Smallpox Preparedness and Response Plan
Submitted to CDC on December 1, 2002
Updated on January 3, 2003
No one in the world has contracted natural smallpox since 1977; smallpox was declared eradicated in 1980. A single case of smallpox anywhere in the world would now be considered an act of terrorism, and a national and international emergency. The purpose of this plan is to describe the critical actions that are being taken to prepare Vermont’s public health, health care and public safety responders to quickly detect smallpox—and limit exposure to, transmission of, and death from the disease.
This plan outlines the strategies and approaches that will guide the public health response to a smallpox emergency. This plan will be regularly updated to reflect changes in federal guidelines and policies, as well as changes in national and local capacities and resources.
Vermont’s plan is modeled on guidelines from the Centers for Disease Control and Prevention (CDC), and is in accordance with the Federal Response Plan, the Vermont Terrorism Response Plan, and applicable state laws.
The commissioner of health has the power and duty to supervise and direct the execution of all laws relating to public health. Vermont law requires health care providers, hospitals, school health officials, laboratories and others to transmit a report of a reportable disease (such as smallpox) to the commissioner of health. The commissioner of health has statutory power to quarantine a person diagnosed or suspected of having a disease dangerous to the public health.
Description of Jurisdiction
Vermont is a small rural New England state, bordered on the south by Massachusetts, the east by New Hampshire, the west by New York and Lake Champlain. On the north is the international border with the Canadian province of Quebec. Vermont is approximately 180 miles north to south and just over 90 miles east to west at its widest point, covering 9,250 square miles. The state is divided north to south by the Green Mountains, with few direct east-west transportation corridors.
Vermont’s population of 610,000 ranks 49th in the nation. The population of the largest city, Burlington, is 39,000. There is one Metropolitan Statistical Area centered in Burlington with a total population of 163,700. Seventy-two percent of the population resides in rural communities. Montreal, Quebec, is the closest large city, with 3.4 million population. Tourism brings in an estimated 3.5 million visitors each year. Peak tourism periods are summer and fall.
Vermont has a system of state and municipal government, but no county government.
Organization and Management
This plan is modeled on CDC guidelines and built upon the strengths and current organization of Vermont’s system of local governance, community partnerships and public health, health care and emergency response systems.
Vermont’s public health system is based on a centralized Department of Health and laboratory in Burlington, with 12 district health offices located throughout the state. In each district office are public health nurses trained in epidemiology and linked directly with the central office. The Vermont Department of Health has strong and long-standing ties with hospitals and primary care providers statewide. There are 14 community hospitals, including Fletcher Allen Health Care in Burlington, which is a tertiary care facility. There are also tertiary care hospitals nearby in Lebanon, NH and Albany, NY, and a Veterans’ Administration hospital in White River Junction, VT.
The Vermont Department of Public Safety, including the state’s Office of Emergency Management, Emergency Operations Center (EOC) and state police headquarters, are located in Waterbury. The state police force is organized into four Regional Terrorism Management Districts, each directed by a troop commander and containing one or more state police barracks.
Many fire and emergency medical services are provided through volunteer services, organized into 13 districts that roughly correspond to county lines. Health Department directors of district health offices represent public health on 11 Local Emergency Planning Committees (LEPCs).
Vermont has a well-developed and practiced state emergency management system, employing an Incident Command System (ICS) in an Emergency Operations Center (EOC) and Joint Information Center (JIC) to respond to any major emergency. The Vermont Department of Health is well represented at the EOC and has primary responsibility for public health response and public health information. The Vermont Department of Public Safety (including the Office of Emergency Management and the Vermont State Police) has primary responsibility for managing emergency operations and logistics, and directing public safety and law enforcement response. Depending upon the situation, the EOC also includes representation from the Vermont National Guard, the Vermont Association of Hospitals and Health Systems, the Vermont Chapter of the American Red Cross, the Vermont Agency of Human Services, and other government departments and agencies.
Smallpox is a serious, contagious, sometimes fatal disease caused by the variola virus, which emerged in human populations thousands of years ago. Smallpox was eradicated in 1980 following a successful worldwide vaccination program. The last case of smallpox in the U.S. was in 1949; Vermont’s last case was in 1937. No one on earth has contracted natural smallpox since 1977. In the U.S., routine vaccination among the general public was discontinued in 1972, when the risk of serious adverse reaction (including death) from the vaccine outweighed the actual threat of disease. No country has vaccinated children since 1984.
The deliberate release of variola virus to start an epidemic of smallpox is now regarded as a possibility. Smallpox is classified as a Category A (most serious) terrorist agent by the Centers for Disease Control and Prevention. This is due to concern that variola virus may exist in locations other than two government laboratories, in the U.S. and Russia, and could be used as a weapon against a largely susceptible population. For these reasons, the U.S. government and the states are making preparations to be ready respond immediately and effectively to a case of smallpox anywhere in the world.
Smallpox Disease Transmission
Generally, direct face-to-face contact (within 3 to 6 feet) is required to spread smallpox from one person to another. Smallpox can also be spread through direct contact with infected bodily fluids or infected objects such as bedding or clothing. In a terrorist attack, exposure to smallpox could occur by breathing airborne virus.
Historically, smallpox kills 30 percent of unvaccinated people who develop symptoms. Smallpox can be prevented through the use of the smallpox vaccine. There is no proven treatment for smallpox disease, but research to evaluate new antiviral agents is ongoing. According to CDC, vaccination within three days of exposure will prevent or greatly lessen the severity of smallpox symptoms in the vast majority of people. Patients with smallpox can benefit from supportive therapy (e.g. intravenous fluids, medicine to control fever or pain) and antibiotics for any secondary bacterial infections that may occur.
- Exposure to the virus is followed by an incubation period during which people do not have any symptoms and may feel fine. This incubation period averages about 12 to 14 days, but can range from seven to 17 days. During this time, the person is not contagious.
- The first symptoms of smallpox include fever, malaise, head and body aches and sometimes vomiting. The fever is usually high, in the range of 101 to 104 degrees Fahrenheit. At this time, people are usually too sick to carry on their normal activities. This is call the prodrome phase and may last for two to four days. During this time, the person is possible contagious.
- A rash then emerges, first as small red spots on the tongue and in the mouth. These spots develop into sores that break open and spread large amounts of the virus into the mouth and throat. At this time, the person becomes highly contagious.
Around the time the sores in the mouth break down, a rash appears on the skin, starting on the face and then spreading to the arms and legs and then to the hands and feet. Usually the rash spreads to all parts of the body within 24 hours. As the rash appears, the fever usually falls and the person may start to feel better. By the third day of the rash, the rash becomes raised bumps. By the fourth day, the bumps fill with a thick, opaque fluid and often have a depression in the center that looks like a bellybutton. (This is a major distinguishing characteristic of smallpox.) Fever often will rise again at this time and remain high until scabs form over the bumps.
Over the next five to 10 days, the bumps become "pustules"—sharply raised, usually round and firm to the touch, as if there’s a small round object like a BB pellet embedded under the skin. The pustules begin to form a crust and then scab. By the end of the second week after the rash appears, most of the sores have scabbed over. Next, the scabs begin to fall off, leaving marks on the skin that eventually become pitted scars. Most scabs will fall off after three weeks.
The person infected with smallpox is contagious to others from the time the rash first emerges as small red spots on the tongue and in the mouth until all of the scabs have fallen off.
The smallpox vaccine helps the body develop immunity to smallpox. The vaccine is made from a virus called vaccinia, which is a "pox"-type virus related to smallpox. The smallpox vaccine contains the "live" vaccinia virus—not dead virus like many other vaccines. For this reason, the vaccination site must be cared for carefully to prevent the virus from spreading. The vaccine does not contain the smallpox virus and cannot give the vaccinated person smallpox disease.
According to CDC, the first dose of the vaccine provides protection for three to five years, and decreasing immunity thereafter. If a person is vaccinated again later, immunity lasts longer. Historically, the vaccine has been effective in preventing smallpox infection in 95 percent of those vaccinated.
The use of smallpox vaccine in focused "ring vaccination" campaigns that used intensive surveillance (searching for cases) and contact tracing during the smallpox eradication program helped bring about the global eradication of smallpox. Vaccinating and monitoring a "ring" of people around each case and contact protects those at greatest risk for contracting the disease, and forms a buffer of immune individuals to prevent the spread of disease.
Production of smallpox vaccine ended in the early 1980s. The currently supply is limited; however, the U.S. government has a large enough stockpile of smallpox vaccine to vaccinate everyone who might need it in the event of an emergency. Production of new vaccine is underway.
For most people, smallpox vaccine has been safe and effective. But because it is produced from a living virus, vaccinia, the vaccine can infect and harm some people. In the past, between 14 and 52 people per 1 million vaccinated experienced potentially life-threatening reactions, including severe eczema and encephalitis. Based on past experience, it is estimated that one or two people out of every 1 million people vaccinated will die as a result of life-threatening reactions to the vaccine. Careful screening of potential vaccine recipients is essential to ensure that those at increased risk do not receive the vaccine.
There are a number of people for whom smallpox vaccine would be dangerous, and vaccination is contraindicated. Careful screening is essential to minimize complications from the smallpox vaccine. Women who are pregnant or planning to become pregnant, people with eczema, HIV/AIDS patients, organ-transplant recipients, and chemotherapy patients should NOT be vaccinated. However, if someone has been exposed to the smallpox virus, these contraindications do not apply.
Two treatments may help people who have certain serious reactions to the smallpox vaccine. These are Vaccinia Immune Globulin (VIG) and cidofovir. Currently there are 700 doses of VIG on hand (enough for predicted reactions with 6 million people vaccinated), and 3,500 doses of cidofovir (enough for predicted reactions with 15 million people vaccinated). Additional doses of VIG are being produced, and measures are underway to increase supplies of cidofovir as well.
Summary Of Vermont’S Smallpox Response Plan
Although there are a number of different ways in which a suspected case of smallpox could present itself, the following describes possible stages of a smallpox outbreak affecting Vermont, and the critical actions that would be taken by medical, public health and public safety responders to prevent or limit the spread of the disease. This plan envisions a rapid, flexible response to a smallpox event as it evolves.
In making this presentation, we assume that public health rapid response teams are vaccinated and ready to respond anywhere in the state, and Health Department district offices are ready to quickly set up clinics to vaccinate in an expanding "ring" around smallpox cases.
The Health Alert Network (HAN), which has been in place in Vermont for several years, electronically links public health professionals at the local, state, and national level. CDC, state and local health departments are part of this network to quickly share critical information regarding serious threats to the public’s health. Health care providers in Vermont have been alerted to the possibility of smallpox and have received basic education about how to recognize, triage, treat and report suspected smallpox cases.
First Alert: Smallpox has been identified somewhere in the world:
The Vermont Department of Health receives the first alert of smallpox via the Health Alert Network (HAN). The health commissioner notifies the governor and the secretary of human services, and they decide who else should be notified. The deputy commissioner notifies the director of the Vermont Terrorism Task Force, director of emergency management, and the EOC duty officer makes further notifications. The Department of Public Safety convenes the EOC, if only for an initial briefing. Emergency response staff at the Health Department and Public Safety Department review pre-event plans, update materials, evaluate staffing capacities, and intensify education and training.
Via HAN, the Health Department (epidemiology staff) notifies health care providers, hospitals, infectious disease specialists, state hospital and home health agency associations, and medical laboratories in the state to intensify active surveillance to detect possible cases in Vermont. Hospitals and health care providers establish or review protocols to triage, isolate, and care for patients with fever/rash, and prepare isolation rooms for patients with suspected smallpox fever/rash illness.
The commissioner of health, with the director of emergency management, designates at least two hospitals as regional referral facilities to receive, isolate and treat smallpox patients in the event that the number of patients exceeds the capacity of community hospitals. The Health Department (emergency medical services program staff) alerts four previously designated and vaccinated interfacility transfer ambulance teams, and reviews protocols and procedures, staffing, supplies and equipment.
The Health Department (immunizations program staff) determines the next group of public health and health care workers and first responders to be vaccinated if that becomes necessary, and reviews vaccination guidance from CDC. Health Department immunization program and district office staff vaccinate designated responders as soon as vaccine is shipped to Vermont.
The Health Department (communications staff) intensifies its public information campaign on smallpox.
A case of smallpox in North America is confirmed:
Via HAN, the Vermont Department of Health receives notification of the first case of smallpox in North America. The health commissioner notifies the governor and the secretary of human services, and they decide who else should be notified. The deputy commissioner notifies the director of the Vermont Terrorism Task Force and the director of emergency management, and the EOC duty officer makes further notifications, including other state and local offices of federal agencies, the Border Patrol, the American Red Cross, and all law enforcement authorities. The Health Department district offices notify other co-located state agencies. Via HAN, the Health Department notifies all public health and health care providers, institutions and laboratories.
Pre-designated regional referral facilities review protocols and prepare premises in case it becomes necessary to care for patients. Health Department district offices prepare to supervise vaccination of confirmed contacts in clinics.
The Department of Public Safety briefs state police, security and other law enforcement personnel and reviews protocols, procedures, precautions and use of protective equipment.
Health Department (communications staff) intensifies public information, promotes www.HealthyVermonters.info smallpox web site and smallpox hotline for public inquiries, emphasizing actions citizens can take to avoid disease and help others. All departments within state government review emergency personnel reassignment procedures, and confirm available staffing.
Suspected or confirmed case of smallpox in Vermont, Quebec, New Hampshire, Massachusetts, or New York, or Vermont contact of a confirmed case of smallpox:
Suspected or confirmed case of smallpox in Vermont is reported to Health Department epidemiology staff via the 24/7 disease reporting hotline—CDC notifies Vermont of any case of smallpox in a bordering state or province.
For any of these situations, the Health Department issues notifications via the Health Alert Network immediately. Health Department (epidemiology) notifies CDC of any suspected case in Vermont.
The EOC is fully activated, with Joint Information Center (JIC), and full staff operating 24/7. As soon as Vermont has a confirmed case or contact of a confirmed case, governor is briefed regarding the possibility of declaring a State of Emergency. Public information and regular media briefings are now coordinated by the JIC. Health Department epidemiologists interview Vermont contacts to ensure all appropriate public health measures are instituted. Health Department requests vaccine from CDC to be delivered to Vermont to prepare for "ring vaccination" around confirmed contacts or cases, or voluntary mass vaccination clinics.
One or more Vermont contacts:
Health Department (epidemiology) continues active surveillance (daily reporting of fever/rash illness from all health care providers and hospitals). All contacts are interviewed and monitored in accordance with CDC and Health Department protocols, and using CDC forms and data management tools. Health Department district office staff, working with local hospitals and health care providers, educate families of contacts about risk, protective measures, fever monitoring, and isolation. District offices hold vaccination clinics for contacts and their families.
The EOC arranges secure transport of vaccine, security for vaccine clinics and isolation facilities, and assists with emergency communications and other logistical support functions. As the number of Vermont contacts grows, staffing, and the number of clinics and facilities are expanded according to plan. The Health Department may request assistance from other parts of state government, CDC and volunteer organizations.
One or more Vermont cases:
Any person appearing for medical care will be immediately isolated and evaluated, using CDC guidelines to determine if they are suspected of having smallpox. Confirmatory testing will be arranged. Any contact of a smallpox case who develops fever and smallpox rash is transferred by pre-designated interfacility transport ambulance, staffed with vaccinated and trained personnel, to regional referral facility for isolation and treatment.
Upon recommendation from the health commissioner, the EOC opens regional referral hospitals; patient assignments are managed by the EOC’s Patient Coordination Unit. Health Department epidemiologists interview each case-patient and all close contacts. The hospital laboratory takes specimen samples from the case-patient; the EOC arranges secure transport of specimen samples to the Health Department laboratory for testing to rule-in varicella (chickenpox), with possible relay to CDC laboratory for confirmatory testing for variola (smallpox).
The EOC briefs the governor about the possibility of activating the Emergency Medical Assistance Compact (EMAC) to request assistance from other states, or declaring a State of Emergency and requesting federal assistance from FEMA.
NOTE: If Vermont cases are among the first in the U.S., the Vermont Department of Health, Vermont Department of Public Safety, CDC, FBI or other federal agencies will collaborate in a joint public health/law enforcement investigation. The clinical specimen would be transported by the FBI (or Vermont National Guard) directly to CDC for testing. These agencies would also join the JIC and coordinate release of public information via regular media briefings, news releases, interviews, web site updates, emergency hotlines and emergency alert system messages.
Once CDC has confirmed cases nationally or in Vermont, further CDC laboratory confirmation of cases likely will not be required. As the number of Vermont cases grows, staffing, training, vaccination clinics, isolation and observation facilities, regional referral facilities, etc. will be expanded according to plan. The Health Department may request additional assistance from other parts of state government, CDC, and volunteer organizations, according to plan. Patient transfer is coordinated by the EOC.
Depending on the number of cases and contacts in the state, in the region, or nationally, and the manner in which these cases occurred (that is, the method of introduction of virus into the population), the Vermont Department of Health, in close consultation with CDC, may quickly move to voluntary smallpox vaccination clinics for the larger community or the general population. The Health Department (community public health and immunization program staff) conducts clinics at pre-designated sites.
All public health measures and public information campaign continues until smallpox outbreak is ended and recovery is complete.