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Transcript of Web-assisted Audioconference (continued)
Jeffrey Levine: Is that the kind of thing that is viable on paper but in effect
harder to demonstrate until you have to demonstrate it?
Dr. Hupert: Well, the nice thing is that you can basically do this for any
type of diagram that you have. In fact, the diagrams can get quite complex.
So at Weill Cornell, we have spent the last half-year thinking up what we think
is a viable smallpox vaccination model. What you can see is the patient flow
plans for this vaccination model. I should add that it differs in some key
ways from the CDC model, which is now available on the Internet. All the numbers
that you will see coming up have to do with this model and not with the CDC
An advantage of creating a flow plan like this is that it can be used for
both a pre-event and a post-event scenario. You can set up one basic plan and
then have different parts of it apply, depending on the scenario that occurs.
So you can see the arrow at the upper left where people enter into this flow
plan and then you can follow the different arrows down the various pathways.
The parts that are in gray would only be used in a post-event plan, according
to this model. The rest of it could be used in a pre-event plan and in a post-event
The basic idea behind this model is that people need to be screened off very
quickly in either a pre-event or post-event setting if they are actually sick.
Of course in a post-event setting that is much more critical. What we have
in the gray is a note that you can put a mask, for example, an N-95 mask which
many people in the audience will be familiar with, on people who might come
into the clinic and say that they have either come in contact with someone
who may have smallpox or who feel sick.
The next steps after the entry in a pre-event setting would be that they would
get forms for example, they would get their briefing, that they would go through
triage, and then perhaps even testing for things like pregnancy or HIV and
that of course can be done on-site or off-site. Then people would go back and
get their vaccine, and of course as we now know, there is a great deal of exit
counseling that needs to be done after people have gotten their vaccination.
Jeffrey Levine: You have got different models then for different scenarios?
Dr. Hupert: That's right. In the post-event setting you can see that one of
the added complications is this whole issue of what to do with people who may
actually have contact and who may not want a vaccination so you can see that
there is a little component there for quarantine counseling, which may come
up, and there are different boxes for exit counseling for people who may be
affected and who may not be affected.
Jeffrey Levine: What then are some examples that you have got?
Dr. Hupert: Well, the nice thing is that once you come up with the floor plan
and with the schematic and you turn it into an Excel spreadsheet, you can actually
generate real numbers that are reflections of how this model would work in
a realistic scenario.
So, for example, you can have a scenario where you have got 500 people who
could be working in your health clinic across your entire community and you
have got 14 days in which to vaccinate a million people. What we did was come
up with a couple of baseline scenarios. So we have got a pre-event scenario,
a small-scale scenario and a large-scale scenario and we have got generalizations
about how quickly things would go in the clinic. Here you can see it is listed
as slow, baseline and fast. From the output that you see there, you can see
that if you have what we considered our baseline time estimates, if you had
14 days in which to vaccinate these one million people, you could actually
do it with 500 staff. In fact, we estimate that it would only take 12 days
to do that. These are numbers that are based on the experience with the CDC
and with other live exercises that we have witnessed from our research group.
On the other hand, you can imagine that there would be a large-scale event
and we have created some outputs for the following scenario, which would be
a large-scale event with five million people affected. The question here for
example would be how many staff would you need in order to actually prophylax
those people? The answer according to this model would be you would need about
6,700 core staff to do that. You can see that in the middle box there.
Now one problem with making outputs like this is that they are very hard to
visualize. So it would be easier for people to get a sense of how many staff
would be required to do these things if we could generate some graphs. Luckily,
since we can automate some of this we actually have the ability to make some
interesting graphs. So here you can see that for a wide range of different
populations, going from 100,000 to eight million, you can see the number of
staff that this model anticipates that you will need in order to complete your
mass-vaccination campaign in a certain amount of time. The little line across
the bottom is four days because a lot of people have talked about four days
as a critical benchmark for how long that would take. So for example if you
look at the yellow line for one million people, you could see that you would
need somewhere between 4,000 and 5,000 people to vaccinate a million people
in four days.
Furthermore, you can come up with some very specific numbers relating to the
clinics. So this graph shows that the number of people you can actually process
through each clinic per day will depend obviously on the hours of operation
of the clinic and the flow of patients through the clinic. But the advantage
of actually modeling it out is that you can come up with a specific number
for an estimated amount of time that you would like your clinic open and then
calculate back and see whether or not that would actually give you the appropriate
coverage for your population.
Jeffrey Levine: Now again, what about the key limitations? You have got a
model; all models have their limits. What about yours?
Dr. Hupert: That is right. It is very important to note these. The accuracy
of any model depends of the quality of the data that you use to make the model.
There are a number of elements of these models that we are still trying to
pin down, mostly because there has been fairly limited experience with real
large-scale mass vaccination campaigns.
One of the critical variables that we are trying to look at is the amount
of time it would take. I know that the Department of Health and Human Services
has done live vaccine exercises and of course Phase 1 will give us a great
deal of information about this.
Second point is that the output of the model has to do with the flow plan
that you use for the model. So this is information that is useful for the model
that we created. A differently designed vaccination center may give a different
result. One of the assumptions that we had with this model is that we would
have multiple centers that basically look the same and that we would be able
to control the flow. Now Eddie mentioned that one of the key features of all
this planning is inter-agency coordination. So, for example, here you would
need law enforcement to coordinate with public health to make sure that the
flow into the vaccine center was kept under control.
Finally, I would say that these numbers reflect only the critical dispensing
staff and not in fact at this point the other ancillary staff or things like
law enforcement, sanitation, in order to set up and run these operation centers.
Jeffrey Levine: It is an elegant design. How would you sum up your conclusions?
Dr. Hupert: Well, I think the best thing you can say about models like this
is that they will allow planners to think with numbers when designing mass
prophylaxis response strategies. What we hope to do is to give people concrete
numbers that they can either agree with or disagree with and if they disagree
with them they can go back to their plans and figure out how to do things better
The second thing is that modeling really forces a critical examination of
all the assumptions that you have about how you are going to do a really large-scale
vaccination plan like this. And it brings to the fore the whole issue of resource
availability. So if it looks from the model like the resources are not going
to be there in terms of what is available on the public side, it may be that
public/private partnerships have to be established.
Finally, I would say that modeling estimates are useful to guide planning
but they don't replace the real thing, which is real, live exercises.
Jeffrey Levine: You mentioned the experience with Phase 1 is already being
somewhat helpful to you.
Dr. Hupert: That's right, that's right, we are going to hopefully use a lot
of the data that we are getting from Phase 1 and validate some of these models.
Jeffrey Levine: Thank you, Nathaniel. We are going to open up the lines for
questions in a few minutes, but before we do I would like to go to Tom Terndrup,
Director of the Center for Disaster Preparedness and Professor and Chair of
the Department of Emergency Medicine at the University of Alabama at Birmingham.
With support from AHRQ, Tom and his colleagues have designed a Web site that
provides resource information and continuing education about rare infections
and potential bioterrorist agents, including anthrax and smallpox, to health
Tom, what are the challenges of training health care providers to recognize
Thomas Terndrup: Thank you, Jeff. The challenges are multiple and some of
them are illustrated in the present slide. The backgrounds of the trainees
are diverse and run the spectrum from the very beginning public health individual
to somebody with a high degree of health care experience. All of these individuals
frequently have a full set of current responsibilities so this becomes an add-on
to their current activities and creates additional stress.
Also there is a need to illustrate for the trainees the difference between
a natural outbreak and that of a bioterrorist attack as we move forward. These
events are rare and if we are lucky, hopefully never in a substantial mass-casualty
situation. But they are very high risk and so we need to be prepared. Finally,
there is limited or no clinical experience with many of these agents and so
the health care community needs to struggle with recognition and awareness.
Jeffrey Levine: How was your Web-based educational project designed to approach
these problems, because as you indicated, they are complicated.
Dr. Terndrup: Yes. The interactive screensaver, which serves as the front-end
to the AHRQ/UAB Web site, is illustrated here. We have a series of six images,
which serve as a billboard effect to alert passersby of important topics. In
this case, rare infections and bioterrorism. A teaser question illustrated
here at the top helps to encourage the passersby to become interested and then
active users of the Web site.
Now at the Web site the trainee then selects from the series on the left-hand
side of the slide on the menu bar. The menu includes answers to the screensaver
teaser questions as well as assistance with complicated differential diagnosis,
continuing education modules, related Web links and publications options for
Jeffrey Levine: Now, the interactive screensaver does promote awareness?
Dr. Terndrup: It does and relevant to images that would capture the attention
of individuals who are near the computer screen. The user might then pause
the image since this is an interactive screensaver, by clicking on the pause
bar they could more closely inspect the image, one that might have further
detail than the chest x-ray seen here. In addition they could click to get
more information which would then take them again to our Web site. So the screensaver
serves to capture the attention and draws potential trainees to the Web site
where more information is then obtained. The Web site is updated regularly,
especially for smallpox and anthrax. Both summary information as well as more
extensive information has been made available.
Jeffrey Levine: Does the screensaver actually serve to improve education on
bioterrorist attacks, would you say?
Dr. Terndrup: We believe that it does. We have collected some preliminary
data summarized here which shows that senior medical students and first-year
house officers in responding to a standard set of bioterrorism and emerging
infection questions. Their performance was improved by virtue of the presence
of the screensaver in the emergency department. We saw roughly a 20-25% increase
in their response rates to these standard questions.
Jeffrey Levine: Which is interesting given the fact that you have a highly
educated population of providers in the first place.
Dr. Terndrup: One thing of note here is during the baseline period was actually
prior to the events of September 11, 2001 and October and so we sort of have
a natural history experience here. So you see that you look at the reddish
bars that there is about a 20% increase in sort of baseline knowledge that
is just related to the general state of awareness in that population of students.
Jeffrey Levine: Of course we are all aware there has been a lot of discussion
in the media about so-called dual-use benefit of enhancing our knowledge of
infectious disease and training for recognizing bioterrorist attacks. What
is meant by that terminology and what degree of risk do different biological
organisms present for a bioterrorist attack?
Dr. Terndrup: The notion of dual use, which you see here now, is to promote
public health preparedness and our view of that is that bioterrorism preparations,
given that this is a rare and hopefully never very significant event in our
country, will result in better public health by establishing mechanisms of
better recognition, by clinicians' treatment involvement in public health emergency
response authorities we believe that bioterrorism preparation is better public
Jeffrey Levine: Do you think that is already happening, there is already a
Dr. Terndrup: I think some of the comments made earlier this afternoon by
the other panel members clearly indicates a need for getting to know who you
are working with and I think there has been a lot of progress in that area
by virtue of our preparedness efforts.
Jeffrey Levine: All right now, much has changed obviously since the Web site
was posted in October of 2001. How have you kept your information up to date?
Dr. Terndrup: Our information has been kept up to date by regular updates
through the Web site. Most especially we have, with the support of AHRQ, included
more primary care providers. In mid-December we included a new pediatrics module.
We also are working with collaborators from internal medicine and family practice
to try to add to our existing, what we term "first points of care contacts" so
that we have primary care physicians incorporated into that fold.
An important aspect of this is also our dermatology referral module, which
will help clinicians, either hospital-based clinicians or those in the primary
care sector, to know when to refer a patient to the dermatology community.
Jeffrey Levine: Tom Terndrup, thank you very much. Let me repeat the address
to Tom's very important Web site. It is www.bioterrorism.uab.edu.
In a moment we will open up the discussion for questions from our listening
audience but first let me tell you how to communicate with us. There are two
ways you can send your questions to us. The first is by telephone. If you are
already listening on a phone, press "*1" to indicate that you have
got a question. If you are listening through your computer and want to call
in with a question, dial 1-888-496-6261 and use the password "bioterrorism".
Then press "*1". While asking your question on the air, please do
not use a speakerphone or a cell phone to ask your question and if you are
listening through your computer it is important that you turn down the volume
after speaking with the operator. There is a significant time delay between
the Web and telephone audio.
If you want to send a question via the Internet, simply click the button marked "Q&A" on
the event window on your computer screen and select the button labeled "Send
a Question". Type in your question and then click the "Submit" button.
One important thing, if you prefer not to use your name when you speak with
us, that is fine. But we would like to know what State you are from and the
name of your department or organization so please provide those details regardless
of the way in which you transmit your questions.
As you are formatting your questions or queuing up on the phone lines, I want
to say a few words about our sponsors. The mission of AHRQ is to support and
conduct health services research designed to improve the outcomes and quality
of health care, reduce its cost, address patient safety and medical errors
and broaden access to effective services. Two of AHRQ's operating components
helped to produce this series of audio conferences. First, AHRQ's User Liaison
Program serves as a bridge between researchers and State and local policymakers.
ULP not only brings research-based information to policymakers so you are better
informed, but we also take your questions back to AHRQ researchers so they
are aware of priorities at the State and local level. Hundreds of State and
local officials participate in the ULP workshops every year.
Second, AHRQ's Center for Primary Care Research provides expertise and leadership
on primary care practice and research, both within AHRQ and throughout the
Department of Health and Human Services. The Center supports extramural and
intramural research that informs a wide range of issues related to primary
care practice and policy.
I would like to take a quick moment to thank Dr. Sally Phillips, Director
of AHRQ's Bioterrorism Preparedness Research Program in the Center for Primary
Care Research, who has been instrumental in helping to produce this series.
The ULP and the Center for Primary Care Research hope that today's Web-assisted
audio conference and the four other events in this series will provide a forum
for a productive discussion between our audience of policymakers and researchers.
We would appreciate any feedback you have on this Web-assisted audio conference.
At the end of today's broadcast, a brief evaluation form will appear on your
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be sure to take the time to fill out the form. Your comments on this audio
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better suit your needs. Alternatively, please E-mail your comments to the AHRQ
User Liaison Program at https://info.ahrq.gov. Now, let's go to the questions from the
This one is from David Rutger. The question is, "I was vaccinated as
a child. My understanding is that it is no longer effective. If I receive the
vaccine now, how long will it be good before I need another?" Good straightforward
question. Who wants to handle that? Nancy, do you want to take a wag at that?
Ms. Ridley: Based on what we have been led to believe is that if you have
been vaccinated within the last three years that is sufficient. However, any
longer than that, and I think it is a matter of we are just not sure how much
residual protection there is from people like us who were vaccinated many,
many years ago, 30 and 40 years ago.
Dr. Terndrup: If I could add to that Jeff, this is Tom, I think the data that
I have seen indicates that there is even some evidence of long-lasting immunity,
albeit it is not quite as good as the 3-5 year interval which we have been
Jeffrey Levine: All right. We have got a caller, Chris Snook from Cincinnati,
Ohio. If you are there, go ahead with your question, Sir.
Chris Snook: OK. In smallpox vaccination campaigns without furlough, how are
concerns regarding contact between vaccinees and immunocompromised individuals
Ms. Ridley: The general recommendation is that this is one area where we are
recommending that hospital workers be reassigned to an area and not work with
immunocompromised individuals. That is a pretty clear directive and recommendation.
Those individuals should not be working during the period of this activity
with immunocompromised individuals.
Jeffrey Levine: This one, I'm sorry. Dr. Raub?
Dr. Raub: I can just add that one of the reasons that Phase 1 is moving as
deliberately as it is ensuring that individuals who are to be vaccinated get
sufficient briefing and understanding that they need about everything from
how to care for the vaccination site to the nature of the contacts that they
Jeffrey Levine: This one is for Nathaniel Hupert. It is from Skip Payne at
Seneca County General Health District in Colorado. The question is, "Is
your program available online for downloading?"
Dr. Hupert: That is a very good question. We have actually just sent out the
guidelines which are 57 pages to our advisory board members who include people
from New York City, from the Federal government, from CDC and from at least
some counties around the country who have been doing a great deal of bioterrorism
preparedness work. We anticipate that in a short amount of time, once we have
gotten comments on this from the advisory board members and once the model
that we have has been vetted, that it will become available either through
AHRQ on the Web or through another means. It is an Excel model and it could
easily be put on a Web site in a downloadable form.
Jeffrey Levine: All right. This one is a call from Janet Murray in Missouri.
Janet Murray: Thank you. My real simple question. Can you repeat that Web
site on the bioterrorism. I don't think I got it copied down correctly. Thank
Dr. Hupert: Yeah. It is going to go up on the screen but it is www.bioterrorism.uab.edu.
Janet Murray: Thank you.
Dr. Hupert: You are welcome.
Jeffrey Levine: All right. This one is for anyone. What is the role of the
professional organization in bioterrorism preparedness, i.e., nursing and other
specialty organizations? Obviously that is a complicated question. Do they
work individually or do they work together? What are they supposed to do?
Ms. Ridley: I'll answer this one. Basically all of the professional organizations,
and I think we have about 60 or 70 in Massachusetts, are members of both our
CDC and our HRSA Statewide advisory committees that are doing all of the planning.
They are active members of every single one of our workgroups and we have at
least ten workgroups so that the organizations really play a key role in representing
their membership across the board regardless of whether it is fire or police
or emergency management or whatever it is. They are very, very active participants
in the statewide advisory committees.
Jeffrey Levine: Eddie Gabriel, you are nodding your head. Do you agree with
Mr. Gabriel: Oh yeah. It is important that every professional organization
look for each other. I am sure that the question was more for the medical professional,
the nurse and the physician, but I like Nancy's answer because what it did
is it closed that gap between those agencies and the emergency response communities
and the other agencies that have professional memberships to get everybody
speaking the same language. I think it is absolutely appropriate.
Ms. Ridley: One other point. In many cases it is the first time that these
organizations have actually sat down and done joint planning for these initiatives.
Jeffrey Levine: All right. This in effect kind of spins off that question.
It is for Bill Raub. What is your view of the fact that several national associations
of nurses and nurses practitioners groups are protesting the smallpox vaccination
Dr. Raub: Well we have a good deal of respect for those who are concerned
and deliberate about the trade-offs associated with the vaccine program. Many
of the nursing groups and others have pointed out that not every nurse in this
country has health insurance, for example. Therefore, not every one of their
members is necessarily in a position to be fully compensated in the event of
an adverse reaction, especially if the workman's comp program in the State
also doesn't cover it or if the employer itself is not providing the coverage.
I stressed at the beginning that the program is voluntary. We think there
are good reasons for this to get serious consideration, but we also respect
those who want to move more deliberately and we are hopeful that as the Congress
debates a compensation package that we may find a way to move forward more
rapidly that will be more comfortable with everyone involved.
Jeffrey Levine: Thank you, Dr. Raub. We have another caller. Peggy Putnam
on the line from Tennessee. Go ahead, Peggy.
Peggy Putnam: I would like to ask what type of vaccine-site care do you recommend
in the pre-event phase of vaccination and for how long?
Jeffrey Levine: Who wants to handle that one?
Dr. Hupert: The Advisory Committee on Immunization Practices has recommended
what is called the semi-occlusive dressing for this site in addition to gauze.
The reason they recommend this particular bandage, and you can get the details
from the CDC Web site if you just look under "smallpox". The reason
they recommend this particular bandage is because in studies that they have
cited, the amount of virus that you can actually get from the other side, the
outsides of this semi-occlusive dressing, is extremely small. Which is why
the ACIP has stated as their official position that people who have gotten
vaccinated can actually go back to work under certain circumstances. Of course,
Nancy has mentioned one particular circumstance where they should not work
directly with immunocompromised individuals. So that is part of the detail
of the dressing. Even in the pre-event phase.
Jeffrey Levine: All right, Nancy we have a question for you from Sandra Woods.
How does Massachusetts' plan to sustain its vaccination effort over time if
the response team members will only be included if they have been previously
vaccinated? Those health care workers under 30 may not have been exposed to
the vaccine, obviously, before.
Ms. Ridley: Well, I think that our, obviously our plan will eventually stand
beyond the 10,000 that we hope to be doing in Phase 1 to additional personnel.
I think that once we get a really good handle and have a core staff immunized,
we will proceed; under-30 will eventually be added to the ranks. There is no
way to get around it at some point. But I think that initially you are better
off starting with those who are least likely to have any type of adverse reactions,
which are those of us that are over 30. Eventually, people regardless of age
will be included on the team.
Jeffrey Levine: We have a call from Dr. Nick Berneer. He is up in Minnesota.
Probably one of the few places that is colder than Washington, DC at the moment.
He is at St. Joseph's Medical Center. Dr. Berneer, are you up there?
Dr. Berneer: I am.
Jeffrey Levine: Go ahead with your question.
Dr. Berneer: I just had a question about any to-date summary had on experience
of vaccinees? Many institutions in Minnesota have been very conservative and
very reluctant to do a pre-event vaccination because of the inability to reassign
nurses to other departments in small communities. Do any of you have any data
on the east coast?
Jeffrey Levine: Nancy Ridley, do you want to take that?
Ms. Ridley: Data on the East Coast in terms of, I'm not sure I understand
Dr. Berneer: Experience of the vaccinees. How many have missed work?
Ms. Ridley: Oh, so far I think if you look at last Friday's MMWR report, the
results on the first 7,400 vaccinees across the country, civilian vaccinees,
show that the numbers of adverse reactions including minor ones was extremely
low. I think it was one serious reaction, one moderate reaction that was linked
to the type of reactions you could see from the vaccination and 23 minor rashes
or aches or pains. We in Massachusetts, with our small numbers, we only did
about 26 so far, have not had any loss of work. As I said before, the only
side effect we have seen has been a hypersensitivity that appears to be due
to the tape on the bandage.
Jeffrey Levine: Actually this would be kind of a follow-up to that. This is
from Robert Helfridge for either Nancy Ridley or Bill Raub. How has recent
vaccination history of side effects compared to historical data? Are we being
overly cautious in preventing volunteers from being vaccinated?
Ms. Ridley: So far it seems like the precautions have been successful in terms
of keeping the side effects or the potential for having an adverse effect to
a very, very low minimum. Yes, maybe we have been over cautious here, but I
think it was wise to start with this type of a process. As we have seen so
far, we have got about 7,500 civilians that been vaccinated. Which is, it may
not have been as fast as the Federal government wanted to see it go, but I
think it is going to prove in the long run to be successful.
Dr. Raub: Just to reinforce Nancy's point, the pattern so far is about what
we would have predicted given the kinds of precautions that are in place. It
is confirming what we had learned from the historical experience and therefore
we are optimistic that as the program evolves that we will have that continued
Jeffrey Levine: We have got a question for Tom Terndrup. Do you have any evidence
that your Web site usage reflects national bioterrorism concerns? In other
words, can you see spikes, ebbs and flows, that kind of thing?
Dr. Terndrup: Sure, Jeff. We have been concerned about the utility of the
Web site and so we recently looked at our data on the number of Web hits at
the AHRQ/UAB bioterrorism Web site. What we found is that beginning in November
of 2001, if you look at the red stipple bars, that is anthrax hits. And the
blue ones, the blue boxes if you will, are smallpox hits. Of course what you
see is ending up in mid-January this year is an increasing number of hits regarding
smallpox. Our interpretation of this data is that this is consistent with the
Web site reflecting national interest and trends.
Jeffrey Levine: Here is one for Eddie Gabriel. In times of crisis, how can
local agencies better coordinate with State and Federal partners that always
seems to be one of those issues? It was handled, well how was it handled on
9/11, let's say and how do you think it could be better handled?
Mr. Gabriel: Well, the example of 9/11 is certainly the extreme, but clearly
it brought emergency management and the coordination of emergency management
does at the local level and at the State level and at the Federal level to
a new level. The emergency management agencies throughout the country have
now been moving more aggressively, I think, to work with their local health
departments, the State health departments and their Federal homeland security
as well as the CDC and HHS on just this kind of planning.
To do that the best way is to plan and do drills. The way to do those kinds
of drills and exercises that bring people to the table and show you those contact
points that allow you to go up and down the chain. Knowing what resources are
available is essentially making this work when the crisis hits. So you need
to know who the contact points are if you want a disaster medical assistance
team, a DMAT team through the CDC or HHS. You need to know where to go for
what resources, how to get them and how your chain works from the lower level
to the State level to the Federal level to get those resources to help you
in the time of crises.
Jeffrey Levine: Bill Raub is the representative of the Federal government.
Do you have some thoughts on this?
Dr. Raub: Yes I do. There is the clich‚ that all politics is local but
all terrorism is local as well. Therefore, one of the highest priorities of
the Department of Health and Human Services is helping to ensure that the local
capabilities are there not only to make the initial response but also to be
able to connect with the assets and other assistance that the State or the
Federal government might provide. That connectivity is so important. The comments
that he made before about incident management and having planned out well in
advance the relationships for response are extremely critical.
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