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West Virginia
Infectious Disease Epidemiology Program

Pre-Event Smallpox Vaccination
Clinic Resources

Vaccinee Education Materials | Clinic Materials and Tools | Tools for Site Care Follow Up
Reporting | Other Tools | Other Resources

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Vaccinee Education Materials

Smallpox Pre-Vaccination Information Packet.  
This information is provided by CDC and includes instructions for local health departments and hospitals on how to use the information, various fact sheets for individuals considering vaccination, a fact sheet for close contacts, and a self screening worksheet to be completed by potential vaccinnees prior to coming to a clinic.  This material is to be used without modification.

Complete CDC Smallpox Pre-Vaccination Information Packet The complete packet is available here in pdf version.  

The CDC Smallpox Pre-Vaccination Information Packet in Word is listed below.  Unlike the pdf version, each Word document is listed as a separate file.

Options for HIV and Pregnancy Testing

  • Pre-Event Smallpox Vaccination Options for HIV and Pregnancy Testing
    (WordPerfect)                    (pdf)
  • AIDS Prevention Centers for the Antibody Testing Program 
    (WordPerfect)                    (pdf)
  • Division of Perinatal and Women's Health Family Planning Program
    (WordPerfect)                    (pdf)

Information on how your agency will address employer issues
(e.g., lost work time, medical expenses if they arise, compensation, etc.) It is important to clearly let individuals know what financial or other risks you the employer will assume directly or indirectly and what are risks or costs for which the vaccinee or their contacts will be responsible. This must be developed by the individual agency. For sample purposes only, we provide the material that WVDHHR utilized for this purpose with their staff (NOTE: OTHER THAN THE WV WORKER’S COMP POLICY ATTACHED, THIS DOCUMENT APPLIES ONLY TO DHHR STAFF).

Coverage Information for DHHR Employees Serving on Public Health Response Teams (developed early February 2003).  Only available in pdf.

Appointment time and directions to the vaccination site.
These must be developed by the individual opening.

Clinic Materials and Tools

 Smallpox Pre-Vaccination Information Packet
The educational info should again be provided to potential vaccinees at the clinic site. This CDC packet is exactly the same as that noted above with two additional forms used in the clinic setting itself:

WVDHHR adapted/added to these two CDC forms for use here.  You may find these additional versions useful as well.

  • Smallpox Vaccine Record of Immunization  (Word)    (pdf)
  • Post Vaccination and Follow Up Information Sheet  (Word)   (pdf)
    The Interim Proof of Vaccination is provided to the patient directly after vaccination as their proof of getting the vaccine.  It also provides reference information in case of problems and a follow-up reminder

Sample Standing Orders    (WordPerfect)    (pdf)
If your existing standing orders are not broad enough to cover smallpox vaccine, you will need to draft standing orders for this.

Job Aids
Basic duties / reminders for some of the key roles in a clinic. You should review and adapt according to how your clinic is organized.

  • Registration Desk Job Aid      (Word)     (pdf)
  • Medical Screener Job Aid       (Word)     (pdf)
  • Vaccinator Job Aid                 (Word)     (pdf)
  • Vaccinator Assistant Job Aid  (Word)     (pdf)
  • Site Care Education Job Aid   (Word)     (pdf)
  • Safety Monitor Job Aid           (Word)     (pdf)

FDA notification extending Dryvax Smallpox Vaccine shelflife to 90 days

HIV Risk Factor Checklist             (Word)       (pdf) 
WVDHHR used a laminated version of this for potential vaccinees to review during medical screening. If any were applicable or the individual had any HIV status concerns, HIV/AIDS testing prior to vaccination was offered.

Site Care Supply List                  (WordPerfect)    (pdf)
This is a shopping list of materials vaccinees may need to purchase to undertake recommended site care. WVDHHR used these in the exit interview station.

Diary for Vaccinees           (Word)     (pdf)
To be given to each vaccinee in the exit interview station. This is important to go over with the individual and to encourage daily completion.

Diary for Controls              (Word)     (pdf)
To obtain baseline background frequency of these symptoms, we are asking Local Health Departments to have any willing, not-vaccinated staff to complete these control diaries.

Tools for Site Care Follow Up Training for all Vaccine Safety Monitors and referral physicians:
Completion of at least one of the following trainings on adverse events is required prior to serving these roles. These and other applicable material can be found at http://www.bt.cdc.gov/agent/smallpox/vaccination/index.asp):

"Smallpox Vaccination and Adverse Reactions: Guidance for Clinicians": (MMWR initially published 1/24/03; republished 2/21 as Recommendations and Reports): http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5204a1.htm

"Smallpox Vaccination and Adverse Events Training Module" (On-line: CME provided): http://www.bt.cdc.gov/training/smallpoxvaccine/reactions/default.htm

"Clinical Management of Adverse Events Following Smallpox Vaccination: A National Training Initiative" (Webcast of 2/4/03 Satellite Broadcast): http://www.bt.cdc.gov/agent/smallpox/training/webcast/04feb2003/index.asp

Vaccine Safety Monitor Clinic Tool      (WordPerfect)     (pdf)
This is a form WVDHHR developed and found useful in site follow up clinics.

Reporting Reports should be submitted, one per region, each week to DSDC, WVBPH. Region specific templates are provided below
Other Tools Sample information for coworkers    (WordPerfect)     (pdf)
You may want to draft information for co-workers of vaccinees to help people understand this effort in the workplace. This is an example of such a communication, developed for WVDHHR use in a regular office setting.

Lessons Learned from WVDHHR Clinics   (WordPerfect)     (pdf)

Other Resources Other applicable information on smallpox, smallpox vaccine, and other potential terrorist agents can be found at the CDC website: http://www.bt.cdc.gov

State of West Virginia (WV)
West Virginia Department of Health and Human Resources (DHHR)
Bureau for Public Health (BPH)
Office of Epidemiology and Health Promotion (OEHP)
Division of Surveillance and Disease Control (DSDC)
Infectious Disease Epidemiology Program (IDEP)

This page was last updated 03/21/03.
If you have questions or comments about the West Virginia Division of Surveillance and Disease Control, please direct them to Loretta Haddy at Loretta.E.Haddy@wv.gov.
If you have questions or comments about this Web page, please direct them to Betty Jo Tyler at Betty.J.Tyler@wv.gov.