At Alert Level 0, each RSDRG will have between three and five
Regional Smallpox Diagnosis and Response Teams depending on local circumstances and cross-cover arrangements, sufficient to allow one of these Teams to be on duty at all times to respond to suspected and probable cases of smallpox. They will be contactable through a single emergency telephone number maintained by the RSDRG.
Each RSDRT will comprise five members: a
Public Health Physician (who is team leader), a
Medical Consultant (usually an ID Physician), a
Public Health/Infection Control Nurse, a
Clinical N
urse with experience in acute emergency medicine, and arrangements for a
Paediatrician. One individual in each role will be on duty at all times. All members of the team will be vaccinated against smallpox (see
Section VIII). The equipment to be carried by Teams is listed in
Appendix 4. They will be given training in smallpox management and additional general emergency medical training such as Advanced Life Support.
At Alert Level 1, the number of RSDRTs per RSDRG will be increased to allow a response to multiple cases arising simultaneously.
Smallpox Diagnostic Experts (SDE)
Smallpox Diagnostic Experts will be Infectious Disease (ID) Physicians who, at Alert Level 0, will be vaccinated against smallpox (see
Section VIII) and given advanced training in smallpox differential diagnosis so that they are able to assess patients with suspicious illnesses safely and accurately.
ID Physicians in each Region will be invited by the RSDRG to become SDEs, and a network of SDEs will be established who will be trained and co-ordinated by the RSDRG.
At Alert Levels 1 or 2, more general physicians and consultants from other specialties will be trained as SDEs.
Procedure for assessment and management of initial cases
Patients with suspicious illnesses may present at a variety of different sites as listed below (in addition, smallpox virus may be seen on routine EM of vesicular fluid - see paragraph 51). General and specific management in the event of each of these scenarios is described in
Figures 1 to 7.
RSDRGs should therefore
examine local hospital isolation facilities to determine which ones might be used for the care of initial probable cases of smallpox. Facilities should meet the minimum specifications outlined in
Appendix 5.
The patient will be transferred in an ambulance, using standard procedures for a
Category 3 infectious removal, accompanied by the RSDRT Medical Consultant, Clinical Nurse, and Paediatrician if appropriate (see also
Appendix 6). A police escort is likely to be required. One relative or friend (a parent if the case is a child) may also accompany the patient.
After the ambulance crew have delivered the patient to the isolation facilities, they will park in a secure area, wipe the vehicle with disinfectant (0.1% hypochlorite) and then lock it. They will then remove and dispose of protective clothing, and shower and change where these facilities are available. They will then leave their contact details with RSDRT before going off shift pending PCR results. If PCR is positive they will be vaccinated immediately. The vehicle will require decontamination - see
Appendix 15. It should not be reused until smallpox has been excluded or decontamination has been completed.
The RSDRT Public Health Physician and/or Communicable Disease Control Nurse will remain at the site to ensure that infection control measures are maintained, continue contact identification and tracing, and begin vaccinating contacts if the case is confirmed.
Diagnosis of a probable case will lead to mobilisation of a public health response including preparation of Smallpox Care Centres and Smallpox Vaccination Centres, contact tracing (see
Section VII) and deployment and distribution of vaccine supplies (see
Appendix 11). However, vaccination should be deferred until confirmation by PCR.
PCR results will be available within 12 hours of dispatch of specimens from anywhere in the UK. A positive PCR is required for confirmation of initial cases. However, in a case with strongly suggestive clinical features and no other diagnosis, smallpox should not automatically be excluded on the basis of a negative PCR result. The case should be reviewed and laboratory tests repeated if necessary.
Further action in the event of initial confirmed cases
Until further staff can be immunised, care of the initial confirmed cases, first at hospital isolation facilities and then at Smallpox Care Centres will have to be carried out by RSDRT members supported by SDEs.
The site will need to be evacuated and sealed until it can be decontaminated (see
Appendix 15).
Scottish and Regional Smallpox Outbreak Co-ordination Centres (SSOCC and RSOCC) will be convened to co-ordinate the public health response and monitor the epidemiological picture in Scotland. A UK NSOCC will alert international authorities and co-ordinate the overall UK response and monitor the UK epidemiological picture (see paragraphs 109-117 for further details).
Major incident control plans will be initiated with a response at regional Scottish and UK level as described in Deliberate Release of Biological and Chemical Agents in Scotland (SEHD May 2002).
Rapid health alerts will be sent out for enhanced surveillance for other cases - see
Section IX. This will include activation of the NHS Helpline and as appropriate
NHS24 advice algorithms.
Designated
Smallpox Care Centres (see
Appendix 6) will be activated at the earliest opportunity, as these will be required to receive new patients once the high security beds are occupied. They will be need to be opened within 24 hours of confirmation of the first case.
Designated
Smallpox Vaccination Centres will also be activated as soon as possible. These will be required for vaccination of contacts of cases.
Vaccination of contacts will proceed. Further healthcare, laboratory, emergency and other essential staff, including a large number of additional RSDRTs and SDEs, will be vaccinated to allow a response to multiple cases arising simultaneously.
Cases arising in hospital
Cases may be detected in A+Es, general hospital wards, ICUs or ID units. The procedures for managing such cases is summarised in
Figures 3 to 6. Contacts in the hospital may be particularly susceptible to infection due to immunosuppressive disorders or treatments, or general ill health. Attack rates in hospital outbreaks of smallpox have been high.
If a patient with a suspicious illness is recognised, the
Hospital Infection Control Team and
Trust Management should be informed as early as possible. Hospital air conditioning systems should be turned off immediately and remain off until smallpox has been excluded or decontamination completed. This may necessitate deployment of alternative cooling facilities.
The Hospital Infection Control Team should assist the RSDRT in identifying all areas that the patient has passed through in order to guide implementation of infection control measures.
The RSDRT has executive authority, through the lead DPH, to implement whatever infection control measures are deemed necessary, including closure of the hospital.
Identification of contacts will require
consideration of airflows within the hospital. Tracing of contacts will include other inpatients, discharged patients who were in contact with the case during their hospital stay, visitors to the hospital, and staff. Vaccination should be prioritised to those who have had the closest and most prolonged contact with cases.
Inpatient close contacts will require cohort observation, with strict infection control procedures observed to avoid spreading infection from any secondary cases that develop. Special consideration for the management of sick inpatient contacts will be required, bearing in mind contraindications to vaccination. Note also that early symptoms of smallpox may be masked by other underlying medical disorders.
It may be necessary to close large areas of the hospital to admissions, and restrict access to essential staff only, until all inpatient contacts are free of disease for 16 days after their last exposure to infection, since secondary cases may arise elsewhere in the building during the incubation period.
Depending on the structure of the hospital, and airflow within it, consideration may be given to vaccinating all patients, visitors, staff and others who have been present in the building with an infectious case.
At Alert Level 0, Hospital Infection Control Teams should examine their hospitals' plans to determine airflows so that they are prepared for contagious pathogens. In the event of a case of smallpox, this will enable risk areas to be determined rapidly, allowing vaccination to be prioritised and disruption to be kept to a minimum.
Decontamination may necessitate prolonged closure of large areas of the hospital. Alternative facilities for healthcare provisions will be required.
Cases arising at Port Health Control Units
It is unlikely that a case will present at an airport since by the time the clinical features of smallpox are apparent, the patient is likely to be too ill to travel. It is possible that a case could present at a seaport. The procedures for managing such cases is summarised in
Figure 7.
In the event of a case presenting at a port it would be possible to hold both the case and contacts against their will, as the Port Medical Officer (PMO) can advise the immigration authorities that passengers should not be allowed to enter the country.
Figure 7 assumes that the Infectious Disease (Aircraft) Regulations or the Infectious Disease (Ships) Regulations have not resulted in prior notification of the case to the Port Health Authorities and the case has presented at the health control unit.
If there is prior notification to Port Health Authorities, then the PMO should board the aircraft or ship, and no one should be allowed to leave until an assessment has been made and the diagnosis confirmed or excluded. If the diagnosis is confirmed then all those on the same plane should be treated as category A contacts. Contacts on a ship may be category A or B depending on proximity and duration of exposure.