Hospitals weigh smallpox shots for their staffs

By Carol M. Ostrom
Seattle Times staff reporter

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At least one hospital in Washington state is declining to participate in a national campaign to vaccinate health workers against smallpox, state officials have confirmed, and more than a dozen other hospitals say they have not decided whether to ask workers to be immunized.

Citing security reasons, Department of Health spokesman Donn Moyer declined to identify the hospital, one of 91 acute-care hospitals in the state, or its reasons for rejecting the vaccination program.

Many hospitals and medical workers have raised concerns about the vaccine, which carries a small risk of severe and even deadly side effects.

Nationwide, two large hospitals announced they would not participate in the program, citing concerns about safety to patients and workers, and several others are reportedly leaning against participation.

The first phase of the federal smallpox anti-terrorism program, which could begin as early as this month, calls for more than 400,000 front-line health workers nationwide, including about 7,000 in this state, to volunteer to receive immunizations.

The vaccinations have prompted worries by workers about health effects and transmission of the live vaccine virus to vulnerable patients, family members or others.

"To me, it's not worth the risk," said Mary Stubbs, an emergency-department nurse at Harborview Medical Center. A single mom and cancer survivor, her calculation pitted personal health and financial risks against the risk of getting smallpox from an act of terrorism.

A bad reaction could mean she'd miss work "anywhere from a few days to, well, forever," Stubbs said.

"There's not a smallpox problem in the community. So when I weigh the risks and benefits, there's too much risk."

Statistics collected in the late 1960s, just before routine smallpox inoculations ceased in this country, suggest that about 15 of every million people vaccinated will face life-threatening complications, including disfiguring rashes and destruction of brain tissue; one or two of them will die. But medical experts caution that a much larger percentage could experience severe reactions today.

Hospitals, already squeezed by a nursing shortage and overflowing emergency rooms, worry about the costs of replacing workers sickened by the immunizations. About one-third of those vaccinated, according to the Centers for Disease Control and Prevention, will feel bad enough to miss work.

The vaccine is made from a live virus called vaccinia — different from smallpox but dangerous to some people. If workers don't carefully cover the vaccination site on their arm for three weeks, they could transmit the virus to others, and hospitals worry about their potential liability if that happens.

Unanswered questions

"Some of our physicians are concerned about their patients coming in contact with a vaccinated health worker," said Marcia Patrick, infection-control manager for MultiCare Health System in Tacoma. "If there's a breach in the dressing protocol and harm to the patient, who's going to pay for that? We've not been able to get a good answer on liability questions."

Mary Selecky, secretary of the state Department of Health, says federal liability protection for hospitals is a key concern, one she has pressed at the national level.

Local public-health officials say resolving liability issues will be the key to making the program work. "We know there are risks; this is the riskiest of vaccines," noted Matías Valenzuela, spokesman for Public Health — Seattle & King County.

About 1,100 public-health workers are among the 7,000 health workers in the state targeted for vaccinations, along with a range of hospital workers, from emergency-department and intensive-care nurses and doctors to security and housekeeping staff.

The union that represents more than 10,000 nurses and hospital employees in the state has called for more safeguards, saying the program puts health workers, patients and families at risk. "Don't create a public-health crisis where there isn't one now," said Diane Sosne, a nurse who heads the local chapter of the Service Employees International Union (SEIU).

The Bush administration also has ordered a half-million soldiers to receive the vaccine. Immunizations have begun at several sites in the country, and officials say they expect them to begin in Washington state this month.

Although vaccinations aren't voluntary for military members, the services, like hospitals, will screen out those who should not receive them, said Col. Randy Randolph, director of military vaccines at the Office of the Army Surgeon General.

They include people with suppressed immune systems, such as those with AIDS or HIV, cancer patients, organ-transplant recipients, pregnant women and people with the skin disease eczema. Those who live with vulnerable people, including children less than a year old, are also advised not to receive the vaccine.

The real wild card in smallpox immunizations, health experts say, is the vastly increased number of people with impaired immune systems — perhaps 100 times that of the late 1960s.

Worse, experts estimate that a quarter of those with HIV don't know they have it.

Hospital officials, as well as infection-control experts, say transmission of the vaccinia virus inside hospitals is a serious concern. Thirty years ago, hospitals weren't filled with immune-

compromised people receiving organ transplants or high-dose steroids, notes MultiCare's Patrick, because those people simply died. Now, hospitals care for the sickest of the sick.

In Spokane, Deaconess Medical Center and Valley Hospital & Medical Center spokeswoman Janice Marich said the hospitals are looking at business and health issues and haven't decided whether to offer the vaccines.

"I think everyone has concerns, that's fair to say," she said. "All organizations have to examine it from the perspective of their business, as well as protecting the community."

Plan called too quick

Some local hospital officials say the program has arrived too quickly.

There hasn't been enough time to formulate questions, much less get answers, said Patrick of MultiCare, which operates Tacoma General Hospital, Allenmore Hospital and Mary Bridge Children's Hospital. "What's the rush here?"

Without more information on liability, it's hard for hospitals to decide what to do, said Garvin Olson, administrator for Deer Park Health Center & Hospital in Spokane County, which is weighing the options. "If there's an adverse reaction and someone gets really ill or dies from a vaccination, where do we stand?" he asked.

Adding to the concerns, experts in a recent issue of the influential New England Journal of Medicine concluded that a smallpox terrorist attack would not be as risky as believed. They questioned the wisdom of vaccinating hundreds of thousands of health-care workers.

Although smallpox is fatal to about 30 percent of those who are not immunized, the vaccine is effective against the disease up to four days after exposure, leading some experts to argue for after-the-fact immunizations, or for far fewer to be immunized.

The health-workers union has asked state and federal officials to more thoroughly address issues such as informed consent, counseling and screening of health-care workers, multilanguage training in infection control, and other measures it believes would reduce the vaccine's risk.

The union also wants to ensure there would be no job discrimination against workers who refuse the vaccine, and that they would be compensated for lost work time.

Hospital workers also are concerned about sick-day coverage if they have to miss work because of side effects from the vaccine. In this state, says Dr. Lee Glass, associate medical director for the state's Department of Labor and Industries, workers' compensation will cover employees whether they are sickened by the vaccination or by transmission from someone else on the job. But that's not full pay, and it won't cover family members — issues health workers say are important.

Anne Newcombe, assistant nurse manager in the emergency department at Harborview, said workers are taking the decision seriously. The hospital is in the midst of a vigorous program to educate workers about the vaccine. "It's something to think about — it's not the same as getting a tetanus shot," said Newcombe.

Newcombe, young enough that she's never had the vaccine, doesn't know how her body will react.

Harborview, like other participating hospitals, has specified the number of workers it believes would be necessary to form a full-time "smallpox team" to treat patients with the disease. It hopes to have enough volunteers to choose only those who have already had the vaccine, because experts predict they'll have fewer and less-

severe reactions.

Recently, MultiCare asked its approximately 2,500 clinical workers to fill out a survey asking if they'd be willing to be vaccinated. The survey noted the medical reasons for not getting the vaccine and explained the program was voluntary.

Patrick held her breath as the surveys trickled in. "I really had no idea what to expect," she said.

MultiCare's goal was 160 people, Patrick said, and a quick assessment of the "yes" pile indicates it will likely meet its goal.

Is campaign a distraction?

On a broader note, some officials complain the intense smallpox-vaccination effort is taking dollars and time away from other important needs.

For example, Selecky noted, the plan has temporarily sidelined other crucial bioterrorism-planning efforts, including a county-by-county update of emergency plans. "It got set aside," she said. "We've focused exclusively on smallpox."

Still, she says she supports the immunization program and is pleased by hospitals' participation.

But, she cautioned, "When we finally have a clinic (to give vaccinations), whenever that is, and people are filling out consent forms, that's when we'll discover what's really going to happen in the state."

Seattle Times staff reporter Sandi Doughton contributed to this report. Carol M. Ostrom:206-464-2249 or costrom@seattletimes.com.

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