after contact with vaccination site or contaminated material most effective prevention

29. Inadvertent inoculation

30.  Adverse reaction rates may be higher today than in 1960s  More persons at risk because of higher prevalence of immunosuppression and eczema/atopic dermatitis  Adverse reaction rates lower among previously vaccinated persons Smallpox Vaccine: Significant Adverse Reactions

31. Smallpox Vaccine Adverse Reactions, and Rates* Reaction Primary Vaccination Inadvertent inoculation 25-529 Generalized vaccinia 23-242 Eczema vaccinatum 10-39 Progressive vaccinia (vaccinia necrosum) 0.9-1.5 Post-vaccinial encephalitis 3-12 Death1 * Rates per million primary vaccinations

32. Generalized Vaccinia  Vesicles or pustules appearing on normal skin distant from the vaccination site  Rash distribution is indiscriminate – follows no set pattern  Often accompanied by fever, headache, and myalgias  Occurred 23-242 cases per million primary vaccinations  Usually occur 6-9 days after vaccination

33. Generalized vaccinia

34. Generalized Vaccinia  Generally self-limited  Most cases do not require therapy  VIG may be considered for recurrent disease or severe disease  Lesions contain vaccinia

35. Post-vaccinial Encephalitis  Usually affects primary vaccinees <12 months of age and adolescents and adults receiving a primary vaccination  Presents with any of a variety of CNS signs (e.g., ataxia, confusion, paralysis, seizures, or coma)  15%-25% die  25% develop neurological sequelae  Occurred 3-12 cases per million primary vaccinations (rare)

36. When to seek Medical Care  Inadvertent inoculation  Widespread rash  Ongoing infection of the skin at the vaccination site with tissue destruction  Allergic response to vaccine (hives, resp difficulty, etc)  Persistent headache,, confusion, seizures, or other neurologic symptoms

37. How to Handle Emergencies in Exit Review Area *Nauseated, anxious, dizzy - Have patient to sit or lie down - Stay with the patient - Have other staff member get float nurse or EMS personnel *Immediate rash, shortness of breath, wheezing - Have patient to lie down - Stay with the patient - Have other staff member get EMS personnel immediately