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Procedure following an outbreak of smallpox in a general hospital
PROCEDURE FOLLOWING AN OUTBREAK OF SMALLPOX IN A GENERAL HOSPITAL By M. J.
PLEYDELL,
M.C., M.D., D.P.H.
CotmO, Medical Officer of Health, O),fordshire FOLLOWING the sudden outbreak of smallpox in 1962, a plan of action to control spread of smallpox infection was drawn up in Oxfordshire, so that it was available as a vade-mecum at a moment's notice if the need should arise on a future occasion. The procedure to be followed was agreed in consultation with the county district medical officers, and was accepted by the local hospital management committee on the advice of their medical advisory committee. Much of this procedure is contained in the Ministry of Health Memorandum on the Control of Outbreaks of Smallpox, but since the first case of smallpox is frequently diagnosed in a general hospital we had considered this aspect of the problem in more detail than that given in Appendix J of the Ministry Memorandum. The action we had agreed upon was based on previous experience and the successful measures of control in general hospitals as described by Dixon and Eastwood. Some of the points which are made may scem very obvious and some may be repetitive. However, in the past the confusion which has resulted following the diagnosis of smallpox in a hospital has meant that the obvious has been overlooked, so it seemed worth while to include the most elementary details. These notes are put forward as a form of "instant guide" in conjunction with the Ministry Memorandum to a medical otficer of health harassed by enquiries and demands from all sides at once, if a case of smallpox is diagnosed in a general hospital in his area. AVOIDANCE
OF
SPREAD
OF
INFECTION
Administration--Standing arrangements prior to an outbreak of smallpox in a general hospital 1. Admission Procedure. General practitioners or hospital officers in charge of a suspected smallpox case must contact the Medical Officer of Health for the area immediately, as the Smallpox Hospital can only be opened to receive cases at the request of the Medical Officer of Health. The Medical Officer of Health may have had consultation previously with one of the practitioners skilled in the diagnosis of smallpox. 2. Medical Officers of Health requesting the admission of a smallpox patient should telephone the Group Secretary, his Deputy, or the Senior Administrative Assistant. 3. Control ofhtfection Committee. There should be a control of infection committee set up, consisting of senior medical and nursing staff and the medical officer of health. 157
158
PUBLIC
HEALTH
VOL.
LXXIX
NO.
3
4. Epidemic Medical Officer'. One medical officer should be appointed as epidemic medical officer for the hospital. He should act as a Deputy Medical Officer of Health to the Medical Officer of Health, who will be busy supervising arrangements for preventing spread of infection outside the hospital. The epidemic medical officer will be responsible for control in the hospital, and should be in a position to ensure that instructions given to consultants and other staff are strictly adhered to.
5. Duties of Epidemic Medical Officer: (a) To consuh the medical officer of health daily and report on the state of the hospital. (b) To ensure that all the medical officer of health's recommendations are carried out. (c) To examine all suspect cases in the hospital. (d) To be responsible for examination, treatment, and supervision of cases admitted to isolation accommodation for observation, if such accommodation is available in the hospital grounds. (e) To be responsible for the daily checking of all resident and nonresident hospital personnel. (f) To provide advice on matters of current difficulty. (g) To maintain close supervision of any patients with unexplained fever. (h) To examine a list of staff absent from duty for any cause, such absence to be reported daily to the medical officer of health who should investigate reason for absence. (i) A detailed report of all patients from the infected area should be sent by the secretary to the epidemic medical officer so that this group of admissions can be kept under close supervision. (j) To review with the hospital pathologist any recent sudden deaths, particularly those thought to be due to atypical chickenpox, scarlet fever, leukaemia, purpura, etc., which might have been cases of fulminating smallpox. 6. Publicity--Liaison with press, radio, television. One of the local press should act as agent or information officer for all publicity and so avoid jamming of lines. Press to be told that no information will be given except through this one local newspaper source. Epidemic medical officer and hospital secretary to be responsible for all statements relating to hospital. 7. Routhte Vaccination. All hospital staff, including staff employed in pathological laboratories, should be revaccinated at least once in every three years.
Procedure followh~g diagnosis of smallpox #t general hospital--Prevention of Spread of Infection 8. The case should be removed by staff wearing caps, gowns and masks to the nearest exit where an ambulance can attend. The mattress, mackintosh sheet and cover should be dispatched by same exit for disinfection.
OUTBREAK
OF
SMALLPOX
1N
A GENERAL
HOSPITAL
159
9. Bed curtains and screen covers round patient's bed, caps, gowns, masks and towels used by staff altending patient arc to be placed in bags in preparation for disinfection. These articles should be sprayed with water to reduce dust, placed gently in containers at tile bedside and removed (by fire escape if possible). Crockery, bedpans, etc., used by patient to be boiled. Bedstead, locker and screen frames round patient's bed to be washed down with White Fluid, 1 in 40. A cloakroom to be set up at the entrance to the ward and all staff to remove caps, coats and aprons before passing into a second room to put on caps, masks and gowns. On leaving ward these articles to be put in special container, the hands then being washed in Dettol solution. A barrier and notice to be placed at ward forbidding entry by unauthorised persons. 10. Food to be sent in marked containers io a given point prior to it being conveyed by the ward staff from Ihere to the ward kitchen. Food containers to be boiled after use. These containers are potentially infectious and should be kept separate from those used by the remainder of the hospital. If possible disposable food containers should be used and then destroyed. 11. Refuse, soiled dressings, etc., not to accumulate but each day to be sprayed with water, taken out by fire escape and burnt. Soiled linen to be moistened, placed in bags, and sent out by fire escape for disinfection, after which it can be dispalched to the hospital laundry. Mattresses and pillows to be sent for steam disinfection. 12. Dressings and medicines can be sent to the ward as required. Returnable containers to be sterilised before sending thern back. 13. Portable telephone in ward will help contact with patients. Extra amenities required for patients, e.g. games, books, etc. Certificates to be obtained from the Ministry of National Insurance in respect of ward patients who have to be detained in incubation period. 14. Isolation and Visit#~g. S~rict isolation is not necessary for any other ward except the ward in which the case has occurred. Hospital visiting to be curtailed. Public informed of restriction through local press and medical practitioners by circular letter. Relatives of dangerously ill patients to be admitted on production of a note signed by the ward sister. Before admission they should be vaccinated. 15. Non-resident nurses to change in the hospital in order to avoid embarrassment when travelling out of doors in uniform. 16. All certificates for the Ministry of National Insurance, etc., to be posted in bulk after being exposed to formaldehyde vapour overnight. This is a psychological measure. PROTECTION
OF
PATIENTS
AND
STAFF
17. Vacc#mtian to be Undertaken as soon as Clhiical Diagnosis Made. There Should Not be Delay in Waiting for Laboratory Diagnosis. (See Appendices J and K of Ministry Memorandum)
160
PUBLIC
HEALTH
VOL.
LXXIX
NO. 3
18. One or two medical officers specially interested in vaccination should undertake all vaccinations. Vaccinations must be horrific to ensure take. Three separate vaccinations should be undertaken on each contact. All vaccinations to be inspected on third day. 19. All ward patients to be vaccinated at once. Vaccinial histories of ward patients to be recorded. Information to be obtained regarding possible contacts, particularly ambulance and hospital staff who attended patient prior to admission to ward. Situation to be explained to all patients, who should be strongly advised to accept protcclion for their own sake and for others. 20. All the Following ShouM be Vaccinated:~ (a) All nursing stall; cadet nurses and male orderlies and their relatives and friends who are contacts. (b) All medical officers and their relatives and friends who are contacts. (c) All laundry staff, kitchen staff. Their relatives and friends who are contacts should also be vaccinated. (d) Clergy attending hospital and relatives and fiiends who are contacts. (e) Men employed on outside undertakings, e.g. gas, electricity, water board, and relatives and friends who are contacts. All outside workmen should report to the secretary's or steward's office before commencing any new work. Firms employed should be informed of this requirement. (f) Patients who are minors should either be vaccinated forthwith or reply paid telegrams sent to nearest relatives for consent. (g) All patients in the hospilal should be given form requesting name and address of any person who visited them on the date the smallpox patient was admitted. These persons should be protected and kept under supervision. 21. Ami-Vacciniat Gamma Globulin. In cases of infantile eczema, hypo gamma globulinaemia, patients receiving cortico-steroid therapy, etc., antivaccinial gamma globulin should be given into the opposite arm at the same time as vaccination. Supplies can be obtained from the Public Health Laboratory Service Laboratories at Birmingham, Bristol, Cambridge, Cardiff, Colindale, Leeds, Liverpool, Manchester, Newcastle, Oxford and Sheffield. 22. Close contacts who are unvaccinated, who do not have a definite vaccination "take", or who are discovered later than five days after the first day of contact, should be given anti-vaccinial garmna globulin in addition to vaccination. The gamma globulin should be given on the ninth day of the anticipated incubation period. MEDICAL
SUPERVISION
OF
PATIENTS
AND
STAFF
23. Patients and staffin infected ward to be examined twice daily. Enquiries to be made regarding headache, backache or malaise. Arms, legs and face to be examined for signs of rash. Temperatures to be checked on charts. Examination to be intensified from the eighth day onwards. Patients in other wards to be seen at least daily by the medical officer in charge of the ward.
OUTBREAK
OF
SMALLPOX
IN
A GENERAL
HOSPITAL
161
All nurses working in the infected ward or who might have been in contact with patient to have temperature taken each morning prior to going on duty. A record of temperature to be kept for daily inspection by the epidemic medical officer. 24. It is not uncommon for nurses to conceal that they feel unwell under these circumstances. All temperatures should be checked by the medical officer himself. Nurses need not be confined to hospital grounds but are advised to avoid visiting crowded places or relatives or friends who are not vaccinated. Nurses should suggest vaccination to all persons they are likely to visit. Resident nurses who are close contacts should have separate sleeping quarters and should not go on weekend or extended leave. Movements may be restricted between the ninth and sixteenth day after contact. Temperatures should be taken before going off duty. 25. Remainder of patients and hospital personnel to be examined daily by medical staff" Special supervision of laundry workers and persons handling incoming soiled linen is necessary. Storemen, kitchen and domestic hands, plumbers, electricians, boilermen, gardeners and mortuary staff to be supervised. 26. Hospital admissions. Initially emergency medical and surgical admissions to be referred to other hospitals. Special arrangements to be made if a patient in an infected ward requires emergency medical or surgical treatment. Arrangements to be made for emergency surgical treatment of a close contact in the community. A separate operating theatre should be used. 27. Midwifery cases to be admitted on condition they agree to vaccination. Husbands not allowed to visit unless vaccinated. Out-patient department to be closed as soon as possible. Decisions when to open part, or all, of the hospital will depend on design and facilities for isolation and policing.
LIAISON
ARRANGEMENTS
28. Close liaison with the Smallpox Hospital and other hospitals in the area is essential. 29. Other hospitals in the area should be alerted immediately and, in particular, pathologists should be warned and advised to be vaccinated. They shouht be asked to review any recent sudden deaths, particularly those thought to be due to leukaemia, purpura, etc., which might have been cases of.fulminating smallpox. 30. Medical Liaison (a) Immediate notification to the Ministry of Health. Close contact to be maintained. (b) hnmediate notification to neighbouring authorities, together with lists of contacts residing in their areas. (c) Immediate notification of all general practitioners in the area. D
162
PUBLIC
HEALTH
VOL.
LXXIX
NO.
3
(d) Immediate notification of Public Health Laboratory with request to make :twfilablc large supplies of lymph. (c) Routine bulletins to be issued to hospitals, general practitioners and ncighbouring authorities. REFERENCES DIXON, C . W . EASTWOOD, J.
(1962). Smallpox. (1955). Med. Off. 94, 365. INDEX
Standing Arrangements in a general hospital prior to an outbreak o f smallpox Admission P r o c e d u r e . . . . . . . . . . . . . . . . . . . . . Controt of Infection Committee . . . . . . . . . . . . . . . . . . Epidemic Medical Officer . . . . . . . . . . . . . . . . . . . . . . . Duties o f E p i d e m i c Medical Officer . . . . . . . . . . . . . . . . . . . . P u b l i c i t y - - L i a i s o n with press, radio, television . . . . . . . . . . . . . . R o u t i n e V a c c i n a t i o n a n d p r o t e c t i o n against infection . . . . . . . . . .
Para.
1
,,
3 4 5 6 7
,
Procedure following notOqcation oj smallpox in a general hospital P r o c e d u r e in the w a r d to which patient has been a d m i t t e d . . . . . . . . . Para. Vaccination a n d p r o t e c t i o n o f patients a n d staff . . . . . . . . . . . . . . Medical supervision o f patients a n d staff . . . . . . . . . . . . . . . . .
8 17 23
Liaison arrangements Hospital liaison Mcdical liaison
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Para.
28 30
PLEYDELL,
M.C., M.D., D.P.H.
CotmO, Medical Officer of Health, O),fordshire FOLLOWING the sudden outbreak of smallpox in 1962, a plan of action to control spread of smallpox infection was drawn up in Oxfordshire, so that it was available as a vade-mecum at a moment's notice if the need should arise on a future occasion. The procedure to be followed was agreed in consultation with the county district medical officers, and was accepted by the local hospital management committee on the advice of their medical advisory committee. Much of this procedure is contained in the Ministry of Health Memorandum on the Control of Outbreaks of Smallpox, but since the first case of smallpox is frequently diagnosed in a general hospital we had considered this aspect of the problem in more detail than that given in Appendix J of the Ministry Memorandum. The action we had agreed upon was based on previous experience and the successful measures of control in general hospitals as described by Dixon and Eastwood. Some of the points which are made may scem very obvious and some may be repetitive. However, in the past the confusion which has resulted following the diagnosis of smallpox in a hospital has meant that the obvious has been overlooked, so it seemed worth while to include the most elementary details. These notes are put forward as a form of "instant guide" in conjunction with the Ministry Memorandum to a medical otficer of health harassed by enquiries and demands from all sides at once, if a case of smallpox is diagnosed in a general hospital in his area. AVOIDANCE
OF
SPREAD
OF
INFECTION
Administration--Standing arrangements prior to an outbreak of smallpox in a general hospital 1. Admission Procedure. General practitioners or hospital officers in charge of a suspected smallpox case must contact the Medical Officer of Health for the area immediately, as the Smallpox Hospital can only be opened to receive cases at the request of the Medical Officer of Health. The Medical Officer of Health may have had consultation previously with one of the practitioners skilled in the diagnosis of smallpox. 2. Medical Officers of Health requesting the admission of a smallpox patient should telephone the Group Secretary, his Deputy, or the Senior Administrative Assistant. 3. Control ofhtfection Committee. There should be a control of infection committee set up, consisting of senior medical and nursing staff and the medical officer of health. 157
158
PUBLIC
HEALTH
VOL.
LXXIX
NO.
3
4. Epidemic Medical Officer'. One medical officer should be appointed as epidemic medical officer for the hospital. He should act as a Deputy Medical Officer of Health to the Medical Officer of Health, who will be busy supervising arrangements for preventing spread of infection outside the hospital. The epidemic medical officer will be responsible for control in the hospital, and should be in a position to ensure that instructions given to consultants and other staff are strictly adhered to.
5. Duties of Epidemic Medical Officer: (a) To consuh the medical officer of health daily and report on the state of the hospital. (b) To ensure that all the medical officer of health's recommendations are carried out. (c) To examine all suspect cases in the hospital. (d) To be responsible for examination, treatment, and supervision of cases admitted to isolation accommodation for observation, if such accommodation is available in the hospital grounds. (e) To be responsible for the daily checking of all resident and nonresident hospital personnel. (f) To provide advice on matters of current difficulty. (g) To maintain close supervision of any patients with unexplained fever. (h) To examine a list of staff absent from duty for any cause, such absence to be reported daily to the medical officer of health who should investigate reason for absence. (i) A detailed report of all patients from the infected area should be sent by the secretary to the epidemic medical officer so that this group of admissions can be kept under close supervision. (j) To review with the hospital pathologist any recent sudden deaths, particularly those thought to be due to atypical chickenpox, scarlet fever, leukaemia, purpura, etc., which might have been cases of fulminating smallpox. 6. Publicity--Liaison with press, radio, television. One of the local press should act as agent or information officer for all publicity and so avoid jamming of lines. Press to be told that no information will be given except through this one local newspaper source. Epidemic medical officer and hospital secretary to be responsible for all statements relating to hospital. 7. Routhte Vaccination. All hospital staff, including staff employed in pathological laboratories, should be revaccinated at least once in every three years.
Procedure followh~g diagnosis of smallpox #t general hospital--Prevention of Spread of Infection 8. The case should be removed by staff wearing caps, gowns and masks to the nearest exit where an ambulance can attend. The mattress, mackintosh sheet and cover should be dispatched by same exit for disinfection.
OUTBREAK
OF
SMALLPOX
1N
A GENERAL
HOSPITAL
159
9. Bed curtains and screen covers round patient's bed, caps, gowns, masks and towels used by staff altending patient arc to be placed in bags in preparation for disinfection. These articles should be sprayed with water to reduce dust, placed gently in containers at tile bedside and removed (by fire escape if possible). Crockery, bedpans, etc., used by patient to be boiled. Bedstead, locker and screen frames round patient's bed to be washed down with White Fluid, 1 in 40. A cloakroom to be set up at the entrance to the ward and all staff to remove caps, coats and aprons before passing into a second room to put on caps, masks and gowns. On leaving ward these articles to be put in special container, the hands then being washed in Dettol solution. A barrier and notice to be placed at ward forbidding entry by unauthorised persons. 10. Food to be sent in marked containers io a given point prior to it being conveyed by the ward staff from Ihere to the ward kitchen. Food containers to be boiled after use. These containers are potentially infectious and should be kept separate from those used by the remainder of the hospital. If possible disposable food containers should be used and then destroyed. 11. Refuse, soiled dressings, etc., not to accumulate but each day to be sprayed with water, taken out by fire escape and burnt. Soiled linen to be moistened, placed in bags, and sent out by fire escape for disinfection, after which it can be dispalched to the hospital laundry. Mattresses and pillows to be sent for steam disinfection. 12. Dressings and medicines can be sent to the ward as required. Returnable containers to be sterilised before sending thern back. 13. Portable telephone in ward will help contact with patients. Extra amenities required for patients, e.g. games, books, etc. Certificates to be obtained from the Ministry of National Insurance in respect of ward patients who have to be detained in incubation period. 14. Isolation and Visit#~g. S~rict isolation is not necessary for any other ward except the ward in which the case has occurred. Hospital visiting to be curtailed. Public informed of restriction through local press and medical practitioners by circular letter. Relatives of dangerously ill patients to be admitted on production of a note signed by the ward sister. Before admission they should be vaccinated. 15. Non-resident nurses to change in the hospital in order to avoid embarrassment when travelling out of doors in uniform. 16. All certificates for the Ministry of National Insurance, etc., to be posted in bulk after being exposed to formaldehyde vapour overnight. This is a psychological measure. PROTECTION
OF
PATIENTS
AND
STAFF
17. Vacc#mtian to be Undertaken as soon as Clhiical Diagnosis Made. There Should Not be Delay in Waiting for Laboratory Diagnosis. (See Appendices J and K of Ministry Memorandum)
160
PUBLIC
HEALTH
VOL.
LXXIX
NO. 3
18. One or two medical officers specially interested in vaccination should undertake all vaccinations. Vaccinations must be horrific to ensure take. Three separate vaccinations should be undertaken on each contact. All vaccinations to be inspected on third day. 19. All ward patients to be vaccinated at once. Vaccinial histories of ward patients to be recorded. Information to be obtained regarding possible contacts, particularly ambulance and hospital staff who attended patient prior to admission to ward. Situation to be explained to all patients, who should be strongly advised to accept protcclion for their own sake and for others. 20. All the Following ShouM be Vaccinated:~ (a) All nursing stall; cadet nurses and male orderlies and their relatives and friends who are contacts. (b) All medical officers and their relatives and friends who are contacts. (c) All laundry staff, kitchen staff. Their relatives and friends who are contacts should also be vaccinated. (d) Clergy attending hospital and relatives and fiiends who are contacts. (e) Men employed on outside undertakings, e.g. gas, electricity, water board, and relatives and friends who are contacts. All outside workmen should report to the secretary's or steward's office before commencing any new work. Firms employed should be informed of this requirement. (f) Patients who are minors should either be vaccinated forthwith or reply paid telegrams sent to nearest relatives for consent. (g) All patients in the hospilal should be given form requesting name and address of any person who visited them on the date the smallpox patient was admitted. These persons should be protected and kept under supervision. 21. Ami-Vacciniat Gamma Globulin. In cases of infantile eczema, hypo gamma globulinaemia, patients receiving cortico-steroid therapy, etc., antivaccinial gamma globulin should be given into the opposite arm at the same time as vaccination. Supplies can be obtained from the Public Health Laboratory Service Laboratories at Birmingham, Bristol, Cambridge, Cardiff, Colindale, Leeds, Liverpool, Manchester, Newcastle, Oxford and Sheffield. 22. Close contacts who are unvaccinated, who do not have a definite vaccination "take", or who are discovered later than five days after the first day of contact, should be given anti-vaccinial garmna globulin in addition to vaccination. The gamma globulin should be given on the ninth day of the anticipated incubation period. MEDICAL
SUPERVISION
OF
PATIENTS
AND
STAFF
23. Patients and staffin infected ward to be examined twice daily. Enquiries to be made regarding headache, backache or malaise. Arms, legs and face to be examined for signs of rash. Temperatures to be checked on charts. Examination to be intensified from the eighth day onwards. Patients in other wards to be seen at least daily by the medical officer in charge of the ward.
OUTBREAK
OF
SMALLPOX
IN
A GENERAL
HOSPITAL
161
All nurses working in the infected ward or who might have been in contact with patient to have temperature taken each morning prior to going on duty. A record of temperature to be kept for daily inspection by the epidemic medical officer. 24. It is not uncommon for nurses to conceal that they feel unwell under these circumstances. All temperatures should be checked by the medical officer himself. Nurses need not be confined to hospital grounds but are advised to avoid visiting crowded places or relatives or friends who are not vaccinated. Nurses should suggest vaccination to all persons they are likely to visit. Resident nurses who are close contacts should have separate sleeping quarters and should not go on weekend or extended leave. Movements may be restricted between the ninth and sixteenth day after contact. Temperatures should be taken before going off duty. 25. Remainder of patients and hospital personnel to be examined daily by medical staff" Special supervision of laundry workers and persons handling incoming soiled linen is necessary. Storemen, kitchen and domestic hands, plumbers, electricians, boilermen, gardeners and mortuary staff to be supervised. 26. Hospital admissions. Initially emergency medical and surgical admissions to be referred to other hospitals. Special arrangements to be made if a patient in an infected ward requires emergency medical or surgical treatment. Arrangements to be made for emergency surgical treatment of a close contact in the community. A separate operating theatre should be used. 27. Midwifery cases to be admitted on condition they agree to vaccination. Husbands not allowed to visit unless vaccinated. Out-patient department to be closed as soon as possible. Decisions when to open part, or all, of the hospital will depend on design and facilities for isolation and policing.
LIAISON
ARRANGEMENTS
28. Close liaison with the Smallpox Hospital and other hospitals in the area is essential. 29. Other hospitals in the area should be alerted immediately and, in particular, pathologists should be warned and advised to be vaccinated. They shouht be asked to review any recent sudden deaths, particularly those thought to be due to leukaemia, purpura, etc., which might have been cases of.fulminating smallpox. 30. Medical Liaison (a) Immediate notification to the Ministry of Health. Close contact to be maintained. (b) hnmediate notification to neighbouring authorities, together with lists of contacts residing in their areas. (c) Immediate notification of all general practitioners in the area. D
162
PUBLIC
HEALTH
VOL.
LXXIX
NO.
3
(d) Immediate notification of Public Health Laboratory with request to make :twfilablc large supplies of lymph. (c) Routine bulletins to be issued to hospitals, general practitioners and ncighbouring authorities. REFERENCES DIXON, C . W . EASTWOOD, J.
(1962). Smallpox. (1955). Med. Off. 94, 365. INDEX
Standing Arrangements in a general hospital prior to an outbreak o f smallpox Admission P r o c e d u r e . . . . . . . . . . . . . . . . . . . . . Controt of Infection Committee . . . . . . . . . . . . . . . . . . Epidemic Medical Officer . . . . . . . . . . . . . . . . . . . . . . . Duties o f E p i d e m i c Medical Officer . . . . . . . . . . . . . . . . . . . . P u b l i c i t y - - L i a i s o n with press, radio, television . . . . . . . . . . . . . . R o u t i n e V a c c i n a t i o n a n d p r o t e c t i o n against infection . . . . . . . . . .
Para.
1
,,
3 4 5 6 7
,
Procedure following notOqcation oj smallpox in a general hospital P r o c e d u r e in the w a r d to which patient has been a d m i t t e d . . . . . . . . . Para. Vaccination a n d p r o t e c t i o n o f patients a n d staff . . . . . . . . . . . . . . Medical supervision o f patients a n d staff . . . . . . . . . . . . . . . . .
8 17 23
Liaison arrangements Hospital liaison Mcdical liaison
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Para.
28 30