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Transcript of Web-assisted Audioconference
This Web-Assisted Audioconference, broadcast on March 3, 2003, was the first in a series on bioterrorism conducted throughout 2003 via the World Wide Web and telephone. This Web conference was designed to address the issues and activities related to preparing our Nation to respond to the potential threat of a smallpox outbreak. The User Liaison Program (ULP) of the Agency for Healthcare Research and Quality (AHRQ) developed and sponsored the program.
Jeffrey Levine: Welcome to Addressing the Smallpox Threat: Issues, Strategies and Tools. This is the first event in a series of Web-Assisted Audioconferences on bioterrorism and health systems preparedness designed for State and local health policymakers and health systems decision-makers. This series is sponsored
by the U.S. Department of Health and Human Services, Agency for Healthcare Research
and Quality, often referred to by the acronym AHRQ.
My name is Jeffrey Levine and I will be your moderator for today's session.
The context for these calls is clear and compelling. Bioterrorism represents
a significant public health threat to the United States. Addressing this threat
requires the rapid development of Federal, State and local capacity to respond
to potential bioterrorism events. To be as effective as possible, these efforts
must be directed toward improving the abilities of both our public health system
and our health care delivery system, including the individual systems of care,
facilities and clinicians that comprise the latter to detect and respond to
In addition, these efforts must ensure that all of these components communicate
and coordinate effectively with one another and with other related systems
such as emergency preparedness and law enforcement. The State and local health
policymakers, program administrators and health system decision-makers, the
intended audiences for these calls, all play an essential role in these efforts.
Within their own jurisdictions, regions or delivery systems they must develop
capacity and coordinate efforts across public health, health care, law enforcement
and related systems. It is therefore extremely important that they have information
about emerging health services research, promising approaches and available
tools that assist in the development of readiness plans.
In addition to today's event, four other calls will be conducted as part of
this series. The next call, scheduled for April 15, will examine issues, experiences
and tools related to disaster planning drills and readiness assessment. The
third call on June 17 will focus on surge capacity assessments and regionalization
issues. The topics for the fourth and fifth calls will be selected at a later
date. I will tell you more about these calls later in the broadcast, but right
now let's turn to today's discussion of important activities, health services
research and newly-developed tools that can help our health care system be
prepared to address the threat of a bioterrorist-caused outbreak of smallpox.
Let me begin by introducing today's panelists. In the studio with me I have
William Raub, Deputy Assistant Secretary in the Office of Public Health Emergency
Preparedness at the Department of Health and Human Services; Nancy Ridley,
Assistant Commissioner of the Massachusetts Department of Public Health; Eddie
Gabriel, Deputy Commissioner for Preparedness in the New York City Office of
Emergency Management; Nathaniel Hupert, Assistant Professor of Public Health
and Medicine at the Weill Medical College of Cornell University; and Thomas
Terndrup, Director of the Center for Disaster Preparedness and Professor and
Chair of the Department of Emergency Medicine at the University of Alabama
Welcome everyone and thank you for joining us. Before we begin our discussion
I would like to tell you a bit about the format of this audio conference. Discussions
with our five panelists will be followed by a question and answer session in
which we will open the lines to take your questions. We will provide you with
instructions on how to send us your questions later on in the program. In the
meantime, if you experience any Web-related technical difficulties at any time
during this event, please click on the "Help" button in your window
to troubleshoot your Web connection. If it appears that the slides are not
advancing, you may need to restart your browser and log on again. If you are
on the phone, dial "*0" to be connected to technical assistance.
Also, if you have any difficulty with the audio stream or if there is an uncomfortable
lag time between the streamed audio and slide presentation, we encourage you
to access the audio via your phone. The number is 1-888-496-6261 and give the
password "bioterrorism" to be connected to the call.
Now I think we are ready to be ready to discuss today's topic, Improving Health
Systems Preparedness to Address the Potential Threat of Smallpox Outbreak.
Let me begin with Bill Raub, Deputy Assistant Secretary in the Department of
Health and Human Services' Office of Public Health and Emergency Preparedness.
Bill, why is smallpox the number one bio-threat agent?
Dr. William Raub: Several considerations come together to put smallpox right
at the top of the list in terms of threat agents. First off, it is highly lethal.
Thirty percent of people exposed can expect to die and of those who survive
there can be lifelong serious morbidities of various types.
Second, the disease is readily communicable from person to person. Respiratory
droplets are sufficient to carry the virus and therefore ordinary day-to-day
contact can be a sufficient exposure to move along the disease.
Third, few people have effective immunity. One of the great triumphs in the
history of public health was the eradication of smallpox from the world, so
declared in 1980 by the World Health Organization. The United States stopped
vaccinating in the 70's and individuals born since that time have no immunity
and those of us who were vaccinated earlier have little or none, depending
on the length of time involved.
Fourth, we have no established treatment. The vaccine itself is protective
within a few days of exposure but once the symptoms present, we have no drugs
or other means to treat much less to cure this disease.
Last but not least, enemies of the United States are going to have the variola
virus, the virus that causes smallpox. We know that the former Soviet Union
produced huge quantities of the virus for its biological weapons program. With
the break up of the former Soviet Union, as scientists and engineers left that
country, we fear that they left with more than their know-how. They may indeed
have left with samples of the virus involved.
Jeffrey Levine: What is the scope, Dr. Raub, of the current smallpox vaccination
Dr. Raub: First I would stress that the program is entirely voluntary. Smallpox
does not exist in the world right now; therefore we believe it would be inappropriate
to have any mandatory vaccination campaign for a disease that does not exist.
But because of the bioterrorist threats some preparation seems important. So
we have identified three stages. The first stage is a focus on epidemiological
response teams, that is, the individuals who would be called upon to investigate
the first suspected or actual cases of smallpox and therefore would likely
be the first individuals exposed.
Second would be other health care workers. Public safety personnel, others
who once there were an outbreak of smallpox would be among the very first to
be exposed to cases and who would want to be protected to be able to carry
out their basic responsibilities.
Stage three, as declared by the President, would open this eventually to private
citizens, as he put it, "those who insist upon being vaccinated."
Jeffrey Levine: Why is the program limited in this way?
Dr. Raub: We placed the limits as a trade-off between the fact of the absence
of smallpox at the moment and the fact that the vaccine, while highly effective,
can nevertheless provoke serious adverse effects. The approach therefore is
to offer the opportunity for vaccination to those at the highest occupational
risk but not to require it, to leave it to the best judgment of those individuals
and their employers as to whether they should be vaccinated now.
The United States is prepared, thanks to extensive planning by each of our
States, to do large-scale vaccinations should there be an actual outbreak,
but we are recommending that those in the first line of exposure, the epidemiological
response team and other health care workers and traditional first responders
in fire and public safety personnel, seriously consider being vaccinated now.
Jeffrey Levine: Now, what are the current major issues associated with the
vaccination program? Of course, there are several.
Dr. Raub: The States and the Department of Health and Human Services have
encountered two major issues. First off, the logistics and cost of stage two.
Most of the States seem comfortable with the numbers and the logistics associated
with the first stage and are finding the funds to do that. But as they look
ahead to the second stage with potentially up to ten million people involved,
working out the type of distribution system, the types of clinics or other
arrangements, access that would be required plus the costs of that are not
trivial. So a number of the States are struggling with that right now.
Also many people have expressed concern about the absence of guaranteed compensation
for vaccine-related injuries. That is in many States, workman's compensation
is covering the compensation needed for vaccine injuries but not in all States.
Many health insurance programs provide coverage for the health care costs associated
with adverse events, but not all of it. In any case, none of them covered the
costs associated with lost work. So a number of our State officials and hospitals
and others are moving very cautiously with the view of hoping there will be
a solution to the compensation problem.
Jeffrey Levine: Thank you very much, Bill. I would like to turn now to Nancy
Ridley, Assistant Commissioner of the Massachusetts Department of Public Health
and take a look at her State's efforts to address smallpox-related issues in
the context of its overall bioterrorism preparedness plan. Nancy, we know that
all State plans are not the same. However, it would be helpful to look at your
State as an example. Can you describe for us some of the core elements of the
Nancy Ridley: Certainly. Massachusetts is a fairly small State, small in geography
but very high density. We have about 6.5 million residents in the Commonwealth.
One thing that differs from many other States is that we don't operate on a
county health system. We have 351 cities and towns. Our 76 acute care hospitals
with emergency rooms make up the core of our acute care system. We have divided
the State recently into seven emergency response-planning regions. The map
shows the seven emergency response planning areas. What we have done is to
base this on our emergency medical services (EMS) system break out of the State
with some further breakout in the eastern part of the State so that we have
an equal number of hospitals and population in each of the sections.
Jeffrey Levine: Did you want to go through some of the details now?
Ms. Ridley: Yeah. The details of the plan itself, we had a statewide smallpox
workgroup as I think every State has had, that included about 40 or 50 very
active constituents, representatives of many, many different segments.
The pre-event plan itself is based on Phase 1, what we call Phase 1, which
is the first phase that Bill was referring to. We have two components to it.
The first is the hospitals. We are going to be vaccinating about 7,600 hospital
staff, averaging about 100 per hospital. In the second part of Phase 1, we
are going to be doing 2,400 community response team personnel. In each of those
7 regions we are going to have 16-member response teams that are capable going
out. In order to be able to ensure that we have 16-member response teams we
are going to have to do probably about 150 individuals per region. From there
we have set some very basic criteria for those 10,000 individuals that will
make up either the hospital or the community response team.
The basic criteria for getting a vaccination, number one you must have been
previously vaccinated. Second of all, there will be very careful screening
of the individuals as well as household contact for contraindications. Third,
there will be extensive follow-up required for adverse reactions. The fourth
component, this is very, very critical, is that we are not advocating or recommending
or proposing to do furloughs.
In terms of what process we are going to use for an orderly progression, first
we start and we did start with our own State health department professionals.
The second phase of this will be to proceed to vaccinating multidisciplinary
teams at the 76 hospitals. Third, once we have completed the hospital teams,
we will be proceeding to doing the seven regional response teams. We are trying
to build capacity in particular to include public health nurses, school nurses
and visiting nurse associations in this process.
From a timeline perspective, we began our process in Massachusetts on February
12 with our initial vaccinations. This again was with the first 15 of the State's
health department personnel. We then will be carrying out Phase 1A, which is
the hospitals, for approximately the next three months. Then we will be proceeding
after the hospitals are completed to vaccinating the community-based response
teams. All in all, this is probably going to take up to six months to get through
both the first and second parts of what we call Phase 1.
The vaccination process itself for hospital response teams, as I said the
DPH did start the process on February 12 and we did vaccinate the first actually
15 public health employees about two and a half weeks ago. I am happy to report
we have had no adverse effects. No lost time at all from any of our vaccinees.
The only slight reactions we have had were some tape hypersensitivity reactions
to the bandage and we found if you leave the bandage on for 3-5 days as opposed
to changing it daily that even that slight reaction is one that we no longer
So basically what we have done is we have started with our State public health
employees. We have actually also as of last week we added Cambridge Health
Department and Boston Health Department employees who work with the hospitals
in both Cambridge and Boston. Those individuals, now we are up to about 26
individuals who have been vaccinated in terms of this process.
Jeffrey Levine: Let's talk a little bit about the vaccination process and
the pre-event phase. Who is actually going to give the vaccinations to the
hospital and community response teams?
Ms. Ridley: Right. It actually, it appears to start with DPH vaccinating the
core State public health staff. Then we will be vaccinating individuals in
each of the hospitals. Then they will individually be carrying out the vaccination
within their own hospital or networks of hospitals.
In the community-based system, we are actually going to be hiring a vendor
to actually do the community-based response team. They include some of your
emergency first responders, fire, police and other community-based responders.
So we are actually going to have vendor-operated clinics for those individuals.
Jeffrey Levine: This is all getting a little complicated here but you mentioned
something about a Phase 2 in the pre-event plan. Does Massachusetts have a
Phase 2 plan and if so what is it?
Ms. Ridley: It is probably one of the most controversial questions we have
had to face. We don't have the specifics on paper for the Phase 2 plan. However,
there are general concepts. If we move to Phase 2 of broader vaccinations,
it will involve approximately 120,000 health care workers and first responders
in Massachusetts. One of the things that is very important to stress is that
moving to the next phase, the Phase 2, is very dependent upon the lessons learned
in Phase 1. We were very pleased to see the report that came out last Friday
from MMWR that shows that the program so far has been very successful with
very, very small numbers of even minor adverse reactions. We think that is
what is necessary to proceed to Phase 2.
Jeffrey Levine: As we were discussing a little bit before with Dr. Raub, there
have been some controversies that have come up surrounding the pre-event vaccination
plans. Can you tell us a bit more about what these controversies are and how
they are being addressed in your State, Massachusetts?
Ms. Ridley: Very quickly I think the next two slides will summarize the issues
everyone is facing. Liability has been pretty much taken care of by the Federal
law, by Section 304. Worker's compensation, because worker's compensation in
our State does not kick in until about the fifth day, the issue has been who
is going to cover the first five days? Many of the larger employers, we are
finding in the Commonwealth, have been coming forward and have said that rather
than having the individual take their own time that they will be covering those
first few days. Malpractice coverage has been an issue on the table. Health
insurance coverage, which Bill mentioned, for side effects. Every insurer,
health insurer we have talked to, managed care plans, indemnity plans, have
said no problem. They will be covering side effects for both vaccinees as well
as any contacts. The issue of furloughs we have talked about. Unions have come
forward and are playing a big role. It is essential to keep them in the loop
and communicate with them.
The next slide shows some of the other issues. Vaccine safety, we got a lot
of comments about is this the strain that is being used here in the U.S. as
safe as or more safe or less safe than the strain in Israel? Actually the strain
we are using here in the United States is safer, it is less reactogenic, and
it doesn't cause as many reactions as the strain that was used in Israel, which
is good. The safety of the bifurcated needle. That has been an issue too because
obviously in this country we have tried to go toward safety needles. The bifurcated
needle is not exactly that type of a needle that we are used to in health care
today. However, it is the needle for which the vaccine has been standardized
and we feel it is critical that we use the standardized product. We understand
there are products under development.
There are additional issues. The difference between municipally-based versus
private first responders, the ambulance companies, dissemination of training
materials was delayed in the beginning and was repeatedly being revised and
that was causing confusion and we are very concerned about the sustainability
of State bioterrorism initiatives. It is a costly process and even in the hospitals
this is not a one-time shot. The initial vaccinations will have to be maintained
on a long-term basis so we have sustainability that is an issue.
Jeffrey Levine: Now switching from your pre-event plan to the post-event plan,
how do your two plans differ and are the controversies surrounding them the
Ms. Ridley: If the pulse of that plan is triggered, it is a very different
issue. The world as we know it would change. A lot of the questions have comments
as to what is going to trigger a post-event? Is it one case in the world? Is
it one case in the United States? That I think is still a very valid question.
It is essential, this is the one thing we know, it is essential that we have
the 10,000 individuals vaccinated should we need to proceed to a post-event
plan. We are going to need every single one of those individuals to be able
to vaccinate 6.5 billion residents within the 3-5 day time period. So it is
absolutely essential that we move through Phase 1 and potentially also Phase
2 as quickly as possible.
Jeffrey Levine: Let's hope there is never a Phase 2. Thank you, Nancy.
I would like to ask Eddie Gabriel, Deputy Commissioner for Preparedness of
the New York City Office of Emergency Management to discuss any issues that
arise at the local level in addressing preparedness.
Eddie Gabriel: Well good afternoon. We can tell you that the incident management
system that we have in place to prepare for this is a language. I think that
one of the issues we need to think about both from a local perspective is that
we get people into a room and begin to talk to each other. Incident management
is really just a way by which local emergency authorities sit and talk to each
other, whether it be emergency response personnel such as fire and police and
ambulance personnel, emergency medical services along with the hospitals that
are now using the incident management systems to coordinate their activities
and response as well as the local public departments of health in our community
talking together. It is a way to bring everybody to the table and get them
to speak the same language. We think in a post-event that we really need to
talk the same language. Otherwise you won't be able to manage the issue appropriately.
Second of all, the way by which these particular bridges, incident management
is used as a bridge to bring those people to the table so people get to know
each other. It is important that people know each other at the local level
on a first-name basis, face to face. We think incident management is the way
to go to get that to happen.
Jeffrey Levine: Now, in your opinion, should the traditional field emergency
response communities such as the emergency medical system, the fire department
and others be considered for vaccination during Phase 1 of the smallpox vaccination
Mr. Gabriel: Well I think that many of the emergency services systems across
the country are asking exactly that question. I think that many of the emergency
medical services systems are saying why aren't we included in Phase 1? Why
aren't we being considered? I think some of that is knowledge and some of that
is education. There are parts of the country where they are being included
in the initial Phase 1 of the program. That is important. Again that goes back
to the premise by which that agencies such as emergency field response people
were traditionally not considered in the hospital and the public health community
as a team. In this particular case I think it is vital to get them all to consider
each other as part of the same emergency response team.
So to be more direct with that answer, I think it is important at the very
least to educate those people and bring them into the fold now. On a broader
perspective consider them for vaccination in the initial phase.
Jeffrey Levine: In the event a smallpox case is confirmed, how do we prevent
all areas of the local government and the health care system from breaking
down during a crisis? Are we protected? Human resource components, including
emergency medical technicians, paramedics, nurses, doctors, police, firefighters,
Mr. Gabriel: Well, I think that when you look at the system at a local perspective,
the thing that needs to be thought about is that health care systems by themselves
are not islands by themselves. That they in fact count on sanitation to pick
up their garbage and they count on security from the local law enforcement
and they count on emergency medical services to bring resources to their institutions.
They count on having their own personal staff, their physicians, their nurses,
their technicians, any of the hospital personnel coming to work so you need
transportation and all those things to sort of operate during this particular
crisis. Especially in a post-event scenario.
So when we talk about managing these cases, we need to not look at health
care specifically, a one patient-one contact scenario. You need to say to yourself, "How
do I make the whole system operate? How do I make sure that essential services
operate during a crisis?" The way to do that is to make sure that local
government includes all those agencies together when they do their planning
for this. That they are not exclusionary, that they are inclusionary.
Jeffrey Levine: Now, in the event that something like that should occur, what
are the multi-agency coordination issues that need to be considered for effective
Mr. Gabriel: Clearly it is a public health decision-making circumstance. The
local public health, as well as the State and Federal partners, but primarily
local public health will work on managing the cases and make those decisions
that need to be made relative to how patients are cared for. However, the rest
of city government or the rest of local government needs to go on. To do that
we can open an emergency command post or command center to bring those agencies
together, to sit them in a room to help make those decisions. You can make
sure that if you have got a failure or a weakness in one part of the system
that some way in this coordinated effort using agencies from all different
city, State and Federal resources in one room can make you answer the call
when it has to happen. For example, the moving of supplies of vaccine when
it gets into a location to be distributed to a location is going to require
transportation resources. How do you make that happen? Well you can't do that
without having mechanisms in place to do that. You can't do that if the roadways
aren't clear. You can't do that without security to transport those resources
from one place to the other. So it is up to the localities to build those approaches
into their plans to make the system work effectively.
Jeffrey Levine: If mass vaccinations are considered in response to such an
event, obviously informing the public is crucial. What are the key components
of a coordinated response there at a State, Federal and local level?
Mr. Gabriel: I think our experiences from September 11 have taught us a lot
about this. I think the issue of one voice, one message, getting the public
information community together to sort of review that message so that everyone
speaks the same language. Whether or not that direction on what needs to be
said comes from the Federal level or whether or not it comes from the local
level, you need to make sure that the answers are coordinated; that you don't
have one local authority saying one thing and a State authority saying another
thing and a Federal authority saying another thing. You can do that a lot of
different ways. You can get the localities, the State and the Feds together
now to put together a public information sort of strategy in case that unfortunately
does occur and we get a smallpox case someplace.
The other way to do it is to make sure that you reel in, if you will, some
of the local people that are responsible for getting the messages out to make
sure that they have their ducks in a row so that the message they send out
is consistent from agency to agency to agency, all at the local level, the
State level and the Federal levels. If we don't do that you will have an expert
on television saying this is what is going to happen. This is how it is going
to happen. And you have no control over that expert if your own locality or
your own State level or you are a Federal-person who is doing the talking,
give different messages.
Jeffrey Levine: Eddie, thank you very much. Now we turn to Nathaniel Hupert,
Assistant Professor of Public Health and Medicine at Weill Medical College
at Cornell University to discuss his work on the development of some interesting
guidelines and interactive tools that State and local planners can use to design
and staff vaccination campaigns.
Nathaniel, I understand you have been working on a project funded by the Agency
for Healthcare Research and Quality to develop guidelines and tools that are
designed to help State and local planners develop smallpox vaccination plans.
Can you tell us more about this project and describe what you have been working
on? I know it is very elaborate. I have seen it.
Nathaniel Hupert: Thanks, Jeff. We have been working with the Agency for Healthcare
Research and Quality since 2000 on some of these projects, but specifically
I will talk to you about one that we started in September 2002. Over the course
of the previous year, a number of studies have come out suggesting that in
certain cases, for example, if a large smallpox attack were to occur, we would
need very large-scale vaccination. This really is one of the most logistically
difficult tasks that a public health authority could be faced with. What we
tried to do was come up with some guiding questions, some written guidelines
and then some models to help the planners do this.
Really, there are three guiding questions. The first is what are the critical
components of a mass vaccination campaign? I say mass vaccination to distinguish
it from for example the Phase 1 campaign that Nancy talked about. Second, what
role can spreadsheet models play in forecasting some of the resource requirements
for mass vaccination campaigns? Finally, what are some of the limitations of
these computer models in developing the actual mass vaccination plans?
The diagram that we can show you on the Internet is one of the products that
we have got in these guidelines. Really the key, if you just look at the pink
boxes, is that what we have tried to come up with is a straightforward way
of representing the complexity of this process. For example, to suggest that
there are people, that is under the "who". There are things that
need to be developed, that is under the "what". There are places
where this has to occur, under the "where". There are triggers for
mass vaccination to occur. That is under the "when". Finally there
is the question of how do you bring this all together in an operationally realistic
The operations are really what I will go into in terms of some of the modeling
that we have done. So over a year ago we, at Cornell University, provided some
modeling expertise to New York City, to the Office of Emergency Management
and to Eddie and also to the Department of Health at New York to help model
what would happen at an antibiotic distribution site. You will see a cartoon
of this distribution site. It is very straightforward to come up with a plan
of how people would walk through a vaccine clinic.
Now what you can do once you come up with an idea of how people would walk
through something like this, you can make a schematic diagram of what the actual
patient flow would be through each of the different stations. For example,
a triage station is an evaluation station and then a dispensing or a vaccination
station. Once you have a view of what the schematic is, there are actually
a couple of techniques that have been developed over the last twenty years
in operations research, to turn that into a computer model. One of the most
straightforward ways of conceiving this is that if you have a clinic, one of
the ideas is that it doesn't continuously back up. If you start vaccinating
on day one, by day ten you wouldn't like the lines in the vaccination clinic
to keep backing up. You can actually come up with a formula that tells you
how many staff you have to have at a given station, say at the vaccination
station in your clinic, to handle a given amount of patient flow in a certain
amount of time. With that formula, which is now put up on the screen, you can
simply make a calculation and then do that calculation over and over again
for all the different stations in your clinic.
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