Smallpox Vaccine
To prepare for the possibility of bioterrorism employing the smallpox virus, the Department of Health and Human Services (DHHS) began to expand the existing stockpile of smallpox vaccine by purchase of vaccine produced in cell culture (Acambis). Some of the vaccine is now approved for use by the FDA, and may be made available in the near future.

Smallpox vaccine is made up of live virus (vaccinia), which does not cause smallpox, but does provide immunity to the disease. Smallpox vaccination is a generally safe, effective preventative against smallpox. However, in a number of individuals, smallpox vaccination can result in untoward effects and adverse reactions. Most are totally benign, if frightening in appearance. Some are serious, but treatable. A few, which rarely occur, are serious, life threatening and can be fatal.

Public Health Response Teams
The Immunization Practices Advisory Committee (ACIP) recommends smallpox vaccination for persons pre-designated by the appropriate bioterrorism and public health authorities to conduct investigation and follow-up of initial smallpox cases that would necessitate direct patient contact. To enhance public health preparedness and response for smallpox control, specific teams at the federal, state and local level should be established to investigate and facilitate the diagnostic work-up of the initial suspect case(s) of smallpox and initiate control measures. Additionally, ACIP recommends that in the first stages of a pre-event smallpox vaccination program, each acute care hospital identify a group of healthcare workers who would be vaccinated and trained to provide in-room medical care for the first few smallpox patients requiring hospital admission and to evaluate and manage patients who present to the Emergency Department with suspected smallpox. For the first 7-10 days after patients with smallpox have been identified, this team would be hospital-based and provide care 24 hours a day, using 8-12 hour shifts. Non-essential workers would be restricted from entering the rooms of patients with smallpox. In order to comply with these recommendations, CDC has asked every state health department, and several city and territorial health departments, to submit a plan for the delivery of vaccine to public health response teams and hospital healthcare teams. CDC has provided documents which serve as guidance regarding who is eligible for vaccination and which personnel should be included in the teams.

Persons eligible for vaccination, and thereby membership in a hospital healthcare team or public health response team, are persons who have been previously vaccinated, who have no contraindications to the vaccine and who volunteer to be vaccinated again. Vaccinating only those who have been previously vaccinated should decrease the likelihood of an adverse event following vaccination. Contraindications to the vaccine are a history of eczema or atopic dermatitis (irrespective of disease severity), currently active acute or chronic skin conditions (e.g. broken skin from burns, severe acne, psoriasis), being immunocompromised for any reason, being pregnant or planning a pregnancy within 30 days of being vaccinated, currently breastfeeding, or having a household member with any of these contraindications. Another contraindication is having a severe allergy such as anaphylaxis to a vaccine component (polymyxin B sulfate, streptomycin sulfate, chlortetracycline hydrochloride, neomycin sulfate).

Mississippi's Plan
The Mississippi Department of Health is developing a central office response team made up of approximately 20 volunteers, including physicians, nurses, disease intervention specialists (DIS), clerks and administrators. Each Public Health District has developed a bioterrorism response team which will be the basis for the development of the smallpox response teams. Each District will have three teams for response to a smallpox case, which will be made up of physicians or nurse practitioners (at least one per team), nurses (to include any or all of: the District epidemiology nurse, chief nurse, surveillance nurse, immunization nurse, TB nurse, and additional county nurses), the District Supervising DIS, the District Office Systems Advisors, the District Administrator and Health Officer, and additional persons to assist with paperwork and organization. All eligible persons in the above listed groups, who have been previously immunized against smallpox, will be offered smallpox vaccine.

These three District teams, or some subset of them with additional help from the counties and districts, will educate and vaccinate the hospital healthcare teams. (The vaccinators must be vaccinated to administer the vaccine to others, but others who are not vaccinated may assist with the vaccination effort, as long as they do not come in contact with the vaccine. In the event of a smallpox case, this would not be true. Only previously vaccinated persons would be allowed to assist with mass vaccination, as they might have a chance of being exposed to a case of smallpox. If a smallpox case were to occur, additional persons would be vaccinated and then be allowed to assist).

Hospital Healthcare Teams
The ACIP recommends that in the first stages of a pre-event smallpox vaccination program, each acute care hospital identify a group of healthcare workers who would be vaccinated and trained to provide in-room medical care for the first few smallpox patients requiring hospital admission and to evaluate and manage patients who present to the emergency department with suspected smallpox. It is recommended that these teams be made up of emergency room staff, intensive care unit staff, general medical unit staff, medical house staff (i.e., selected medical, pediatric, obstetric, and family physicians) medical subspecialists, (e.g., infectious disease specialists, local medical consultants with smallpox experience, dermatologists, ophthalmologists, pathologists, surgeons, anesthesiologists in facilities where intensivists are not trained in anesthesia) to deliver consultative services, infection control professionals (ICPs), respiratory therapists, radiology technicians, security personnel, and housekeeping staff (e.g., those staff involved in maintaining the health care environment and decreasing the risk of fomite transmission). All members should be volunteers.

All Mississippi hospitals that have emergency rooms will be offered vaccine. The amount will be determined by the size of the facility, their ability to isolate patients, and demand. The hospitals will be responsible for deciding who will be vaccinated.

Vaccine delivery
After further education and screening of possible vaccinees, Public Health Response Teams will be vaccinated starting with the central office team, then progressing to the district teams.

The Hospital Healthcare teams will be vaccinated by the Public Health Response Teams. Each Public Health Response Team will be responsible for a certain number of hospitals in their geographic area. Hospital Teams will be vaccinated, after being provided verbal and written education regarding the vaccine, adverse events, and contraindications, and allowing time for individuals to seek provider consultation regarding possible contraindications. Persons will be vaccinated in a staged manner, with one third of the hospital team members being vaccinated at a time, with one week in between vaccination days, so that immunization sites may be inspected by the Public Health Response Teams at the time of the next vaccination day.

Followup
Data regarding adverse events and whether or not the vaccinee responded to the vaccine will be collected. Experts will be available for referral or consultation regarding possible adverse events. CDC will have a national hot line through which CDC personnel will provide answers to questions from the public, and will provide additional expert consultative services and treatment protocols, including the use of vaccinia immune globulin and cidofovir for adverse events if needed.