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 features | Varicella:
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.
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
P.O. Box 235 Hayden, ID 83835-0235
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.
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