By Gideon Gil
ggil@courier-journal.com
The Courier-Journal

Milly Noonan vaccinated Dr. Rice Leach against smallpox earlier this year. Leach is the commissioner of the Kentucky health department.

PHOTO BY STEWART BOWMAN

The crash program to vaccinate health-care workers against smallpox has fallen far short of expectations in Kentucky and Indiana, as well as in the rest of the nation.

State health officials acknowledge they are not prepared for a terrorist attack with the lethal virus.

The Bush administration said in December that such an attack was possible but not an imminent threat.

Three months into the vaccination campaign ordered by President Bush, fewer than 10 percent of the 450,000 public-health and hospital workers designated as possible recipients have been inoculated, according to the federal Centers for Disease Control and Prevention in Atlanta.

The agency expected the vaccinations to take one month, but in Kentucky, 787 health-care workers have been vaccinated, of about 8,000 offered the vaccine.

In Indiana, 765 have been inoculated, when the state initially estimated it would target about 6,000 medical personnel.

The small numbers are forcing states to revise their smallpox-preparedness plans, even as they get ready for the next phase -- the vaccination of ''first-responders,'' including police and ambulance crews, who would be the first on the scene of an attack.

''We're getting there, but we're not as prepared as we would like to be at this point,'' said Doug Thoroughman, a Centers for Disease Control epidemiologist who is assigned to Kentucky for bioterrorism preparedness.

The smallpox program was designed to have teams of health-care workers inoculated so that if there is an attack, they could treat patients, investigate the source and vaccinate the public.

But some people were disqualified because of weakened immune systems, skin conditions or other health problems. Others declined a vaccination because of worries about possible side effects, the delayed passage of federal legislation to compensate injured vaccine recipients and the undefined nature of the smallpox threat.

Still, even the small number of vaccinated health-care workers gives the nation a significant measure of protection, said Dr. Paul McKinney, associate director of the University of Louisville's Center for the Deterrence of Biowarfare and Bioterrorism.

Any attack would likely occur in a metropolitan area, he said, and ''at least all the states and major cities have a core group of people who would be able to jump into action immediately.''

In a report released Wednesday, the General Accounting Office, an investigative arm of Congress, said the CDC has reconsidered its initial target of vaccinating as many as 500,000 health-care workers in 30 days.

The CDC has said there is no longer a deadline for the first stage, and ''as few as 50,000 vaccinated health workers nationwide'' would be enough to respond to a smallpox attack, according to the report.

''You need more than that number of people to deal with a smallpox outbreak, but you don't need that many people vaccinated up front,'' Dr. Raymond Strikas, director of smallpox preparedness and response for the CDC, said yesterday.

He said the vaccination program was put together in a hurry and states' initial numbers were ''a rough estimate.''

Asked whether the nation is prepared for a smallpox attack, Strikas said, ''We're a whole lot better off than where we were a year ago.''

In addition to vaccinating health personnel, he said, much time has been spent planning for an outbreak, educating health-care workers and improving communications and surveillance.

Thoroughman said Kentucky officials initially expected about 80 percent of the state's 104 acute-care hospitals to participate in the vaccination program, but only about 40 hospitals did.

In Louisville, for example, the five Norton Healthcare hospitals did not take part.

The smallpox vaccine is still effective if given within three or four days of exposure to the virus, but having to vaccinate health-care workers after an attack would slow the response, Thoroughman said.

''You've got some delays in there, and if there really is a big emergency, that raises the potential for panic and fear among the population,'' he added.

The primary reason that many hospitals opted out was ''the lack of a defined threat'' of bioterrorism and the perception that the threat was less than the small but known risk of side effects, Thoroughman said.

The unexpected occurrence of heart problems in a small number of the more than 34,000 civilian recipients nationwide -- including six heart attacks and 10 cases of inflammation of the heart and its lining -- led to a steep drop in volunteers for the vaccine, he said.

One Kentuckian suffered chest pains after vaccination, said Dr. Steven Englander, the state epidemiologist.

After the side effects appeared, the CDC instructed states to screen out anybody with known heart problems. But Indiana went further, suspending its vaccination program in March.

Margaret Joseph, spokeswoman for the Indiana State Department of Health, said the agency is awaiting the results of a CDC investigation of the heart-related problems and the extent to which they were caused by the vaccine.

At the same time, Indiana revised its smallpox plan. Recognizing that it had not vaccinated enough people to do everything needed in the event of an outbreak, the state began training health professionals to administer the vaccine to the public without requiring that they be vaccinated in advance of an attack.

''If we're going to vaccinate 5 million people . . . in a 10-day period, we've got to get these people trained now,'' Joseph said.

She said 1,200 to 1,500 people have volunteered for the training, and local health departments began training programs about two weeks ago.

''We know that we're much more prepared than we were five months ago or three months ago,'' Joseph added. ''Is it adequate? My crystal ball is a bit cloudy. I wouldn't want to say that.''

Like Indiana, Kentucky is planning to train medical professionals during the next year to administer the vaccine without requiring them to get inoculated in advance, Thoroughman said.

Kentucky officials also will ask local health departments and hospitals to revise their smallpox plans to reflect the smaller number of healthcare workers who have been vaccinated, Englander said.

''In Louisville, they certainly did not have the kind of uptake that they expected,'' so the question now is ''how do we have to adjust these plans so that if something happens, we're prepared?'' Englander said.

Meanwhile, Kentucky has begun plans to vaccinate emergency workers, the next step in the president's smallpox preparation program.

On Friday, the CDC told states to submit plans by July 1 for training and vaccinating first-responders ''that may be put in harm's way,'' including police officers, emergency medical services crews, hospital staff workers and private physicians.

Strikas said the CDC is leaving it up to the states when, and whether, to vaccinate first-responders.

Kentucky's tentative goal is to begin around July 1, Thoroughman said.

State health officials have asked local health departments to report by May 15 how many first-responders are in their areas, and by the end of May they are to notify the state how many they expect to vaccinate.

tucky should have about 150,000 emergency workers, Thoroughman said.

Englander said a federal law to compensate vaccine recipients who suffer side effects, which President Bush signed last week, should remove an impediment that made health-care workers reluctant to volunteer.

Dr. Greg Wilson, Indiana's health commissioner, is hoping for more information on the heart-related side effects before vaccinating first-responders, Joseph said.

McKinney, who is associate dean of U of L's School of Public Health and Information Sciences, said the CDC's analysis of heart-related problems should be completed before expanding the vaccination program.

''There doesn't seem to be any excessive urgency to move faster than that,'' he said.