within four days of first exposure has been shown to offer some protection against acquiring the infection and significant protection against a fatal outcome. An emergency vaccination program should include all health workers at clinics or hospitals that may receive such patients and all disaster workers such as EMS, hospital staff, police, public health staff, and mortuary staff. These personnel should be vaccinated as soon as the first case is diagnosed, irrespective of prior vaccination status. Vaccination should be considered for any other persons who would be responsible for patient care during a suspected outbreak of smallpox and for the investigation and control of suspected outbreaks of smallpox.


Smallpox Vaccine

l     Only way to prevent smallpox

l     Most U.S. children vaccinated until 1972

l     Vaccine made from vaccinia virus- live virus

l     Successfully used to eradicate smallpox

l     Delivered using a bifurcated needle, prick skin 15 times

l     Successful vaccination:  Red itchy bump in 3-4 days

l     95% effective in providing protection



l    Live virus

l    Can spread to other parts of the body or to other people from the vaccination site

l    Spread is prevented through proper vaccination site care and good hand washing after contact.


l    Vaccination after exposure:  within 3 days, protective against disease; within 4 days, protective against fatal outcome

l    First dose – Protection for 3-5 years

l    Those revaccinated may have longer immunity



l    Offers the best protection if exposed to the smallpox virus

l    Normal reaction to the vaccine:  mild

–    Sore arm

–    Fever

–    Body aches

l    1/3 may miss work, school, recreational activity, or have trouble sleeping


l     1000/1,000,000 vaccinated for the first time experienced serious, non-life threatening reactions

–     Vigorous take

–     Vaccinia virus spread

l     14-52/1,000,000 may have a potential life threatening reaction

l     Eczema vaccinatum: Caused by implanting the vaccinia virus into diseased skin

l   Progressive vaccinia: primary vaccination site fails to heal and spreads

l1-2/1,000,000 may die

l     Careful screening for contraindications is essential


Contraindications to Smallpox vaccine

 Who should not get vaccinated during pre-event vaccination

l     Persons with eczema or atopic dermatitis or other skin conditions.

l     Immunosuppressed persons with weakened immune systems or autoimmune disease.

l     Pregnant women

l     Breastfeeding women

l     Inflammatory eye disorders

l     Vaccine component allergy

l     Those under 18 years

l     Anyone with a household contact with any of the above conditions (except those under 18)

Adverse Events Associated with Vaccination

l     Accidental Implantation by autoinoculation or contact

l     Bacterial infections

l     Eczema Vaccinatum : Caused by implanting the vaccinia virus into diseased skin

l     Erythema Multiforme:  hypersensitive and/or toxic rash

l     Generalized vaccinia:  caused by viremia

l     Progressive Vaccinia:  primary vaccination site fails to heal and spreads

l     Vaccinia Keratitis:  vaccinia virus is implanted in the eye


Public Health Preparedness Efforts in Cuyahoga County

Some important features of these efforts are:

l    Received funding for improvement of local public health infrastructure for multi-jurisdictional response to public health events

l    Formed the Cuyahoga County Public Health Collaborative (CCPHC)

l    Common disease reporting and response

Sharing of disease data – ODRS Ohio Disease Reporting System -   (electronic reporting mechanism for Ohio Department of Health)

l    Expanding syndromic/influenza surveillance activities

l    Public health awareness and response training

l    Regional coordination with other public health entities (Lorain, Lake, Geauga, and Ashtabula counties)

l    Specifics may vary by Region (7 regions in the state)


Ohio Regional Map



Smallpox Pre-event vs. Post-event Planning

The idea behind this pre-event vaccination program within the civilian community is to produce a cadre of medical and emergency personnel who would be able to investigate index cases of smallpox and care for smallpox victims while not becoming casualties themselves.


l     Pre-event:  Planning for vaccination when no cases of smallpox have been identified

–     Conservative, tiered approach: limited to specific groups of people

–     Ample time to vaccinate

l     Post-event:  Planning for vaccination in response to an outbreak of smallpox.

–     All inclusive approach : mass vaccination

–     Limited time to vaccinate


Pre-Event Smallpox Vaccination Strategies

l    Pre-Event:  Planning for vaccination program; no cases of Smallpox have been identified.

l    Phase 1:  One cadre of “first responders;” 15,000 in Ohio, 500,000 in USA

l    Phase 2:  Expands to all “first responders”; 10 million in USA; 500,000 in Ohio

l    Phase 3:  Expands to public

Public Health Preparedness Efforts in Cuyahoga County: Phase 1

l    Pre Event Smallpox Plan

–    Regional public health pre-event plan submitted to Ohio Department of Health (ODH) on 5thDecember 2002.

–    Statewide pre-event plan submitted to Center for Disease Control (CDC) on 9thDecember2002.           

Based on current ACIP (Advisory Committee on Immunization Practices)






Public Health Preparedness Efforts in Cuyahoga County: Phase 1

l     Pre-Event Smallpox Plan – Highlights

–    Regional Coordination

–    Timeline for Program Implementation

–    Incident Command Structure with Job Descriptions

–    ID Public Health Smallpox Response Teams members

–    ID Healthcare Smallpox Response Team members

–    Hospital and Public Health Responsibilities

–     Vaccination clinic location

–     Training and education plan

–     Scheduling

–     Vaccine Logistics and security

–     Clinic operations and management

–     Vaccine safety monitoring, reporting, treatment, and patient referral

–     Data management

–     Communications plan


Pre-Event Smallpox Vaccination Strategies – Phase 1

l    Phase 1 Timeline

–    Phase 1A and 1B

–    Phase 1A:  Vaccination of Regional Public Health Team

l   Start: February 20, 2003

–    Site evaluation /dressing change upon request at LHD by Medical Director or designee
–    Evaluation of Take Day 7-10 post vaccination by Medical Director

–    Phase 1B:  Vaccination of HC Teams (400)

l   Start:  Mid- March

l   Completion:  Mid-April

–    Clinic location:  Fairgrounds
–    Clinic hours:  10:00 – 3:00
–    Clinic staff:  Regional public health staff – ICS used
–    2 clinics, 8 days apart
–    Daily site evaluation/dressing change at respective institutions
–    Evaluation of Take Day 7-10 post vaccination at respective institutions

l     Public Health Responsibilities

–     Conduct “Public Health volunteer” pre-screening and education

–     Vaccine receipts/storage/inventory/safety

–     Administration of Vaccine to HD/HC Response Team

–     Clinic Design/Set up/Flow

–     Coordinate scheduling of healthcare teams in collaboration with regional hospital coordinator

–     Data management – Vaccine/Vaccine take

–     Communication with ODH/CDC

–     Education/Hot-line



Clinic Layout





Pre-Event Smallpox Vaccination Strategies: Phase 1

l     Participating Hospital responsibilities

–     Assess makeup of healthcare smallpox teams

–     Identify Hospital smallpox healthcare team leader

–     Conduct “volunteer” pre-screening and education

–     Maintain list of “qualified” volunteers to be sent to LHD

–     Develop individual hospital plan regarding:

l   Site management

l   Evaluation of Vaccine Take

l   Adverse Events

l   Communication with LHD


Pre-Event Smallpox Vaccination Strategies: Phase 2


l    Expands to all “first responders”; 10 million in USA; 500,000 in Ohio

l    Police, fire, EMS, health care personnel, public health personnel

l    No timeline or further guidance yet available

Pre-Event Smallpox Vaccination Strategies: Phase 3


l     Vaccination offered to the public: 2004?

l     Implement our Mass prophylaxis plan

l     No timeline or further guidance yet available





Public Health Preparedness Efforts in Cuyahoga County



CDC has released an updated version of the post-event Smallpox Response Plan and Guidelines. This is the second revision to these guidelines since they were released in November 2001.

Version 3 of the guidelines contains an important addition---the "Smallpox Vaccination Clinic Guide." This guide provides the operational and logistical considerations associated with implementing a large-scale, voluntary vaccination program as part of a multifaceted response to a confirmed smallpox outbreak.

 Following a confirmed smallpox outbreak within the United States, rapid, voluntary vaccination of a large segment of the population might be required to

 1) Supplement priority surveillance and containment control strategies in areas with smallpox cases.

 2) Reduce the at-risk population for additional intentional releases of smallpox virus if the probability of such occurrences is considered significant

 3) Address heightened public concerns about access to voluntary vaccination.

The most important component of smallpox containment is the rapid identification, isolation, and vaccination of close contacts of infected patients and contacts of their contacts (i.e., ring vaccination).

This strategy involves identification of infected persons through intensive surveillance, isolation of infected persons, vaccination of household contacts and other close contacts of infected persons (i.e., primary contacts), and vaccination of household and other potential contacts of the primary contacts (i.e., secondary contacts).

The clinic guide will assist planning for larger-scale, post-event vaccination when exposure circumstances indicate the need to supplement the ring vaccination approach with broader protective measures. The clinic guide describes the activities and staffing needs associated with large-scale smallpox vaccination clinics, including suggested protocols for vaccine safety monitoring and treatment. The clinic guide provides an example of a model smallpox clinic and provides samples of pertinent clinic consent forms and patient information sheets that would be used at a clinic.

The clinic guide and the Smallpox Response Plan and Guidelines, Version 3 are available at http://www.cdc.gov/smallpox. 


Post Event Smallpox Plan - Highlights

–     Designated clinics for mass vaccination (70)

–     Isolation and treatment sites

–     Response team members

–     Necessary documentation to be used

–     Incident Command Structure and Job Descriptions

–     Communication Plan

–     Security Plan

–    Cuyahoga County plan submitted to ODH November 14. 

–    Statewide plan submitted to CDC on December 1.

–    Would become effective if a case of smallpox was identified.

–    Mass vaccination (1.4 million people) within 4 days after exposure.


Public Health Preparedness Efforts in Cuyahoga County


l    Comprehensive approach: based on a worst case scenario

l    Plan can be scaled back depending on need

l    Many logistics and staffing issues exist


l    Identified potential sites across the county

–    Based on population centers

–    Primary (70) and secondary sites (50) have been indicated emergency coordinators and public health

–     Community leaders will be asked to secure the sites for use during a public health emergency

–    Schools are the preferred sites

l    Planning for 24/7 operation


Clinic Logistics

l    Clinic Facility Survey and Memorandum of Understanding (MOU)

–    24/7 contact information

–    Available equipment

–    Food prep areas

–    Communication mechanisms

–    Map of school/facility including:

l  General layout

l  Parking

l  Exits and entrances

l  Loading dock

l  Handicap accessible areas

l  Helicopter landing area

Clinic Logistics

l    Clinic Flow

–    Designed a model based on other flow models used across the country (D.C., New York)

–    Clinic flow is designed to avoid bottlenecks

–    Planning to provide 5000 people/day or approx. 225–325/hr vaccinated or prophylaxes at each facility

–    Must be done quickly and efficiently




Clinic Flow

l     Greet/Triage area (near entrance)

l     Forms distribution area

l     Briefing

l     Medical Evaluation/Screening

l     Vaccination/dispensing of medication

l     Exit

l     Other areas

–     Education/Resource

–     Special Needs/Mental Health

–     EMS/Sick Room


Other Post-event Planning Issues

l    Community Awareness

–    Publicizing the clinic information:  Media kit

–    How/when will residents be asked to arrive

l   Stagger for treating:

–    325/hour, 16 hour operation
–    225/hour,  24 hour operation

–    Providing general information/crisis communication


l    Families of clinic personnel

–    Proposed that families of clinic personnel will receive treatment prior to community wide implementation

–    Conducted at 9 sites throughout the county



Regional Map

Clinic Staffing Issues

l    Medical staff

l    Non-medical staff (community volunteers)

l    Approx. 70 sites throughout the county

l    Approx. 103 staff per shift, 206 per day

–    34 Medical volunteers

–    69 Community volunteers

l    Estimated resources needed county-wide:

–    14,420

Clinic Staffing Issues:
Medical Staff

l    34/shift or 68/day

l    Physicians

l    Nurses

l    Pharmacists

l    Dentists

l    Paraprofessionals

Clinic Staffing Issues:
Non-medical (community) Staff

l     69/shift or 138/day

l     Local emergency coordinators

l     Community leaders

l     City management

l     Local police, fire, EMS, auxiliary police

l     School employees:  maintenance, custodians, health educators, teachers, cafeteria, security, crossing guards

l     Red Cross

l     Faith community leaders


Managing the operation

l    Use of the Incident Command System

l    Emergency Operations Center (EOC)

–    Unified Command:  Local public health officials

l   Public Information Officer

l   Legal Officer

l   Liaison Officer

l   Medical Advisory Committee

l   Safety and Security Officer

l   Logistics, Planning, Finance, and Operations


Medical and Public Health Roles and Responsibilities at the Clinic


l     Liaison Officer

l     Medical Supply inventory and storage

l     Planning


l     Medical Staff leader

l     Medical evaluation

l     Vaccination or Dispensing or meds

Site Community Roles and Responsibilities at the Clinic

l      Staff support

l      Transportation

l      Traffic control and Security

l      Facility support

l      Data management

l      Office supply inventory and storage

l      Finance

l      Volunteer staff leadership

l      Communications

l      Briefing, forms distribution, and completion

l      Flow coordination

l      Education and resource area

l      Special needs

l      EMS

l      Logistics

l      Clinic Manager

l      Operations


Other Considerations

In the event this plan is activated, a level 3 emergency will be declared and we will need to close schools or other public buildings designated as clinics.

A full-scale decontamination of the school or other public building is not necessary or recommended.  Institutional cleaning products commonly used during normal cleaning in facilities is sufficient.


Public Health Preparedness Planning: Next Steps


l    Medical Reserve Corp development

–    CWRU/Red Cross/Public Health initiative

–    Form a Medical Reserve Corp : CWRU, Academy of Medicine and Public Health

Volunteer Recruitment

l     Form a Community Emergency Response Team

–     ARC and Community Emergency Coordinator

l     All volunteers would receive training and some type of certification

l     Additional training opportunities would be available

l     ARC is developing a volunteer recruitment strategy and model to be shared with all communities in the county

Public Health Preparedness Planning: Next Steps

Community Awareness Training – March 27

l     Convene Emergency Coordinators, Police and Fire Chiefs, School and city officials, local volunteers

l     Walk through a simulated Mass Vaccination Clinic

l     Debriefing

l     Overview of CCBH Mass Care Plan

l     Planning: City and School activities

l     MOU, Facility Survey, 24/7 Contact

l     Managing and Staffing a clinic: ARC

–     Establishing a Volunteer Coordinator


Your Roles and Responsibilities in Preparedness Efforts

l    Know your community’s disaster plan and partners (emergency coordinator)

l    Communicate regularly with your emergency coordinator or volunteer coordinator

l    Know the schools and/or public buildings in your community that may be used as shelters or mass care facilities



Role and Responsibilities of Schools in Preparedness Efforts


l    Share information to increase awareness in the community


l    Be a community volunteer and assist with recruitment of others



CDC will take additional steps to increase preparedness to respond to a smallpox exposure of any magnitude, including updates to the Smallpox Response Plan and Guidelines. Updates on infection control, in-hospital isolation recommendations, post-event vaccination protocols, and outbreak response strategies are under way and will be posted on the CDC website.







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From the Methodist Medical Center, Dallas, Texas.

Pharmacotherapy 23(3):271-273, 2003. © 2003 Pharmacotherapy Publications



Resources and Contact Information

www.cdc.gov/smallpox and www.ccbh.net

Cuyahoga County Board of Health

Rebecca Hysing