Are you ready to carry out smallpox vaccine plans?

Have you been putting off planning for smallpox vaccination because your key concerns have not been addressed? If so, new recommendations will provide some answers.

The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices has recommended that each hospital identify a smallpox health care team, comprised of staff from the ED, intensive care unit, infectious disease specialists, and respiratory therapists. Each team of 40 or more people would include 15 or more ED nurses and physicians, with the exact figures determined by individual hospital needs and staffing levels. Some hospitals will vaccinate 100 or more staff members.

The panel’s recommendations must be acted upon at the state and federal level before they become official, notes Karen G. Ketchie, RN, EMT-P, disaster preparedness manager at Shands Jacksonville (FL) Medical Center. Ketchie has a "wait and see" attitude about the new recommendations. "Our facility is handling this information judiciously," she says. "I am not putting much weight into the recommendations just yet, as I believe that major components will change."

Hospital administrators have held several meetings to discuss plans for the vaccine, but Ketchie reports that thus far, the issue has not been addressed with staff. She says that won’t change until the federal government officially requests that ED staff be vaccinated.

However, there is a lot you can do now, based on the new recommendations, says Robert Suter, DO, FACEP, senior consultant for Dallas-based Texas Emergency Physicians and director of physician practice development for Greater Houston Emergency Physicians, both ED physician practice groups. Identify volunteers to receive the vaccine, notify staff about implications of the proposed policy, and prepare draft policies for discussion, Suter says. "When recommendations are finally approved, you can expect that there will be tremendous pressure to implement them quickly," he advises.

"Attempting to simultaneously educate and implement these policies will probably create apprehension, fear, and resistance from staff." Give staff ample time to consider the information so that they can make logical, informed choices when it becomes necessary to do so, Suter adds. Bring up the topic at the next regularly scheduled meetings with staff and administration, and provide draft recommendations for discussion, he says.

Although some important issues such as liability remain unanswered, many concerns have now been addressed. Here are the panel’s key recommendations:

Vaccinated staff would not be quarantined. The necessity to furlough or quarantine vaccinated staff was clearly a barrier to participation, according to Suter. "This was particularly true due to the national staffing crisis we are experiencing for ED staff, in particular with nurses," he says. Implementing a program involving quarantines would have been a tremendous financial burden on hospitals, Suter says.

Individuals will be screened before receiving the vaccine. ED physicians and nurses live by the axiom that "all women of childbearing age are pregnant until proven otherwise," yet the panel does not recommend routine pregnancy testing, Suter notes. "If testing is not done, there definitely will be fetal exposures," he says. Similarly, he says that HIV-positive staff may be unaware of their immunocompromised status and be harmed from the vaccine as a result, since the panel did not require confirmation of recent testing. "It would be prudent to exceed the panel’s recommendations in these areas, particularly since we are immunizing against a threat that may or may not be real," he advises.

Vaccinated staff would use bandages to protect others. Secure dressings and long sleeves should protect patients and other staff from recently vaccinated individuals, he says. "This certainly can be effective with appropriate discipline on the part of those vaccinated," Suter says.

The vaccination program would be voluntary. There was great concern about a mandatory program, particularly due to the rare but potentially severe side effects of vaccination, says Suter. "We saw that even high-risk military personnel objected to anthrax vaccines on the basis of perceptions about the side effect profile," he notes.

Fifteen or more staff members from each ED would receive the vaccine. The program will be phased in at each site. "I think that this is an intelligent approach to attempt to minimize the dangers of the program overall," Suter says. The panel recommends a combined team of 40 or more individuals, comprised of ED, ICU, and other health care workers, he notes. "Working together, this team should be able to take care of a small outbreak if team members are flexible about their job duties and locations." However, Suter notes that if a community smallpox epidemic is not identified early, the numbers of patients generated easily would overwhelm one of these teams. "For a hospital to manage that type of scenario would require full staff participation or outside assistance," he says.


For more on the smallpox vaccine plans, contact:

• Karen G. Ketchie, RN, EMT-P, Disaster Preparedness Manager, Shands Jacksonville Medical Center, 655 W. Eighth St., Jacksonville, FL 32209. Telephone: (904) 244-2598. Fax: (904) 244-4285. E-mail:

• Robert E. Suter, DO, FACEP, Senior Consultant, Texas Emergency Physicians, 5926 Saint Marks Circle, Dallas, TX 75230-4048. Telephone: (214) 739-2776. Fax: (214) 739-0658. E-mail: