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Last Updated

12 May 2003

Source: Washington Post, May 12, 2003

Smallpox Strategies Shifting

Inoculations Fall Far Short of Goals In Nation, Region

By Christian Davenport, Washington Post Staff Writer

With the campaign to vaccinate hundreds of thousands of health care workers for smallpox now at a virtual standstill for lack of volunteers, local public health officials are worried they might have to resort to a riskier plan for fighting the deadly disease: immunizing doctors and nurses after an outbreak begins.

Regional health officials say there is little more they can do to persuade reluctant health professionals to take a vaccine that has possibly severe side effects. The end of the war in Iraq -- and with it the perception that the threat of a bioterror attack has waned -- has stiffened resistance to the vaccine, as has its link to several cases of heart inflammation.

The debate over immunization, which is playing out across the Washington area and the nation, comes as the federal government is revising its own smallpox preparedness plans, and as the outbreak of severe acute respiratory syndrome, known as SARS, has distracted attention and diverted resources.

President Bush, who received the smallpox vaccine himself in December, set a goal of vaccinating 500,000 health care volunteers in the first round of inoculations. But five months after he announced the plan, only about 35,000 have been inoculated, and the federal Centers for Disease Control and Prevention recently said that 50,000 is a more realistic objective.

Locally, too, the effort has fallen way short of expectations. In the District, where officials initially hoped to vaccinate 3,000 workers, only 100 stepped forward. Maryland and Virginia, which received a total of 16,000 doses from the federal government, have each vaccinated fewer than 800 people. Just 26 of Virginia's 88 acute-care hospitals have at least one staff member who has been inoculated.

Some experts are exhorting health leaders to continue on two fronts: pushing reluctant health care workers to take the vaccine, while planning for an outbreak at the same time.

"We need more people to be vaccinated so we can set up that emergency vaccination program," said Daniel Lucey, director of the Center for Biologic Counterterrorism and Emerging Diseases at Washington Hospital Center.

But having concluded that they won't be able to enlist adequate numbers of volunteers, other public health officials said they have no choice but to revise their plans.

"It's kind of like a war," said Lynn Frank, the Montgomery County public health chief. "You try one thing. It doesn't work, so you try something else."

For many jurisdictions, that has meant a greater emphasis on preparing to vaccinate workers in the days after an outbreak begins, further complicating what already would probably be a chaotic, perhaps even panic-ridden, environment.

And because the vaccine can cause so many adverse effects, some officials are worried that those health care workers who wait to be inoculated until after an outbreak starts might not be available when they are needed most.

"We can't afford to have staff on sick leave as a result of minor reactions to the smallpox vaccine," said Frances Phillips, the Anne Arundel County health officer. "We need to have some level of capability right now."

Some officials take solace in the fact that people exposed to smallpox can take the vaccine up to four days later and be safe.

But Lucey said that "assumes you know when you were exposed, which is a big assumption. Some people are putting a lot of faith in that time frame."

An outbreak, he said, is like "a ticking clock. The sand is going down the hourglass, and every hour counts."

There is another risk in waiting until after an event, experts say. Although the vaccine works in the overwhelming majority of those who get it, a small percentage are still not immune after the first attempt.

In other words, after an outbreak starts may be too late for a vaccination to help. Other experts say that people who are vaccinated can transmit the disease to others for up to three weeks, which is why some hospitals won't allow recently vaccinated employees near patients.

Apprehensions about the vaccine and uncertainty over the likelihood of an outbreak have left many governments and health providers struggling to formulate their own definitions of preparedness.

"I can't tell people what the risk of a smallpox outbreak is, so I can't say what the benefit of getting the vaccine is," said Lisa Kaplowitz, the Virginia Department of Health's deputy commissioner for emergency preparedness and response. "And that's what impacts individual and institutional decision-making."

Thomas Calhoun, the medical director of the Emergency Health and Medical Services Administration for the D.C. Department of Health, said volunteers have been harder to find since the war in Iraq ended.

"As we get further and further away from the conflict in Iraq, it's my sense there are going to be fewer and fewer people who will want to be vaccinated," he said.

That's troubling, he said, because the city was counting on having vaccinated workers to inoculate others in case of an outbreak. While the city is still desperately trying to find volunteers -- Calhoun said it is even planning a media event at which Police Chief Charles H. Ramsey and other top officials would get vaccinated "to encourage others to do it" -- it also has broadened its approach.

The District is seeking pharmacists and dentists who could be trained to give the vaccine. Retired doctors may be called into service.

"We're going to go ahead and do this because the numbers are just not coming in, and if we're going to wait -- God forbid something happened -- we wouldn't have enough people trained," he said.

Virginia Commonwealth University Hospital in Richmond has decided not to vaccinate its staff -- not until it is convinced that the threat of an outbreak outweighs the vaccine's risks.

"If the government really wants this to happen, they have to articulate the threat," said Michael B. Edmond, an infectious disease specialist with VCU.

The hospital also is concerned that some employees might feel pressured into taking the vaccine for patriotic, not medical, reasons.

In a letter to newspaper editors, Edmond and a colleague wrote that "many of our public health officials have chosen political expediency over the health of citizens they are entrusted to protect. Debate is being stifled and many are afraid to oppose or openly question the public health plans."

Northern Virginia's Inova Health System also has struggled with how to balance the threat of an outbreak against the danger the vaccine poses to its staff and patients. But after weeks of meetings, the hospital system decided to start vaccinations last month.

"We understand the geography that we occupy," said Allan J. Morrison Jr., Inova's epidemiologist. "We're in the nation's capital, and we have a commitment to providing safe and effective health care to a major metropolitan region."

Howard County General Hospital also wanted to move ahead with vaccinations, but first it had to address its staff's concerns.

"Do you continue to get paid even though you can't work?" said Mary Patton, the hospital's spokeswoman. "Do you continue to get paid even though you can't care for patients? What happens if you die? Are you covered? What kind of survivor benefits do you get? All of those things were not really resolved when this started, and that held people back."

When smallpox vaccination was routine, about 1,000 of every million people inoculated had minor reactions, such as a rash or fever. An additional 14 to 52 people suffered severe complications, such as blindness and encephalitis, and one or two of them died, according to the CDC. In the current inoculation drive, the vaccine has been linked to three dozen cases of heart inflammation.

It wasn't until this month that Bush signed a law ensuring that health care workers would get paid for lost time or injury. And health officials said the low number of vaccinated workers isn't only because of fear of the vaccination or compensation concerns. Many who want to take the vaccine don't meet governmental health standards.

Officials from across the area have met for several smallpox drills in recent months, where they went over the details of a mass vaccination: making sure there is adequate staffing, food, power, transportation, parking. An outbreak also would be expected to cause mass panic, so there are concerns about security and crowd control.

Hospitals were urged to review staffing levels, how to identify smallpox symptoms and how to notify local, state and federal health officials. They discussed how to vaccinate the public at the clinics that would be set up across the area and be open 24 hours a day.

The planning has gotten to "the level of how many pencils and how many tables do you need," said Mercedes Lawrence, director of the Prince George's County Division of Epidemiology and Disease Control.

States and communities also have made plans to get additional doses from the federal government "on very short notice," said Kaplowitz, of Virginia's Department of Health. "We're talking hours."

Through the Sept. 11, 2001, attacks, the anthrax scare and now the appearance of SARS, many health officials say they are much better prepared to handle all sorts of emergencies, including smallpox. And despite the different views on how best to prepare for a smallpox outbreak, Frank, the Montgomery County public health chief, said she was comfortable with the region's progress.

"The practice of medicine is very welcoming of vigorous debate and questioning," she said. "It's how practices improve."