ACIP plan limits vaccine to selected hospitals
Plans to vaccinate selected health care workers against smallpox are a good first step but don’t go far enough to protect those workers in the event of a bioterrorism event, employee health and emergency management experts say.
In June, the Advisory Committee on Immuniza-tion Practices (ACIP) recommended that only smallpox response teams and certain clinical personnel at smallpox referral hospitals receive smallpox vaccinations. Nationwide, some 10,000 to 20,000 people might receive the vaccine under that plan, says Julie Gerberding, MD, acting deputy director of the Centers for Disease Control and Prevention (CDC). (For a copy of the ACIP recommendations, go to: www.cdc.gov/nip/smallpox/supp_recs.htm.)
However, as hospitals consider their bioterrorism preparedness, the vaccination of a few key staff — from lab workers and security guards to doctors and nurses — might not be enough to create confidence among employees if smallpox cases are diagnosed, says Robert Wise, MD, vice president of the division of research standards at the Joint Commission on Accreditation of Healthcare Organizations.
"As a strategy to give health care workers the confidence to keep coming to work, it’s moving in the right direction," Wise says. "I don’t think it’s a complete enough solution to be able to guarantee or predict the number of health care workers who would be willing or available to work through this kind of epidemic."
Wise notes that the Joint Commission expects hospitals to consider the needs of employees’ families in an emergency response. "If the health care workers and their family do not feel safe, then you’re not going to be able to get the health care workers to continue to work," he says.
ACIP, an expert advisory panel, issues policy recommendations to CDC and the Department of Health and Human Services (HHS). The recommendations could be altered by the CDC and HHS.
ACIP clearly was trying to take a middle road between widespread vaccination and waiting until actual cases are identified. Smallpox vaccination is effective even a few days after exposure, and vaccination of smallpox victims’ contacts is a key strategy of containment.
But Wise and others questioned the wisdom of selecting hospitals that would handle smallpox cases.
While it makes sense to limit exposure to designated facilities that are prepared to handle cases, "in practice, there’s always the question about whether or not that will actually work," says Susan McLaughlin, a Barrington, IL-based consultant in health care safety and regulatory compliance who specializes in emergency preparedness.
After all, people with early symptoms are likely to show up at the nearest emergency department or doctor’s office regardless of federal and state planning, she notes.
No one knows the risk
The most important question about smallpox vaccination is the one that can’t be answered: What is the risk of exposure?
ACIP characterized the risk of deliberate release of smallpox by terrorists as low, and stated, "the population at risk for such an exposure cannot be determined." Hospitals prepared to treat smallpox cases would be designated in state bioterrorism response plans, and the individual hospitals would decide who should be vaccinated, the panel said.
But without any further guidance on risk assessment, it’s difficult to make a decision about who needs the vaccine, explains Geoff Kelafant, MD, MSPH, FACOEM, medical director of the occupational health department at the Sarah Bush Lincoln Health Center in Mattoon, IL.
"Where do you stop? If the EMS people are getting [the vaccine], then the emergency room people are getting it. If the emergency room people are getting it, why shouldn’t the intensive care personnel get it?" he asks.
"It becomes a policy issue, not just a medical issue," says Kelafant, who is chairman of the medical center occupational health section of the American College of Occupational and Environmental Medicine in Arlington Heights, IL.
In a press briefing after the ACIP meeting, chairman John Modlin, MD, explained that a predesignated response team would include "a team leader, a team physician, team nurses, public health personnel who would aid in quarantine and surveillance, and security/law enforcement personnel."
He did not outline any specifics about vaccinated hospital personnel. "The makeup of these teams would appropriately vary from one location to the next, depending upon the circumstances and the nature of the need and their requirements," says Modlin, who is professor of pediatrics and medicine at Dartmouth Medical School in Lebanon, NH.
Meanwhile, the CDC is trying to get a better assessment of the risks of vaccination. About 1,000 individuals per million vaccinated could have moderate-to-severe adverse effects from the vaccine, which is made from the live vaccinia (cowpox) virus. Five to 20 individuals per million would develop postvaccinial encephalitis, which could lead to neurological impairment or death.1 Side effects are lowest among those who have previously been vaccinated, and highest among those who are immune-compromised.
"It’s really important to help people understand that unlike all of the other vaccines that we use, this vaccine has special risks," Gerberding said at the press briefing, emphasizing that other vaccines have a higher level of safety.
The vaccination of health care workers would be voluntary, public health officials said. CDC also will establish an oversight board to monitor the use of the smallpox vaccine.
Because of the risks of the vaccine and the fears about bioterrorism, vaccination efforts must be accompanied by thorough employee education, says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, executive president of the Association of Occupational Health Professionals in Healthcare in Reston, VA, and employee health nurse practitioner at Western Pennsylvania Hospital in Pittsburgh.
Some employees may be afraid to have the vaccine, while others may be upset that they aren’t included in the vaccination group.
But Gruden notes that a limited supply requires more selective vaccination.
"You can start to vaccinate people even once an outbreak starts," she notes. "I think that’s another piece of the educational process."
Reference
1. Vaccinia (smallpox) vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001. MMWR 2001; 50(RR10);1-25.
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