OVERVIEW OF MEDICAL SCREENING AND COUNSELING

1. OVERVIEW OF MEDICAL SCREENING AND COUNSELING

2. Job Description For Staff • Review medical history for clients with contraindications to vaccination and answer questions about informed consent • Examine all forms for completeness of information for those clients discharged to the Vaccination Area • Assist clients in completion of forms if necessary

3. DISCHARGE OF CLIENTS • To the Vaccination Area for administration of the vaccine if it is determined there are no contraindications and the client is willing to be vaccinated. • Exit the vaccination clinic if it is determined that the client has contraindications that make vaccination unwise or the client declines vaccination.

4. Smallpox Vaccine Contraindications and Screening Department of Health and Human Services Centers for Disease Control and Prevention December 2002 Note: this graphic file matches the content of William Atkinson’s on-air presentation. A separate graphic file includes this information as well as information on contraindications and precautions to vaccination included on the smallpox vaccine administration videotape.

5. SMALLPOX VACCINE • Vaccine contains live vaccinia virus which is administered into the superficial layers of the skin • A successful vaccination produces a lesion on the skin that contains vaccine virus for up to 3 weeks. • Vaccinia virus can be transmitted to household and other close contacts • Candidates for vaccination must be screened for contraindications • Certain medical conditions in the person’s household contacts must also be considered as contraindications for vaccination

6. Smallpox VaccineContraindications and Precautions(Non-exposure situations) • Serious allergic reaction to a prior dose of vaccine or vaccine component • Children <12 months of age • Moderate or severe acute illness • Pregnancy or pregnant household contact • Breastfeeding (because of close physical contact)

7. Smallpox VaccineContraindications and Precautions(Nonexposure Situations) • Eczema or atopic dermatitis (current or past history) in the recipient or household contact • Acute, chronic, or exfoliative skin conditions (until improved or resolved) • Immunosuppression in the recipient or household contact

8. SEVERE ALLERGIC REACTION TO VACCINE COMPONENT • Urticaria, wheezing, anaphylaxis, difficulty breathing • Reaction is to one of antibiotic components of vaccine, or to phenol • New vaccines won’t have antibiotics

9. Screening for Pregnancy • In pre-event setting or post-event without exposure, should NOT be given to: • pregnant women • women trying to become pregnant • Educate women of child-bearing age about fetal vaccinia • Advise avoidance of pregnancy for 4 weeks following vaccination

10. Fetal Vaccinia • Rare complication (<50 cases reported) • Usually following primary vaccination of the mother in the second or third trimester • Fetal infection following vaccination in the first trimester may result in spontaneous abortion • No known pattern of congenital malformations

11. Fetal vaccinia

12. Examples of Immunosupressive Diseases • Leukemia • Lymphoma • Generalized malignancy (active) • Solid organ or stem cell transplant • Humoral or cellular immunity disorders • Autoimmune diseases • HIV infection

13. Examples of Immunosuppressive Therapy • Alkylating agents • Antimetabolites • Radiation • High dose corticosteroid therapy: • > 2 mg/kg/day, OR • > 20 mg/day for > 14 days

14. Screening for HIV Infection • Vaccine should NOT be administered to those with HIV infection or AIDS unless directly exposed to smallpox • Protective T-cell count unknown • HIV testing will not be readily available in the post event setting, so educate regarding risk: • Risk of vaccine for those with HIV/AIDS • Risk factors for HIV

15. Progressive Vaccinia • Occurs almost exclusively among persons with cellular immunodeficiency • Can occur in persons with humoral immunodeficiency • Can occur following revaccination of people who have become immunosuppressed since their primary vaccination • Occurred 0.9-1.5 cases per million primary vaccinations (rare but potentially fatal)

16. Progressive Vaccinia • Primary vaccination lesion does not heal • Progresses to ulcerative lesion, often with central necrosis • Little or no inflammation at the site and generally little pain • Virus continues to spread locally and through viremia

17. Progressive vaccinia

18. Screening for Eczema and Atopic Dermatitis • Risk factor for eczema vaccinatum • Do not administer if history of eczema OR atopic dermatitis • Do not administer if household members have history of eczema OR atopic dermatitis • Other acute, chronic, exfoliative conditions – wait until resolved or under good control

19. Screening for Eczema and Atopic Dermatitis Questions and Information: • Have you or member of your household been diagnosed with eczema or atopic dermatitis? • Eczema/atopic dermatitis usually is itchy, red, scaly rash that lasts more than 2 weeks and comes and goes. If you or household member EVER had a rash like this, you should NOT receive smallpox vaccine, unless you are directly exposed to smallpox.

20. Examples of Acute/Chronic/Exfoliative Skin Conditions • Varicella infection (Shingles or Chickenpox) • Contact dermatitis • Active psoriasis • Burns • Impetigo • Herpes • Severe Acne • Darier’s Disease

21. Eczema Vaccinatum • Generalized spread of vaccinia on the skin of a person with eczema or true atopic dermatitis, or a history of eczema or atopic dermatitis • Severity independent of the activity of the underlying eczema • Severe cases among contacts of recently vaccinated person • Occurred 10 to 39 cases per million primary vaccinations (rare but potentially fatal)

22. Eczema Vaccinatum • Skin lesions may be papular, vesicular, or pustular • May occur anywhere on the body • Predilection for areas of previous atopic dermatitis or other abnormal skin, then spreads (non-centrifugal) • Patients often severely ill • Occurs 5 – 19 days post vaccination

23. Eczema vaccinatum

24. CONTRAINDICATIONS TO VACCINE IF EXPOSED TO SMALLPOX: • None. • Benefits now outweigh risks.

25. For More Information • CDC Smallpox website www.cdc.gov/smallpox • National Immunization Program website www.cdc.gov/nip