The mission of smallpox transmission: Risk managers seek to minimize trouble

Education about risk is important; thorough planning needed

The federal government’s plan for vaccinating key health care workers against smallpox immediately set off warning bells for risk managers. Though it appears the risk for health care providers won’t be as bad as some initially feared, that doesn’t mean you can take the smallpox vaccinations lightly.

The first concern for many risk managers is the scale of the vaccination plan; few hospitals will be exempt from the recommendations. The Centers for Disease Control’s (CDC) Advisory Committee on Immunization Practices (ACIP) recently recommended smallpox immunization for 510,000 health care workers. All hospitals should designate a smallpox care team that will be immunized first, the committee says. That team should include about 40 health care workers per hospital, including the epidemiologist, infection control staff, 15 emergency department (ED) physicians and nurses, eight intensive care unit (ICU) nurses for adult patients, eight pediatric ICU nurses, one infectious disease consultant, one dermatology consultant, four respiratory therapists, four radiology technicians, two engineers, and selected staff from the security and housekeeping departments.

With that core team vaccinated, the hospital should be able to respond to the first cases of a smallpox outbreak without exposing health care workers unnecessarily, says Jane Siegal, MD, who advised ACIP on the issue as a member of the CDC’s Healthcare Infection Control Practices Advisory Committee. The exact makeup of the team will be left to the individual hospital to decide, she says.

Treat it like other vaccinations, but still some problems

Risk managers should approach the smallpox vaccination plan like any other vaccinations for health care workers, but with a few exceptions, says Michael Seitz, vice president for risk management with Fairview Healthcare Services in Minneapolis, and a board member of the American Society for Healthcare Risk Management. Many health care workers already receive vaccinations for various diseases, so Seitz suggests you use the same framework as the smallpox vaccinations. There’s no need to start from square one just because smallpox is a high-profile, particularly scary disease now, he says.

"I don’t see the smallpox vaccination plan being an additional risk for health care employers right now, if you do some things right," Seitz says.

Similar assurances come from risk manager Gina Pugliese, RN, MS, vice president of the Premier Safety Institute in Chicago. Though there is no reason to panic, she cautions risk managers that the smallpox vaccination plan will be a major program for each hospital, and one in which the risk manager should be play a significant role. Most health care providers will set up a multidisciplinary committee to make all the key decisions about who will be vaccinated and how. She says the risk manager must sit on that committee.

Employee furloughs were one of the first potential problems that sprung to mind for risk managers. Initial reports suggested that, because employees might spread the virus to others for up to 19 days after vaccination, they would have to be sent home for that time. With staffing shortages already threatening patient safety, the furloughs were considered a genuine threat. But now the CDC reports that, while health care workers who receive smallpox vaccine should keep the vaccination site covered until the scab separates, they would be allowed to care for patients immediately after vaccination.

John Modlin, MD, chairman of the ACIP, says the vaccination site should be covered with absorbent material such as gauze, and "at least a single layer of impermeable acoustic dressing" until the scab separates. But he says the committee recommends against placing health care workers on leave after receiving smallpox vaccinations unless they develop symptoms from the vaccination or do not adhere to infection control precautions.

In a press briefing at the CDC, Modlin stressed that, "The very close contact required for transmission of vaccinia to household contacts is unlikely to occur in the health care setting."

Risk managers should note, however, that not everyone can receive the vaccine. The ACIP recommends that health care workers with eczema, atopic dermatitis, or other skin conditions not be vaccinated. Between 2% and 5% of adults have eczema or atopic dermatitis, Modlin says. Other skin conditions mean that the vaccine may be contraindicated for up to 10%-20% of people.

The vaccine also is contraindicated for pregnant health care workers, those with HIV/AIDS, and other immunocompromised individuals. Modlin says female health care workers should be counseled not to become pregnant for four weeks after vaccination and that health care providers should offer HIV testing before vaccination.

The CDC also announced recently that a network of experts will be available for consultation at any hour in case of bad reactions to the vaccination.

Liability possible if you don’t screen workers

Seitz says those contraindications could be the biggest concern for risk managers. If you don’t properly screen workers and prevent transmission of the virus to others after vaccination, the hospital could be sued, he says. For instance, risk managers may need to think in terms of a wide circle of people the vaccinated employee will contact. The CDC says employees can work after vaccination, but what about those in the workers’ homes who might be susceptible to the virus? If anyone in the employee’s household has eczema or is immunocompromised, for instance, the CDC says the employee should be excluded from the vaccination program. To properly screen out such situations, the hospital might need to be especially attentive to educating employees about the risk of transmission, Seitz says.

He also raises the issue of how much vaccinated workers should be restricted in the days soon after receiving the vaccine. Should they be prohibited from certain areas in which patients or others are more vulnerable?

"There is a potential liability if we didn’t make the proper assessment and caused some additional exposure," he says. "What if someone goes from the emergency department to the obstetrics ward and exposes a father there in the waiting room? He exposes the wife and his newborn, and then people ask why you allowed that employee to spread the virus."

Let’s talk immunity

Federal officials are discussing the possibility of providing some type of immunity for health care providers for vaccination-related claims, but Seitz says it is far too early to know if that protection will be available. The publicity over smallpox has heightened the public’s awareness and could lead to more lawsuits than those prompted by less sensational infections in the hospital. But he says the risk really comes into play only if you don’t take the appropriate precautions. If there’s an outbreak of smallpox and people flood the hospital, that’s probably less of a liability exposure because that’s a community disaster in which transmission is hard to control, he says.

"For the vaccination plan, the community standard will be what everyone else had in place to prevent these accidental transmissions. You will be compared to other hospitals in the area," he says. "If we have a hospital that just wants to close its eyes and not do anything, that’s the one that’s going to have major problems because they haven’t been responsible in getting ready for this."