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Last Updated

13 Dec 2002

Source: New York Times, December 13, 2002.

State Officials Question Timetable for Smallpox Vaccines


Some state officials and medical authorities said yesterday that they doubted they could carry out the first smallpox vaccination campaign in three decades within the planned time frame called for by President Bush given the major logistical hurdles yet to be surmounted.

The doubts emerged with news that President Bush would call for vaccinating military personnel, health care and emergency workers against smallpox within weeks, and possibly the public in 2004.

But state and local officials said that some hospitals only now are beginning to prepare for vaccinations and that they needed more time to solve issues like educating medical personnel and the public; reducing risk of complications from the vaccine; ensuring that hospital care does not suffer if vaccinated workers feel ill; and determining who would pay for liability claims, lost work or supplies like bandages.

The plan, to be announced today, comes against the backdrop of a possible war against Iraq and fears over whether terrorists or hostile nations might attack with the contagious virus, which kills about one in three unvaccinated people.

The initial phases of the vaccination plan would cover about 500,000 military personnel and 500,000 civilians, mostly health care and emergency workers who would most likely be exposed if someone contracted smallpox, officials said. Eventually as many as 10 million people in law enforcement, health care and emergency response could be offered the vaccine. Defense officials said troop vaccinations could start today.

Yesterday, federal officials said an effort over the last two months to prepare the states for the immunizations had paid off, and that problems in carrying out the large effort would be small.

Dr. Ed Thompson, a liaison with state health departments for the Centers for Disease Control and Prevention, said, "We have no illusions of this being an easy task."

For many state health workers, "this will be the biggest challenge of their career," said Dr. Thompson, who recently left his position as state health officer in Mississippi. "There will be some stumbling and they will be learning as they go along." Since the program "is important to protect our citizens, we are going to make it work."

"Some of the things you do best are the ones you are scaredest of when you start," Dr. Thompson said.

Dr. Michael T. Osterholm, an adviser to the secretary of health and human services, said the civilian immunizations "will surely challenge state and local health departments. But it's very doable. I don't want to suggest it's going to be a cake walk. But we can do it with minimal interruption of services and activities."

When Dr. Osterholm was Minnesota's state epidemiologist, his team vaccinated 26,000 people against bacterial meningitis in four days, he said.

But smallpox vaccination is more complicated and dangerous because the virus in the vaccine can be transmitted inadvertently to other people, state and infectious disease experts said.

Dr. C. Mack Sewell, New Mexico's epidemiologist, said in an interview that the federal smallpox plan was too ambitious. "We were told you must start and finish in 30 days," he said. "We felt that was not reasonable, and other states feel the same way. We need more time to do this carefully and properly."

In particular, Dr. Sewell and other experts said, doctors need time to build up experience in administering the smallpox vaccine while avoiding danger. People at risk of complications include those whose immune systems have been weakened by cancer, AIDS or other diseases.

"We want to go cautiously to do our absolute best so as to minimize the number of adverse reactions," he said. "We want to make certain we screen properly and get mechanisms in place. If the threat assessment changed, we'd be ready to move more quickly."

The vaccine, made of a live virus closely related to smallpox known as vaccinia, can cause death or injury in susceptible people. They could presumably decline to be vaccinated, but they would remain vulnerable to infection with vaccinia virus shed by those who had taken the vaccine.

Dr. Sewell said New Mexico planned to immunize just 120 people in the first round, gradually expanding to about 12,000, a process that could take six to nine months. The state's plan, he added, had major uncertainties. "As with everybody else, it remains to be seen how many people will volunteer for this," Dr. Sewell said.

A doctor at a major East Coast hospital said the logistics of the vaccinations were incredibly complicated. "It's not down pat," he said of the preparation effort. "We're just getting started."

New York City's health and mental hygiene commissioner, Dr. Thomas R. Frieden, said he planned to move cautiously in vaccinating the the first wave of people. "We want to err on the side of safety," he said.

On Monday, a federal deadline passed for states and large cities to file their proposals on how to immunize health workers against smallpox, the first such plan in 30 years.

Yesterday, the Centers for Disease Control and Prevention in Atlanta announced that it had finished its first review of the state plans, and found them encouraging. The states were responding to documents from the disease control centers asking that they develop 30-day plans for vaccinating specific groups of health workers.

"We are extremely pleased and quite impressed with the plans that have been submitted to the C.D.C. so far," Tommy G. Thompson, secretary of health and human services, said in a statement. "It is obvious that state and local health departments and hospitals have stepped up to the plate under an extremely tight timetable."

A federal expert, who spoke on the condition of anonymity, said the numbers of health workers proposed by states for the first immunizations ranged from the hundreds to 70,000. "Some of those states who reported the highest numbers will probably be lowered," the official said, adding that no other significant changes in state plans were expected.

Civilian workers are being allowed to decide whether to receive the vaccine. State health officials have identified more than 3,300 health care facilities that would participate.

Dr. William Schaffner, chairman of the department of preventive medicine at Vanderbilt University, who also advises the Tennessee Department of Health, said in an interview that hospitals were scrambling to carry out the plans.

"It's a huge task to do in a relatively short time, 30 days," he said, adding that federal officials said the time frame might be extended to six weeks. Even then, he said, "It would be a huge load."

Doctors, he said, would face perplexing and time-consuming problems like vaccinated people wanting to know if mild symptoms even a pimple are signs of a serious reaction.

Even though an advisory group to the C.D.C. began openly discussing the possibility of a renewed smallpox campaign last spring, the nation's medical community is just now starting to wrestle with the vaccination plan, Dr. Schaffner said. "Even among infectious disease specialists, there's a variable level of knowledge," he said.

Tennessee, he said, is trying to be "very realistic" about how many people can be vaccinated in a given time. "It's clear," he said, "that not all local health departments have enough staff to carry out the program and they're going to have to tap local hospitals to help them out."

The reactions in Tennessee, Dr. Schaffner said, have been starkly opposed: those eager to volunteer to be vaccinated, and "an equally large group that is skeptical and dubious that Tennessee would be targeted for an attack."

Dr. Schaffner said that the way Mr. Bush framed the issue today would be important and could convince people that vaccination was a patriotic duty.

Despite the federal push for quick vaccinations, experts said, concerns over liability could delay any vaccinations until Jan. 24, when a new law to reduce the legal risk is to go into effect.

"Practically speaking, it's hard to imagine a hospital moving forward with actual vaccinations without that in place," said Dr. Thomas Inglesby, a physician at the Johns Hopkins Center for Civilian Biodefense Strategies in Baltimore.

The Association of State and Territorial Health Officials said news about the vaccinations had taken it by surprise and that it would have no comment until after the formal announcement. The decision emerged Wednesday night when ABC News broadcast excerpts of an interview with Mr. Bush.

The first American troops to be vaccinated would be military specialists who would respond to a smallpox outbreak, as well as forces assigned to units in the Middle East or that could eventually deploy there, military officials said. Of the 1.4 million service members on active-duty, 350,000 to 500,000 would be vaccinated under the new policy, the officials said.

"It's a matter of cranking up and preparing and getting ready and actually implementing it," Defense Secretary Donald H. Rumsfeld told CNN while traveling in the Persian Gulf state of Qatar yesterday. "It's been through the process at the Department of Defense and we've coordinated it with the White House, and they're aware that we do plan to provide smallpox vaccinations to first responders and to people who conceivably could be vulnerable to the disease."

Military personnel will be asked the same series of questions that civilian emergency personnel will address to determine if they have a higher risk of suffering side effects from the vaccine. Those at high-risk will not be vaccinated unless there is a confirmed outbreak of smallpox that could affect them, defense officials said.

The military bars individuals infected with the AIDS virus from joining the armed forces, and screens all military personnel periodically for the virus. If service members are found to be infected, they are allowed to continue their duties but are not deployed overseas.