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A plan that targets hospital emergency workers to receive a smallpox vaccination first will substantially lessen the potential threat of a public-health nightmare, according to sources. "If there is an outbreak and most health care workers are unprotected, then we may see some workers not showing up for their shifts when the epidemic hits the streets of the U.S.," warns Gary Wright, MD, FACEP, medical director of the ED at South Baldwin Regional Medical Center in Foley, AL.
According to a Bush administration plan, still to be finalized at press time, the vaccine will be offered first to hospital emergency workers because these workers are considered to be at greatest risk of coming into contact with a patient infected with smallpox.
Despite the announcement, ED managers have not developed concrete plans for how the vaccination process would be handled. "I have fielded several questions from nursing and physician personnel, but we have not yet had any meetings addressing this issue," Wright says. The lack of a plan is due largely to practical concerns that have not been addressed by government officials. "Until we find out the requirements for post-vaccination duty, we are not going to proceed," he points out.
Wright says he suspects that if staff are required to be off for a two- to three-week period after vaccination, his facility won’t participate as a voluntary center. "From a personal standpoint, if I am not allowed to return to duty after vaccination, I will also not be seeking vaccination," he adds. If ED personnel are allowed to rapidly return to work, there will be good participation in the program, Wright predicts. "Otherwise, I feel there will be dismal participation," he says.
Nancy Auer, MD, FACEP, medical director for hospital bioterrorism planning for the state of Washington, acknowledges that plans for vaccination cannot be made until certain issues are addressed. "Until then, we will not advocate for pre-exposure vaccination," she says.
In particular, Auer says that the government has to announce its policy for furlough after vaccination, who pays for disability if a vaccinated worker becomes ill, and liability if an individual develops vaccina through exposure from a vaccinated individual. "One of the problems we currently face is that the smallpox vaccine is considered an experimental vaccine, so there is no liability coverage from the federal government under the usual coverage for vaccines," she says. "We also need to know who will distribute the vaccine, and when and how it will become available."
Here are items you should consider, in order to prepare:
• Risks of immunocompromised individuals. The Atlanta-based Centers for Disease Control and Prevention recently announced that there may be higher rates of complications from smallpox vaccination now than in the past, due to increased numbers of individuals with immune suppression as a result of organ transplants and such illnesses as cancer and HIV/AIDS. (Go to the CDC web site: www.bt.cdc.gov/agent/smallpox/index.asp. Under "News," click on "Chart: Smallpox Vaccine Adverse Event Rates.")
Wright notes that patients who are immunocompromised would be at increased risk if large numbers of staff are vaccinated, but he adds that most of these individuals need to avoid hospitals anyway. Often, it isn’t known which patients are immunocompromised, so he suggests putting out a public notice for those individuals to avoid the facility unless arrangements are made with their physicians.
• Staffing issues. Wright says his biggest operational concern is the proposed requirement to keep workers out of contact with patients for a two- to three-week period after vaccination. "If this is a requirement, I suspect there will be almost zero participation other than the military, public health workers, and other state or federal employees who would get paid leave or be reassigned," he says. "For those of us having to fund our own employment, I suspect almost no one will want to take three weeks of unpaid leave."
Wright suggests that one possibility is to give employees the vaccine just before they take off for a two-week vacation. Over the course of a year, most workers could be vaccinated. "Granted, they would probably not like the idea of being ill for their only vacation of the year," he says. "However, I doubt any hospital system is going to fund two weeks of paid leave for every employee."
Another approach would be to vaccinate half of the employees, wait three weeks, and vaccinate the other half, says Wright. "During this six-week period of time, the employees would be allowed to continue working."
For more information about administration of the smallpox vaccine to emergency department staff, contact:
• Nancy J. Auer, MD, FACEP, Vice President for Medical Affairs, Swedish Medical Center, 700 Minor Ave., Seattle, WA 98104. Telephone: (206) 386-6071. Fax: (206) 386-2277. E-mail: firstname.lastname@example.org.
• Gary Wright, MD, FACEP, Medical Director, Emergency Department, South Baldwin Regional Medical Center, 1613 N. McKenzie, Foley, AL 36535. E-mail: email@example.com.
For updated recommendations, go to the Centers for Disease Control and Prevention’s Smallpox web page: www.bt.cdc.gov/Agent/Smallpox/SmallpoxGen.asp.