Smallpox, Big Decision

Health Care Workers Must Decide Whether to Be Vaccinated  

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Public Health Feature -- February 2003

By  Ken Ortolon
Senior Editor

If bioterrorists unleashed smallpox on an unsuspecting community in the United States, the results could be devastating without a rapid response from frontline health care workers trained and ready to contain the disease. But those health care workers themselves would be at serious risk if they treated smallpox victims without being vaccinated.

Unfortunately, the vaccine presents something of a gamble because known side effects can cause serious illness and even death. But that's a gamble the federal government is asking hundreds of thousands of public health and hospital emergency personnel to take to ensure that America is prepared to respond if a smallpox attack occurs.

Acting under orders President George W. Bush issued in December, public health officials have begun vaccinating about 500,000 public health and hospital emergency personnel, including nearly 40,000 in Texas, against smallpox. The vaccinations were scheduled to begin in late January and continue throughout most of February.

The vaccination of public health and emergency department personnel is the first phase of a plan that eventually will expand to include millions of police, fire, and emergency medical service (EMS) personnel likely to be first responders in case of smallpox emergencies. Ultimately, the smallpox vaccine will be made available to anyone in the general public who wants it.

Texas Commissioner of Health Eduardo Sanchez, MD, says the effort is necessary to protect the public even though there is no information that a bioterrorist attack using smallpox is likely.

"The last known case of smallpox in the United States was in 1949. We last vaccinated against smallpox in Texas in 1972," Commissioner Sanchez said. "Nonetheless, the Texas Department of Health (TDH) is prepared to follow the direction of federal authorities. We have been working with the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta on a statewide vaccination plan for public health system and hospital personnel who would be the first line of defense in case of a smallpox emergency."

Despite some concerns about potential adverse reactions to the smallpox vaccine, most public health and hospital personnel in Texas appear to be ready to be vaccinated.

Executing the Plan

Public health and hospital-based personnel in Texas are being vaccinated under a plan developed by TDH and submitted to CDC on Dec. 9, 2002. The plan calls for vaccination of approximately 3,000 state, regional, and local public health workers who will make up some 70 smallpox public health response teams and 36,700 hospital emergency personnel who will be part of hundreds of smallpox health care response teams.     

The plan was drafted in about three weeks, following a Nov. 18, 2002, meeting at which TDH sought input from a number of physician and hospital groups, including the Texas Medical Association.

The TDH Office of the State Epidemiologist will be responsible for implementing and managing the smallpox vaccination program. Two different types of smallpox "response teams" will be created across the state. The public health workers to be vaccinated will make up a series of smallpox public health response teams that will provide epidemiological support and administer vaccinations to the hospital-based personnel. The vaccinated hospital-based personnel will form smallpox health care teams that will care for smallpox victims.

Most of the state's 65 local full-service health departments, as well as the eight TDH regional health offices and the TDH central office in Austin, will create smallpox public health response teams. Each team will include epidemiologists, nurses, and advisors. The TDH central office response team will include physicians, epidemiologists, disease investigators, public health technicians, selected microbiology laboratory personnel, and public health nurses.

Ten TDH public health nurses attended a CDC training session in mid-December on how to give the vaccinations, how to care for the vaccination site, which is usually on the arm, and how to train others to do so. Additional training activities were being done through satellite downlinks, videotapes, and Webcasts. Unlike other immunizations that require a single shot with a traditional needle and syringe, the smallpox vaccine is administered with a bifurcated needle dipped into the vaccinia vaccine solution. Then, 15 vigorous jabs are made with that needle into the arm.

State epidemiologist Dennis Perrotta, PhD, says 61 of the 65 full-service local public health departments in Texas and 375 of 550 acute care hospitals in the state have agreed to participate in the plan. Because the health departments and hospitals were given only a few days to decide whether to participate and how many of their personnel should be vaccinated, some were hesitant to sign on, Dr. Perrotta says. Some had questions about potential liability for adverse reactions to the vaccine. At least one city attorney advised his local health department not to participate because of the liability concerns, Dr. Perrotta says.

"This was all a real rush for everyone," Dr. Perrotta said. "So I don't think everybody had the amount of time necessary to make the kind of decisions necessary to do this." He expected additional health departments and hospitals to sign up by the time the vaccinations actually began.

But some hospitals across the country apparently are not prepared to vaccinate their physicians and staff unless there is a credible smallpox threat. Kenneth Mattox, MD, chief of staff at Ben Taub General Hospital in Houston, says the entire administrative and medical staffs at major hospitals in Atlanta, Richmond, Philadelphia, and elsewhere have declined to be vaccinated until a threat arises.

Fernando Guerra, MD, director of the San Antonio Metropolitan Health District, says his organization is ready to move forward as soon as the vaccine is distributed. The district has 134 employees who have volunteered to be vaccinated and serve on the response team. Dr. Guerra says he probably will choose 80 to 100 to be vaccinated in the initial phase of the program. The remainder could be vaccinated in the second phase of the immunization plan when police, fire, and EMS personnel will be vaccinated.

Dr. Sanchez says there is as yet no timetable for when Phase 2 will begin, but Dr. Perrotta says he expects it to follow quickly on completion of Phase 1, possibly during spring 2003.

Caring for Smallpox Victims

The responsibility for treating smallpox victims would fall to the smallpox health care teams at each of the 375 acute care hospitals across the state. Each hospital was asked to determine the composition of its own team, but the teams likely will include emergency department physicians and nurses and ancillary staff, intensive care unit physicians and nurses and selected ancillary staff, infection control personnel, respiratory therapists, radiologists and radiology technicians, security personnel, housekeeping personnel, occupational health nurses, surgical teams, dermatologists, ophthalmologists, pathologists, dietary staff, laboratory staff, and general medical unit staff.

Pat Crocker, DO, chief of staff and chief of emergency medicine at Brackenridge Hospital in Austin, says his hospital probably will draw on workers who have had one or more previous vaccinations to make up its response team.

"We're primarily going to draw upon those who have one or two prior immunizations so we have a low incidence of potential complications," Dr. Crocker said. "The incidence of complications goes down to about one-tenth that of first-time immunizations."

Dr. Perrotta says CDC guidelines suggest that each hospital receive between 45 and 100 doses of vaccine for its response team members. But Dr. Mattox says that's not enough to ensure that a large public hospital such as Ben Taub can deal with smallpox cases and preserve the infrastructure to handle catastrophic conditions such as pneumonia, heart disease, stroke, and trauma that will be ongoing during a smallpox emergency.

"We began to count the minimum number of people required to run a hospital during such emergency conditions and where those people are," Dr. Mattox said. "They're not limited to the emergency department. You're going to have to have engineers, security officers, medical records people to deliver records up and down, nurses, and doctors. And, if you're going to do surgery, that surgeon is going to require a nurse, he's going to require an assistant. And after you finish the surgery, you're going to have to have somebody clean up the room. So you're going to have to have some orderlies, some transportation personnel, some ICU nurses."

Ben Taub estimates it would need 300 people per eight-hour shift to ensure its continued operation, so it requested 1,000 doses of vaccine, Dr. Mattox says.

Dr. Perrotta says it is unlikely that Ben Taub or any other hospital would get that many doses, but TDH recognizes that the larger hospitals will need more than the 100 doses. TDH requested enough extra vaccine to make sure that large hospitals are able to immunize 200 to 300 workers. And, if a smallpox emergency does occur, TDH and local health departments are prepared to carry out wider vaccination of hospital employees rapidly.

"If there's a smallpox case anywhere in the United States, that's a national emergency," Dr. Perrotta. "If it occurs in Houston and goes to Ben Taub, you know that we are going to have smallpox vaccine on the next plane to Texas. We'll meet it in Houston and we'll have vaccinators, including those who were vaccinated in this pre-event stage, there immunizing every person in that hospital."

Dr. Crocker says that should be adequate to protect most hospital workers because of the rapid effect of the vaccine. "The average case in an unprotected individual has a 30 to 40 percent mortality rate," he said. "But, if you take somebody who was exposed to the virus and is on Day 1 of the fever and you immunize them, then the death rate goes down to 1 percent. So the presumption is if we start immunizing large groups of care providers early on, we should have a very well protected population within just a week or so."

Preventing Accidents

Two additional concerns arise from the vaccination program. First is assuring that hospitals have adequate personnel to continue caring for patients in case large numbers of the vaccinated response team members have adverse reactions significant enough to cause them to miss a few days of work. Second is protecting against "accidental inoculation" of patients, coworkers, or family members from contact with the vaccine site.

Dr. Sanchez says one in three people vaccinated likely will have fever or other symptoms severe enough to cause them to miss a day or two of work. Therefore, response team members will be vaccinated in three or four separate groups approximately seven days apart to avoid the loss of the entire team.

Since the smallpox vaccine uses a live vaccinia virus that can be spread from the vaccination site, TDH is giving all public health and health care response team members extensive training on care of the vaccination site.

Dr. Crocker says Brackenridge will follow the CDC recommendations for a double barrier on all vaccination sites that includes gauze and a semipermeable plastic membrane, such as Opsite.

Calling for Volunteers

Because there is a possibility of severe reaction to the smallpox vaccine, including death, no one will be forced to get the vaccine or be a member of the response teams. Dr. Sanchez says all of the response team members will be volunteers. Extensive screening will be carried out to ensure that persons with contraindications to the vaccine -- such as pregnant women, those with eczema or atopic dermatitis, and those with compromised immune systems resulting from chemotherapy, HIV, or other immunosuppressive illnesses or medications -- are not put at risk.

The rate of severe reaction to the smallpox vaccine is very low (deaths occur in only one or two people out of 1 million vaccinated), so TDH does not expect many serious reactions with only 40,000 in the initial round of vaccinations. However, Dr. Sanchez says it is a decision individuals have to weigh carefully. He will not be vaccinated because his wife is pregnant and he likely will not have face-to-face contact with smallpox patients should an outbreak occur. Dr. Perrotta, however, says he will get the vaccine.

"I will be vaccinated because it's my job," he said. "I have to be able to do a face-to-face interview with a smallpox patient. I'm not worried about adverse events. I'm just worried about making sure I can do the job that I want to do."

Drs. Crocker and Guerra also say they will be vaccinated. Dr. Mattox says he will be vaccinated only if there is a credible threat that smallpox will be used as a weapon.

While some health care workers will choose not to be vaccinated, others say they feel a responsibility to volunteer.

"I think it is prudent for the government to suggest that health care providers across the nation have at least a limited number of people who are protected in the event of an outbreak, regardless of the cause," said Rick Gastelum, RN, a charge nurse in the emergency department at Austin's Brackenridge Hospital . "If I were asked to volunteer I certainly would. I don't have any apprehension at all in receiving the vaccine."

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.

Smallpox Reference Guide Available

Because routine smallpox vaccination ceased more than 30 years ago, many clinicians are unfamiliar with the vaccine and its potential side effects. But now a new pocket reference guide is available that gives physicians concise information on the vaccine, its administration, and its side effects.

The guide was developed by the Office of Public Health Emergency Preparedness of the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention (CDC), and Logical Images, a developer of interactive diagnostic tools that integrate clinical photographs and medical knowledge. The guide describes how the vaccine is administered and depicts both normal and adverse reactions to the vaccine. It includes images and text that help differentiate the more common, self-limiting reactions to the vaccine from those that are serious and may require intervention.

Funding to produce and distribute the pocket reference guide has been provided by the Pharmaceutical Research and Manufacturers of America.

The pocket guide is available on the Texas Department of Health.

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