Last Updated

05 Dec 2002

Source: Wall Street Journal, June 20, 2002.

HEALTH

Hospitals Dodge as CDC Seeks Smallpox Treatment Centers

By ANN CARRNS, Staff Reporter of THE WALL STREET JOURNAL

Hospitals are usually eager to tout their expertise in treating various diseases. But there is little upside, it seems, in becoming St. Smallpox .

Across the country, state and local officials developing smallpox-response plans at the behest of the federal government are discovering that hospitals are reluctant to be tapped for the duty. The Centers for Disease Control and Prevention recommends that planners identify a "Type C," or facility for contagious smallpox patients, in each community or region, to be activated in the event of an outbreak. Such centers would house confirmed and probable cases.

Hospitals, though, see little advantage in being designated the local smallpox sanctuary. Some fear losing revenue; if their beds are filled with smallpox patients, other patients would have to get treatment elsewhere. Others worry that once an outbreak ends, patients might be reluctant to return to such a hospital, fearing that lingering germs could pose a threat.

Even in the absence of an outbreak, some hospitals worry that the mere association with the disease could carry a stigma. It simply "isn't a good marketing strategy for them," says Steven Wiersma, Florida's state epidemiologist. Adds Jim Bentley, a policy official with the American Hospital Association: "There's the same kind of issues people worried about in being designated as an AIDS facility, before people became educated about the disease."

Another concern is staffing -- a newly vaccinated worker can't serve patients with weakened immune systems for a certain period of time.

Swedish Health Services, a three-hospital group in Seattle, opposes designation as a center for contagious smallpox patients primarily on economic grounds, says Dr. Nancy Auer, vice president for medical affairs. In an outbreak, the hospitals would have to cancel or defer procedures such as elective surgeries, which generally bring in high insurance reimbursements, for the unknown reimbursement of treating smallpox patients.

"There's no mechanism through the federal or state government that would compensate" for that lost revenue, she says. "If the government wants to guarantee hospitals that they'll pay for opportunity loss and work out a formula, there might be more willingness to do that."

Such concerns aren't farfetched, says Susan Waltman, general counsel for the Greater New York Hospital Association, which represents 100 not-for-profit hospitals in the New York City region. In the months after the Sept. 11 terrorist attacks, New York City hospitals lost an estimated $100 million in revenue from patients who were afraid to venture into the city for procedures, her group estimates. Federal emergency payments have helped but haven't reimbursed many hospitals for anywhere near their full losses, she says.

The CDC also is encouraging communities to designate two other types of smallpox centers: One would isolate people who have had contact with an infected person, but whose diagnosis is uncertain; this also is likely to raise alarms at hospitals. The second is for those who have had contact with an infected person but show no symptoms. This could involve simply monitoring patients at home. While the CDC carries great weight among health-care officials, it can't force hospitals to accept a designation as a smallpox-outbreak center.

Smallpox was officially declared eradicated world-wide in 1980. The only known stocks of the virus are kept in labs in the U.S. and the former Soviet Union. But renewed fear that terrorists could have procured the germ has prompted a re-examination of the nation's readiness for an outbreak. In 1972 the U.S. stopped vaccinations for the disease. Roughly half the population has no immunity, while that of the other half is waning, at best. A federal advisory panel is scheduled to meet Thursday in Atlanta to recommend to the Bush administration whether voluntary vaccinations should be revived.

Some hospitals argue that the course of an actual outbreak may make predesignation of a smallpox center moot. The first victims would be unlikely to know initially they had smallpox -- the disease's distinctive rash doesn't appear until days after a patient falls ill with high fever and headache -- and would probably visit the nearest emergency room. That is what happened in Gainesville, Fla., in September, with a woman who was feared to have smallpox but who turned out to have lab-acquired cowpox, a related illness.

"There is no real reason to designate some [place], in a public manner, as a smallpox hospital," says Ms. Waltman of the New York hospital group, who adds that the best approach is for all hospitals to develop a minimum-response capability for at least a handful of cases, something many are doing.

Paul Ford, director of safety and security at Florida's 877-bed Tampa General Hospital, argues that "it would be totally impossible for us to be designated as the isolation hospital" because, as the regional burn center, it provides unique services. "You aren't going to close the burn center down," he says. He says it makes more sense to designate smaller hospitals to handle a small outbreak, and identify a bigger building -- a hotel, dormitory or vacant building -- that could be converted to an isolation center in a larger outbreak.

Others argue that advance preparations could help avoid incidents such as the one in Seattle in December, when an overseas traveler arriving at the city's airport was suspected of being infected with smallpox . Before the threat was determined to be false, public health officials called area hospitals only to find that none felt adequately prepared to accept such a patient.

The incident accelerated the city's smallpox-response planning, says Jeffrey Duchin, chief of communicable diseases for Seattle and King County. Still, Dr. Duchin says, no hospital has volunteered to be the city's dedicated smallpox facility, although all agree they must be ready to handle at least a few cases.

Most officials expect decisions about smallpox facilities to be hashed out over the coming months. But some planners refuse even to identify the facilities they are considering, citing security concerns.