Readiness is more than vaccination’

Smallpox planning reaches new stage

A year after states began drafting smallpox vaccination plans, preparedness is moving into a new phase with a new challenge: How do you sustain those efforts?

While still encouraging vaccination, the Centers for Disease Control and Prevention (CDC) and state health officials are asking hospitals to bolster education programs and communications capabilities. They also will need systems to track vaccinated employees. Five years after their vaccination, those employees will need a booster to remain fully protected against smallpox, the CDC says.

Just 235 hospitals nationwide have vaccinated a response team of at least 25 employees, and just 24,000 health care workers received the vaccine. But with or without a team, hospitals need a preparedness plan. If smallpox occurs anywhere in the world, or in the nation, who would be vaccinated first at the hospital?

Which employees would conduct the vaccinations? What is the hospital doing to heighten awareness of all bioterrorism agents and improve the likelihood of early identification?

"Readiness is more than just vaccination," says Lynn Steele, MS, CIC, senior adviser in the CDC’s Office of Terrorism Preparedness and Emergency Response. It is more than just an algorithm showing the difference between smallpox and chicken pox, although the CDC provides detailed information on such issues on its web site. (See: for a form to evaluate rash illness.)

"We would want [health care workers] to be trained to vaccinate others," says Donna Knutson, MSED, senior adviser in the terrorism office.

"We would want them to be trained in the appropriate isolation and infection control procedures. We would want the [members of the] team to be trained so they understand their role in the overall response plan," she explains.

Education has to match those needs, and may be incorporated into annual infection control training, Steele says. "It’s not just a one time shot to begin to prepare people to begin thinking about the possibility of smallpox. We have to think about educational strategies that are more ongoing and repetitive."

CDC officials acknowledge they are disappointed by the response to the smallpox vaccination program. Some hospitals decided that the risks of side effects from the vaccine outweighed the benefits of vaccination — with the risks of an actual smallpox event impossible to determine. Those hospitals would need to be prepared to move swiftly to vaccinate employees if a smallpox event occurs.

"Some facilities have a list of people who would volunteer to be a part of a program if indeed there would be an event," Steele adds. "They’ve done everything to prepare people except put the vaccine in their arm."

That is the approach taken by Baystate Health System in Springfield, MA. James Garb, MD, director of occupational health and safety, is developing a post-event vaccination plan, including training potential vaccinators. "We need to identify an appropriate location and identify what we’d need for supplies. We should do some training and at some point enact a drill."

He has identified volunteers for a response team but has not initiated pre-event vaccination. "The chance of us seeing a [smallpox] patient before someone else in the world is pretty small. It could happen, but a more likely scenario is that we would have a case of smallpox somewhere else and the risk-benefit equation would be drastically altered. We’d need to vaccinate people."

Nonetheless, the Massachusetts Department of Public Health is trying to promote more pre-event vaccination. As of early September, only 136 health care workers had been vaccinated in the Massachusetts, according to CDC data.

"If you don’t have vaccinated people, you’re always stuck with the need to have people expose themselves to smallpox and the risk of dying from it. That’s the bottom line for me," says state epidemiologist Al DeMaria, MD, director for communicable disease control and a member of the Healthcare Infection Control Advisory Committee, a federal panel that advises CDC.

"We can’t really know if [smallpox] exists or not. We can’t know until it happens," he says. "If it’s not somebody who’s already vaccinated, it’s going to be someone who depends on personal protective equipment." While post-exposure vaccination can prevent infection, it isn’t completely protective. "People can still get smallpox and transmit smallpox after exposure [and vaccination]." Further-more, vaccinees won’t know if they had a take until about seven days after vaccination, he says.

Meanwhile, hospitals need a way to keep track of their vaccinated employees, which may include some employees who were vaccinated as a part of the military program. The vaccine monitoring system used to track and report adverse events may be adapted as a tracking tool, DeMaria says.

"It’s going to be the hospital’s responsibility to know who’s vaccinated and to replace people who leave or retire with other vaccinated people," he says.