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AAOHN’s comments regarding the use of the smallpox vaccine, in
preparation for the possibility of a bioterrorist attack becoming a
reality:
Use of
the Smallpox Vaccine in Bioterrorism Preparedness Efforts
June, 2002
You have asked for public
comments, requesting specifically for the input of health care
providers. As the professional association representing occupational
health nurses, our primary mission is to help our members and
related stakeholders/publics, and advance the health, safety, and
productivity of America’s workers.
Our responses to the
three questions you have posed for comments are as follows:
Question #1 – Relating to
the Routine Vaccination of the General Population
AAOHN supports the CDC’s current recommendations,
and suggests no change to the current standard. The association
does not support the re-introduction of routine smallpox
immunizations for the U.S. population. AAOHN does support
the CDC’s current recommendations to not vaccinate persons
in the general population unless a biological terrorism event has
occurred.
The potential benefits of
vaccinating the entire population must be weighed against the
actual risks, such as serious adverse reactions, and the
greater number of contraindicated individuals who would be
vaccinated in an indiscriminate mass vaccination campaign.
The duration of post-vaccination
immunity to the virus that causes smallpox is unknown. According
to the CDC’s own MMWR dated June 22, 2001, resistance to
the disease is highest in approximately the first 5 years,
apparently with "waning immunity" lasting possibly up to 10
years (emphasis added).
Resources spent on vaccinating
members of the general public would be better utilized in
preparing the nation as a whole for responding—in general—to a
bioterrorist attack.
Question #2 -
Identification of Certain Individuals for Non-exposure-related
Vaccination
AAOHN supports the
current CDC recommendations and suggests no changes to the current
standard. To clarify our support of the current standards:
AAOHN does not support an
attempt to identify certain individuals whose occupations may
place them at increased risk of exposure – because of the
difficulty in determining the criteria for precisely who is
at risk.
Our experience with both anthrax
and the events of 9/11 demonstrates the difficulty of pinpointing
the targets of terrorists, also to be considered in terms of the
location(s) of the strike(s), when considering any
non-exposure-related vaccination of health care workers and
emergency response personnel.
Again, AAOHN has concerns regarding
the unknown length of protection/decreasing efficacy of the
smallpox vaccine. How frequently would those selected for
vaccination be expected to repeat the process of vaccination and
the ensuing isolation?
AAOHN has specific
concerns and recommendations regarding the support of health and
safety of health care workers during response to a bioterrorist
attack.
AAOHN urges the
CDC to protect the health and safety of health care workers by
considering the following:
When vaccinating health care
workers, not all members of
any health care team or any one type of health care professional
should be vaccinated at the same time, since vaccinated
individuals must be isolated—for 14 to 21 days—from those who have
a compromised immune system, in order to prevent inadvertent
transmission of the vaccina virus.
Many health care providers may
be unable to be inoculated due to contraindication, as in the
case of immunosuppression. This causes additional concerns and
also sets up a situation in which these workers may in turn become
"unfit for duty" and unable to respond as needed in such a crisis.
Prevention of exposure
to smallpox among health
care and other high-risk workers is another concern. Smallpox is
spread from one person to another primarily through infected
saliva droplets that expose a susceptible person having
face-to-face contact with the ill person. The transmission risk
lasts until the scabs have fallen off, although the risk is
highest in the first week of illness. Proper training and use of
appropriate personal protective equipment (PPE) by those coming
into contact with the smallpox virus could thus greatly reduce the
exposure rate. Considerations in implementing the use of PPE as a
strategy to protect health care workers would include:
Occupational health nurses and appropriately trained safety
personnel who would provide respirator qualification and fit
testing may be unavailable, thus adding to the concern of
adequately protecting exposed healthcare providers. In addition,
some of these professionals may have contraindications to using
PPE such as respirators.
Any terrorism response plan must
take into account the shortage that is impacting many of the
health professions—with no end in plain sight— and take sensible
precautions against unduly burdening these critical
workers. We have a known shortage of registered nurses, safety and
other health care personnel. Scarce resources must be considered
as we work to craft effective, realistic—and thus,
usable—response plans.
Question #3 – Relating to
the Use of "Ring Vaccination"
The association does support any
vaccination strategy for containing a smallpox outbreak
utilizing the "ring vaccination" concept.
Vaccinating and monitoring a "ring"
of people combined with surveillance and isolation of cases is a
more effective way of utilizing resources to contain any
outbreaks. Occupational health nurses employed by the U.S. Postal
Service demonstrated during the anthrax crisis the critical
role the profession plays in the active health surveillance
efforts that would lead to identification and reporting of
suspected smallpox cases. Our members are most often the first
health care professional workers turn to for advice and council,
and referral for additional health care.
AAOHN recognizes that there is some
concern over the efficacy of the ring vaccination method in more
densely populated areas. Mass vaccination may be one option to
consider. As a part of this consideration, CDC must investigate
fast, effective, and safe methods of vaccinating large numbers of
people in a limited amount of time (within 3 to 4 days of
exposure). In addition, the CDC should ensure that a sufficient
supply of vaccinia immunoglobulin (VIG) is available to health
care providers in the area, in order to deal with particular
serious side effects certain to be experienced by some during such
a broad, large-scale vaccination campaign.
Key to the effectiveness of any
response to a bioterrorist attack is emergency planning and
disaster management. The government may have a stockpile of
smallpox vaccine large enough to inoculate the entire population,
but what about readily available supplies, e.g. VIG, disposable
bifurcated needles? Will it be available to the health care
providers of the affected population within a reasonable length of
time—given the small window of time to inoculate those exposed to
the virus? How will the vaccine be stored and distributed in order
to ensure its efficacy? Are health care providers, safety
personnel, and other responders appropriately educated and trained
in how to administer the vaccine, side effects of the vaccine,
treatment of adverse effects? Are/Have there been appropriate
steps taken to educate the public? In order to accomplish
these things and more—possibly some unforeseeable tasks—there must
be coordination, cooperation, and—the lynchpin—communication
among health, safety, and policymaking, and other officials at all
levels of government. The time to begin these combined efforts is
now, so that there is a strategy in place if and when
another bioterrorist attack should occur.
As the largest group of
health care providers at the worksite, occupational health nurses
play a critical role as first responders in the event of a
bioterrorist attack. These nurses also routinely work with employers
to design, manage and implement emergency planning and disaster
management programs. They work with a number of community agencies
that would be involved in the event of a bioterrorist attack (e.g.
local emergency personnel, police, fire departments and local board
of health). Occupational health nurses’ credentialing, training and
access to large population groups uniquely suit them to fulfill a
key role in the nation’s response to bioterrorism.
The American Association of
Occupational Health Nurses (AAOHN) works collaboratively with many
federal agencies such as the CDC, NIOSH, and OSHA. We urge the CDC
and this committee to call on AAOHN to help craft the most
appropriate emergency response to this and other potential
biological and yet to be determined threats which would impact the
health, safety and security of our nation, our workers, and
communities in which they live, work, and serve.
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