Saturday, December 14, 2002

By Anita Srikameswaran, Post-Gazette Staff Writer

The director of the Allegheny County Health Department yesterday revealed a proposed two-tier strategy to vaccinate health care workers and others at high risk of exposure to smallpox.

Dr. Bruce Dixon said a team of 8 to 10 people would receive smallpox vaccinations in the first tier. They will then administer it to a second tier of health care workers, emergency responders and public safety people who volunteer to have it, inoculating perhaps as many as 10,000 people.

"The plans for that and the training for people to do that are presently under way," he said, adding that "the vaccine in Allegheny County will be available solely through the public health agency."

He estimated that the vaccination system will be in place within the next three to four months, but he noted that the vaccine won't be administered to the general public until 2004.

Dixon was part of an expert panel, convened yesterday at the University of Pittsburgh Medical Center, that discussed the highly contagious and potentially fatal viral disease after President Bush outlined national initiatives to counter the threat smallpox poses as a terrorism agent.

The health director did not share all the details of the plans submitted by the state to the U.S. Centers for Disease Control and Prevention, such as what the response would be to an actual smallpox case.

"The plan has not yet been approved by the CDC, although it should be at the end of next week or so," he said.

A county public health worker will likely be going with state health staff to the CDC offices in Atlanta at the end of next week. They will be vaccinated and taught how to properly administer the shot, which is different from standard inoculations.

In smallpox vaccinations, a two-pronged needle is dipped into the vaccine, made of a cousin of smallpox called vaccinia virus. A small area of the upper arm skin is abraded and the needle is used to prick the skin several times in a few seconds, enough to draw a drop of blood.

"If you don't get it deep enough, you don't get a take," Dixon explained. "If you get it too deep, you get a poor take."

The techniques will be taught to others who will man three teams that will then vaccinate heath care and public safety workers in Allegheny and neighboring counties in southwestern Pennsylvania.

Dixon said vaccination is only one part of an overall plan to control any smallpox outbreak. Historically, the disease has been kept in check by isolating patients, and Dixon noted that as recently as the 1950s, the health department quarantined measles patients in their homes .

"We do have the authority to isolate people," Dixon said.

Smallpox vaccination has risks that must also be considered. According to the CDC, one out of three people will be ill enough after vaccination with such symptoms as fever or soreness that they must take time off from work. About 1 in a million people could die from complications.

On the other hand, smallpox itself is so contagious that it takes perhaps 1 or 2 virus particles to make a person sick, said Dr. Michael Allswede, section chief of special emergency medical response at the University of Pittsburgh School of Medicine. Up to 30 percent of unvaccinated people die from the disease, and survivors often have permanent scars.

And adults who got smallpox vaccinations as children should consider getting them again, because the vaccine's effect is considered good for only 5 to 10 years.

"This is the art and science of public health, to try to manage all these various competing risks," said Allswede, who noted that making a decision about vaccination is difficult because it's not known if smallpox will be used in a terrorist attack.

People shouldn't get the vaccine if they have skin conditions such as eczema, are taking drugs or have diseases that suppress the immune system, or are pregnant or breast-feeding. That could exclude an estimated 30 percent of the population.

For the same reasons, some health care workers may not be able to be vaccinated, Allswede said.

"Hospital workers must be screened so that we know who can be vaccinated and who cannot," he said. "Who can take these jobs that the nation would need in time of crisis and who cannot?"

Dr. Karin Byers, an infectious disease specialist at Pitt's medical school, said that individuals should think through the decision to get vaccinated for smallpox by first determining if there is any medical condition that would argue against it.

The next thing to consider is the short term possibility that vaccinia virus will be shed from the site and infect others, making some of them very ill.

Health care workers may interact more with already sick people, but their institutions can arrange for infection control people to examine their vaccination sites daily to make sure they are covered properly to reduce the likelihood of transmission. People who have sick relatives at home or children under 1 year old should get some medical advice before making a decision.

Then people should think about whether they can tolerate potential side effects, such as being sick and having to take time off work.

More information can be found at www.smallpox.gov

Anita Srikameswaran can be reached at anitas@post-gazette.com or 412-263-3858.