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.

"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.

"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.

"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."

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

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)

HEALTH & SCIENCE