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Hospital in the heartland is smallpox success story
Team undersized, but immunized
While much attention has been focused on adverse reactions following smallpox vaccination, the story of hospitals that have successfully completed the program has been somewhat overshadowed.
One such facility is Methodist Hospital in Omaha, NE, where 22 immunized health care workers now form a core smallpox response team.
Though the hospital did not reach its target of 39 immunized workers, it now has the essentials in place to respond to a bioterrorism release of smallpox, says Sandy Vyhlidal, RN, MSN, CIC, coordinator of epidemiology at Methodist.
"That’s what we ended up with," she says. "We have a plan if a true event occurred. We will take those 22, and they will quickly vaccinate our staff. Those who are vaccinated then will be trained to give the vaccine and expand our team. We could roll that out pretty quickly."
The most common adverse effects were the expected mild reactions, she says. Itching (100%) and swelling (58%) at the site were the most frequently reported mild reactions. No moderate or severe reactions (progressive vaccinia, encephalitis, cardiac event, or death) occurred. One worker missed two days of work related to a fever and chills; another left work left work early two days due to fatigue. Although the numbers are small, those who were vaccinated had positive outcomes, she emphasizes.
Groundwork in place
Part of the reason the program went smoothly is that the groundwork already was in place when the federal government made the historic offer of smallpox vaccine to thwart a bioterrorism attack. A group of safety officers, emergency room managers and infection control professionals from several Omaha hospitals started meeting in 1998 to address bioterrorism events in a citywide, standardized approach, she says.
"When we talked to emergency room and infection control people we realized we had no plan other than a disaster plan and triage," she says."
So we started meeting. It started with a handful of hospital people, and it just expanded from there. By the time 9/11 occurred, there were a lot of people who wanted in. [In Nebraska], we had all the hospitals buying in to work together as a team," Vyhlidal explains.
At 430-bed Methodist Hospital, plans moved forward to establish a smallpox response team plan.
One goal was to be able to care for a patient with known or rule-out smallpox in case of a bioterrorism event. Secondly, planners wanted to be able to vaccinate the remaining hospital and clinic employees within three to four days of an actual threat of smallpox. It was determined that a minimum of 38 physicians and nurses were needed for the pre-event team.
At the onset, the decision was made to restrict the volunteer vaccinees from care of high-risk patients, including those who were immune suppressed, pediatrics, and surgical patients undergoing wound-opening procedures.
"[We] felt that we needed to go the extra step for the patients we serve," she says. "Any chance of that virus in an open wound and there could be a blown-out full vaccinia situation."
The hospital had 69 volunteers after an initial mailing and education effort explaining the program. The preliminary screening tool was returned to Vyhlidal, who clarified any risk factors denoted on the form with the volunteer.
"My job was take the screened candidate and make sure that those who met our criteria initially got this education," she says. "We wanted them to fill out this detailed screening tool, and I went over it again. Sometimes, I would put a question mark, then I would make a phone call and say, Tell me more about this.’"
If no risk factors were identified, volunteers were scheduled for the vaccination and a follow-up "take" assessment. Vyhlidal became the contact person for rescheduling or canceling appointments after the original schedule was completed. "I was the liaison with the health department; the last filter," she says.
After completing self-screening tools, and attending educational presentations, 43 volunteers were exempted from the program. The most common reasons for the deferral were personal skin conditions (23%), followed by the 16% of volunteers who objected to being temporarily reassigned to a lower-risk patient population.
"Some staff didn’t want to be rescheduled," she says. "It was a personal preference whether they were willing to work elsewhere for about three weeks."
After education and screening, 27 volunteers attended the vaccination clinic; one was deferred due to an identified family risk issue related to a skin condition. Therefore, 26 were vaccinated, but four ultimately did not have adequate takes to meet immunization criteria.
Adhesive irritation reported again
While there were no serious reactions, an interesting finding was skin irritation from the tape and adhesive on the transparent dressing. A similar problem — adverse skin reactions to the adhesive on the semipermeable dressings — was recently discussed in Atlanta at a meeting of the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee.
Vyhlidal says she found that 23 (88%) of the 26 immunized workers reported skin irritation from tape or adhesives on the dressing. Of those 23, eight people reported skin breakdown and blisters.
"The health department chose the dressings; so when that didn’t work, I went to two transparent dressing products that we had that would fit over the gauze," she says. "That helped all of them except one. It didn’t matter what I used or how I put the dressing on, she just continued to get blisters. She wanted to work, and she knew she had to have the dressing on, so she put up with it until the scab fell off."
No neutral observer, Vyhlidal was immunized and was on hand to scrutinize the health department’s careful process of providing the vaccinations. "It is important that at least one person in infection control be immunized, so we can be in the hub of the situation," she says.
"The health department [staff were] very good [aseptically]. They used the needle once, holding it in a downward position so that the vaccina was on the probe of the needle. They wore gloves. When they punctured the skin site, they threw that needle away and took off their gloves immediately. They used an alcohol hand de-germer immediately and then did their paperwork. It was a very good process," Vyhlidal adds.