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Smallpox Alert!

Idaho Post-Event Smallpox Plan:
For other states, Click here: http://www.vaclib.org/links/posteventindex.htm

Attention activists:

After a month of politely insisting upon seeing a copy of Idaho's smallpox response plan, it was finally received. First, a FAXed copy from a local newspaper reporter who was noticeably upset by the contents of the plan, arrived Dec. 30, 2002. And then, finally, without a note or anything else attached, the Idaho Department of Health & Welfare (IDHW) Bureau of Health Policy and Vital Statistics forwarded a clean copy of the 34-page plan that arrived January 2, 2003. The following is a scanned version of that "official" copy from the IDHW.

Though a few mistakes may still appear in the 16,755-word plan, great care has been taken to correct scanning errors and reproduce the document exactly as it appears on paper. All boldface and italics are taken from the original.

From the Table of Contents one can see the gravity of what is being proposed with this mass vaccination plan. Though the plan below is specific to Idaho, the plans submitted to the CDC by every state are no doubt similar as they, like Idaho, are modeled on Centers for Disease Control and Prevention (CDC) recommendations that were forwarded to the several states Sept. 22, 2002.

Pandemic preparedness plans have been under construction since President Ford ordered the Federal Guidebook to Pandemic Preparedness to be drafted in 1973 after the swine flu mass vaccination disaster. The guidebook was still in draft form when President Clinton ordered it be completed in 1993. By 1998, cities and counties all over the nation began adopting emergency powers ordinances that would trigger the implementation of martial law in the event of a declared state of emergency. By Nov. 1, 2001, the CDC had released its Model State Emergency Health Powers Act (MEHPA), which, if adopted by the several states, would give governors the power to suspend their state constitutions and declare states of medical martial law.

Detailed descriptions of MEHPA are available at http://www.vaclib.org

Both Vaccination Liberation and The Idaho Observer have been studying the history of pandemic preparedness in the U.S. and have been monitoring its snowballing evolution since 1998. Just close your eyes and imagine the logistics of feeding a machine that will vaccinate, within a few days time, at least 80 percent of the people in a mid-sized town close to you. Once you fully understand the resources, manpower and police-state controls that will be in place locally to accomplish that seemingly impossible task, broaden your perspective to encompass vaccinating some 80 percent of America's 280,000,000 people within 10 days. This is not a matter to be taken lightly. Every city, county and state in the nation is actively preparing for mass vaccination while we wonder if they will ever manufacture the public health emergency to justify such a campaign.

Though we finally received most of the state plan (notice that the section relating to the transition to mass vaccinating the public is not available to the public), the local plans are "confidential" and are also unavailable to the public.

It is our belief that decades of preparation make the eventual implementation of medical martial law inevitable. The American public has been prepped for medical martial law by being taught to fear infectious diseases and then told repeatedly that vaccines are the only way to prevent them. We will not go into the details of 50 years of disease-scare in America at this time. We will, however, preface the following plan by stating without reservation that FRAUD is the engine driving the national mass smallpox vaccination plan.

The following plan perpetuates several smallpox "myths" to justify mass vaccination.

1. Regardless that the World Health Organization declared the world "smallpox free" in 1980, it is notthe name of the disease was merely changed. Based upon the false belief that smallpox no longer appears naturally, the CDC claims one case will indicate we are under biological attack, thus triggering mass vaccination on a premise that does not withstand medical reality or scientific scrutiny.

2. According to the CDC, 30 percent of people die from the disease. We have CDC virologists on record stating that the 30 percent figure is comprised largely of impoverished, malnourished third-world children who live in unsanitary conditions and is not representative of figures that would result in the U.S. Besides, no one "dies" from smallpoxthey die from secondary infections like pneumonia which result from improper care of the primary smallpox infection.

3. The CDC claims that the smallpox vaccine is "considered safe." The vaccine is arguably the most unsafe of all vaccines and has been linked to numerous chronic ailments that plague modern Americans. The package insert for the smallpox vaccine describes how dangerous the vaccine really is. Plus, much of the vaccine is diluted from old stock produced decades ago and is experimental in nature (30 percent of healthy college students have experienced adverse reactions in recent clinical trials).

4. The CDC claims that the vaccine prevents the spread of smallpox. The claim is absurd on its face because the vaccine contains "vaccinia" virus (diseased material taken from cows) and the virus associated with smallpox in humans is called "variola." Vaccine theory demands a specific antigen be provided for a specific virus.

5. The CDC claims publicly that smallpox is virulently contagious when its own documents prove that it is not very contagious.

The list of inaccuracies regarding the epidemiological potential of smallpox and the medical illogic perpetually cited as appropriate public health policy goes on and on. Regardless, they intend to vaccinate us all anyway. That is why Vaccination Liberation and The Idaho Observer published Smallpox Alert!an eight-page, publication of historical and contemporary truth regarding smallpox. Smallpox Alert! is a fascinating and engaging read designed to prompt people to question the intelligence of blindly accepting an injection containing unknown substances.

If we are to derail this plan, which will likely result in a public health disaster of cataclysmic proportions, it is going to come from educating ourselves, friends, family and the various human components of the mass vaccination machinerypolice, doctors, nurses, elected officialsto the point they resist participating in this lunacy.

On a personal note, I have been an opposition publisher since 1995. A lot of things have happened in America since that time. The end result of horrific events reported in the media is the federal government grows in both size and authority. Increasing numbers of people are becoming concerned that the federal government will not stop usurping power until it controls everything there is to control. We can clearly see the federal octopus in operation now and, the bigger it gets, the less likely we, as Americans, will be able to stop it with petitions and organized non-violent civil disobedience.

It has also become obvious that the federal government, which has clearly left the confines of its constitutional straightjacket, will eventually clash with those who intend to put it back into its constitutional place. What would come of such a confrontation is the stuff from which daydreams and movies are made. In my own daydreams, as various scenarios have played themselves out in my mind, it never occurred to me that it could end up this way.

To think that our country could be destroyed because our people have become so accepting of their slave status they would climb over one another with their sleeves rolled up--begging for the poisoned needle. How pathetic. How dishonorable. How undignified. Free people will not allow government to inject dangerous vaccines into their bodies under the guise of public health.

One last comment before you begin to read the "plan" your government has for you. Go to Revelations 16:1-2. The King James Version is best for our purposes because the language used is amazing for the subject of this post. Some may view God as using the Bush administration to accomplish a task and that mass vaccination against smallpox is inevitable. What remains to be seen, however, is who will succumb to the "vials" of God's wrath. That, it seems, is totally dependent upon each of us and our relationship with God.

Good luck to us all in 2003. We have a lot of work to do. Our mission is not to change the government which, unfortunately is a mirror image of ourselves as a nation, but to change the hearts and minds of our countrymen. If we will accomplish this, our government will have little choice but to be a reflection of our better selves.

No matter what,

Don Harkins
The Idaho Observer

PS: Should you decide to help change the hearts and minds of those in your community, Smallpox Alert! ordering information can be found at the end of this post.


Idaho

Post-Event Smallpox
Response Plan and Guidelines

Draft 5.0 - 12/20/02

Idaho Division of Health
Idaho Department of Health and Welfare

With input from:

Idaho District Health Departments (Feb 2002)
Idaho Biosecurity Council (Feb 2002)
Smallpox subcommittee of the Idaho Biosecurity Council (September 2002)
Intermountain chapter of the Association for Practitioners in Infection Control and Epidemiology, Inc. (Feb 2002)
Presented to Boise Bug Club (regional microbiologists and infectious disease physicians, Feb 28 2002)
Comments of the national APIC on the CDC Smallpox plan dated Feb 20, 2002 and updates to the CDC Smallpox Response Plan were also incorporated into this document.

Table of Contents
I. Executive Summary
II. Criteria for implementation of CDC and Idaho Smallpox Plans     4
III. Notification Procedures for Suspected Smallpox Cases           5
IV. Outline of CDC and State/Local Responsibilities                 5
V. CDC Vaccine Deployment                                           7
VI. CDC Personnel Mobilization and Deployment for Assistance        7

Guide A -
Surveillance, Contact Tracing, and
Epidemiological Investigations Guidelines                          10
 1. Pre-event rash surveillance
 2. Smallpox clinical presentations and differential diagnosis
 3. Smallpox case definitions
 4. Epidemiological (case and outbreak) investigation
 5. Surveillance following an outbreak
 6. Contact identification, tracing and surveillance
 7. List of Forms

Guide B - Vaccination Guidelines                                    16
 l. Vaccination strategies
 2. Source of CDC Guidelines on:
 Indications for vaccination;
 Contraindications for vaccination;
 Reconstitution, administration, and storage of vaccine;
 Recognition of expected vaccine reactions/take;
 Recognition of adverse reactions; indications and guidelines for 
   VIG administration; 
 Contingencies for re-sterilization of bifurcated needles

Guide C - Isolation Guidelines                                      18
 1. Isolation Measures
 4. Quarantine
Guide D - Specimen Collection and Transport Guidelines              20

Guide E - Communications Plans and Activities                       21

Guide F - Decontamination Guidelines                                31
 1. Reusable medical equipment
 2. Medical waste
 3. Surfaces
 4. Protective clothing, bedding, linens, etc.
 5. Facility/Rooms
 6. Transportation vehicle

Guide G - Transition to Mass Vaccination - Official Public Health Use Only
[Please note that page numbers in table of contents correspond with the hardcopy documented as forwarded to Vaccination Liberation by the state of Idaho and will not necessarily be reflected in the scanned electronic version of the state plan to follow ~DWH).

I. Executive Summary

These guidelines were written to help coordinate an organized plan for preparing for, and responding to, cases or suspect cases of smallpox, or suspected exposures to smallpox, in Idaho. They are designed to be used together with the Center for Disease Control and Prevention's Interim Smallpox Response Plan and Guidelines (CDC ISPR). It is recommended that anyone referring to this plan for guidance also view the CDC ISPR. Some information from the CDC ISPR is duplicated here, but many sections were not repeated in order to make the Idaho guidelines as streamlined as possible, while still containing enough general information to be helpful to a user without access to the CDC ISPR.

The CDC ISPR is being updated at the time of this writing. The most current version is available at the website: http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp

If an outbreak of smallpox were to occur, several factors could contribute to a more rapid spread of smallpox than was routinely seen before this disease was eradicated. These factors include:

1. Virtually non-existent immunity to smallpox in the absence of naturally occurring disease and the discontinuation of routine vaccination in the U. S. in the early 1970's,

2. Delayed recognition of smallpox by health personnel unfamiliar with the disease, and

3. Increased mobility and crowding of the population.

Because of these factors, a single case of smallpox would require an immediate and coordinated public health and medical response to contain the outbreak.

Smallpox Variola virus is the etiological agent of smallpox. The only known reservoir for the virus during the smallpox era was humans; there were no known animal or insect reservoirs or vectors. The most frequent mode of transmission is person-to-person spread via direct deposit of infective droplets onto the nasal, oral, or pharyngeal mucosal membranes, or the alveoli of the lungs from close, face-to-face contact with an infectious individual. Indirect spread (not requiring face-to-face contact with an infectious individual) via fine-partide aerosols or fomites containing the virus has been reported but is less common. In most cases, symptoms of disease begin within 12 - 14 days (range 7 - 17) following the exposure of a susceptible person to the virus. A 2 - 3 day prodrome of high fever, malaise, and prostration with severe headache and backache is followed by a maculopapular rash (eruptive stage) that progresses to papules (1 - 2 days after appearance of rash), vesicles (4 - 5th day), pustules (by 7th day), and finally scab lesions (14th day). The rash generally appears first on the oral mucosa, face, and forearms, then spreads to the trunk and legs. Lesions are also seen on the palms of the hands and soles of the feet. The skin lesions of smallpox are deeply embedded in the dermis and feel like firm round objects embedded in the skin. As the skin lesions heal and the scabs separate, pitted scarring gradually develops. Smallpox patients are most infectious during the first week of the rash when the oral mucosa lesions ulcerate and release large amounts of virus into the saliva and are less infectious once the lesions have scabbed over. A patient is no longer infectious once all the scabs have separated (usually 3 - 4 weeks after the onset of the rash). The overall mortality rate associated with smallpox was approximately 30%. Other less common but more severe forms of smallpox can occur (See the CDC ISPR for a more complete discussion of smallpox).

Smallpox Vaccine Smallpox vaccine is a highly effective immunizing agent. It is a live-virus vaccine composed of vaccinia virus, an orthopoxvirus that induces antibodies that also protect against smallpox. Its use in focused ring vaccination campaigns that utilized intensive surveillance and contact tracing during the smallpox eradication program helped bring about the global eradication of smallpox. Smallpox vaccine production ceased in the early 1980's and current supplies of smallpox vaccine are limited ~15.4 million doses in the U.S.A. as of 12/2712001). However, it is expected that new cell-culture grown smallpox vaccines will become available for use within the next few years. Although smallpox vaccine is considered a safe vaccine, post-vaccination adverse events can occur. These adverse events and their rates as determined in a 1968 10-state survey include:

1. Inadvertent inoculation (529,2/million primary vaccinations),
2. Generalized vaccinia (241,5/million primary vaccinations),
3. Eczema vaccinatum (38.5/million vaccinations),
4. Progressive vaccinia (1.5/million primary vaccinations), and
5. Post-vaccinial encephalitis (12.3/million primary vaccinations),
6. Death (one per million primary vaccinations -- usually a result of progressive vaccinia, post-vaccinial encephalitis, or severe eczema vaccinatum).

Several groups have been identified as having a higher risk for developing post-vaccination complications. These include:

1. Persons with eczema (including a history of eczema) or other forms of chronic dermatitis, 2. Persons with altered immune states (e.g. HIV, AIDS, leukemia, lymphoma, immunosuppressive drugs, etc.), 3. Pregnant women, 4. Children under 1 year of age, older adolescents or young adults receiving primary vaccination may also have a greater risk of post-vaccination complications.

Note that in the case of a known exposure to smallpox, these contraindications are not absolute, and vaccination should be strongly considered due to the high risk of disease and death from smallpox. Vaccinia Immune Globulin (VIG) is used to treat certain vaccine adverse reactions, however, supplies of VIG are limited.

CDC Interim Smallpox Response Plan (CDC ISPR) and Guidelines The CDC ISPR is a working document that is updated regularly. It is recommended that each Idaho district health department have printed copies of the forms from Guide A in the plan available, and bookmark the Internet site listed above, which will contain updated versions of the plan. The CDC ISPR is operational and would be implemented should a smallpox emergency occur. The Idaho Interim Plan will be updated if significant changes in the CDC ISPR require adjustments to the state plan, or if new information becomes available which changes elements of the planned public health response.

General Strategy and Priority Activities for Smallpox Outbreak Containment The first and foremost public health priority during a smallpox outbreak is control of the epidemic. The following activities would be essential to accomplishing this goal.

Ring (aka "Focused") Vaccination According to CDC, any vaccination strategy for containing a smallpox outbreak should utilize the ring vaccination concept. This includes:

1. Isolation of confirmed acid suspected smallpox cases, 2. Tracing, vaccination, and close surveillance of contacts of cases, and 3. Vaccination of household contacts of the contacts.

Vaccinating and monitoring a "ring" of people around each case and contact will help to protect those at the greatest risk for contracting the disease as well as form a buffer of immune individuals to prevent the spread of disease. According to CDC, this strategy would be more desirable than an indiscriminate mass vaccination campaign for the following reasons:

1. Focused contact tracing and vaccination combined with extensive surveillance and isolation of cases was successful in stopping outbreaks of smallpox during the eradication program without the need for indiscriminate vaccination.

2. Adverse events would be expected to be higher in an indiscriminate vaccination campaign due to vaccination of persons with unrecognized contraindications (e.g. undiagnosed immuno-suppressive disorders such as H1V or AIDS). Careful screening for contraindications to vaccination would also be more difficult in a large-scale vaccination campaign. The risks vs. benefits of vaccination ratio would be higher in such a campaign because of the inevitable vaccination of persons with high risk of adverse events and a low risk of smallpox.

3. Current supplies of VIG would not be sufficient to treat the number of expected adverse events that would occur with a large, indiscriminate vaccination campaign.

4. Current supplies of smallpox Vaccine would be exhausted quickly if an indiscriminate campaign was utilized, potentially leaving no vaccine for use if smallpox cases continued to occur

5. Mass, indiscriminate vaccination of a large population would require a very large number of health-care/public health workers to perform vaccination and deal with the higher number of adverse events

6. Utilization of mass vaccination may lead to improper reliance on this strategy to control the outbreak with less focus on other essential outbreak control measure such as careful surveillance, contact tracing, and isolation of cases. This could also lead to inadequate supplies of vaccine for areas with the greatest need and potentially prolong the epidemic instead of controlling it. The size of the vaccinated "ring" of individuals surrounding a case or contact may be expanded or contracted, depending upon:

1. the option for outbreak control that is selected,
2. the size of the outbreak,
3. personnel/resources,
4. effectiveness of other outbreak control measures, and
5. vaccine availability.

However, the ring vaccination concept should be maintained overall. The determination of the initial vaccination ring size or alteration of subsequent vaccination ring sizes will be made jointly by Federal and State health officials.

Identification of Priority Groups
The following are considered high risk groups and should be prioritized for vaccination in a smallpox outbreak:

1. Face-to-face close contacts within 6.5 feet, or household contacts of smallpox patients after the onset of the smallpox patient's fever. (Although individuals with smallpox are not infectious until the onset of rash, vaccinating contacts from the time of the onset of fever helps provide a buffer and assures that contacts who may have been exposed at the early onset of rash, when the rash may have been faint and unrecognized, have been vaccinated.)

2. Persons exposed to the initial release of the virus (if the release was discovered during the first generation of cases and vaccination may still provide benefit).

3. Household members (without contraindications to vaccination) of contacts of smallpox patients (to protect household contacts should smallpox case contacts develop disease while under fever surveillance at home). Household members of contacts who have contraindications to vaccination should be housed separately from the other vaccinated household members until the vaccination site scab has separated (~ 2 weeks) to prevent inadvertent transmission of vaccinia virus. They should be also be housed separately from the contact until the incubation period for smallpox has passed and the contact is released from surveillance.

4. Persons involved in the direct medical care, public health evaluation, or transportation of confirmed or suspected smallpox patients. This includes personnel whose public health activities involve direct patient contact such as case interviewing.

5. Laboratory personnel involved in the collection and/or processing of clinical specimens from suspected or confirmed smallpox patients.

6. Other persons who have a high likelihood of exposure to infectious materials (e.g. personnel responsible for hospital waste disposal and disinfection).

7. Personnel involved in contact tracing and vaccination, or quarantine/isolation or enforcement, or law-enforcement interviews of suspected smallpox patients.

8. Persons permitted to enter any facilities designated for the evaluation, treatment, or isolation of confirmed or suspected smallpox patients (only essential personnel should be allowed to enter such facilities). Only personnel without contraindications to vaccination should be chosen for activities that would require vaccination for their protection. Personnel with contraindications should not perform duties that would place them at risk for smallpox exposure and should otherwise only be vaccinated if an exposure has already occurred.

9. Persons present in a facility or conveyance with a smallpox case if fine particle aerosol transmission was likely during the time the case was present (e.g. hemorrhagic smallpox case and/or case with active coughing). Evaluation of the potential risk for aerosol transmission and initiation of vaccination for nondirect contacts will be done by CDC, state, and local public health officials. The decision to offer vaccination to non-direct contacts of smallpox cases will be made jointly by Federal, State and district health officials.

Additional Groups that May Be Considered for Voluntary Vaccination Federal, State, and Local response personnel not involved in direct patient or contact evaluation or care but whose uninterrupted support of response activities is deemed essential may be considered for voluntary vaccination. Vaccination of these personnel will be dependent upon the size of the outbreak, availability of vaccine, the assessed risk for unintentional or unrecognized contact with smallpox cases, and a careful assessment of the benefits vs, the risks of vaccination. Personnel within these non-patient contact groups who have no contraindications will be considered for vaccination. Persons within these groups with contraindications should not be vaccinated. The decision to offer voluntary vaccination to non-patient contact personnel will be made by the Director of CDC. These groups include, but are not limited to:

1. Public health personnel in the area involved in surveillance and epidemiological data analysis and reporting whose support of these public health activities must remain unhindered

2. Logistics/resource/emergency management personnel whose continued support of response activities must remain unhindered

3. Law enforcement, fire, and other personnel involved in other non-direct patient care response support activities such as crowd control, security, law enforcement, and firefighting or rescue operations

II. Criteria for Release of Smallpox Vaccine and implementation of the CDC ISPR The CDC Director may authorize the release of all or portions of the smallpox vaccine stockpile and implement all or portions of the CDC ISPR according to guidelines set in their plan. The CDC Director will notify the Surgeon General and other federal agencies prior to the release of smallpox vaccine.

III. Notification Procedures for Suspected Smallpox Cases - For Official Public Health Use ONLY:

District public health staff and health care workers should notify the Idaho Department of Health and Welfare (IDHW) Epidemiology Program immediately for any of the following:

1. A suspected case of smallpox with request for clinical specimen testing

2. An outbreak of illness that is clinically compatible with smallpox

3. A request to test an environmental sample, package, distribution device, or other device associated with potential human exposure for smallpox virus

Contact numbers at the IDHW:

Epidemiology: Monday through Friday, 8am - 5pm MST: 208-334-5939 24-hour emergency line (after hours, or during working hours if no immediate response to above number): 1-800-632-8000. Public health will be paged.

Although telephone reporting is preferred, redundant mechanisms should be utilized for reporting, including fax and email, should telephone contact not be immediately established. In addition, plans for alternate reporting should phone lines be down or power be lost should be made (e.g., through the local 911 system to the State Communications Center).

State public health authorities will notify CDC immediately of any suspected smallpox case or exposure. One of the following CDC offices will be notified:

1. Bioterrorism Preparedness and Response Program
a. Daytime telephone: 404-639-24~8 or 404-639-0385
b. Night, weekends, and holidays: 770-488-7100
2. Poxvirus Section, Division of Viral and Rickettsial Diseases, NCID, CDC
a. Daytime telephone: 404-639-2184 or 404-639-4931 ~laboratory),
or 404639-3532 (branch), or 404-639-3311 (division)
b. Night, weekends, and holidays: 770-488-7100 3. Emergency Preparedness and Response Branch All times: 770-488-7100

IV. CDC, State and District Health Responsibilities and Actions in the Event of a Smallpox Outbreak

CDC Responsibilities and Actions (from the CDC ISRP)

1. Delivery or standby readiness for delivery of smallpox vaccine and vaccination components.

2. Initial laboratory confirmation of smallpox infection and establishment of laboratory protocols for confirmation in surge capacity laboratories.

3. Coordination with state/local health officials to establish communications and implement federal-state response plans.

4. Immediate mobilization and deployment of CDC personnel to assist local and state public health officials with epidemiologic investigations, surveillance, implementation of case isolation protocols, contact identification, vaccine administration. adverse events monitoring, and vaccine inventory monitoring.

5. Development of vaccination strategies and prioritization.

6. Distribution of guidelines for surveillance, contact identification and tracing, vaccination, isolation strategies, specimen collection and transport, public/media communications, decontamination, and smallpox patient medical care guidelines.

7. Provision of technical assistance to the national authority responsible for coordinating the overall federal efforts for managing the event.

8. Coordination with federal law enforcement agencies conducting the criminal investigation

9. Provide recommendations on quarantine needs that supercede the capabilities of local and state authorities and statutes.

10. Coordination with state/local authorities for public and media communications.

11. Tracking and reporting of national surveillance information regarding outbreak.

12. Coordinate between states for contact tracing and monitoring.

State Public Health Responsibilities and Actions

1.Activation of state emergency response plans for bioterrorism and smallpox.

2. Designation of state leads for the following activities:
-- case surveillance and isolation,
-- contact tracing and monitoring.
-- epidemiologic investigation,
-- vaccine administration,
-- adverse events monitoring,
-- coordination with CDC response team, FEMA, and other state agencies
-- coordination with local, state and federal law enforcement agencies conducting the criminal investigation.

3. Designation, in concert with the affected district health department(s), of sites/clinics for vaccine administration.

4. Designation, in concert with the affected district health department(s), of sites for patient isolation.

5. Designation, in concert with the affected district health department(s), of sites for contact isolation if initiated.

6. Utilization of state public health statues and resources for implementation and enforcement of isolation and quarantine within the state.

7. Coordination with federal authorities for public and media communications.

District Public Health Responsibilities and Actions

1. Activation of local emergency response plans for bio-terrorism and/or smallpox outbreaks

2. Designation of district leads for the following activities:
-- case surveillance and isolation,
-- contact tracing and monitoring,
-- epidemiologic investigation,
-- vaccine administration,
-- adverse events monitoring,
-- coordination with CDC response team
-- coordination with local. state and federal law enforcement agencies conducting the criminal investigation.

3. Mobilization of local public health resources to conduct epidemiological investigations, surveillance, implementation of case isolation protocols. contact identification, vaccine administration, and adverse events monitoring

4. Designation, in concert with the state health department, of sites for vaccine administration,

5. Staffing and management of sites/clinics for vaccine administration

6. Designation, in concert with the state health department, and management of sites for patient isolation

7. Designation, in concert with the state health department, and management of sites for contact isolation if initiated

8. Utilization of local public health statutes and resources for implementation and enforcement of isolation and quarantine within the local jurisdiction

9. Coordination with other local and state law enforcement agencies conducting the criminal investigation

10. Coordination with other local and state authorities for public and media communications

V. Vaccine Mobilization and Deployment

The state immunization program manager or state health officer will request vaccine immediately if a case of smallpox is suspected, or if Idaho citizens are determined to be at risk of exposure to smallpox due to a release of the virus. The National Pharmaceutical Stockpile (NPS) may be activated, following the state and federal NPS plan. Initial deployment of smallpox vaccine and vaccine components will occur once approval for release has been obtained from the Director of CDC. Criteria for release are detailed in the CDC ISRP.

VI. CDC Personnel Mobilization and Deployment

Once an outbreak of smallpox has been identified, the Director of CDC will initiate mobilization of personnel to satisfy their responsibilities outlined in section [V, above. Details are outlined in the CDC ISRP. If personnel needs extend beyond CDC staffing capabilities, the Director of CDC will seek the assistance of other Federal agencies.

Guide A - Surveillance, Contact tracing and Epidemiological Investigation

Should this plan be activated, the state epidemiologist or designee will coordinate overall case surveillance and epidemiological investigation activities for the state. This person will work closely with Federal and district health agencies on all aspects of the epidemiological investigation, surveillance and contact tracing.

Note: activities and actions described within this section may be altered depending upon the size and characteristics of the outbreak. If this occurs, information regarding the new procedures to follow or actions to take will be communicated to local health department personnel by the state epidemiologist or health officer, and federal health authorities.

Outbreak Definition: because smallpox no longer exists as a naturally occurring disease, an outbreak of smallpox is defined as a single laboratory confirmed case.

This section will cover the following topics:

1. Pre-event rash surveillance
2. Clinical presentations and differential diagnosis
3. Case definitions
4. Epidemiological (case and outbreak) investigation
5. Surveillance following an outbreak
6. Contact identification, tracing and surveillance

PRE-EVENT RASH SURVEILLANCE
Idaho is in the process of establishing enhanced pre-event surveillance for generalized febrile vesicular-pustular rash illness. An algorithm and protocol for evaluating patients with febrile vesicular-pustular rash illness has been developed by CDC (see CDC ISRP Annex 4).

CLINICAL CASE DESCRIPTION AND DIFFERENTIAL DIAGNOSIS
Smallpox is characterized by both an enanthem with lesions in the mouth and posterior pharynx and an exanthem (rash). Constitutional symptoms prior to onset of rash (exanthem) include fever (100%), which generally occurs about 1-3 days before rash onset, headache (90%). backache (90%), chills (60%), and vomiting (50%). Less common symptoms include pharyngitis and severe abdominal pain. The hallmark of the ordinary (or classic) type of smallpox is a generalized vesiculopustular rash with lesions found more densely on the face and extremities (centrifugal), including the palms and soles. All lesions on any one part of the body are at a similar stage of development and are approximately the same size. Rash progresses from sparse macules (day 1), to papules (day 2), vesicles (days 3-4), pustules (days 5 to approximately 12), and scabs (days 13-18) for a total duration of 2-3 weeks. Less common presentations of the smallpox rash include flat, or hemorrhagic lesions. A rash that progresses through the stages more rapidly and has fewer lesions characterizes modified smallpox. which occurs more commonly among previously vaccinated persons. Infection via cutaneous inoculation also has a shorter course with appearance of one or several vesicles at the site of inoculation after about 3 days. Asymptomatic cases are very uncommon and their role in transmission is unclear but likely to be minimal.

Because routine childhood vaccination in the U. S. stopped in 1971, persons currently < 30 years of age are generally totally susceptible to smallpox and if exposed, are expected to exhibit classic or atypical presentations. Persons aged 30 years or more may have been vaccinated during childhood or as adolescents or adults for travel or occupational reasons. Vaccination of health care workers and persons traveling overseas continued until the late 1970s and military personnel were vaccinated until 1990. Epidemiological studies have shown that an increased level of protection against smallpox persists for < 5 years after primary vaccination and substantial but waning immunity can persist for ~ 10 years. Antibody levels after revaccination can remain high longer, conferring a greater period of immunity than occurs after primary vaccination alone. Although it is assumed that adults ~ 30 years in the U. S. may have little or no immunity to smallpox, there is evidence that vaccination during infancy results in long term reduction in mortality. Therefore, it is possible that if smallpox virus were introduced into the U.S. population. some vaccinated adults -- especially those who have received 2 or more doses of smallpox vaccine -- may develop modified smallpox following exposure and that mortality would be markedly lower than unvaccinated persons. The most likely condition to consider in the differential diagnosis of vesiculopustular rash is varicella (see box below).

Smallpox: clinical featuresVaricella: clinical features
Major distinguishing features febrile prodrome: temperature >102 and systemic symptoms (prostration, severe headache, backache, abdominal pain, or vomiting) 1-4 days before rash onset No or mild prodrome before rash onset
   Lesions are deep, firm, well-circumscribed
pustules; may be confiuent or umbilicated
Lesions typically superficial vesicles
Other distinguishing features Rash concentrated on face and distal extremities (centrifugal) Rash concentrated on trunk and proximal extremities (+/- face, scalp)
  Rash in same stage of evolution on any one part of the body Rash appears in crops; lesions are in different stages of evolution (papules, vesicles, crusts) on any one part of the body
  First lesions on oral mucosalpalate First lesions on trunk
  (enanthem); followed by exanthem (rash)
on face or forearm
(occasionally face)
  Lesions on palms and soles (seen in > 50%) Lesions very uncommon on palms and soles
  Lesions may itch at scabbing stage Lesions generally intensely itchy
  Lesions evolve from papule to pustule in days. Lesions generally evolve from macules to papules to vesicles to crusts in <24 hours
  Illness lasts 14 to 21 days Illness lasts 4-7 days


Other differential diagnoses:
In herpes tester, lesions are usually localized to 1 or 2 dermatomes, but can become generalized, especially among immunocompromised persons. The lesions in localized herpes zoster are painful and could likely be differentiated from smallpox based on their appearance.
Other diagnoses to consider include drug eruptions, erythema multiforme, impetigo, disseminated herpes simplex, enteroviral infections associated with a vesicular rash, and others.

CASE DEFINITIONS AND CASE CLASSIFICATION

These preliminary case definitions are from the CDC ISRP, and will be followed exactly in Idaho.
Preliminary case definitions may require revision by public health personnel conducting the epidemiological investigation depending upon the specifics of the epidemic.

a. Clinical Case Definition
An illness with acute onset of fever > 101° F followed by a rash characterized by firm, deep seated vesicles or firm pustules in the same stage of development without other apparent cause.

b. Laboratory Criteria for Confirmation* (to be conducted in Level C or D laboratories only)
1. Isolation of smallpox (variola) virus from a clinical specimen (Level D laboratory only), or

2. Polymerase chain reaction (PCR) identification of variola DNA in a clinical specimen, or

3. Negative stain electron microscopy (EM) identification of variola virus in a clinical specimen (Level D laboratory or approved Level C laboratory)

*Level D laboratories include the CDC and USAMRIID. Initial confirmation of a smallpox outbreak requires testing in a Level D laboratory. Level C laboratories will assist with testing of clinical specimens following initial confirmation of an outbreak by CDC.

c. Case Classification

  • Confirmed: A case of smallpox that is laboratory confirmed.
  • Probable: A case that meets the clinical case definition that is not laboratory confirmed but has an epidemiological link to another confirmed or probable case.
  • Suspected: A case that meets the clinical case definition but is not laboratory confirmed and does not have an epidemiological link to a confirmed or probable case of smallpox, OR a case that has an atypical presentation that is not laboratory confirmed but has an epidemiological link to a confirmed or probable case of smallpox. Atypical presentations of smallpox include
    a) hemorrhagic lesions OR
    b) flat, velvety lesions not appearing as typical vesicles nor progressing to pustules.

    d. Definition of Contact: A person who has had contact with a suspected, probable, or confirmed case of smallpox during the contagious period, which will be considered from fever onset until scabs have all separated for this document. (Note that although a person is not contagious until rash onset, at times the oral enanthem, which is less obvious on physical examination, may precede the external exanthem; the oral lesions do spread disease by respiratory droplet nuclei. For this reason, the onset of fever is used in this document as the beginning of "exposure time", even though in many cases, the person will not have become contagious until several days later.) A contact's risk of contracting smallpox increases with close contact, increasing length of exposure to a case and the stage and severity of clinical case. Thus close contact is defined as any face-to-face contact (< 6.5 feet) with a smallpox case and duration of contact should be quantified, if possible.

    The importance of case confirmation using laboratory diagnostic tests differs depending on the epidemioiogical situation. Laboratory confirmation is important for a first case in a geographic area, reading to release of Vaccine as part of a response. In a setting where multiple cases are identified, laboratory capacity may soon be overwhelmed. In such instances, priority for laboratory resources will include
    1) clinical or environmental specimens that will provide information about a potential source of exposure, facilitating law enforcement activities and case detection; and
    2) clinical specimens from cases with an unclear presentation but who are suspected as cases following expert consultation (see above).

    POST-EVENT RESPONSE: EPIDEMIOLOGICAL INVESTIGATION

    When this plan is activated, the state epidemiologist or designee will coordinate the epidemiological investigation in collaboration with federal health authorities. An estimate of the number and kind of personnel necessary for performing these functions will be made and additional assistance requested as needed. The lead state and federal staff will coordinate all aspects of the investigation with relevant district, state and federal authorities including the FBI, police, quarantine officials, and others.

    All personnel designated for case interviews must be vaccinated prior to initiating their first face-to-face interview with a suspected, probable or confirmed smallpox case.

    The purpose of the case investigations are:

  • To establish the diagnosis and case classification;
  • To identify contacts for tracing, vaccination and surveillance;
  • To impose isolation of confirmed, probable and suspected cases;
  • To identify the most likely source of initial exposure for the case;
  • To monitor clinical course and outcome of cases; and
  • To monitor the epidemiology of the outbreak for analysis and communications purposes.
    Case investigation forms (CDC ISRP Forms 2-4) prepared by CDC will be used for initial case investigations. Once person-to-person transmission is ongoing, shorter case surveillance forms (CDC ISRP Forms 5A and 5B) may be used together with the contact identification module (CDC ISRP Form 3). Much of the epidemiological investigation may be performed in conjunction with identification and evaluation of potential smallpox cases. However, because of the urgency of the outbreak, adequate personnel must be available to collect and analyze data that would allow rapid:

    1. Identification of persons who have had close contact with the smallpox case since date of onset of fever. Since smallpox is a contagious disease, once a case is confirmed, the highest priorities for public health officials are to reduce risk of ongoing transmission by immediately identifying and vaccinating close contacts of cases and isolating the cases.

    2. Identification of the most likely source of initial exposure (hopefully within 24 hrs of the first confirmation of smallpox). This may require extensive trace-back capabilities if the initial recognition and confirmation of smallpox occurred later than the first generation of disease in the outbreak.

    3. Identification or estimation of the population at risk. To the extent possible. the population at risk should be identified. Exposure could be due to an infected persons present at a specified location; use of a specified of mode of transportation; or presence at a location of suspected smallpox virus release. These persons should be placed under surveillance; public health action to consider would include offering smallpox vaccine to the exposed population and to their household contacts.

    4. Identification of any unexpected epidemiological features of the outbreak (e.g., unusual presentation, morbidity, mortality, incubation period, transmission, affected population)

    5. Evaluation of characteristics and extent of the outbreak to develop the most effective containment strategies.

    Expected epidemiological features of smallpox and varicella are outlined in the CDC ISRP.

    POST-EVENT SURVEILLANCE
    Once a confirmed case(s) of smallpox has been identified, the district public health staff will initiate immediate active surveillance for additional suspected, probable and confirmed cases, with assistance from the IDHW epidemiology staff. Detailed guidelines provided in the CDC ISRP will be followed. and will include these general areas:

    1. Distribution of clinical case definitions and case classifications for suspected, probable and confirmed cases.

    2. Distribution of reporting forms from the CDC ISRP.

    3. Daily contact with major reporting sources to encourage timely reporting.

    Reporting

    (See section III, above, for contact numbers).

    A computer system for data entry and analysis of all the collected case investigation and surveillance information will be provided by federal health authorities and will be managed and maintained at the state IDHW for all confirmed, probable, and suspected cases. Methods will be established to follow up on laboratory results and epidemiological links for probable and suspect cases. The data management system will provide a daily tracking form (such as CDC ISRP Form 6) for monitoring such cases.

    Case information will be immediately shared by the agency initially receiving the report to surveillance partners at the appropriate district, state, and federal (CDC) health departments. If possible, personnel should prioritize the risk of contacts and sites based on closeness and duration of contact and stage of the illness.

    Confirmed contact lists will be given to personnel responsible for tracing, vaccinating and following up on contacts. If resources permit, personnel assigned to verify cases, travel histories, contacts, and conduct the epidemiological investigation may also participate in contact tracing.

    Out-of-state contacts or places of travel will be immediately reported to the CDC Coordination Group, which will assist with notification of the appropriate health authorities in affected states.

    Surveillance data will be reported on a daily basis to the CDC Coordination Group. This group will be responsible for maintaining the national surveillance database and helping with notification of out of state contacts. Mechanisms for reporting to CDC including the data format (Excel file, Access file, etc.) will be distributed to surveillance personnel at the time of the outbreak.

    Methods for enhanced hospital-based surveillance

    Once a case of smallpox has been confirmed in the community, patients with febrile rash illnesses will be directed to seek evaluation and care at a small number of facilities (clinics, hospitals) where physicians and health professionals familiar with smallpox and similar rash illnesses will see. diagnose and triage patients. If vaccinated smallpox response teams are available in the affected community, they will be utilized to triage ill persons and care for the case until others can be successfully vaccinated.

    Precautions to prevent spread of possible smallpox will be implemented by infection control practitioners. In addition, other area hospitals will be asked to initiate active surveillance for cases to identify patients admitted with compatible illnesses. Idaho Department of Health and Welfare, and the district health departments. are contracting and working with the Idaho Hospital Association to form hospital coalitions to make emergency plans for large outbreaks. including the evaluation of sizeable numbers of patients with rash illnesses.

    Active Surveillance in Hospitals

    1. Each hospital in the active surveillance network will identify one person ~preferably an infection control practitioner (ICP) who will be responsible for daily active surveillance at that institution.
    Patients will be evaluated and assigned a risk category: high, medium or low. The ICP will notify the district health department immediately of any high-risk patient for transfer to the designated type C facility for isolation of smallpox cases. All patients identified as medium risk will be notified to the district health department and transferred to a type X facility. In the event that there are no suspected smallpox patients, a report will still be sent to notify the district health department that surveillance was conducted and has not yielded suspect patients ("zero reporting"). Smallpox surveillance forms will be completed on all suspect cases. This information will be given to the district and state health department's epidemiology programs on a daily basis. Line lists will be maintained and updated daily by the district and state health departments, with daily contact between the agencies to ensure consistency and accuracy, and will include both new patients and previously reported patients until smallpox is ruled out.

    2. Prospective surveillance: Active surveillance for possible cases of smallpox currently hospitalized will be performed prospectively from the time of first report of an index case in the emergency department, (and any other unit that could accept patients directly without having ED evaluation), intensive care units, pathology and laboratory departments. Whenever possible, potential cases will be seen by an infectious disease consultant, dermatologist or smallpox consultant to clarify the diagnosis. Surveillance in each department is described below.

    3. Retrospective surveillance: In order to identify cases that may have been admitted before the outbreak was recognized but once transmission in the community was theoretically possible, retrospective screening of patients admitted with compatible syndromes will be conducted from the date determined by district health department personnel. If resources are available, records will be reviewed for all patients who were seen in the emergency department and discharged home, admitted, or transferred to another hospital. Charts of patients with a non-lab confirmed diagnosis of varicella, or generalized herpes roster or HSV, or those described to have a diffuse vesicular or pustular rash with fever and no lab-confirmed diagnosis will be reviewed to determine if the illness may have been smallpox. Patients currently in the hospital will be evaluated, and those transferred to another facility, discharged or expired will be reported to the district health department for follow-up.

    Classification of evaluated patients

    High Risk (epi-linked):
    1) Patients epidemiologically linked to a confirmed case of smallpox who have a history of a febrile prodrome and on examination had a maculopapular rash with predominantly face/distal extremity distribution OR involvement of the palms and/or soles.
    2) Patients epidemiologically linked to a confirmed case of smallpox who have a viral syndrome with fever 2101 and systemic symptoms (prostration, headache, backache, chills, vomiting, or abdominal pain) for <4 days but who do not have a generalized rash on examination.

    High Risk (not epi-linked):
    Patients with a severe prodromal illness consisting of temperature > 101 ° F 1-4 days before rash onset, AND at least one of the following. prostration, headache, backache, chills, vomiting, or abdominal pain AND 1) Generalized rash of acute onset that is either: comprised of deep, round, dermal lesions characteristic of smallpox; maculo-papular rash involving the palms and/or soles OR distributed more densely on the face and distal extremities than the trunk AND no other lab- confirmed diagnosis that would adequately explain the illness 2) Prostration or shock AND either maculo-papular rash, hemorrhagic rash, or rash with flat, velvety lesions that may be confluent AND no other lab-confirmed diagnosis that would adequately explain the illness.

    Moderate Risk (not epi-linked):
    Patients with no known contact, brief or uncertain contact to a smallpox case with a prodromal illness consisting of temperature >101 ° F and at least one of the following: prostration, headache, backache, chills, vomiting, or abdominal pain AND a generalized rash of acute onset that is atypical for smallpox (e.g. lesions on oral mucosa only, maculo-papular rash with localized distribution to face, or face and forearms, hemorrhagic/petechial rash) AND no other lab-confirmed diagnosis that would adequately explain the illness

    Low Risk (not epi-linked):
    Patients who are not epidemiologically linked to a smallpox case AND 1) Lack a history of a febrile prodrome
    2) Do not have classic smallpox lesions, OR
    3) Have a laboratory confirmed non-smallpox diagnosis compatible with their illness

    Strategies for Conducting Active Surveillance (refer to CDC ISRP for details).
    Surveillance in hospitals should cover the following areas:
    1)ER/ICUs/Wards
    2) Pathology Department, in hospitals where autopsies are performed
    3) Laboratories
    4) Lists of high risk, and moderate risk cases should be maintained and continually updated.

    6. CONTACT IDENTIFICATION, TRACING, VACCINATION, AND SURVEILLANCE

    All personnel designated for case interviews or contact-tracing activities must be vaccinated prior to initiating their first face-to-face interview with a suspect, probable or confirmed case or contact tracing activities.

    Identification of Contacts

    A single person will be designated by Director of the affected District Health Department to coordinate overall onsite contact identification, tracing, vaccination assurance and surveillance activities. Additional state and federal resources will be provided to assist with these activities.
    Personnel designated for contact identification and determination of case travel history should perform the tasks listed below. Additional staff will be assigned for tracing, interviewing, arranging vaccination and surveillance of contacts, The following general activities should be covered:

    1. Using CDC ISRP Forms 3 and 3A-D, interview each suspected, probable, or confirmed case to get detailed name and contact information for all persons with whom case had face-to-face contact (defined in the CDC ISRP) since onset of fever until the time of the interview.

    2. Seek detailed information on places visited since fever onset.

    3. If possible, interview the patient's family, close friends, and work associates to verify his/her travel and contact history since onset of fever.

    4. If only contacts in one state are involved, give all the information obtained to the appropriate district epidemiologist and state epidemiology program staff. The names of the contact and household members of contacts should be provided to personnel or clinics responsible for completing contact information and vaccination of contacts. If out-of-state contacts or travel are identified, state epidemiology staff will give the information to the CDC Coordination Group.

    5. Once all contacts are listed, allocate them to priority categories for vaccination based on duration of exposure according to the CDC ISPR guidelines.

    Determination of source

    The case or suspect case will be interviewed to determine possible exposure mechanisms. If this is an index case, appropriate law enforcement personnel will be notified of the suspected case, and information regarding the suspected exposure scenario will be shared with law enforcement.

    Tracing and interviewing of contacts

    A single person will be designated by the state epidemiologist to coordinate tracing, interviewing, arranging for vaccination and the surveillance of contacts in the state. A single person will be designated by the Director of the affected District Health Department to coordinate tracing, interviewing, arranging for vaccination and the surveillance of contacts in the district. Additional

    personnel will be provided from state resources as needed. Personnel assigned to trace contacts will receive names and any (known address, telephone number(s), or other locating information for these contacts from case investigation personnel. The number of contacts for each case may require a very large number of personnel be identified, trained and available for contact tracing and follow-up activities. For details on contact tracing procedures, see the CDC ISRP.

    Surveillance (monitoring) of health status and vaccine "take" of contacts

    Contacts who do not have fever or rash at the time of interview must remain under active surveillance for 18 days after their last contact with the smallpox case, or 14 days following successful vaccination. Procedures for contact tracing will follow the CDC ISRP.

    LIST OF FORMS

    Forms for Guide A can be found in the CDC ISRP.

    Forms 1-4 Detailed case investigation 4 modules*
    Form 1 Patient, medical history and clinical case information
    Form 2 Laboratory form
    Form 3 Contact identification module (used as module in detailed case investigation and as required module for surveillance) includes the following forms:
    Form 3A Household contact Form for listing all household contacts of case
    Form 3B Non-household contact Form for listing all named non-household contacts plus duration of exposure
    Form 3C Contact site list for listing sites where unnamed contacts may have been exposed to case
    Form Contact transportation list for listing sites (cities, states, countries) where case traveled during infectious period and modes of transportation
    Form 4 Source of exposure module, which includes the following forms:
    Form 4A Exposure source site form for listing sites visited during period of possible exposure
    Form 4B Exposure source transportation form for listing sites (cities, states, countries) where case traveled during period of exposure and modes of transportation
    *Note: The modules represented by the series of forms 1-4 are intended to be used in the initial stages of a smallpox outbreak investigation. The investigation will require 2 or 3 staff working concurrently; using forms 1 and 2, a medical epidemiologist should abstract information from admitting medical record or ER record while another epidemiologist/PHA interviews the case (or family member/friend if case is too ill for the interview) starting with forms 3 (contact identification module) and then forms 4 (source of exposure module). Information needed for form 1 that is not available from the medical record should be obtained from the case or a close family member or friend.
    Forms 5A & 58 Surveillance short forms; these forms will replace forms 1 -4 once cases are more common and detailed case investigations, especially to determine source of exposure, are not needed. Note: must continue to use Forms 3: contact ID module with forms 5.
    Form 6 Daily tracking case status form, used for updating case information that affects case classification e.g. lab results, epi linkage
    Form 7 Hospital surveillance tracking form
    Form 8 Form for interviewing each contact and identifying household contacts of contacts
    Form 9 Form for referral of Contacts and Household Members For Vaccination to a fixed site
    Form 10 Individual contact surveillance form to record vaccine "take" and serious adverse events for vaccinated household members of contacts (for use by contact tracer)
    Form 11 Master form for daily tracking of contact list

    Forms still under development

    Form 12 Form for contact to record daily temperatures, health status, vaccine take and serious vaccine adverse events and Vaccine take and serious Vaccine adverse events of household contacts (this could be the same form as form 10 or with minor modifications)
    Form 13 Daily master form to summarize contacts found/not found. symptoms of contacts, disposition of found contacts (vaccinated/referred for vaccination, referred for illness evaluation, isolated if fever or rash develops, status of contacts not found, number of contact's household members and those vaccinated or referred for vaccination. (this may not need to be a form but rather a computer generated report from contact form data.)

    NOTE: UPDATED FORMS WILL BE USED BASED ON CHANGES TO THE CDC ISRP.

    Guide B
    Vaccination Guidelines

    The state health officer will assign a person or persons to assume organizational responsibilities for state and local resources for vaccine administration during a smallpox outbreak. This person will work with Federal and other state emergency management authorities to implement vaccine administration strategies.

    Detailed vaccination guidelines are available in the CDC ISRP, Guide B. Only general principles are outlined here.

    Overall Vaccination Strategy
    According to the CDC, focused vaccination of close contacts is the mainstay of smallpox outbreak control as it assures the administration of vaccine to those with the greatest risk of developing disease and limits the number of unnecessary vaccinations in those individuals with little risk of disease. Judicious use of the Vaccine by establishing priority vaccination of those individuals who have the greatest risk of disease must also be exercised to effectively utilize the currently limited supplies of smallpox vaccine. Vaccination of those at low risk for disease will decrease the number of vaccine doses available for necessary outbreak control activities and may seriously compromise the chance for outbreak containment.

    Once a smallpox outbreak has been confirmed, vaccination efforts will focus on:

    1. contacts of cases
    2. household contacts of those identified as contacts of cases
    3. non-contact high-risk personnel

    The following activities must also take place to support vaccination administration in a smallpox
    emergency:
    1. Establish controlled, non-hospital vaccination sites for contacts or other broader public vaccination campaigns that may be implemented. Sites must have:

    a. appropriate vaccine storage capabilities (vaccine stored at 2-8° C)
    b. space for screening, vaccination, and education of vaccine recipients
    c. communication capabilities including at least telephone and fax capabilities
    d. adequate security to provide safe storage of vaccine and protection for personnel
    e. equipment needed for re-sterilization of needles if required

    2. Establish controlled, non-hospital vaccination sites for medical, public health, or other designated responders.

    3. Establish a system for vaccine adverse events tracking and reporting

    Primary Vaccination Strategy: Contact Identification and Vaccination
    If contacts can be vaccinated within 4 days of their contact with the smallpox case, they may be protected from developing the disease or may develop a less severe illness. Since smallpox is usually transmitted by close contact, people with face-to-face or household contact with a smallpox case are the ones at greatest risk for developing the disease and should be prioritized for vaccination. Individuals most likely to come into contact with an asymptomatic contact to a smallpox case (i.e. household members of a contact) should also be vaccinated to prevent infection of those individuals, should the initial smallpox contact later develop the disease. In addition, contagious individuals must be isolated to prevent contact with nonvaccinated or susceptible individuals during their period of infectiousness (from onset of fever or rash until all scabs have fallen off), further limiting the opportunity for disease transmission. Intensive surveillance for other contacts and potential cases in the area will help to quickly identify other groups for focal vaccination and isolation.

    Smallpox vaccination strategies in an outbreak will be based on the following 6 principles:
    1. Quickly identifying and isolating smallpox cases.

    2. Identifying and vaccinating their close contacts.

    3. Monitoring the vaccinated contact and isolating the contact if fever develops.

    4. Vaccinating household members of contacts without contraindications to vaccination in order to protect them if the contact develops smallpox. Household members of contacts who cannot be vaccinated due to contraindications should avoid the contact until the incubation period for the disease has passed (18 days) or 14 days following successful vaccination of the contact.

    5. Vaccinating health-care and public health workers (physicians, nurses, EMTs, etc.) who will be directly involved in evaluating, treating, transporting, or interviewing potential smallpox cases

    6. Vaccinating other emergency, law enforcement, or military response personnel who have a reasonable probability of contact with smallpox patients or infectious materials.

    Procedures for Vaccination follow-up to confirm vaccine take will utilize a vaccine site reaction recognition card given to vaccine recipients at the time of vaccination. if personnel resources permit. vaccine takes should be confirmed and recorded by health personnel 7 days following vaccination. if personnel resources do not permit direct follow-up for vaccine take confirmation, recipients will have instructions to call for evaluation if the Vaccine site does not look similar to that depicted on the card at day 7.

    Supplemental Strategy (See Guide G for transition to Mass Plan) A broader vaccination campaign to increase community immunity to smallpox may be instituted by Federal public health authorities in addition to continuing contact tracing and vaccination activities under the following conditions:
    i. The initial number of smallpox cases or identified locations of smallpox outbreaks is considered too large to allow contact tracing with vaccination to be effective as the only vaccination strategy for outbreak containment.
    2. New cases fail to show a decline after 2 or more generations from initially identified case(s).
    3. Initial outbreak control measures fail to show a decline in the number of new cases after approximately 30% of the current stores of vaccine have been utilized.

    As of this writing, Idaho strategies will be heavily dependent upon CDC actions, including release of the vaccine, recommendations, and status of the CDC ISRP at the time of activation of the Idaho plan. Therefore, specific vaccination strategies as of this writing follow the CDC plan exactly. Refer to the CDC ISRP, Guide B, "Vaccination Guidelines for State and Local Health Agencies" for current guidelines on:

    Use of Diluted Vaccine
    Indications for Vaccination, During a Smallpox Emergency
    Contraindications for Vaccination of Non-Contacts During a Smallpox Emergency
    Reconstitution, Administration, and Storage of Vaccinia Vaccine
    Recognition of Expected Vaccine Reactions/Take
    Recognition of Adverse Reactions
    Indications and Guidelines for Vaccinia Immune Globulin (VIG) Administration, and
    CDC Recommendations for Handling, Cleaning and Sterilizing Bifurcated Immunization
    Needles in Healthcare Settings

    Guide C
    Isolation and Quarantine Guidelines

    The state health officer will designate a person or persons to coordinate with federal authorities
    all activities related to isolation or quarantine and care of the specific groups listed below.

    The IDHW and the district health department directors are granted authority to isolate under certain conditions

    Idaho Code permits quarantine authority (see Idaho Code TI'TLE 46-1008) once the governor declares a disaster emergency. State legal statutes are proposed to be modified in the 2003 legislative session to allow public health intervention and implementation of the isolation and quarantine measures outlined in this section.

    CDC isolation Guidelines as outlined in the CDC ISRP Guide C will be followed.

    Preparation activities that are in progress or need to be initiated in Idaho in order to implement the recommendations of the CDC ISRP Guide C include:

    1. Identification of personnel responsible for local/state coordination of isolation and quarantine activities.

    2. Identification of appropriate facilities to be utilized for isolation and care of smallpox patients and febrile contacts as outlined and establishment of procedures for activating them.

    3. Identification of appropriate law enforcement entities to enforce isolation and quarantine orders.

    4. Identification of appropriate personnel to maintain and staff facilities.

    5. Establishment of procedures for monitoring and controlling access to facilities.

    6. Establishment of procedures for appropriate disposal of medical waste when using a nonmedical facility.

    7. Establishment of laundry service arrangements (on-site if possible) and appropriate disposal of medical waste.

    8. Arrangement for food service support for facility occupants.

    9. Establishment of procedures for monitoring health status of facility staff and plans for referral to appropriate care.

    SECTION 1: ISOLATION MEASURES. See CDC ISRP Guide C.

    Note that Standard, Contact, and Airborne precautions are recommended for smallpox
    patients in a healthcare facility.

    For guidelines for handling bodies after death from smallpox, see CDC ISRP Guide D,
    under "Autopsy specimens".

    SECTION 2: QUARANTINE MEASURES AS PART OF THE RESPONSE TO A SMALLPOX EMERGENCY

    A. State Quarantine Laws

    In recent years, while quarantine has not been widely employed by states as an infection control measure, Idaho does have current experience with legal isolation through its application to limited numbers of patients with tuberculosis. The Idaho attorney general's office has reviewed state laws regarding quarantine and emergency response to identify gaps. The legislature will consider a proposal in 2003 to strengthen legal authority for quarantine and isolation by public health officials in Idaho.

    A summary of the public health powers needed for adequate response to a bioterrorism event is listed in the CDC ISPR Guide C and is summarized below.

    Public Health Powers Needed by a Health Officer in a Bioterrorism Event

    Collection of Records and Data: Reporting of diseases, unusual clusters, and suspicious events, Access to hospital and provider records, Data sharing with law enforcement agencies, Veterinary reporting, Reporting of workplace absenteeism, Reporting from pharmacies

    Control of Property: Right of access to suspicious premises, Emergency closure of facilities, Temporary use of hospitals and ability to transfer patients, Temporary use of hotel rooms and drive-through facilities, Procurement or confiscation of medicines and vaccines, Seizure of cell phones and other "walkie-talkie" type equipment, Decontamination of buildings, Seizure and destruction of contaminated articles

    Management of Persons: Identification of exposed persons, Mandatory medical examinations, Collection of lab specimens and performance of tests, Rationing of medicines, Tracking and follow-up of persons, Isolation and quarantine, logistical authority for patient management, Enforcement authority through police or National Guard, Suspension of licensing authority for medical personnel from outside jurisdictions, Authorization of other doctors to perform functions of medical examiner

    Access to Communications and Public Relations: Identification of public health officers, e.g. badges, Dissemination of accurate information. rumor control, 1-800 number, Establishment of a command center, Access to elected officials, Access to experts in human relations and post-traumatic stress syndrome, Diversity in training, cultural differences, dissemination of information in multiple languages

    Related Idaho Law:

    In addition of the state and district powers of quarantine listed above, the Governor's explicit powers during a disaster, including the authority to restrict movement of persons, are outlined in the Idaho Code: Title 46 "Militia and Military Affairs", Chapter 20, "State Disaster Preparedness
    Act", section 46-1008, "The Governor and Disaster Emergencies".


    B. Federal Assistance in Enforcement of State Quarantine. See CDC ISRP.

    C. Federal Intervention When State Response is Inadequate. See CDC ISRP.

    Guide D
    Specimen Collection

    The Idaho Bureau of Laboratories, Division of Health, in Boise will soon be receiving the technology and training to rapidly test for (varicella) chickenpox by PCR methods. This technology will hopefully be useful in diagnosing chickenpox rapidly in cases where smallpox may be in the differential diagnosis. For details, contact the Bureau of Laboratories Virology Program:
    208-334-2235.

    CDC has laboratory facilities for testing clinical samples for smallpox.

    No laboratory in Idaho is set up to safely handle clinical smallpox specimens at this time; therefore, all suspect samples must be sent to CDC for testing.

    Approval must be obtained prior to the shipment of potential smallpox patient clinical specimens to CDC. The district or state health department's epidemiology program should be notified immediately if any sample is being collected for smallpox testing; the epidemiology program will assist in obtaining CDC approval for the shipment of samples.

    See the CDC ISRP Guide D for details on specimen collection and shipping. Note that chain of custody documentation may be a critical part of the specimen handling procedures.

    Specific directions regarding the transportation method for the packaged specimens to CDC will be given at the time of consultation.

    Shipping address at CDC:

    Centers for Disease Control and Prevention
    1600 Clifton Road NE
    ATTN: DASH (forward to Dr. Rich Meyer)
    Atlanta, GA 30333

    For shipping questions relating to sending specimens to the CDC, contact

    (404) 639-0075 weekdays/business hours
    (404) 639-4931 - weekdays/business hours
    (770) 488-7100 nights/weekends/holidays

    Guide E
    CDC and Idaho Communications Plans and Activities

    To address public questions, false rumors and misinformation, it is imperative that public hearth officials acknowledge the seriousness of a smallpox outbreak and provide accurate, timely information to the public through the media. Government agencies, including CDC, the Idaho Department of Health and Welfare, and the district health departments, need to respond to media inquiries immediately, and work to maintain effective relationships. The public must perceive that federal, state, and local health officials are effectively responding to the smallpox emergency.
    Together, they must convey a strong impression the public health system is responding in a sound manner and fashion.
    This communications plan is based on the CDC plan found in Guide E of the CDC ISRP, and is grounded in the guidelines that communication experts have recommended for effectively addressing public concerns and fears. These principles of "crisis communication include:

  • Adopting a policy of full disclosure about what is and is not known.

  • Recommending specific steps that people can or should take to protect themselves.

  • Avoiding speculation.

  • Avoiding the issuance of statements or information that is at conflict with that being provided by other government agencies.

  • Delivering information in a non-patronizing manner.

    In the event of an outbreak or highly suspected case, a smallpox Communications Command Center would be immediately established at CDC to help manage communications to the media, health care providers, public health partners, and the general public. This Center will direct all CDC smallpox communications activities, including communications strategy development, key message development, web site development and management, materials development and dissemination, national media relations, media monitoring and all other national communications components. Similarly, the Idaho Department of Health and Welfare would designate a staff member to be the point person for media inquiries, and to spearhead message development.

    Overall Smallpox Communication Objectives

    1. Instill and maintain public confidence in the nation's public health system--and its ability to respond to, and manage, a smallpox outbreak--by providing accurate, rapid, and complete information to calm fears and maintain a sense of order.

    2. Minimize, as much as possible, public panic and fears related to smallpox.

    3. Rapidly provide the public, health care providers, policymakers, and the media access to accurate, consistent, and comprehensive information about smallpox, smallpox vaccine, and the management of the situation.

    4. Address, as quickly as possible, rumors, inaccuracies, and misperceptions.

    5. Provide accurate, consistent, and highly accessible information and materials through the coordination of communication efforts with other federal, state, and local partners.

    Guiding Principles - Smallpox communication plans and activities should be guided by the following primary principles:

  • Effective communications require preparing and disseminating messages and materials right now that will increase public, health care professional, policymaker, media, and key partner knowledge and understanding about smallpox, smallpox vaccine, and health strategies related to smallpox. For example, the public should be educated about smallpox disease containment strategies, such as quarantine and isolation, so that such approaches are understood and accepted.

  • The first suspected or confirmed case of smallpox wilt generate immediate, intense, and sustained public, health care provider, media, and policymaker concern, interest, and demand for information. The reaction will exceed that generated by the first recently reported case of anthrax. It will take an enormous amount of preparation and effort to effectively respond to an enormous public, media, policymaker, and health care provider demand for information and guidance. The public will immediately need to be given information that will help people minimize their risk.

  • The city in which the first confirmed case of smallpox takes place will experience a tremendous amount of media attention, interest, and coverage. The media will nock to the site of the first outbreak. And the public is likely to flock to area hospitals, physicians' offices, and public health offices/agencies. Managing the media demands. along with assisting local hospitals and health care providers in responding to public, practitioner, and media inquiries, will necessitate the deployment of at least two or three communications specialists to the area.

  • A great deal of the initial media, public. health care provider, and policymaker interest and attention will be on the source of the infection--that is, who is infected, how and when did that person get infected, and who else may have been infected. The Idaho public health system needs to be prepared to immediately address these questions related to the source of the initial case and provide guidance to the public regarding disease susceptibility, diagnosis, treatment, and immunization. Further, the number of cases, confirmed, suspected, and potential, will constantly need to be placed into context.

  • Effective smallpox communications encompasses more than media management and relations. Communication centers must also communicate, and address the needs of, state and local health departments, local health care providers and hospitals, and key partner organizations (e.g., professional medical organizations). We need to be able to provide physicians and other health care providers the detailed information they need to identify and treat suspected or confirmed cases of smallpox.

  • To reduce public fear and minimize the spread of rumors, inaccuracies, and misinformation, it is imperative that timely, accurate, and comprehensive information be available immediately in the event of a confirmed smallpox case or outbreak. The public and media must perceive that the public health system is prepared and working.

  • CDC plans on dispatching at least two CDC communications experts to any community that has a confirmed case of smallpox, to coordinate all communications and media relations activities at the field site and to coordinate communications with public and private sector health care providers and agencies. However, it is likely that in the event of a case of smallpox outside of Idaho, no specific aid would be available to the Idaho public health system, and the communications staff from the IDHW will be primarily responsible for message development.

  • Developing. before a confirmed case of smallpox, information resources and materials that can be quickly and broadly disseminated to the media, health care providers, state and local health departments. and other key partners through a wide variety of distribution channels, is critical. Further, authorities for reviewing and clearing smallpox-related messages and materials needs to be established now--prior to a smallpox outbreak.

  • Websites need to be used as a central component to managing the flood of information requests from the public. Strategically-designed websites should be used to organize and quickly provide information, updates, fact sheets, frequently-asked question documents, health care provider resources, including patient and public education materials, and media materials to a range of audiences. Much of the work on these websites should be done before a reported case of smallpox (e.g., created and housed on development web servers that could be activated when needed). In addition, a targeted distribution plan that directs information and education materials will be implemented to help address the needs of health care providers and local health officials.

  • The CDC's National Immunization information Hotline will be utilized to immediately provide information to the public. Specific regional information about clinic locations and, quarantine guidelines will be available through the hotline. Hotline staff will access website information to help them address public questions. The hotline also will be used to provide ongoing guidance to communication staff about new messages and materials that need to be developed to respond to public needs. NIIH Numbers: 1-800-232-2522 or 1-800-232-0233 (Spanish).

  • A toll-free Hotline will be established to provide consultation with district and state health departments and refer the public to clinic locations. Hours of the Hotline may be expanded as needed during the crisis.

  • Systems and methods for rapidly identifying, tracking, and responding to public, health care provider, and media concerns and questions should be established in the pre-event planning phase. This includes contracts for initiating or adding telephone information lines to the Idaho Careline, preparing e-mail response systems, and putting in place Joint Information Centers (JIC) for factual and consistent distribution of information.

  • A portfolio of communication, information, and education sources and materials need to be in place on a range of topics, including: characteristics of the disease, diagnosis (clinical and laboratory), vaccine management and administration (storage and handling, administering the vaccine, contraindications and adverse events) and vaccination and containment strategies (household contacts, case investigation etc) and vaccine safety (e.g., Vaccine Information Statements, adverse event recognition, management and reporting), roles and responsibilities of different agencies (e.g., CDC, FDA, state health departments, local health departments, health care providers, etc.).

  • Recognized and trusted health officials, smallpox experts, and health communications experts should be identified and consulted during the planning and preparation phases to assist in the development of effective messages and materials, including the delivery of public health information to the mass media.

    Pre-Event Communication Objectives (i.e., before a confirmed case of smallpox)

    1. Identify public and health care provider knowledge, understanding, and beliefs related to smallpox, smallpox immunization, and other smallpox-related public health issues, such as quarantine and isolation, vaccine safety, and disease transmission.

    2. Increase public, health care provider, public health official, policy maker, media and key partner knowledge and understanding of smallpox disease, smallpox immunization, and the general approaches/concepts that will be used should there be a confirmed case or outbreak of smallpox; this includes quarantine and isolation, immunization strategies, and vaccine administration.
    Ideally, communications and education will help "de-mystify" smallpox and increase knowledge and understanding of isolating and quarantining smallpox patients.

    3. Identify and develop messages and materials that address public, health care provider, public health official, policy maker, and key partner needs, knowledge gaps, and interests related to smallpox disease, smallpox vaccine(s), and smallpox-related public health strategies.

    4. Increase the range and type of smallpox materials available to the public, health care providers, policy makers, and the media from the IDHW and the district health departments.

    5. Help prepare and establish appropriate public, health care provider, policy maker, and media responses to a smallpox case or outbreak. including an understanding of how the public health system will respond, roles and responsibilities of the different sectors involved, and reasonable expectations regarding the scope and effects of public health actions.

    6. Establish the protocols that would be used to communicate the specific data that would need to be reported daily after a confirmed smallpox case (e.g., morbidity and mortality figures;
    geographic location of cases; number of persons in quarantine; location of immunization clinics;
    number of persons vaccinated, number of doses of vaccine used and available, etc.).

    Event/Post-Event Activities (e.g., after a likely or confirmed case)

    Idaho Smallpox Communications Command Post

    1. Once smallpox has been verified anywhere in the U.S., full-scale communications activities at the Idaho Communications Command Post should be activated. Staffing assessment will be made and personnel will begin staffing the command post for extended hours and days.

    2. Implement at least two dedicated telephone lines to the Idaho Smallpox Communications Command Post so that public health staff can have immediate access. Implement another community phone line for health care providers and public persons who have been quarantined. All other calls will be directed to the CDC's National Immunization Information Hotline.

    3. Activate the emergency "Smallpox" website and bring the website up.

    4. Contact toll free Hotline number and provide them with the Idaho smallpox web site address for information .

    5. Contact state and local government agency partners and provide them with materials that will enable them to respond to media, public, and health care provider inquiries. Implement twice-a-day briefings with these partners.

    6. Create and disseminate a media advisory that provides information regarding the situation, the major actions being taken. information about smallpox, public guidance, and resources.

    7. Rumor control will be the main concern for the first few hours and days, until the organism is definitely identified and confirmed, thus it will be imperative to immediately issue information updates and to correct, as much as possible, errors and misperceptions.

    8. All media and public materials should be posted to the Idaho smallpox website and all Idaho smallpox printed information should provide the website address. The Idaho smallpox websites should be used heavily for most of the media updates related to Idaho smallpox activities.
    It is important that in all contacts with the media, that IDHW's role in this response is made clear.
    Prior to press briefings, interviews. teleconferences, etc., it should be explained that our primary focus is "to identify the public health threat and take actions to protect the public." IDHW will gladly answer questions concerning smallpox and the actions we are taking to contain it.
    Questions concerning the source of the smallpox, how it was dispersed, who dispersed it and why, should be directed to the law enforcement officials involved in the investigation (personnel dealing with the media will be trained on the types of questions they should answer and the types of questions that should be directed elsewhere). IDHW must establish that we are the source for public health information only-- and cannot address questions related to bio-terrorism activities.

    9. Implement daily routines for informing, and responding to, the media, health care provider, partner, and public inquiries.

    a. The Idaho Smallpox Communications Command Post will establish teams patterned along the same lines as pre-outbreak activities (i.e., media, website, public education, health care provider and partner communications). Each team will have a team leader, who will report to the Smallpox Communications Command Post director.

    b. The teams will meet twice daily--at the beginning of a work shift. and at the middle of a shift--for briefings, updates, and to share information and materials.

    c. Should smallpox be affecting Idaho directly (cases or contacts in the state, persons in the state recommended to Set vaccine, etc), public health updates should be posted twice daily to the Idaho smallpox website and sent to appropriate partner organizations ~morning and late afternoon).

    d. The CDC ISRP states they will be planning daily or twice daily teleconferences, preferably around 10 a.m. and 4 p.m.. The briefings will be characterized as public health response updates (not bioterrorism updates) to reinforce the CDC's role in the response. Ideally, the same CDC experts will conduct the media briefings. If necessary, these daily activities can be extended.

    e. Personnel responding to media calls or local community calls from health care providers or quarantined individuals should take notes that enable identification and tracking types of questions and concerns, and as frequently as possible:
    1. post questions and answers to smallpox website,
    2. send to any and all relevant information services (e.g., Hotline and e-mail services). and
    3. state and local health departments and appropriate external partner organizations.

    f. The smallpox content management team at the home base CDC Atlanta will begin identifying and creating new messages and materials that address the emerging questions and concerns of the media. public, health care providers, policy makers, and others. As appropriate and feasible, field team communications staff will tailor smallpox education and communication materials to community needs. IDHW Communications Center staff will work with CDC partners as needed to maintain consistency and accuracy in public health information .

    Role of CDC in Communications

    The interaction between the Idaho Communications Center and the CDC Communications team will vary greatly depending on the nature of the incident, whether it is affecting multiple states or only one state, and whether Idaho is directly involved. The following notes are based on the CDC ISRP regarding the anticipated role of CDC Communications in a smallpox event.

    CDC On-Site Communications Operations
    CDC will establish an on-site JIC in addition to the centralized communications command center located in Atlanta. If an event occurred in Idaho, a JIC would be established here. The Idaho Public Health Preparedness program staff will designate a person or persons to coordinate communication and media activities related to notification of the news media for the local and state health departments, and to work with the CDC field communications liaison (FCL).

    The CDC FCL Media objectives include:

  • Working with state and local officials to instill and maintain public confidence;
  • Facilitating the effective management of local communication efforts and the on-site communications center;
  • Facilitating the provision and management of accurate, timely, and relevant information to the public and media;
  • Assisting in the management of public expectations;
  • Facilitating timely and appropriate responses to errors and misinformation;
  • Enhancing and increasing state and local communication efforts (e.g., helping to obtain or verify information or facts, prepare and debrief subject matter experts, obtain needed information, etc.);
  • Communicating with law enforcement officials to assure a safe and orderly public health and community environment.

    The CDC FCL Media Person will:

    1. Serve as the principal CDC media advisor in the field, and assist the CDC Smallpox Response Team leader in serving, as appropriate, as a media spokesperson. It is essential that the FCL Media person be included as a part of the decision-making team. This means meeting with CDC, State/local health officials, and law enforcement meetings on a regular basis, attending all staff meetings, and being included in all meetings involving issues that will result in media coverage or have an impact on public knowledge, perceptions, opinions, and behavior(s). Once on-site, the FCL should immediately begin to assist in the creation, provision, and management of the flow of information and the coordination of local contacts.

    2. Assist state and local officials in preparing statements and materials to   1) inform the public that there is a suspected (or confirmed) case of smallpox in the city and State,
      2) state that health officials are working with CDC to confirm or rule-out the diagnosis (or to prevent further transmission), and
     3) assure the public that measures to prevent the spread of the disease are being implemented. An initial key message is likely to be: "Only unvaccinated persons who were in close contact (face-to-face) to a person with smallpox are at risk of contracting the disease.
    These persons should get vaccinated as soon as possible.

    3. Work with the CDC Smallpox Communications Command Post to determine the most appropriate messages and timing for the notification of the news media and general public, and to assure proper clearances for messages and materials. This includes developing and utilizing short fact sheets and question-and-answer documents.

    4. Coordinate with Joint Information Centers (JIC) for factual and consistent distribution of information as well as identification of information needs (e.g., frequently asked questions). The JIC will be operational at the beginning of the federal response to the outbreak and will consist of representatives from all local, state, and federal agencies involved in the response to the outbreak. The following information will be coordinated and distributed through the JIC once it is operational :

  • Progress reports / updated information on the latest developments
  • Requests for locating spokespeople and key subject matter experts
  • General disease and vaccination information
  • Public health announcements related to the outbreak
  • Other information requests related to the outbreak which require distribution to the media and general public.
    Once a JIC is operational, all media contacts and information should be handled through this center to assure consistent and accurate information distribution. This includes:
  • Establishing a "news desk operation" to coordinate and manage media relations activities (e.g., handle media requests and inquiries);
  • Providing a place for the CDC, HHS, state, and local communications and emergency response personnel to meet and work side-by-side in handling media inquiries, writing media advisories and briefing documents, providing access to appropriate subject matter experts and spokespeople, etc.
  • Responding to routine (i.e., frequently occurring) media questions with established fact sheets, talking points, and question-and-answer documents.
  • Issuing media credentials
  • Developing, coordinating, and managing local websites

    5. Help develop a list of "authorized" public health spokespeople, and assist in directing local media to previously identified reliable state and local smallpox subject matter experts (e.g., local health officers, infectious disease physicians).

    6. Assist state and local officials in preparing for media interviews, developing media materials, scheduling and managing media interviews, and other arrangements as necessary. This includes assisting in logistics, such as arranging for tables and chairs, media telephone lines, staff telephones, audio-visual equipment, etc.

    7. Work with the General Services Administration (GSA) to lease space for briefing rooms or media response offices and media workspace.

    8. Provide regular updates to the CDC Smallpox Communications Command Center regarding local developments, concerns, and issues. This includes breaking news, frequently asked questions, and local communications and media strategies.

    9. Help arrange and publicize state and local smallpox information resources, such as websites and toll-free information numbers. It will be important to direct routine inquiries concerning state or local programs to the appropriate local program personnel or authorized spokesperson.

    10. Assist in preparing bulletins, Frequently Asked Questions, and Question-and-Answers pertaining to information on the disease, contact tracing, recommendations for vaccination, disease transmission, surveillance activities, laboratory testing, etc.

    Field Communications Media Liaison Initial Actions
    During the initial phase the on-site FCL will establish CDC and HHS as credible sources of information. Messages will convey that CDC and local health officials are effectively addressing the public health issues and their approaches are reasonable, professional, scientific and caring.
    Upon arriving at the affected community, the FCL should:

  • Meet with local health Public Information Officer(s) (PIOs) to assess staffing needs, develop media lists, discuss local political sensitivities, assign duties, determine briefing room location, and determine media needs.
  • Set-up an emergency communications center for the media.
  • Work with GSA to lease space for briefing room and media response offices (if not available through local health department or other local means) and media work space.
  • Work with state and local officials to develop a list of authorized government spokespeople and subject matter experts.
    First contacts should include:
  • Public affairs directors or information officers from local and state health departments (e.g., NPHIC members).
  • City and state government public affairs offices (i.e., mayor and governor).
  • Local congressional delegation and offices
  • Local police and fire departments and emergency management officials
  • Regional HHS Health Officers and Regional Office of Emergency Preparedness
  • Local hospital public relations/affairs departments
  • State and local Emergency Operations Center Coordinators

    Field Communications Liaison Guidelines and Suggestions
    CDC field staff should remember that it is impossible for any one person to handle all aspects of media relations in the event of a smallpox outbreak. A joint information center is the best way to coordinate and manage media relations activities. Public information officers from a wide range of federal, state, and local agencies (e.g., CDC, HHS, state and local health departments, and law enforcement) will need to work side-by-side handling media inquires, writing releases, providing information on their agencies and other duties as appropriate.

    The FCL should establish a daily routine for coordinating and communicating with the various contacts outlined above (especially state and local officials) on media briefings and media materials. Arrange personal briefings. At these briefings, remind those attending that this is confidential information and any public or media release of information should be done through appropriate spokespeople and channels (e.g., media briefings). If people do not respect media guidelines or information embargoes. caution should be exercised when providing them additional information. Cooperation and understanding among all the involved agencies will greatly enhance the success of the media operation. The FCL should work closely with communications staff and officials from focal and state health departments as well as law enforcement agencies.

    Together, these groups will create and manage the flow of information to the media. It will also be important to work closely with mayoral. governor, and Congressional media and communication staff. State and local health department public information officers can offer valuable insights into crucial issues in the state and local community, as well as guidance in dealing with local media. In addition, they can provide information about media contacts, outlets, directories, and telephone and fax numbers to facilitate distribution of information to the media. They may also have facilities and infrastructure for briefings. Don't overlook local hospital media offices. They generally have good relationships with the media, as does the local fire department P1O. In most communities, fire departments deal on a daily basis with the local media and can be one of the FCL's most valuable resources.

    CDC Field Communications Community Liaison (FCCL)
    The CDC field Communications Community Liaison will serve as the principal CDC community relations advisor in the field, and assist the CDC smallpox response team leader in serving as the principal contact point to local hospitals, infectious disease specialists, National Guard officials, and health departments. Once on-site, the FCCL should.

    1. Attend all CDC response team meetings and provide updates to the CDC
    team leader and Media Communications Liaison on community outreach and education activities.
    This should include detailing any encountered or anticipated barriers or problems as well as suggested actions.
    2. Immediately meet with lead local health officials and identify key community partners. Develop and maintain a contact list of key community and state partners. Establish regular briefings with key community and state partners on a daily basis, including members of health care and law enforcement agencies.
    3. Work with the immunization services team members and law enforcement officials to assist in identifying, communicating and safely securing places for "first responders" to receive smallpox vaccine. Key personal identified in first immunization wave include selected local service providers that provide essential non-medical services to quarantined households.
    4. Establish a community phone line to assist in responding to the questions and concerns of state and local health care providers, pharmacists, law enforcement personnel, and any quarantined members of the community. Provide national materials and work with key partners to implement a follow up resource and referral list for phone center staff.
    5. Work with CDC Response team members and local partners to coordinate communication and health education activities by identifying needs, tracking progress and reporting to the CDC smallpox response team leader on key communication and health education activities planned and executed. These activities may include:
     1) information campaigns for the affected community, e.g. planned immunization activities, quarantine information, and/or clinic information,
     2) health care provider education campaigns and activities, including first responders,
     3) education and communication with state and community people involved in meeting community needs or community actions designed to prevent the spread of the disease, and 4) helping to assure quarantined persons have access to essential information on how to obtain needed supplies or services .
    6. Tailoring, as appropriate and feasible, communication and education services and messages to the affected community. This will likely include meeting with community and state partners to identify specific community resources that can be utilized and secured. In addition, the field communications community liaison will work with quarantine teams to customize materials to community and disseminate information and materials to quarantined individuals. Specific issues to be addressed in the materials should include local phone numbers for assistance, along with information for quarantined individuals on how to obtain food, medical care, emergency home care needs (plumbing; electricity), and even recreation services.
    7. Develop a list of key health care facilities in the community and doctors offices for information dissemination purposes and for health education activities. Coordinate with CDC medical team staff in initiating contact with health care providers. Cross train key partners to assist in education and outreach efforts.
    8. Obtain and track information daily on numbers and location of new cases; number and location of new quarantine cases; number and location of immunization efforts, and number of doses of smallpox vaccine used and available. Utilize these reports to prioritize community outreach and education efforts.
    9. Work with the CDC Smallpox Communications Command Post to determine the most appropriate messages and timing for the notification of the community, and to assure proper clearances for messages and materials. This includes working with partners in rapidly identifying community needs, communicating these needs to appropriate program staff and developing information distribution plans.
    10. Provide feedback to and coordinate with the Joint Information Center (JIC) for factual and consistent distribution of information as well as identification of information needs (e.g., frequently asked questions).
    11. Assist in tailoring messages and materials to the affected community (e.g., Frequently Asked Questions documents and information materials on the disease, contact tracing, recommendations for vaccination. disease transmission, surveillance activities, laboratory testing, quarantine, etc.).

    On-Site Media Briefings and Teleconferences
    Generally, media briefings should be no longer than 30 to 45 minutes. The FCL or state/local public information officer should moderate the briefing, as well as begin and end it. The moderator should set ground rules, announce times of future briefings and make housekeeping announcements - for example, asking for contact numbers or email addresses so reporters can be quickly notified of breaking events. Before beginning, the moderator should make sure the television camera operators as well as reporters are ready. The moderator will release general facts - number of cases, deaths (before releasing names, make sure you have family approval), and provide other updated statistics. Do not release any personal information without prior written approval. All interview requests involving victims or victim family members should be coordinated through the FCL or other appropriate public health information officer.

    The moderator should briefly introduce each panel member. including name and spelling, title, agency, expertise, and briefly explain what the panel member will discuss. Each panel member should speak for 3 to 5 minutes on issues related to his/her area of expertise. All questions should be held until all panel members have spoken. Questions should be directed to the moderator, who will either answer the question or refer it to the appropriate panel member. The moderator should conclude the briefing after about 30 minutes by reminding reporters of the next briefing. Following the conclusion of the briefing, all spokespeople should leave. Spokespeople should be advised to avoid participating in individual media interviews with panel members following briefing. The FCL should be notified immediately of any potential issues, including new questions that need to be answered. identified during media briefings. This can include inaccurate information or reports of rumors in the community.

    General Guidelines for Working with the Media

    Establishing credibility and a working relationship with the media is critical.

  • All media requests should go through communications and public affairs personnel. People handling media calls should take the reporter's name, number and affiliation, as well as ask what information they are seeking and what their deadline is.
  • Communications and public affairs personnel handling media inquiries should, as much as possible, assume full responsibility for assisting the reporters--avoid referring the members of the media to other communications staff.
  • Ideally, media calls should be handled by a live voice within 30 minutes, if possible.
  • All media personnel should be treated with the same respect and professionalism-irrespective of the size and scope of the medium's audience. While there is often a greater urgency and priority associated with national media, that urgency should not translate into actions that are disrespectful to smaller media, especially local media. It is important to remember that CDC will be guests in the community, and any slight to local media or local officials can have a long-lasting negative effect. Always be polite and diplomatic.
  • Questions related to criminal investigations or activities should be directed to law enforcement agency personnel. Law enforcement agencies are specifically trained to respond to questions concerning crimes and ongoing investigations. Inappropriate responses in a public setting or to the media can jeopardize criminal investigations or subsequent trials.
  • Spokespeople should have media experience or training.
  • Spokespeople and public affairs staff should be quick, factual, and consistent in dealing with, and responding to, media inquiries.
  • Provide the media with information about what the public and/or health care providers should expect or do. Use media interviews as a way to give advice and guidance to the public and health care providers.
  • Respond promptly to all media calls. Be aware of deadlines. An answer after deadline is as bad as no answer at all.
  • Reply to questions accurately, but avoid providing more information than is requested. Know the key messages and talking points and communicate them frequently.
  • Don't speculate. If you don't know an answer, don't be afraid of saying you don't have that information, but will try to find an answer.
  • Never discuss programs of other agencies beyond what is contained in approved fact sheets or news releases.
  • Repeat the key facts about events. Publicize additional sources of information (e.g., web sites, hotlines, partner organizations).
  • When possible, provide the media with written materials and resources (including websites).
  • Be prepared to describe what is being done, the number of CDC personnel involved, and their general activities and responsibilities.
  • In general, references or referrals to other agencies or programs should not be made without prior approval or notification.
  • Avoid the phrase "No comment." It often is interpreted in a negative light, irrespective of the speaker's intent. Effective alternatives include: "I can't answer that question until we have more complete information." "I don't have that information. But I will try to find and answer for you.
    "I'm not qualified to answer questions on that topic. I will have someone get back with you." "We will have a statement on that shortly.
  • Eliminate obstacles whenever possible. Obstacles imply to reporters that there is an untold story; that something is being hidden from the public. if there is something that cannot be discussed in a public forum, say so. Most reporters will understand.
  • Use judgment when releasing information to the media. Consider possible consequences, and remember to put numerical information into a context. It is important to respond to the media. but always consider the public to be your primary audience.
  • Don't intentionally mislead the media.

    Guide F
    Decontamination Guidelines from CDC ISRP

    Only vaccinated personnel should perform the following decontamination procedures. Protective clothing including, gowns, gloves, shoe covers, caps, and masks should be worn.

    Ideally, all disposable protective clothing worn by decontamination personnel should be placed in biohazard bags and autoclaved or incinerated before disposal. However, if needed due to shortages of protective clothing, re-useable protective clothing that can be laundered may be transported to the laundry in biohazard bags, then laundered using hot water (71° C) and bleach according to the standard proportions recommended by the manufacturer. The contaminated clothing should be wetted before sorting by laundry personnel to help prevent the aerosolization of contaminated particles during sorting. (see Fenner, F, Henderson DA, Arita I, Jelek Z, Ladnyi
    ID. Smallpox and its eradication. Geneva, Switzerland: World Health Organization; 1988: p.194, and Henderson DA, Inglesby TA, Bartlett JG, et al. Smallpox as a biological weapon; medical and public health management. JAMA. 1999; 281(22): 2127-2137).
    Re-useable materials should be laundered on site and all personnel handling laundry must be recently vaccinated (within 3 years). Decontamination personnel should immediately shower with soap and water after the contaminated protective clothing is removed.

    A. Reusable medical equipment
    Reusable medical equipment should be cleaned with a 5% aqueous solution of a phenolic germicidal detergent or other EPA-approved germicidal detergent per manufacturer's recommendations, then decontaminated using one of the following methods. The method selected should be based on manufacturer recommendations for decontamination of the equipment.

    1. Autoclave decontamination- Manufacturers standard protocols for autoclave decontamination may be used.

    2. Ethylene oxide decontamination Equipment that must be decontaminated using this method should be bagged in plastic bags that are permeable to gaseous ethylene oxide. Humidify the material to be sterilized by injecting water into the plastic-bagged material to produce a relative humidity of 50 - 70%. Place the bags into an ethylene oxide sterilizer and allow an exposure of at least 24 hours at a concentration of at least 800 mg per liter ethylene oxide.
    The equipment should be allowed to fully aerate after ethylene oxide decontamination.
    3. Solution soak decontamination - Soak equipment in a 5% aqueous solution of a phenotic germicidal detergent (e.g. industrial strength Lysol or Amphyl, )for at least 1 hour. APIC [ACIP] recommends decontamination should be done with an EPA-approved germicide per
    manufacturer's recommendations.

    B. Medical waste
    Medical waste should be bagged in appropriately marked biohazard bags and incinerated or autoclaved on-site if possible. Alternatively, if on-site autoclaving and incineration is not possible, medical waste may be transported to an appropriate facility for autoclaving or incineration. If incineration takes place in an area other than the facility, the outside of the bag should be sprayed with a suitable disinfectant (e.g. Lysol, household bleach) prior to transportation to the area for incineration. All personnel involved in handling, transportation, and disposal of medical waste from facilities where confirmed or potential smallpox patients are housed must have recent vaccination (within 3 years).

    C. Surfaces
    Contaminated horizontal surfaces may be decontaminated using a 5% aqueous solution of a phenolic germicidal detergent (e.g. industrial strength Lysol, Amphyl, or other commercial decontamination solution). APIC recommends using EPA-approved hospital-grade germicidal detergent per manufacturer's recommendations. All surfaces should be thoroughly wet with the solution. Allow the solution to stand for at least 20 minutes then wet vacuum or wipe with clean cloths or disposable wipes. If a wet vacuum is not available or practical and mops are used, disposable mop heads should be used for no more than 500 sq. ft. of floor area. The cloths or disposable wipes, mop heads, vacuum cleaner contents, and protective clothing worn by the decontamination personnel should be bagged and incinerated or autoclaved. If needed because of material shortages, re-useable protective clothing and cleaning materials that can be laundered may be bagged then laundered using hot water (71° C) and bleach as outlined above. The vacuum cleaner should also be disinfected with EPA-approved hospital-grade germicide per manufacturer's recommendations after use to further disinfect the non-disposable parts of the vacuum cleaner (nozzle, hose, etc.).

    D. Protective clothing, bedding, linens, etc.
    Contaminated protective clothing should be bagged immediately after removal and then incinerated or autoclaved. However, if needed due to shortages of protective clothing, reuseable protective clothing that can be laundered may be bagged then laundered using hot water (71° C) and bleach as outlined above. Bedding, linens, clothing, or other reusable cloth materials may be autoclaved or laundered using hot water (71° C) and bleach as outlined above, Mattresses and pillows should be cleaned with EPA-approved hospital-grade germicide per manufacturer's recommendations.

    E. Room/facility
    Facilities or rooms that were used to house smallpox patients should be decontaminated once they are no longer used to house such patients. All disposable items should be bagged and incinerated or autoclaved.
    1.All horizontal surfaces, furniture, fixtures, and walls should be decontaminated as outlined in C above.
    2. All mattress covers, curtains, clothing, and other removable cloth items should be bagged and autoclaved, incinerated, or laundered in hot water (71° C) and bleach as described.
    3. Items that should not be autoclaved or incinerated should be bagged and decontaminated using EPA-approved hospital-grade germicide per manufacturer's recommendations as outlined above.

    If smallpox patients are housed in their own homes, at a minimum, the following decontamination procedures should be performed:
    1. All disposable items that came into contact with the smallpox patient should be bagged and incinerated. If incineration takes place in an area other than the home where the patient was housed, the outside of the bag should be sprayed with a suitable disinfectant (e.g. Lysol, household bleach) prior to transportation to the area for incineration.
    2. Bedding, linens, clothing, curtains, or other cloth material that came into contact with the smallpox patient should be transported in biohazard bags to be laundered using hot water (71° C) and bleach or incinerated (see step 2 above).
    3. Surfaces, furniture, fixtures, and walls should be thoroughly cleaned with a 5% aqueous solution of a phenolic germicidal detergent (e.g. Lysol, Amphyl).
    4. Carpets and upholstery should be cleaned using an EPA-approved hospital-grade germicide per manufacturer's recommendations.

    F. Vehicles (e.g, ambulance)
    Ambulances should be decontaminated after transporting a smallpox patient(s) before re-use to transport non-smallpox patients. Wet decontamination and cleaning of the entire passenger compartment and all door handles should be done as outlined below:
    1. All items that can be incinerated or autoclaved should be bagged and processed by one of these methods.
    2. Heat-sensitive, reusable items should be sterilized using ethylene oxide as outlined above.
    3. Larger items such as the stretcher should be decontaminated at the same time as the ambulance.
    4. Spray the entire interior of the ambulance heavily (until the solution runs off) with a 5% aqueous solution of a phenolic germicidal detergent (e.g. Lysol, Amphyl). Personnel performing this step should wear respiratory protection.
    5. Allow the solution to stand on all surfaces for at least 20 minutes.
    6. Wet vacuum or wet clean with clean cloths, disposable wipes, or mops with disposable mop heads, all surfaces inside the ambulance and all outside door handles
    7. Vacuum cleaner contents, cloths or disposable wipes, mop heads, and protective clothing worn by the decontamination personnel should be bagged and incinerated, autoclaved, or laundered as outlined above.
    8. The vacuum cleaner should be disinfected with EPA-approved hospital-grade germicide per manufacturer's recommendations after use. The above procedures may not be possible for private vehicles used to transport smallpox patients. At a minimum, the following decontamination procedures should be performed:
    1. All disposable items in the vehicle should be bagged and incinerated.
    2. All surfaces in the vehicle should be thoroughly wiped down with EPA-approved hospital-grade germicide per manufacturer's recommendations.
    3. Carpets and upholstery should be cleaned using EPA-approved hospital-grade germicide per manufacturer's recommendations. The solution should be allowed to remain on the carpets and upholstery for at least 20 minutes before being wiped off. Cloth upholstery should be allowed to completely dry before use.
    4. All outside door handles should be thoroughly cleaned using EPA-approved hospital-grade germicide per manufacturer's recommendations.
    5. All cloths used to wipe down the inside of the vehicle should be laundered using hot water (71° C) and bleach or bagged and incinerated (see above).


    [End, 34 pages total, 16,755 words]

    Smallpox Alert!
    VacLib
    and The Idaho Observer in conjunction with several vaccine awareness activists have printed the Smallpox Alert! in response to the constant stream of propaganda we are being fed on this.

    Smallpox Alert! 8 - 17" by 11" pages of newsprint includes:
    *Historical overview of smallpox, smallpox vaccine and public health -- although this information is well-documented, it is relatively unknown
    *Applicable excerpts from the DryVax smallpox vaccine packet insert
    *Statements made by officials at the CDC proving that its smallpox plan is the recipe for a public health disaster
    *A variety of articles covering the full spectrum of smallpox and vaccine issues
    *How to protect yourself and your loved ones from this planned smallpox pandemic

    100 newspapers for $15 + $8 S&H = $23.
    Each paper can be mailed to friends and relatives with one 37 cent stamp.
    The full text of the second edition with pictures and graphics is posted at www.vaclib.org


    Send a check or money order made payable to: The Idaho Observer
    PO Box 457
    Spirit Lake, Idaho 83869
    (208) 255-2307

    If you prefer to place an order with a credit card, you may order online using PayPal at http://www.vaclib.org or call Tetrahedron Publishing at 888-508-4787.