Smallpox vaccine planned for 500 front-line health workers

By Terry Murray

TORONTO – The federal health department has announced plans to begin vaccinating 500 front-line health-care workers against smallpox by the end of this year.
   But with less than two months to go, the underpinnings of the plan have yet to be finalized.
   Chief among the obstacles is that Canada has no vaccinia immune globulin (VIG) needed to treat adverse effects of the vaccine.
   Plans for recruiting volunteers, obtaining consent and screening them for contraindications to vaccination also still need to be put in place, added Dr. Paul Gully, director-general of Health Canada's Centre for Infectious Disease Prevention and Control.
   Still, he stands by the plan to begin vaccinating by the end of the year.
   "This is something we haven't done before, and therefore I can say we'd like to do it before the end of the year. Whether we will in fact be able to do it or not is another question," he said in an interview.
   "If we don't do it, it's not for any fault of ours. It may be that the recruitment, the consent, the availability of vaccine and the availability of the VIG was not as available as we planned. But we can still plan to do it."
   A vaccination program will not begin until VIG is available, but Dr. Gully downplayed the difficulty of securing an adequate supply. It's estimated 100 to 150 VIG treatments are needed for every one million people vaccinated, meaning Canada's requirement would be "very, very small."
   "So we would have to assure ourselves we had access to a supply of VIG either in Canada or the U.S. by arrangement before we started any vaccination," he said. "We would have to have agreements in place by the time we started to vaccinate.
   "We're working on that, but I can't tell you who we would be in discussion with."
   But the 500 figure—which Dr. Gully said was determined by expert opinion—is seen as low by some provincial and local health officials.
   Among them is Dr. Bonnie Henry, Toronto associate medical officer of health, who estimated 2,000 people would need to be vaccinated in Toronto alone before there's an actual smallpox attack.
   "I think it's a reasonable thing to try to do it in groups of 500, but that's a start, not an end," she said.
   In mid-October, federal officials finished cross-country consultations with provincial, territorial and local counterparts in emergency preparedness planning. If a review of the findings of those conferences indicates that 500 is too low a number, "I'll see that we take that into account," Dr. Gully said.
   But the adequacy of the number "depends on what level of risk one's working to," he added. "According to the information we have, the risk of smallpox is no greater than it was before Sept. 11, 2001.
   "It would obviously appear the U.S. is estimating the size of the threat to be much greater than we would in Canada, and that inevitably is going to translate into the amount of preparedness we're willing to put time and resources into."
   Dr. Henry cited another fundamental issue that needs to be resolved before vaccinations begin—the bifurcated needle, the standard for smallpox vaccination, is not licensed in Canada.
   "We stopped giving vaccine before it was invented," Dr. Henry said.
   The stockpiled vaccine was licensed as a kit for use with a straight needle—technically rendering it an experimental vaccine until the bifurcated needle is approved, she added.
   The "pre-event" vaccination plan has been discussed separately from the Canadian Smallpox Contingency Plan, which has been undergoing revision since the beginning of the year, Dr. Henry said.
   The two should be considered together, and the pre-event vaccination issue needs wider consultation, "with Canadians as well as with the key stakeholders of public health, infection control, and emergency departments," she said, adding the recent consultations did not achieve that.
   "We need a similar process to what they had in the U.S., although not on the same scale. There needs to be some understanding of what the public expects, what the experts in Canada believe and what's feasible."