A Centers for Disease Control and Prevention (CDC) advisory committee has recommended that smallpox vaccinations be made available to first responders and pre-designated hospital personnel, but not the general population or other health care workers. Although it has not been determined whether the recommendations will be implemented, the CDC’s Advisory Committee on Immunization Practices (ACIP) says the potential benefits of vaccination fail to outweigh the risks and complications of the vaccine.
The CDC committee discussions indicated that some 15,000 first responders and health care workers may be immunized. However, officials at the Dept. of Health and Human Services later indicated that number could go as high as 500,000 people. While the issue remains under discussion, here are some reactions of ED managers regarding immunization:
• Individuals most likely to be exposed should receive immunizations. Denny Swick, RN, CEN, EMT-P, EMS coordinator for emergency services at Columbus (OH) Children’s Hospital, argues for protection of groups who could be exposed without advance notice, such as ED staff. In contrast, he notes that any team members responding to a suspected outbreak presumably would not need immunization in advance, as they would know they are potentially going into an infectious zone.
• Some ED staff say it should be their decision. Many ED managers view the decision not to vaccinate health care workers as appropriate, because they have no desire to risk the potential side effects of the vaccine, and they have no guarantees such a risk would result in the appropriate immunity, according to Bettina Stopford, RN, CNE, chair of the national Weapons of Mass Destruction work group for the Des Plaines, IL-based Emergency Nurses Association. Still, many would like the choice to be their own, says Stopford, noting that health care professionals are the first line of defense in the identification of a biological agent release.
"After 9/11, I have changed the way I view issues, both personally and within the ED," says Brian Miluszusky, RN, BSN, director of nursing for the ED at New York (City) Presbyterian Hospital. "I personally don’t know if I would take the vaccine, but I think that all ED and hospital staff should be able to take the vaccine, and so should their families," he points out.
There is a concern about time off if mass vaccinations are needed. Miluszusky points to current CDC recommendations that health care workers who are vaccinated, particularly those who work around immunocompromised patients, not return to work for up to two weeks after vaccination to prevent inadvertent transmission of the virus. "Can you imagine what would happen if there was even one unrecognized case in the ED?" he asks. "Anyone in contact would have to get the vaccine, including nurses, doctors, clerks, and registrars. Think about how crippling this would be."
• The possibility of side effects is acknowledged. Eric Lavonas, MD, FACEP, emergency physician and toxicologist at Carolinas Medical Center in Charlotte, NC, says he believes that most people would choose to be vaccinated for the peace of mind. "However, I work for a hospital system with 27,000 employees," he says. "If I was the CEO, I’m not quite sure what I’d say to my employees who got seriously ill because they worked for me and chose the vaccine."
• The bottom line is EDs remain vulnerable. Stopford says that EDs remain vulnerable. She points to the absence of the following:
- active surveillance system;
- appropriate education to recognize suspicious syndromes;
- appropriate level of personal protective equipment;
- readily available local supply of pharmaceuticals;
- rapid access to the Atlanta-based National Pharmaceutical Stockpile. The stockpile is a component of the CDC’s Bioterrorism Preparedness and Response Initiative that supplies vaccines, pharmaceuticals, and medical supplies as needed.
The ED still is a primary site in which to identify and treat victims infected with a potentially lethal biological agent, Stopford says, and she notes that EDs have varied response capabilities, dependent upon resources allocated to their preparedness.
• A mass vaccination plan should be in place if needed. Lavonas notes that, due to side effects, a mass vaccination campaign of health care workers or the general public would cause illness instead of preventing it. He adds that if intelligence agencies learn that terrorists have acquired a supply of smallpox virus, then mass vaccination would make sense. "The ACIP guidelines take this into account," he says. Lavonas says that vaccination after a smallpox exposure is still believed to be effective during the incubation phase. "Also, the same droplet isolation procedures we use to prevent the spread of tuberculosis in the hospital setting will work for smallpox," he says. "We are not defenseless."
While Lavonas thinks the ACIP recommendation to vaccinate some health care workers who can provide immediate care in the event of a rapid mass vaccination program is appropriate, he says it’s even more important to have a "Plan B" if needed. "We need to develop the capability to vaccinate a large population within 24 hours of the appearance of smallpox, so that we could stop an outbreak in its tracks," he says.
Sources
For more information about the recommendation, contact:
• Eric Lavonas, MD, FACEP, Department of Emergency Medicine, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232-2861. Telephone: (704) 355-4212. Fax: (704) 355-8356. E-mail: [email protected].
• Brian Miluszusky, RN, BSN, Emergency Department, New York Presbyterian Hospital, Cornell Campus, 525 E. 68th St., New York, NY 10021. Telephone: (212) 746-0721. Fax: (212) 746-4883. E-mail: [email protected].
• Bettina Stopford, RN, CNE, Denver Health Medical Center, 777 Bannock St., MC0261, Denver, CO 80204. Telephone: (303) 436-3431. Fax: (303) 436-6213. E-mail: [email protected].
• Dennis Swick, RN, CEN, EMT-P, Emergency Services, Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205. Telephone: (614) 722-4350. Fax: (614) 722-6890. E-mail: [email protected].
For the complete text of the Draft Supplemental Recommendation of the ACIP Use of Smallpox (Vaccinia) Vaccine, June 2002, go to: www.cdc.gov/nip/smallpox/supp_recs.htm.
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