Healthcare Facility Response Activities

In a smallpox emergency, your facility may be called upon to care for patients with the disease, or suspected of having the disease. Plan now how your facility will respond quickly and effectively to identify and treat patients.

Identify and diagnose smallpox as quickly as possible

There has not been a case of smallpox in the world in almost 40 years. Most medical staff practicing today have never seen a case of smallpox, which might make diagnosing the disease in an emergency difficult.

CDC has developed tools to help clinicians recognize smallpox. Include how to recognize the signs and symptoms of smallpox in your facility's regular training. Also ensure staff know your facility's plans for how to respond, including how to contact local and state public health departments and CDC to confirm or rule out the disease.

Isolate infected patients from general patient population

If consultation with CDC and local and state public health departments suggests a patient is at high risk of having smallpox, or confirms a diagnosis of smallpox, isolate the patient from the general patient population as soon as possible. Follow standard, contact, and airborne precautions.

Transport the patient safely to an airborne infection isolation room (AIIR).

• AIIRs should have negative air pressure in relation to the corridor and surrounding areas with all exhaust externally vented away from air intakes or where people may pass.
• If possible the air should be externally vented after passing through a filter with a MERV rating* of at least 17.
• The filters should be disposed of in an appropriate manner (discarded in biohazard bags and autoclaved or incinerated).
• Air exhaust should also be separated by >25 feet from the air intake.

Take precautions to prevent the spread of disease during transport:

• If the patient has a rash, cover the patient with a sheet to prevent rash particles from becoming airborne.
• Cover the patient's nose and mouth with a surgical mask or N95 respirator.
• Use only personnel who have been vaccinated against smallpox OR vaccinate personnel within 72 hours of their first exposure to the patient (preferably within 24 hours).
• Personnel should wear personal protective equipment (PPE) and adhere to standard, contact, and airborne precautions.
• After transporting the patient, disinfect any equipment used (such as gurneys, wheelchairs, etc.) using standard disinfection procedures and handle linens with care.

Patients will need to remain in an AIIR for the duration of their illness, which may last 3 to 4 weeks.

If the facility does not have an AIIR:

• Place the patient in an exam room and close the door.
• Give the patient a surgical mask or appropriately fitted N95 respirator and instruct them on using it.
• Transfer the patient to a healthcare facility that has an AIIR. Disinfect the ambulance after transporting the patient and before transporting anyone who does not have the disease.

Emergency plans should address the need to protect non-smallpox patients within the healthcare facility. Depending on the number of smallpox patients a facility is treating, the facility may need to discharge some patients (if medically indicated) or transfer others to different facilities in the area. In a smallpox emergency, work with local and state public health authorities to determine the best course of action.

Care for smallpox patients

The medical management of smallpox patients is generally supportive. Patients are considered infectious once lesions in the throat and mouth appear, throughout the course of the disease, and until the last scab falls off. The duration of ordinary type smallpox typically lasts 3 to 4 weeks.

In addition to providing medical care to the patient, consider other areas that support the patient's general well-being. Patients in isolation may suffer from anxiety, depression, or report feeling stigmatized. They may also feel forgotten, as the need for PPE reduces the frequency of interaction with clinical staff. Include in your facility's plans ways to allow for visitors, especially for pediatric patients. All visitors will need to be vaccinated and wear appropriate PPE.

The most important method for preventing transmission of smallpox is vaccination. All staff who provide care for smallpox patients must be vaccinated against smallpox. In a smallpox emergency, only staff with confirmed vaccination status should provide direct care to patients with suspected or confirmed smallpox.

ACAM2000® and APSV smallpox vaccines provide immunity after the confirmation of a "take" 6 to 8 days after vaccination. JYNNEOS^TM (also known as Imvamune or Imvanex), may not provide full immunity until 2 weeks after the second dose (for primary vaccinees – those who have not previously been vaccinated for smallpox), which may leave primary vaccinees unprotected for 6 weeks after the initial dose.

Consider ways to use only staff who are able and willing to be vaccinated with ACAM2000® or APSV for work that exposes them to the smallpox virus.

The considerations in this section apply to staff vaccinated with ACAM2000® or APSV.

Staff with confirmed vaccination status includes those vaccinated prior to, or who could be vaccinated within 72 hours after (preferably within 24 hours), contact with a smallpox patient.

Staff may continue to work, as they feel able, including providing patient care during the time between vaccination and take-evaluation.

This includes staff who:

• Provide direct patient care (including nurses, doctors, mid-level providers, assistants, and technicians)
• Collect specimens or perform laboratory testing for smallpox patients (such as phlebotomists and laboratorians)
• Perform supportive, housekeeping, and administrative assistance (such as maintenance, housekeeping, laundry, food service, and administrative staff)
• Transport patients to the healthcare facility (including EMTs and other ambulance service staff)

Contraindication to vaccination

During a smallpox emergency, there are no clear, absolute contraindications to vaccination. Each staff member will need to make an informed decision about receiving the smallpox vaccination based upon his or her personal medical history and current health status.

Any staff person who cannot be vaccinated or refuses vaccination should not work in a healthcare facility that is caring for smallpox patients. They should also follow the same precautions as unvaccinated members of the general public.

Obtain and administer the vaccine

In the event of a declared smallpox emergency, the Strategic National Stockpile (SNS) will coordinate with state and local public health departments to provide smallpox vaccine from the Strategic National Stockpile to affected areas.

Work with your state or local public health department to coordinate vaccination of all staff in your facility. More information about the vaccines and how to administer them are available in the Vaccination section for Clinicians.

Prevent spread of vaccinia by caring for the vaccination site

ACAM2000® and APSV are live virus vaccines containing vaccinia virus. Those vaccinated with either of these vaccines who do not properly care for their vaccination site may spread the vaccinia virus to other parts of their body or to other people, including patients. All vaccinees who receive either of these vaccines should follow vaccination site care instructions fully until the vaccination scab falls off.

Clinical staff may continue to treat patients after receiving the vaccination. The facility's Infection Control Practitioner(s) should consider ways to ensure each worker's vaccination site is properly protected, following additional precautions, before the worker begins patient interaction each shift.

When clinical staff are caring for patients, they should take additional precautions to prevent the spread of vaccinia virus.

• Cover the vaccination site with gauze or other similar absorbent material, changing the material every 3 days or sooner, if it becomes soiled.
• Cover the gauze dressing with a semipermeable bandage to provide a barrier over the vaccination site. Do not use a semipermeable bandage without gauze. This may cause the skin at the vaccination site to soften and wear away (maceration), which may lead to irritation and itching, and possible transfer of vaccinia to other parts of the body or to other people.
• Wear long sleeves to cover the bandage.
• Follow these instructions until the scab falls off the vaccination site.
• Practice thorough hand hygiene, by either washing hands with soap and water or using an alcohol-based hand sanitizer.

Monitor symptoms after vaccination

Even though the smallpox vaccines are believed to be highly effective when given prior to exposure to the smallpox virus, there is a chance that a vaccinated staff member will not develop immunity. This chance may increase if the staff member is not vaccinated within 72 hours of initial exposure to the smallpox virus.

To protect both staff and patients, monitor all vaccinated staff members for signs of illness. Assign a staff person to monitor and record any symptoms staff members have after vaccination, in case they begin to develop signs or symptoms of smallpox. Staff members should take their temperature every 12 hours and report the results to the designated monitor. If a staff member has 2 successive fevers greater than or equal to 101°F (38.3°C), medical personnel should evaluate the staff member for possible smallpox infection.

Evaluate vaccination site for "take"

Evaluate the staff member's vaccination site 6 to 8 days after vaccination with ACAM2000® or APSV to determine the success of the vaccination. If a staff member does not have a successful take, repeat the vaccination. If the staff member does not have a successful take after the second vaccination attempt, contact local public health authorities for consultation.

Plan for effects on staffing: Normal responses, adverse events, and vaccine refusals

Up to one-third of all smallpox vaccinees may feel sufficiently ill after vaccination to stay home from work. This is considered a normal reaction to vaccination. Some staff, such as those who were not screened for contraindications properly, may experience an adverse event, which will require follow-up care. These staff members will not be available to work. Other staff members may choose not to be vaccinated, which may also reduce staff available to provide direct patient care and other support during the emergency. Include contingencies for reduced staff availability in your facility's emergency plan.

During a smallpox emergency, patients will not be the only ones who require extra care. Healthcare and public health responders will have their own needs, as well. Your staff will be strained from caring for their patients, and they will likely have their own fears and concerns about the safety of their family members and loved ones. Each patient with smallpox may be hospitalized and require care for 3 to 4 weeks. Depending upon the scale of the emergency, this might require an especially long, protracted response by your facility's staff.

One way you can help your staff is by including in your emergency plans ways to prevent, recognize, and treat staff burnout and secondary traumatic stress. CDC has resources to help emergency responders cope.

Only vaccinated individuals should have access to the healthcare facility treating smallpox patients. Facilities may need to limit entrance to only approved, vaccinated individuals during a smallpox emergency. This includes staff, visitors, and any non-staff individuals who provide services for the facility (delivery or service personnel, public health officials, law enforcement, etc.). Limiting access may require designating staff to maintain lists of individuals approved to enter the facility, check identification, and monitor individuals for signs and symptoms of smallpox.

All staff should follow standard, contact, and airborne precautions, and use the appropriate personal protective equipment (PPE), regardless of vaccination status. This helps assure that healthcare workers are protected regardless of when they were last vaccinated. It also provides additional protection should there be any modification to the infectivity of the smallpox virus. These precautions also apply to visitors and any other person entering the patient's room.

Train healthcare facility staff prior to an outbreak on:

• How to follow standard, contact, and airborne precautions in each staff member's line of work.
• The correct ways to don (put on) and doff (take off) PPE.

Prior to entering a smallpox patient's room, all staff should put on the appropriate PPE:

• Disposable gown and gloves
• NIOSH-certified N95 (or comparable) filtering disposable respirator that has been fit-tested for the staff member using it. This is especially important for extended contact in the inpatient setting.
  • Visit the National Personal Protective Technology Laboratory (NPPTL) for frequently asked questions and answers about wearing respirators versus surgical masks.
• Eye protections (such as face shields or goggles), as recommended under standard precautions, if medical procedures may lead to splashing or spraying of a patient's body fluids.

Staff should remove all PPE, except for the N95 respirator, before leaving the patient's room. After removing gloves, the staff member should wash his or her hands with soap and water or use an alcohol-based hand sanitizer. Maintaining proper hand hygiene will help limit the spread of disease.

Ensure your facility will have enough PPE available to protect staff caring for one or more patients with smallpox in AIIRs. Include in your emergency plans how you will acquire additional PPE quickly to handle a potential surge.

Current practices for disinfection and sterilization of patient-care equipment and environmental surfaces also apply to facilities evaluating and caring for smallpox patients. There is no EPA-registered disinfectant approved to inactivate variola virus (the virus that causes smallpox). Since variola virus is similar to vaccinia virus (the virus used in the smallpox vaccine), any EPA-registered hospital disinfectant approved to inactivate vaccinia virus may be used to disinfect nonporous surfaces contaminated by variola virus. Follow the manufacturer's recommendations for concentration, contact time, and care in handling. The nature and extent of surface contamination will dictate the level of disinfection (i.e., low-level or intermediate-level) needed to make the surface safe to handle or use.

All personnel performing environmental control tasks in a facility caring for smallpox patients should be vaccinated and wear appropriate PPE.

Specific considerations:

• Disposable medical instruments and patient-care devices: Place in containment for safe handling. Follow waste management guidelines for Category A waste when discarding. This differs from smallpox vaccination-related waste, which contains vaccinia virus, and is Category B.
• Ambulances: Disinfect ambulances using EPA-registered hospital disinfectants approved to inactivate vaccinia virus (as described above). Follow manufacturer's recommendations for use. Fumigation of the interior space is not indicated. Follow guidelines for disposal of medical waste, including disposable medical instruments and patient-care devices, and PPE. Follow instructions for proper handling of patient laundry. Do not transport any non-smallpox patients in the vehicle until disinfection has occurred.
• Interior surfaces of spaces occupied by smallpox patients: Disinfect non-porous surfaces using EPA-registered hospital disinfectants approved to inactivate vaccinia virus (as described above). Fumigation of rooms, facilities, or vehicles is not indicated for environmental control of variola virus. Additionally, a properly engineered heating, ventilation, and air-condition (HVAC) system can minimize the possibility of airborne spread of variola virus in facilities providing care for smallpox patients. Placing smallpox patients in airborne infection isolation rooms can help to limit distribution of virus in the air.
• Carpets and upholstery: Use a vacuum cleaner equipped with a high efficiency particulate air (HEPA) filter for cleaning carpeted floors or upholstered furniture. As long as the HEPA filter is installed properly and remains intact during use, you do not need to disinfect the vacuum cleaner. Place the full vacuum cleaner bag in another closable container and discard as routine solid waste. Commercially available products are acceptable to remove visible soil.

Treat laundry carefully, as there have been reports of re-aerosolized transmission of variola virus from infected fabric and bedding (fomites). Never shake or handle the linens roughly, as this may contaminate air, surfaces, and others with infectious particles.

Personnel handling laundry from smallpox patients should be vaccinated and wear appropriate PPE.

• Bag or contain all laundry and linens at the point of use, following OSHA regulations (OSHA; 29 CFR 1910.1030(d)(4)(iv)). If you have wet textiles, first bag them, and then place the bags in a leak-proof container. Most, if not all, forms of containment used for routine healthcare laundry are acceptable for containing laundry generated in care areas for smallpox patients.
• Use routine laundry protocols for healthcare facilities to launder materials from smallpox patient care areas (i.e., hot water [160°F or 71°C] washing with detergent and bleach and hot air drying).

Only vaccinated personnel should handle waste from a facility caring for smallpox patients.

All waste contaminated with smallpox (or suspected to be contaminated with smallpox) is a Category A infectious substance regulated as hazardous material under the U.S. Department of Transportation (DOT) Hazardous Materials Regulations (HMR; 49 CFR, Parts 171-180). These regulations require special packaging of hazardous materials prior to shipment or transport. DOT may grant special permits to allow a variance to the regulations, as long as the applicant can demonstrate alternative packaging meets certain requirements. Other state and local transportation guidelines may apply. Include representatives of these departments in your facility's planning process.

Other options for disposal include:

• Inactivation through use of appropriate autoclaves
• Incineration

Note: Waste generated from the smallpox vaccine, which contains vaccinia virus, is a Category B infectious substance under the same regulations.