President Bush revealed his plan Friday to vaccinate troops and medical personnel against smallpox, but opposition is building among the civilian health care workers who will be among the first asked to take the 30- year-old vaccine.

An estimated 500,000 troops will be required to take the vaccine, which carries a small risk of serious complications -- statistically, one of those soldiers can be expected to die from them. Vaccination of a small number of military personnel is already under way.

Bush told reporters at a Washington, D.C., briefing that he felt obliged as commander-in-chief to be vaccinated himself. "I do not believe that I can ask others to accept this risk unless I am willing to do the same," he said.

By summer, administration officials said, the vaccine will be available to any healthy adult American who demands it, but because of the its dangerous side effects, they strongly discouraged average citizens from being inoculated.

Health care workers who would be most likely to treat smallpox victims are being asked to take the vaccine voluntarily. But some doctors, nurses and other hospital workers are balking.

UNIONS URGE CAUTION

Health care worker union members staged press conferences throughout the nation Friday -- including one at San Francisco General Hospital -- to voice concerns over the safety of the vaccine and the practical problems of giving it to so many medical staffers at one time.

"We're going to discourage people from participating until a plan is put forward that adequately protects both health care workers and their patients," said Lorraine Thiebaud, a San Francisco General Hospital nurse and vice president for Local 790, of the Service Employees International Union.

"We are so stretched here, with budget cuts coming down on us, and now we are asked to run out and get vaccinated against an imaginary threat," Thiebaud said.

Among her concerns is whether vaccinated health care workers will be permitted to stay home from work during a period when they could infect their patients with the live virus found in scabs formed by their vaccination.

Smallpox vaccine is made from a live cowpox virus, a weaker germ that is closely related to smallpox but not nearly as dangerous to human beings. But it can be dangerous to people whose immune systems are weakened by HIV, cancer chemotherapy or immunosuppressive drugs for organ transplants. The vaccine is not recommended for pregnant women or people with a history of the skin condition eczema.

RISK OF ACCIDENTAL STICK

Thiebaud also noted that the vaccine would be administered with a nonretractable lancet, resembling a miniature two-pronged fork, designed to scratch the skin at the inoculation site. It is a 50-year-old technology and poses a small risk of nicking a nurse or doctor with a blood-contaminated point.

Thiebaud's local union was instrumental in pushing for laws that banned use of unsafe needles in hospitals across the nation.

The SEIU, which represents 750,000 health care workers in 22 states, has been campaigning for a variety of safeguards before the vaccine campaign is rolled out.

"Let's slow down and do it right," said Sal Rosselli, president of Local 250, which represents nursing home workers and hospital orderlies in Northern California.

Rosselli said the union has been talking with Northern California hospital operators, but he is concerned the workers' concerns will be ignored in other locales.

NOT ON FEAR ALONE

Robert Golomb of Lafayette, an emergency room doctor, had reservations.

"I must assume that the president is aware of clear evidence that smallpox can be used as a bio-weapon and is not making a decision based on fear alone," he told The Chronicle. "Only on this basis can I support his policy and have myself revaccinated."

Anticipating the federal plan to inoculate health care workers, California has ordered 40,000 doses of smallpox vaccine from the federal Centers for Disease Control and Prevention, which controls the national supply of it. According to Health and Human Services Secretary Tommy Thompson, the nation now has enough vaccine on hand to protect the entire country in the event of a terrorist attack.

An international vaccination campaign wiped out naturally occurring smallpox in 1980. While the United States kept cultures of the virus under tight security, there are lingering fears that stocks of the virus were maintained in Russia, and possibly Iraq and North Korea -- and that terrorist organizations have been actively seeking it.

The risk that terrorists would gain access to the long-silenced smallpox virus is theoretical, but the danger posed by the vaccine is real. For every 1 million Americans vaccinated against smallpox for the first time, an estimated 15 will suffer life-threatening complications, and one or two will die.

With that risk in mind, federal health officials have decided against a mass immunization campaign -- which many of Bush's more conservative backers were demanding. Instead, the president said his administration "will work to accommodate" members of the general public who want to be vaccinated, but will not recommend that they seek it.

Bush told reporters that neither his staff nor his family would be vaccinated, "because our health and national security experts do not believe vaccination is necessary for the general public."

The smallpox vaccine is considered more dangerous than other modern vaccines because it consists of a live virus. The vaccine actually causes a mild case of cowpox, a disease closely related to smallpox but not remotely as lethal. Antibodies raised against cowpox will protect against smallpox for an unknown period -- experts estimate between five and 30 years. But almost no one has received a smallpox vaccination in the United States since 1972, when routine vaccinations were halted.
 

Dispensing the vaccine

The smallpox vaccine is administered to the skin over the deltoid muscle using a cool and sterile bifurcated needle.

A very small volume of vaccine is held between the fork of the needle and then released onto the skin.

Needle is held perpendicular to the arm.

Then 15 strokes are rapidly made within an area about 5 mm in diameter. The strokes are vigorous enough for a trace of blood to appear on the skin. .

GROUPS BEING OFFERED THE SMALLPOX VACCINE

MILITARY

Who: About 500,000 personnel in "high-threat areas."

When: Vaccinations began Friday at Walter Reed Army Medical Center in Washington. How: Mandatory.

STATE DEPARTMENT

Who: About 20,000 people working in U.S. embassies in the Middle East.

When: Not specified.

How: Recommended, but not mandatory.

CIVILIAN SMALLPOX RESPONSE TEAMS

Who: About 450,000 people most likely to come in contact with a contagious smallpox patient, including people who work in hospital emergency rooms and people on public health teams who would investigate suspicious cases of smallpox. States already submitted plans identifying people in this group and plans for vaccinating them.

When: Beginning in late January, or when states are ready. Program expected to take 30 days, although health officials said some states may take longer. How: Recommended, but not mandatory.

HEALTH CARE WORKERS AND EMERGENCY RESPONDERS

Who: About 10 million total. People who work in hospital intensive care units, infectious disease doctors, dermatologists and other health care workers who might deal with smallpox. First responders including police and fire.

When: States must develop plans; timetable uncertain.

How: Recommended, but not mandatory.

GENERAL PUBLIC

Who: Adults who insist on getting the vaccine.

When: People can enroll in clinical trials now under way at various sites across the country. The Department of Health and Human Services will create a new program available in every state for people who want to sign up, expected by late spring or early summer. Under both measures, complicated paperwork would be involved, because people would be enrolling in experiments to see if the vaccine works. People also could wait until 2004, after enough vaccine is licensed.

How: Not recommended, but available.

Source: World Health Organization