Health care gearing up for smallpox vaccination

Focus on education, pre-screening of volunteers

The first stage of smallpox vaccination has begun, even before the doses are released or a final plan formulated. Across the country, hospitals are educating health care workers about smallpox and the vaccinia vaccine.

It’s impossible to know how many health care workers will decline the vaccine due to concerns about adverse events. But already, nurses have shown a patriotic commitment to fight bioterrorism: More than 2,900 have expressed interest in becoming part of the National Nurses Response Team, a group co-sponsored by the American Nurses Association (ANA) and the U.S. Public Health Service, both in Washington, DC.

The team’s mission is "to vaccinate and administer chemoprophylaxis in the case of use of a biological agent," says Cheryl Peterson, RN, a senior policy fellow at the ANA. "We have a number of nurses who are concerned because they want to help.

"What we’re seeing is that many nurses did not feel equipped to respond on Sept. 11. They didn’t feel they could do anything. If they did respond, they weren’t utilized well," she says. "We’re seeing a lot of nurses who are saying, I want to be able to respond.’"

Otherwise, health care workers’ unions have heard surprisingly little from their members who may be asked to take the vaccine. That underscores the need for education to make sure workers know what health issues, such as eczema and other skin conditions, might make them ineligible for the vaccine.

"Once they start vaccinating people, the phone’s going to be ringing off the hook; by then, it will be too late," says Bill Borwegen, MPH, director of occupational health and safety for the Service Employees International Union (SEIU) in Washington, DC.

At Memorial Sloan-Kettering Cancer Center in New York City, Kent Sepkowitz, MD, director of hospital infection control, has begun educational sessions to help health care workers decide if they should receive the vaccine. "I’ve been impressed that most workers are of a mind to volunteer and take their chances. It seems like the right thing do," says Sepkowitz, who also is associate professor of medicine at the Weill Medical School of Cornell University, also in New York City.

He is encouraging a conservative approach to vaccination, starting with small groups of vaccinees and closely monitoring adverse events. Congress removed one hurdle to the vaccinations by addressing an aspect of liability: A provision added to the homeland security bill states that the federal government will assume liability for serious adverse effects of the vaccine. Those administering the vaccine cannot be held personally liable for adverse events, and those suffering from the effects can receive compensation but not punitive damages.

As the nation moved closer to smallpox vaccination, the Centers for Disease Control and Prevention (CDC) released new educational resources. On-line continuing education training on the vaccine and its potential adverse effects now is available on the CDC web site at www.bt.cdc.gov/training/smallpoxvaccine/reactions/default.htm. The site includes images of normal reactions and adverse reactions, such as eczema vaccinatum, in which the vaccinia virus becomes implanted in the diseased skin and produces numerous lesions.

Contraindications could affect thousands

The most important aspect of the training involves the contraindications, screening, and reporting of complications of the vaccine. For example, CDC recommends against vaccination for those who have a history of eczema or who have other skin conditions, including acne and contact dermatitis, or those who have close household contacts with those conditions. That exclusion alone could affect thousands of health care workers.

The Association for Professionals in Infection Control and Epidemiology in Washington, DC, has an on-line course and templates for bioterrorism preparedness (www.apic.org). Judith English, RN, MSN, CIC, chair of APIC’s Bioterrorism Work Group and director of infection control at the National Naval Medical Center in Bethesda, MD, lauded CDC’s educational efforts.

"Those real concerns are being addressed. [Health care workers] know they need to self-select out if they are personally at risk or if their significant others are at risk," she says.

In its Smallpox Vaccination Clinic Guide, the CDC provides a sample screening form and screening information. This information was developed to help state and local governments plan for widespread emergency vaccination following an actual case of smallpox. However, it provides a useful tool to educate health care workers about the vaccine. (More information is available at www.bt.cdc.gov/agent/smallpox/ response-plan/files/annex-3.doc.)

Many questions still unanswered

Even as more information emerges about the vaccinia vaccine, many questions remain unanswered. Data on adverse effects of the vaccine come from immunization that occurred more than 30 years ago, Sepkowitz notes. Today’s population — including cancer patients and individuals with HIV infection and other immunosuppressant conditions — is more vulnerable to accidental transmission of the live virus from injection sites. Two federal expert advisory panels have stated that precautionary measures such as covering the site with gauze and a bandage would prevent transmission.

Sepkowitz reviewed the literature on nosocomial transmission of vaccinia, encompassing 12 articles published between 1907 and 1975. The 62 individuals who acquired vaccinia from nosocomial transmission all had underlying skin disorders. Most cases involved children, some of whom were in different cribs or even different wards from the source case, and the mortality rate was 16%.

"The route of transmission is still puzzling to everyone," he says. But by taking a slow and cautious approach, hospitals can successfully vaccinate health care workers without putting patients at risk, Sepkowitz adds. "I think that flexibility is the key. You start conservative and slowly gain confidence."

Meanwhile, advocates for health care workers are looking for job protections as well as education and screening. "Who’s going to protect people from discrimination if their employer says, We want you to be vaccinated?’ Most people are going to be reluctant to say no; but if they say no, are they going to be protected from discrimination?" Borwegen says. "We would argue if people want to be reassigned because they don’t want to be in a job that requires smallpox vaccination, they should be allowed to transfer into a job with the same pay and benefits."

Borwegen and others want to know who will pay for medical treatment for workers or their family members who suffer adverse effects. They also want reassurance that education and vaccination will occur during paid time.

"We have more questions than we have answers," Peterson says. "I really think some of these questions need to be addressed by the [Bush] administration or there needs to a dialogue about them among the stakeholders."