No one is immune: Outpatient surgery will feel impact of smallpox vaccine

You could face rescheduled surgeries, sick staff, and converted facility

The recently announced national smallpox vaccination plan will have a significant impact on your same-day surgery program, whether you work in a hospital, surgery center, or office setting. You may have vaccinated patients who reschedule surgery, vaccinated staff who need to avoid spreading the vaccination virus and may be out of work due to side effects, and staff and managers who may be asked to serve on smallpox response teams. In fact, your facility might be converted into a smallpox vaccination site!

In terms of the specific impact that the smallpox vaccine will have on individual same-day surgery programs, many questions remain unanswered; it has been nearly 25 years since the smallpox vaccination was suspended in the United States, says Donald E. Fry, MD, FACS, professor and chairman of the Department of Surgery at the University of New Mexico School of Medicine in Albuquerque and chair of the Governors’ Committee on Bloodborne Infection and Environmental Risk for the American College of Surgeons. "Outpatient surgery was truly in its infancy at the time that smallpox vaccination was stopped," Fry says.

This much is known: Many same-day surgery providers will be offered the smallpox vaccine in Phase 2 of a national smallpox vaccination plan announced Dec. 13 by President Bush. At press time, the first phase of the voluntary plan had begun to inoculate about 1 million military personnel, people who work in hospital emergency departments, and those on special smallpox response teams.

The second phase is likely to include offering the vaccine to about 10 million people including same-day surgery staff in hospitals, same-day surgery centers, and office-based settings, according to reports from the American Medical Association and other groups. The second phase will include police, firefighters, and other health professionals. While plans are not finalized, this phase is expected to immediately follow Phase 1 and be completed within 45 to 90 days.

Adults who want the vaccine can sign up for clinical trials now under way. By late spring or early summer 2003, the government will make the vaccine available to the general public on a voluntary basis.

People who have had the vaccine should wait until the vaccination site has healed before having elective surgery, says Douglas R. Bacon, MD, associate professor of anesthesiology and history of medicine at the Mayo Clinic in Rochester, MN. "I would suspect that the immune system will react better without the confounding stresses of surgery and anesthesia," Bacon says.

Another potential problem is that vaccinees may suffer side effects, says Joan Blanchard, RN, MS, MSS, CNOR, CIC, perioperative nursing specialist at the Association of periOperative Registered Nurses in Denver. Vaccinees can move the vaccine virus to another spot simply by touching, she says. "If the vaccine virus is in more than one area, they would not be [having] surgery, because that would put them at risk and other people at risk," Blanchard says.

According to the Centers for Disease Control and Prevention (CDC), it takes 2½ to three weeks for the scab to detach and a well-formed scar to remain. Others are more conservative in their estimates of how long patients should wait to have outpatient surgery. The vaccine for smallpox is infection with the virus vaccinia, Fry says. "In surgery, it would generally not be advisable to perform an operation when a patient has a concurrent infection," he says. For example, if a patient had a urinary tract infection or a paronychia of the finger, infection rates at the surgical site would be greater than would ordinarily be expected, he says. "Thus, my recommendation would be that elective outpatient operations should be postponed for four to six weeks following smallpox vaccination."

Some hospital-based same-day surgery staff already are being asked to serve on special smallpox response teams that will be inoculated in the first phase. Managers, surgeons, and anesthesiologists are most likely to be asked. Regardless of when it happens, same-day surgery staff who received the vaccine can continue working but must take extra steps to ensure that they don’t spread the vaccine virus. "The important part is to use gauze and a semipermeable dressing over that vaccination site, and long sleeves with a cuff," Blanchard says. A warm-up jacket, for example, is ideal, she says.

Other tips for your staff from the Department of Health and Human Services: Don’t touch the vaccination site or materials that have touched it. If you do touch the site or materials that have touched it by accident, clean your hands right away. Also, don’t let others touch the vaccination site or materials that touched it.

There’s no reason staff who have been vaccinated shouldn’t continue working, provided they don’t suffer side effects, sources say. "I would have no concerns about staff transmitting the virus to immunocompromised patients assuming that the vaccination site was covered," Bacon says.

Others are a little less certain. "If you’ve been vaccinated, can you treat a patient who is immunosuppressed or a transplant patient? We don’t know the answer to that yet," says J. Wayne Meredith, MD, FACS, chairman of the Department of Surgery at Wake Forest University School of Medicine in Winston-Salem, NC, and chairman of the Committee on Trauma for the American College of Surgeons. Liability issues also haven’t been resolved, he points out.

When your staff are receiving vaccinations, keep in mind that between 25% and 50% of vaccinees have mild reactions. "It’s not a vaccine that is simple to get and you’re on your way, like the flu vaccine," Blanchard says. According to the CDC, normal typical mild reactions include lymphadenopathy (local, 25% to 50%); myalgia, headache, chills, nausea, and fatigue (0.3% to 37%), and fever (2% to 16%). "If they have reactions — temperatures, signs and symptoms of a reaction — they may not feel like working or be able to work," Blanchard says. In fact, the CDC says that one out of three vaccinees may feel bad enough to miss work.

For that reason, managers will want to ensure that vaccinations are staggered so that the programs can be staffed sufficiently, sources suggest. You also may be affected if your facility is selected as a spot to vaccinate the general public, Blanchard warns. "When you look at the numbers of people that they’re thinking of vaccinating, they have to have space to do it, and they have to have trained people approved to give the vaccine," she warns.

Resources

For more information on the smallpox vaccination plan, contact:

Joan Blanchard, RN, MS, MSS, CNOR, CIC, Perioperative Nursing Specialist, Association of periOperative Registered Nurses, 2170 S. Parker Road, Denver, CO 80231. Telephone: (303) 755-6304, ext. 393. Fax: (303) 338-5165. E-mail: jblanchard@aorn.org.

Donald E. Fry, MD, FACS, Professor and Chairman, Department of Surgery, University of New Mexico School of Medicine, Albuquerque. E-mail: dfry@salud.unm.edu.

For resources on smallpox, go to these web sites:

Centers for Disease Control and Prevention. Web: www.cdc.gov/smallpox. This site offers resources for clinicians such as an adverse events training module.

Department of Health and Human Services. Web: www.smallpox.gov. This site answers questions about smallpox and the president’s vaccination plan. This site may be helpful for those receiving the vaccination or debating getting the inoculation.