Summary of the Smallpox Plan

1. Summary of the Smallpox Plan Part 6b of 13 Comments and contributions are encouraged: please e-mail DRcomments@hpa.org.uk HPA Centre for Infections Reviewed April 2009

2. Smallpox Plan: Guidance • Guidelines for Smallpox Response and Management in the Post-Eradication Era [Version 2] • Published 15th December 2003 • This document revises the Interim Guidelines that were published on 2nd December 2002 • Smallpox Mass Vaccination An operational planning framework • Published 24th June 2005 • This document complements the Guidelines and sets out specific measures for providing rapid mass vaccination should that become necessary • Both documents available on DH website www.dh.gov.uk

3. Smallpox plan • A patient may present in a number of places: • Home, and then seen by GP • GP surgery • Accident and Emergency units • Medical Wards • Intensive Care Units • Plans made out for each of these eventualities

4. Smallpox Plan • Alert Level 0:Smallpox eradicated - no credible threat of a release • Alert Level 1: Heightened threat - Case confirmed outside UK Confirmation of virus found outside the WHO designated repositories • Alert Level 2:Case confirmed in the UK • Alert Level 3:Outbreak occurring in the UK • Alert Level 4:Large outbreak not controlled by ring vaccination • Alert Level 5:Outbreak controlled – no further cases

5. Smallpox plan • *Needs to cover different stages of a possible incident * Summary of each alert level and action required is in Appendix 3 of the document

6. Smallpox Groups • There is a Regional Smallpox Diagnosis and Response Group (RSDRG) for each Standard Government Region (nine in England and one each for Scotland, Wales, Northern Ireland) • RSDRG • Headed by RE on behalf of RDPH • Co-ordination and organisational role • Responsible for planning and provision Smallpox Diagnostic Expert (SDE) and Smallpox Management and Response Teams (SMART) • SMART • ID physician, public health doctor, an ID and acute care nurse and paediatrician (with backups, X5 for each RSDRG)

7. Role of RSDRG: • Alert level 0: To lead most aspects of planning for outbreaks of smallpox • Provide expert advice and management for initial suspected cases through the smallpox teams • Co-ordinate vaccinations at Alert level 0 and 1 • Training • Identification of smallpox vaccination and care facilities

8. Role of RSDRG: • Work with laboratory networks to ensure appropriate management of samples (including vaccination at alert level 1) • Identification of 2nd tranche of individuals to be immunised if Alert level changes • Maintain network of diagnostic experts (SDE) • Distribute a national diagnostic algorithm to clinicians • Multi-agency working including emergency services

9. SMART • Teams would be vaccinated and have diagnostic and care kit ready • Would be alerted by the SDE and visit patient (after standard evaluation of case) wherever they are situated • Will stay with patient until EM results available and then manage accordingly

10. Initial EM results • Organism other than smallpox (eg HSV, VZV) = negative • No organism seen = equivocal • Diagnosis cannot be excluded until result from reference lab • Orthopox virus = probable case • * Each results in different action*

11. If probable case: • While awaiting PCR result: • Patient transferred to HSIDU [depends on proximity and patient’s clinical condition] – SMART to examine local facilities that could be used • Contacts identified • Preparation for deployment and distribution of vaccine • National and Regional Smallpox Outbreak Coordination Centres initiated

12. If confirmed case: • PCR result confirms smallpox: • Vaccination of household and other close contacts will proceed • Vaccination of front-line staff will commence • Designated smallpox hospitals will be activated • Major control plans initiated (DH) • Enhanced surveillance for other cases

13. Classification Fever * Rash * EM Identificatn of orthopox PCR +ve for smallpox Epidemiological link to another case of smallpox Suspected (Initial cases or during outbreak) + + - - - Probable: Initial cases During outbreak + + +/-** - - + + - - + Confirmed: Initial cases During outbreak + + + + - + + +/-** - + Possible During outbreak + - - - + Summary of case classifications* fever/ rash consistent with case definition**EM not required if case has strongly suspicious features with no other diagnosis

14. Primary Contacts • Primary contactsare persons who have had contact with confirmed cases of smallpox during the infectious period or with contaminated fomites. [The infectious period should be regarded as from 24 hours prior to the first recognised symptoms until the last scab has been shed]. • Two categories, A and B, according to risk of infection • These categories should be regarded as a guide: Individual’s risk of infection should always be considered in the context of the nature and duration of exposure.

15. Category A primary contacts (highest risk of infection) • Household contact • Face-to-face contacts • Fomite contacts • Others thought to have shared a common exposure including initial release of smallpox

16. Category A primary contacts (highest risk of infection) • Action: • Vaccinate immediately • Formal monitoring for 16 days from last exposure • Restrictions on activity – 9 days after first exposure until 16 days after last exposure • Transfer to smallpox observation ward if develop prodromal symptoms (possiblecase) • If rash, transfer to smallpox treatment ward (probable case)

17. Category B contacts(lower risk of infection) • Shared room or other enclosed spaces • e.g. Work colleagues • Shared air-conditioned buildings • Action:  vaccinate unless contraindication • No need for formal monitoring (advice sheet) or restriction on activities • Transfer to observation ward if symptoms (possible case) • If rash, transfer smallpox treatment ward (probable case)

18. Secondary Contacts • Close contacts of category A primary contacts • e.g. ongoing household contact with category A primary contacts during the formal monitoring period, and who may therefore be exposed to infection if the primary contact becomes symptomatic

19. Secondary Contacts • ACTION all secondary contacts should be vaccinated. • No monitoring or restrictions on activity are necessary unless the primary contact becomes symptomatic, and therefore becomes a possible or probable case • If smallpox is confirmed in the primary contact, then the secondary contacts become category A contacts themselves. • Depending on scale of outbreak, may be necessary to manage secondary contacts as category A contacts from moment their primary contact becomes symptomatic

20. Control • Would aim to control the outbreak by: • isolation of cases and • effective identification, tracing, vaccination and monitoring of contacts • But would vary depending on circumstances