Should access workers be immunized?
As hospitals and health systems begin to put together their bioterrorism response plans, access managers should take an active role, asking, "How does this apply to my department and what should I do?"
"All of us need to be leaders in our areas, especially in the emergency department (ED), where the first wave of exposure will be," suggests Kathleen Ramey, RN, MN, CEN, director of emergency services for Providence Health System in Portland, OR.
As the government considers recommendations from the Centers for Disease Control and Prevention (CDC) regarding the immunization of health care workers against smallpox, a key question is how many should be vaccinated. Suggestions have ranged from 15,000 to, more recently, 500,000.
"It will be helpful to hear what the final recommendation will be," says Ramey, who is in charge of the safety department and emergency preparedness for the Providence system in the Portland area. "I do feel strongly that access services folks that work in the ED should be put in that first class of health care providers [to be vaccinated]. ED patients would be in the first wave of those affected and when a patient approaches the ED, he may see a triage nurse first or he may see an access employee."
While taking their guidelines from public health officials, hospital administrators will want to work in concert with those officials, she notes, so that once the vaccine is released, they can have some influence in who gets it. "There was a similar process with the flu vaccine when decreased amounts were available," Ramey points out. "In that case, access services people were considered in the first wave."
Public health officers in the four counties that overlap the Portland metropolitan area have put together a committee to work on a system approach to a variety of issues related to a possible smallpox outbreak, she says. The committee, of which she is a member, includes ED, emergency medical services, and public health personnel, as well as physicians, Ramey adds. "We’re working on smallpox scenario planning and part of that planning is the vaccination process itself."
Part of the focus is on how best to inform the public, she notes. "We’re trying to work on educational components and figure out communication [strategies] with public relations people. We’re all concerned that mass hysteria could break out."
Because there is a significant risk of serious side effects with the smallpox vaccine, part of that educational effort will involve the warning that will go along with each dose, Ramey says. "There will be a form, a questionnaire that each recipient would need to fill out."
As with any other potential recipient group, access personnel with HIV or AIDS would be among those for whom the vaccine is not recommended, she says. Also complicating any decision to vaccinate is the fact that of about 900,000 people living with HIV infection, approximately 300,000 do not know they are infected.
Trying to screen out people who are HIV-infected as part of a smallpox immunization program could open up a legal quagmire of testing and confidentiality issues, it was pointed out at a meeting of clinicians and experts called together in Atlanta earlier this year by the CDC.
Complicating the issue further is the possibility that the HIV-infected person may be a health care worker or one of the other groups recommended for immunization.
If the choice is to immunize, a massive education effort will be necessary to influence physician attitudes and explain the reasoning of the program, Glen Nowak, PhD, CDC, associate director for health communications for the CDC, said at the Atlanta meeting.
"As hospitals begin their planning and education and distribution of whatever the plan will be," Ramey adds, "I recommend that access managers take it seriously, that they get involved. In the past, [some managers] have tended to brush off disaster planning."
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