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http://www.nytimes.com/2002/12/14/health/14YORK.html?tntemail1

Limited Vaccination Plan Is Applauded

By LAWRENCE K. ALTMAN

eaders of public health organizations, many hospital officials and experts in infectious diseases generally applauded President Bush's announcement yesterday that he would not recommend smallpox vaccinations for the public.

Instead, Mr. Bush authorized a voluntary program to vaccinate about 450,000 doctors, nurses and emergency workers who would be the first to respond to any effort by terrorists or hostile nations to use smallpox as a weapon. The vaccinations are expected to be given from late January through March.

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Then, smallpox vaccinations are to be offered to 10 million Americans in health care, law enforcement and emergency response.

Dr. W. Michael Scheld, president of the Infectious Diseases Society of America, said, "We are very pleased that the president is discouraging the general public from being immunized now and is setting an example with his own family and staff."

"Mass vaccination of the general public is not warranted prior to an actual smallpox event," Dr. Scheld said.

Dr. Scheld said the Bush administration needed to address a number of issues to put the plan into effect, "including liability protections for health professionals who provide immunizations, compensation for those who may be injured by the vaccine, and screening procedures to protect those at greatest risk from adverse reactions."

Mr. Bush also said the government would try to find ways to vaccinate those "who insist on being vaccinated now" and urged that everyone be given adequate information about the vaccine risks.

Tommy G. Thompson, the secretary of health and human services, said the government would "develop a very orderly process" for those vaccinations "either in 2003 with an unlicensed vaccine, or in 2004 with a licensed vaccine."

In recent months, an advisory panel on immunization policy, many public health leaders and infectious disease experts have expressed deep concern that smallpox vaccination, the most dangerous human immunization, posed too great a risk for the public because no case of smallpox has occurred anywhere since 1980.

Smallpox vaccine poses definite risks to recipients and contains a live virus that is closely related to the smallpox virus. It is unlike other immunizations because it can inadvertently harm people who are not vaccinated, through transmission of the vaccine virus, known as vaccinia.

For this and other reasons, health experts have questioned the need for any smallpox vaccinations without evidence of a documented threat, and some had hoped that Mr. Bush would provide that evidence in making his long-awaited announcement of his plan.

Dr. John F. Modlin, the chairman of the immunization advisory panel, said that the Bush administration clearly had gone far beyond his group's recommendations in planning to vaccinate the 10 million workers and some members of the public.

A professor of pediatrics at Dartmouth, Dr. Modlin said he could not recall any other time that the government had not followed the recommendations of the panel, known as the Advisory Committee on Immunization Practices.

"From a pure public health standpoint, I and many members of the committee would still feel more comfortable with a more limited vaccination program unless the assessment of risk was greater than it appears to be," Dr. Modlin said.

But Dr. Modlin said he understood that Mr. Bush had to consider a number of issues concerning national security that committee members would not know about. "The president has a unique perspective," Dr. Modlin said.

Yesterday Mr. Bush repeated what his administration has said — that it believes that governments hostile to the United States may have stocks of the smallpox virus.

But Mr. Bush said his recommendations came as "a precaution only and not a response to any information concerning imminent danger."

Dr. Timothy T. Flaherty, a trustee of the American Medical Association, said his group supported Mr. Bush's plan and was working with the administration "to ensure that vital federal liability protections are in place prior to the initiation of any smallpox vaccination program."

Any plans for voluntary vaccination beyond the recommendations from the immunization panel "will need to be reassessed using the scientific data collected from monitoring the initial vaccinations," Dr. Flaherty said.

Dr. Georges C. Benjamin, the executive director of the American Public Health Association, said that vaccinating health care workers was "a prudent first step," but urged setting criteria before expanding the vaccination program.

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Dr. E. Stephen Edwards, president of the American Academy of Pediatrics, urged the Bush administration to "consider the devastating effects" smallpox vaccinations could have on children. "No trials have been conducted on children," who may have a higher incidence of injury from the vaccine than adults, Dr. Edwards said.

In supporting the Bush plan, the Gay Men's Health Crisis in Manhattan urged the government not to rush into vaccinations because of the increased risk of complications to those with weakened immune systems from infection with the AIDS virus and other diseases.

Dr. Thomas R. Frieden, the New York City health commissioner, said the city would begin vaccinating about 15,000 health and emergency workers in late January. These workers would be part of what Dr. Frieden called a "strategic reserve" to care for and investigate the first case or cases of smallpox if an outbreak occurred.

Dr. Frieden also said the city had a rapid response plan, in case of an outbreak, to vaccinate all New Yorkers in four to five days.

Many hospitals in the New York area have been making plans for months to vaccinate staff members, but experts said that only now were many hospitals elsewhere starting to consider such plans.

New York University Medical Center in Manhattan "has started to identify staff that would be part of our initial response teams," said Steve Weiner, a member of its emergency preparedness committee.

Initially, Mr. Weiner said, the hospital will vaccinate at least 100 employees, from various departments, including three shifts of doctors, nurses, housekeepers, security officers and technicians in radiology and other areas.

"I'll be surprised if we can't find enough people who will take it," Mr. Weiner said. "A lot of people accept that a small level of risk is part of what we do."

Tests for H.I.V. or pregnancy will be provided for those who request them, but, Mr. Weiner said, the hospital has not yet decided whether to perform them routinely before vaccination. People who are pregnant or H.I.V.-positive should not be routinely vaccinated.

John J. Sweeney, president of the A.F.L.-C.I.O., which represents 500,000 nurses and other health care workers, criticized Mr. Bush's smallpox vaccination plan as failing to provide adequate protection for these workers, their families and their patients.

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