Transcript Slide 1

Exit Review Area
 Objective

Understand Your Role in the Exit Review Area
Job Description of
Exit Review Area Personnel
(Majority of Counseling Will Be Showing Where in Patient’s
Package)
Knowledge of All Materials in the Patient’s Package
(May need to read information to the patient)
Knowledge of & Ability to Answer Any Questions on:
 Contraindications of Vaccine
 Normal Side Effects
 Care of Vaccine Site
 “Take”
 Adverse Events
 1-800 # to call for Questions
How to Deal With an Immediate Emergency
Supplies For Exit Review Area
 Table
& Chairs
 CDC Smallpox Vaccination Pamphlet
 Extra Forms of:
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CDC/VIS on Vaccination Site Appearance
And Care
CDC/VIS on Reaction After Vaccination
 May
Need Ammonia, 2x2 Gauze, Tape
Vaccine “Takes”, Normal Vaccine
Side Effects, and Site Care
 Job
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Description: Exit Review Personnel
Knowledge of all materials in the Patient’s
information package
Knowledge of/ability to answer any questions on:
• Contraindications of vaccine
• Normal Side Effects
• Care of Vaccine Site
• “Take”
• Adverse Events
How to deal with an immediate emergency
Clinical Response to
Vaccination*
Symptom/sign Time after Vacc
Papule
2-5 days
Pustule
7-10 days
Maximum erythema
8-10 days
Scab
14 days
Scab separation
21 days
*typical response in a nonimmune person
Normal Response To
Smallpox Vaccination
Day00
Day
Day33
Day
First dose
Booster dose
Day 77
Day
First Dose
Booster Dose
Day 10
10
Day
Day14
14
Day
Progression of smallpox vaccination site in a
non-immune person
TAKE VERSUS NON-TAKE
 Major
reaction and take: area of definite
induration/congestion surrounding a
central pustule about day 7 – 8 indicates a
take.
 Equivocal – Erythema and a small,
temporary papule that resolves quickly.
Revaccination is required.
 No reaction at all. Revaccination is
required.
Vaccination Site Care
 Virus
can be recovered at site from time of
papule until scab separates
 Site should be covered until scab falls off
(approximately 3 weeks)
 Site should be kept dry
 Normal bathing can occur if covered by
waterproof bandage
Vaccination Site Care
 Hand
hygiene immediately after handling
dressing or contact with site CRITICAL to
preventing spread
 Clothing over site (long sleeves when
sleeping)
 May place gauze with tape over vaccine
site, allowing site to “breathe”
Site Care at Home
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Change dressing if gauze becomes saturated
(wet, soiled, or loose)
 If drainage gets on clothes or linens, wash in hot
water (160°) separately
 If bandage removed/changed at home, place in
ziploc bag and discard in regular trash (also
scabs)
 Avoid placing ointments or ice on vaccination
site
Normal Side Effects of
Smallpox Vaccine
 Pain,
swelling, erythema at vaccination
site (40 -47% have pain)
 Regional
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lymphadenopathy (21-38%)
Begins 3-10 days after vaccination
Can persist for 2-4 weeks after
vaccination site heals
Reaction Rates among adults
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Elevated temperature 7 to 12 days post
vaccination:
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17% >100o F
1.4% >102o F
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Systemic symptoms (malaise, myalgias)
8 – 10 days post vaccination
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20 - 36% sufficiently ill to miss work, school,
or recreational activities or had trouble
sleeping
Normal Variants of
Vaccine Reaction
 Local
edema at vaccination site
 Lymphangitis
 Regional lymphadenopathy
(nonfluctuant)
 Satellite lesions (Incidence of 2.4
– 6.6%)
Lymphangitis following smallpox vaccination
Satellite lesions
Local Reactions Following
Smallpox Vaccine
 Allergic
reactions to bandage and tape
adhesives
 Large
primary vaccination reactions
(“robust primary takes” – RPT)
 Secondary
bacterial infection
Allergic reaction to tape
Local Reactions to Adhesive
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Erythema corresponds to placement of adhesive
tape
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No systemic symptoms
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Treat with antihistamines, NSAIDs, frequent
bandage/tape change
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Steroid treatment not recommended
Robust Primary Takes (RPT)
 Expected
variant of normal reaction
 >3 inches of erythema with induration,
pain, warmth
 Occur in 5%-15% of recipients
 Peak at day 8-10 post-vaccination
 May resemble bacterial infection (“viral
cellulitis”)
Robust primary take
Robust Primary Takes (RPT)
 Observe
carefully
 Supportive therapy
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Rest affected limb
Analgesia (non-aspirin)
NSAIDs
 Usually
improve in 24-48 h
Secondary bacterial infection of vaccination site
Secondary Bacterial Infection
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More common among children than adults
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Usually Staphylococcus aureus or Group A
beta hemolytic Streptococci
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Anaerobic and mixed infections may occur
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Evaluate with gram stain and culture
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Antibiotic therapy based on culture
Rashes Following Smallpox Vaccine
(Erythema multiforme, roseola vaccinia, toxic
erythema, postvaccinial urticaria)
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Flat, erythematous, macular, or urticarial
lesions
Usually do not become vesicular
Do not appear to involve viral multiplication
or systemic dissemination of vaccinia virus
Occur approximately 10 days after
vaccination
Resolve spontaneously within 2 to 4 days
Erythema multiforme following smallpox
vaccination
Inadvertent Inoculation
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Transfer of vaccinia virus from vaccination site
to another site on the body, or to a close
contact
Most frequent complication of smallpox
vaccination (about ½ of all complications)
Occurred 25-529 cases per million primary
vaccinations
Most common sites are face, eyelid, nose,
mouth, genitalia, rectum
Lesions contain vaccinia virus
Inadvertent Inoculation
 Uncomplicated
lesions require no
therapy, self-limited, resolve in ~3 weeks
 VIG
may speed recovery if extensive or
painful genital involvement
 Hand
washing after contact with
vaccination site or contaminated material
most effective prevention
Inadvertent inoculation
Smallpox Vaccine: Significant Adverse
Reactions
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Adverse reaction rates may be higher today than
in 1960s
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More persons at risk because of higher
prevalence of immunosuppression and
eczema/atopic dermatitis
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Adverse reaction rates lower among previously
vaccinated persons
Smallpox Vaccine Adverse
Reactions, and Rates*
Reaction
Primary
Vaccination
Inadvertent inoculation
25-529
Generalized vaccinia
23-242
Eczema vaccinatum
10-39
Progressive vaccinia (vaccinia
necrosum)
Post-vaccinial encephalitis
0.9-1.5
*Rates per million primary
Death
vaccinations
3-12
1
Generalized Vaccinia
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Vesicles or pustules appearing on normal skin
distant from the vaccination site
Rash distribution is indiscriminate – follows no
set pattern
Often accompanied by fever, headache, and
myalgias
Occurred 23-242 cases per million primary
vaccinations
Usually occur 6-9 days after vaccination
Generalized vaccinia
Generalized Vaccinia
 Generally
self-limited
 Most cases do not require therapy
 VIG may be considered for recurrent
disease or severe disease
 Lesions contain vaccinia
Post-vaccinial Encephalitis
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Usually affects primary vaccinees <12 months of
age and adolescents and adults receiving a
primary vaccination
Presents with any of a variety of CNS signs
(e.g., ataxia, confusion, paralysis, seizures, or
coma)
15%-25% die
25% develop neurological sequelae
Occurred 3-12 cases per million primary
vaccinations (rare)
When to seek Medical Care
 Inadvertent
inoculation
 Widespread rash
 Ongoing infection of the skin at the
vaccination site with tissue destruction
 Allergic response to vaccine (hives, resp
difficulty, etc)
 Persistent headache,, confusion, seizures,
or other neurologic symptoms
How to Handle Emergencies
in Exit Review Area
*Nauseated, anxious, dizzy
- Have patient to sit or lie down
- Stay with the patient
Have other staff member get float nurse or EMS
personnel
*Immediate rash, shortness of breath,
wheezing
- Have patient to lie down
- Stay with the patient
- Have other staff member get EMS personnel
immediately