Challenges lie in details of smallpox plan
Health professionals are being asked to step up to be
vaccinated, but physicians and other experts worry about putting
immune-compromised patients at risk.
By
Victoria Stagg Elliott, AMNews staff.
Jan. 6, 2003. Additional information
Military personnel and embassy staff in high-risk areas
will get it. President George W. Bush will, too. But his family members
won't. And emergency physicians, other doctors and health care workers
will be offered it as a precaution in the event they are part of volunteer
response teams in the aftermath of an attack.
It is the smallpox vaccine, and the specifics of who should get
it and when are part of President Bush's smallpox response plan unveiled
in December 2002.
But the details of how the approach will be implemented are raising
concerns within the physician community over persistent questions of
logistics, safety and liability.
For now, though, the president's marching orders are clear: "Our
government has no information that a smallpox attack is imminent," he
said. "Yet it is prudent to prepare for the possibility that terrorists
... who kill indiscriminately would use diseases as a weapon."
During the past year, public health agencies have been planning for
this type of attack, stockpiling enough vaccine to immunize every person
in the United States, drawing up response models and training several
thousand clinicians to administer the vaccine to those most likely to be
on the front lines. The public is expected to be offered the vaccine next
year. For many public health officials, the vaccination question is the
most unusual health issue they've ever faced.
The vaccination plan raises questions about logistics, safety and
liability.
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"This is not a very easy decision," said Jonathan B. Weisbuch, MD,
representing the American Assn. of Public Health Physicians at the AMA
Interim Meeting in New Orleans in December 2002. "We're being asked to do
harm to people in [light] of unknown risk out there."
The mixed reaction from the health care community to the president's
plan reflects this uneasiness.
Several medical groups, including the Infectious Disease Society of
America, the American Public Health Assn. and the AMA, endorsed the
approach. But Service Employees International, the country's largest union
of nurses and other hospital employees, and the American Nurses Assn. did
not -- warning that the plan put their members and patients at risk.
Serious issues remain
Even those who are most supportive of the plan have reservations. Their
focus is on issues of liability, the risks posed to patients and
themselves, and how screening procedures could determine who among the
most likely first responders should receive or not receive the vaccine.
The Homeland Security Act passed in 2002 does give physicians and other
health care workers who administer the vaccine liability protection, but
several organizations have expressed concern that this shield may not go
far enough. For example, the doctor or nurse who gives the injection will
be protected, but what about the patients who receive it?
A vaccinated person will be a potential danger to immune-compromised
people for a few weeks. Will that individual be at fault if the virus is
inadvertently transmitted to another?
50% of the public would turn to their physicians for information in
a smallpox crisis.
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"The Dept. of Homeland Security bill was signed by the president, and
that addresses some of the issues of liability, but there are questions
that continue to be asked by physicians and patients for which we still
await the answers," said Scott D. Deitchman, MD, MPH, a member of the AMA
Council on Scientific Affairs, in New Orleans.
But although physicians are worried about being liable for any adverse
reactions, there is also great concern about ensuring compensation for
those harmed by the vaccine. The SEIU and ANA both issued statements
saying that such funding might be needed, not just for the people who may
be killed or disabled, but also for those who may be sickened for a few
days and lose work and wages.
Both groups also were concerned that the vaccinations be truly
voluntary, without fear of discrimination or reprisal for declining the
offer.
As for public health officials, they are struggling to create an
effective screening process and to develop a hierarchy to figure out who
should be vaccinated in the first phase. Those who are full-time hospital
staff members should be easy to track. But what about temporary and
part-time workers, especially in a large facility?
And if all of those on the list are vaccinated at once, who will care
for patients? Should the effort include staggered timing to ensure that
doctors, nurses and aides are not all exposed to the vaccine at once, to
ensure adequate staffing can be maintained?
Meanwhile, there is evidence that covering the injection site with a
dressing and long sleeves may prevent transmission. Frequent hand-washing
also will help. But nothing is 100% effective.
58% of the public fears a smallpox attack.
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"It reduces the risk significantly but not to zero," said Michael
Williams, MD, an American Academy of Neurology delegate to the Interim
Meeting. "There are many who are seriously considering that we ought to
advocate for administrative leave for health care workers because we don't
know what the risk to our patients would be, even if that risk is low."
President Bush did not comment on the steps to be taken in case of an
outbreak, but the CDC's response plan includes guidelines for organizing
"ring vaccinations," a strategy for immunizing all contacts that
effectively eradicated smallpox.
This approach has been endorsed by several medical associations,
including the AMA. Few public health experts, however, believe that it
would be workable.
"As much as I, from a public health purist perspective, would like to
use the post-event ring strategy -- and it will be important initially --
ultimately ring vaccination will fail in this country if imposed, simply
for political reasons," said Donald E. Williamson, MD, Alabama state
health officer, speaking for the Assn. of State and Territorial Health
Officials at the AMA meeting. "It simply won't happen."
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ADDITIONAL INFORMATION:
Worry erupting
A recent poll reflects a growing concern among the public about the
threat of a smallpox terrorist attack. Findings are based on a telephone
survey of 1,002 adults conducted in October 2002 and compared with
results from a similar survey taken in May 2002. Of those questioned:
- 65% are willing to be vaccinated against smallpox, compared with
59% last May.
- 58% said they are worried about a possible smallpox attack,
compared with 43% in the earlier survey.
- 50% said they would put their highest level of trust in their
doctor when seeking information during a smallpox crisis.
- 12% said they were not at all worried about an attack, down from
25% in May.
Source: Robert Wood Johnson Foundation
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Weblink
CDC smallpox site
(http://www.bt.cdc.gov/agent/smallpox/)
HHS smallpox site
(http://www.smallpox.gov)
AMA Council on Scientific Affairs
bioterrorism site (http://www.ama-assn.org/ama/pub/category/3945.html#bioterror)
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Copyright 2003 American Medical Association. All
rights reserved.
