New York State Smallpox Preparedness Planning

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New York State Smallpox Preparedness Planning
Guthrie Birkhead, MD, MPH New York State
Department of Health
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Last Smallpox Outbreak in NYC - 1947
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Spectrum of Vaccination Options

• No change
• Limited recommendation for vaccination of
  pre-designated public health and health care
  staff who will care for smallpox patients
• Wider recommendation for vaccination of first
  responders
• Permissive vaccination policy
• Universal vaccination recommendation.

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Context for Smallpox Vaccine Discussion

• Post 9/11 and Anthrax preparedness planning
• Intensive State and Local preparedness planning
  efforts
• gt1 billion in supplemental Federal funds for
  public health and hospitals for bioterrorism
  preparedness
• Large populations of immunocompromised persons
  (HIV, transplant, cancer therapy, elderly).

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New York State Public Health Health Care System

• 57 county health departments NYC
• 72,000 physicians
• 260,000 RNs
• 55,000 EMTs
• 13,000 medical residents

• 260 acute hospitals
• 66,200 hospital beds
• 2,200 isolation rooms
• 680 nursing homes
• 36 trauma centers

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Federal Bioterrorism Funding
CDC Public Health NYS 29 Million
NYC 23 Million HRSA Hospital NYS 4.4
Million NYC 3.3 Million CDC/Assn of
Schools of Public Health Albany SPH 1
Million
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CDC Bioterrorism Grant Focus Areas
A Preparedness, Planning and Readiness
Assessment B Surveillance and Epidemiology
Capacity C Laboratory Capacity - Biologic
Agents D Laboratory Capacity - Chemical
Agents E Health Alert Network/Comp Information
Technology F Communicating Health Risks Health
Info. Dissemination G Education and Training
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Examples of CDC Grant Funded Activities

• Focus A Incident command structure review of
  state statutes, state/local smallpox plan, mass
  vaccination plan
• Focus B 24/7 real time syndromic disease
  surveillance from all emergency rooms
• Focus C Strengthen state laboratory, establish
  two regional Level 3 labs, train 200 Level A
  clinical labs.
• Focus E Triple redundant, internet/ISDN
  communication with local health departments,
  hospitals over secure, encrypted network.

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HRSA Hospital Grant Activities

• Joint State/NY City process to award funding
• Base grant to all hospitals
• Establish a few regional centers with enhanced
  capability
• Needs assessment
• Develop and drill hospital BT response plans
  including smallpox care plan for each region of
  the state.

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State and Local Smallpox Preparedness Plans

• Pre-event surveillance and case investigation
  protocols
• Search, containment, ring vaccination procedures
• Smallpox vaccination operational plan
• Plan for clinical care for smallpox patients
• Where? -- Who?
• Isolation, quarantine, decontamination plans
• Communications, training, security plans

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Type C Facility (Contagious)

• Infectious individuals (confirmed, probable, and
  suspected smallpox cases)
• Examples of potential Type C facilities include
  any empty facility (e.g. motel, hospital,
  separate building of hospital, college dormitory,
  etc.).
• All persons entering or admitted to Type C
  facility, including cases, must be vaccinated.

Source CDC. Smallpox Response Plan and
Guidelines, Draft 2.0,11/21/01.
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Suggested Pre-Event Activities Associated with
Isolation/Quarantine

• Identify appropriate personnel (medical,
  maintenance, etc.) to maintain/staff facilities
• Establish procedures for monitoring access to
  facility
• Establish procedures for appropriate disposal of
  medical waste from facility
• Establish laundry service arrangements (on-site
  if possible) and appropriate disposal of medical
  waste
• Arrange for food service support for facility
  occupants
• Establish procedures for monitoring health status
  of facility staff.

Source CDC. Smallpox Response Plan and
Guidelines, Draft 2.0,11/21/01.
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CDC Field Teams (Pre-vaccinated)

• Senior level physician/medical epidemiologist
• Senior public health advisors
• Medical epidemiologists surveillance, epi
  investigation and infection control
• Medical epidemiologists vaccine safety
• Laboratory scientist or technician(s)
• Communications specialist
• EISO/PMR/PHAs

Source CDC. Smallpox Response Plan and
Guidelines, Draft 2.0,11/21/01.
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NY Hospital Preparation - 1

• Set up smallpox emergency planning process
• Pre-hospital telephone triage system
• transport
• Effective ER triage to immediately isolate all
  febrile/rash patients
• Identify smallpox medical care and support team
• Smallpox vaccination history
• History of military service in 1980s/early 90s.

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NY Hospital Preparation - 2

• Provide/fit test HEPA masks all ER/care team
• Test integrity of negative pressure isolation
  rooms on regular basis
• Review airborne and contact isolation precautions
  with all staff on a regular basis
• Identify isolation ward/building with staffing
• separate air supply exhausted through HEPA
  filter,
• 100 yards from other buildings.

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Vaccination Issues Identified in Smallpox
Response Planning

• Designated public health and clinical staff may
  not care for or work with smallpox patients
  unless pre-vaccinated
• Pre-vaccination
• Allows for planned vaccination
• Avoid worksite disruption from workers furloughed
  or experiencing fever following vaccination
• Avoids breakthrough smallpox cases in staff.

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Limited Vaccination ProgramPre-designated
PH/Clinical Staff

• 10,000 or fewer vaccinees nationwide
• eg in NYS 20 facilities, 50/facility 1000
• Provides for initial staffing needs in an
  outbreak a larger campaign would occur after
  identification of an outbreak
• Avoids wide spread vaccination campaign, with
  attendant vaccine adverse events.

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Concerns About Wider Vaccination Efforts

• No clear threat
• Immunocompromised populations who already have a
  lot of contact with first responders
• 130-170,000 HIV, 1/3 not aware of their status
• Transplant and chemotherapy patients.
• Logistics and cost of delivery through the public
  health system (eg polio and Swine Flu).