Smallpox Vaccine Use ACIPNVAC Smallpox Working Group

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Smallpox Vaccine UseACIP-NVAC Smallpox Working
Group

• Gianfranco Pezzino, MD, MPH
• Council of State and Territorial Epidemiologists
• Gpezzino_at_kdhe.state.ks.us
• 785, 296-6179

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CSTE Who we are

• Council of State and Territorial Epidemiologists
• Organized in early 50s
• Promotes the effective use of epidemiologic data
  to guide public health practice
• About 400 members from all states and
  territories
• Members engaged in practice of epidemiology at
  the state level
• Focus on surveillance and epidemiology of
  infectious diseases, chronic diseases and
  conditions, and environmental health

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Public Health Decision Process
How Common?

How Severe?

How Preventable?
_________________
Science
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Public Health Decision Process
How Common?
Public Perception


External factors (e.g., economics, politics)
How Severe?


How Preventable?
Societal, ethical, and individual values
_________________
_________________
Science
Other Forces
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Public Health Decision Process
How Common?
Public Perception


External factors (e.g., economics, politics)
How Severe?


Societal, ethical, and individual values
How Preventable?
_________________
_________________
Science
Other Forces
Priorities, Policies
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The Science

• How common?
• Smallpox is the only disease on earth eradicated
  from nature
• Current risk is UNKNOWN!
• How serious?
• Very
• How preventable?
• Very preventable, BUT at a price

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The Other Forces

• Public fear may easily escalate
• Public perception
• Preferential treatment for privileged groups
• Trust What is the government hiding?
• Ethical issues
• Individual freedom versus the good of the whole
• Practical issues
• States want their own internal first response
  capacity
• Timing is essential (e.g., immediate interview of
  index case while still conscious, immediate
  contact tracing)
• Unprotected first responders may not be available
  when needed

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The Answers

• General Principles
• Any distribution of vaccine should be limited to
  the minimum required to achieve the desired goals
• Most CSTE members favor restrictive policies in
  vaccine use before event
• Epidemiologic data should ALWAYS be considered
  when formulating vaccine policies
• Public discussion and information are essential

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Question 1 Pre-event vaccination of the general
population

• Permissive use not recommended at this time
• Illness and deaths from side effects greater than
  from disease
• Availability for general population not
  recommended until
• Risk of disease is quantifiable and substantial
• Vaccine is available outside I.N.D.
• Vaccine availability is assured to control
  outbreaks
• VIG availability is assured to control vaccine
  side effects

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Questions 2 - Should early responders be
vaccinated before an event?

• Most difficult and divisive of all the questions
• No to a mass vaccination of all first responders
• Consider a limited vaccination of people involved
  in immediate first response likely to be in
  contact with index case(s)
• Eligible individuals identified in the context of
  statewide smallpox response plan, e.g.
• Some staff of Level C (containment) structure
• State/local public health rapid response teams
• Adequate screening for contraindications and
  follow up must be assured
• Practical challenge to define target population
• Apply uniform criteria

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Question 3 Is ring vaccination the control
strategy of choice?

• Yes, in the absence of evidence in favor of
  alternative strategies
• Doubts about feasibility and efficacy of ring
  vaccination under a BT scenario remain
• Extent of required activities
• Multiple foci intentionally spread in a
  non-natural fashion
• Quickly analyze epidemiologic data and modify
  recommendations accordingly
• Population-wide campaign at local, regional, or
  national level may become necessary after cases
  appear

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Additional Comments

• Need for broad discussion, consensus process
• Vaccine prepositioning should be considered
• Public Information is of paramount importance
• Regardless the option chosen, the public and
  first responders must receive adequate
  information and explanation
• Issue must be revisited as assumptions change
• Any guidelines from ACIP should be considered as
  preliminary and subject to change based on new
  evidence
• Is there a rapid mechanism for this?