1. Smallpox Vaccination: Risk Assessment and Perspectives of the Health Care Provider, Institution, and State of Illinois

2. Edward P. Sloan, MD, MPH Associate Professor Dept of Emergency Medicine University of Illinois College of Medicine Chicago, IL

3. Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Medical Center

4. Some Considerations The disease The risk of an attack The public health impact of an attack The medical literature Current recommendations Questions for today

5. The Disease Easily spread: Most infectious disease Significant morbidity and mortality 500 million deaths in 20 th century 2 million deaths in 1967 Real morbidity

6. The Risk of an Attack 1980: Soviet Union starts Smallpox weapons program 1986: WHO recommends destruction of existing virus stocks 1994: Alibek defects, former deputy director of Soviet bioweapons program

7. The Risk of an Attack USSR producing “tons of virus” Successful weaponization of smallpox accomplished Virus transferred to a facility in Siberia Occurred concurrent with serious economic problems in Russia Might other countries might acquire the technology and weapons?

8. Public Health Implications of a Smallpox Attack 1972: Yugoslavia 1 case identified 11 people infected 138 people then infected 10,000 people isolated 20,000,000 people vaccinated

9. The Medical Literature NEJM Early release of articles Free distribution of materials Six articles Public, risk, vaccination, public health Good information for framing discussion

10. NEJM: Schraeder Obligation to protect public health Public health decisions “Trust our heads and our hearts”

11. NEJM: Blendon Public knowledge unclear Survey of 1006 adults False smallpox vaccination beliefs Need for public education

12. NEJM: Bozzette Scenarios of smallpox attacks Stochastic model of outcomes Risk of attack, risks of vaccination No risk: no vaccination Some risk: vaccinate HCWs High risk: vaccinate public

13. NEJM: Sepkowitz How contagious is vaccinia? 1907-1975: –12 outbreaks –85 secondary cases 75%: young children, atopic dermatitis Immunocompromise in HCWs Risk of hospital vaccinia outbreak

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

15. NEJM: Hanrahan Smallpox false alarm: case report Papulovesicular rash, same stages Centrifugal distribution Prodrome with fever, N/V CDC specimens: HSV positive Hospital test for HSV, VZV, syphillis Digital camera for email to CDC

16. Current Recommendations CDC Advisory Committee on Immunization Practices (ACIP) June 2001: Initial recommendations June 2002: “Smallpox Health Care Teams” October 2002: 8 Specific Issues Comment: CDC HICPAC, DHHS NVAC

17. ACIP Recommendations Smallpox health care teams Smallpox vaccination site care Phase in: no administrative leave Screen: atopic dermatitis, pregnancy, HIV Administer other vaccinations Vaccinate the vaccinators

18. Questions for Today Knowns: –Risk of disease –Risk of vaccination Unknowns: –Risk of attack –Effect in society with immunocompromise –Public health value of vaccination –Need for vaccination

19. Questions for Today What are the risks of attack in 2003? What are the risks of vaccination? Who should get vaccinated? Who should get vaccinated first? Does prior vaccination matter? What happens after vaccination? Who assumes liability of vaccination?

20. Questions for Today What does the state expect of us? What are hospitals doing? Why? What are the risks of vaccination? What do we need to get it done? What are our knowledge gaps What comes next?

21. Our Speakers Patricia Lee, MD –Advocate IMMC –Smallpox and vaccination Dino Rumoro, DO –Rush-Pres-St Luke –Hospital perspective John Lumpkin, MD, MPH –Illinois Dept of Public Health –State public health perspective

22. Format & Information Three 20 minute lectures Opportunity for questions Videostreamed content Slides and lectures on internet www.FERNE.org Link from www.ICEP.org