Local agencies say smallpox vaccinations hurting other efforts

A survey of local public health agencies by the National Association of County and City Health Officials (NACCHO) in Washington, DC, indicates the nation’s smallpox vaccination program negatively impacts other bioterrorism preparedness activities such as development of response plans, disease surveillance systems, and epidemiologic capabilities.

According to the survey results, local public health agencies find it difficult to maintain routine public health services such as vaccination clinics, maternal and child health programs, and environmental health programs, while meeting the demands of planning and implementing the smallpox vaccination program and other bioterrorism related activities.

Of 539 agencies responding to a question about whether smallpox preparation efforts had taken away from other bioterrorism activities, 79% said there had been a negative impact.

"Efforts to prepare for chemical, biological, and radiological terrorism have been taken off track in order to meet the demands of the smallpox vaccination program," NACCHO says in a research brief. "Many respondents cited limited resources and staffing, the complexity and resource-intensity of the program, and the lack of additional bioterrorism funds as a cause. [The local agencies] expressed concern about the country’s vulnerability to attacks from agents other than smallpox, such as ricin, dirty bombs, and anthrax."

About half of the agencies that responded to the survey said bioterrorism preparedness planning has taken away from their other public health programs and activities. Most of those who offered a more detailed explanation said staff, resources, and funds had been diverted from other public health activities to help with smallpox vaccination planning and implementation. A significant number of local agencies said they deferred, delayed, or cancelled specific public health programs and activities due to smallpox vaccination planning and implementation.

Interestingly, one-third of the respondents said that bioterrorism and other preparedness planning had helped their other public health activities, especially through establishing better relationships with community partners.

Vulnerability could increase

NACCHO concludes that limited resources and growing workloads are preventing local public health agencies from giving equal attention to maintaining current levels of service, developing a smallpox vaccination program, and preparing for bioterrorism events. Continued diversion of resources, it says, will increase communities’ vulnerability to ongoing public health threats such as influenza, West Nile virus, contaminated drinking water, food-borne illnesses, and chronic diseases.

"Notably, this level of disruption to the local public health system occurred before a single volunteer was vaccinated" the report says. "It can be expected that, without additional resources, the negative impact of the smallpox vaccination program on general bioterrorism preparedness activities and routine public health services will increase."

Some relief may be on the way as the Department of Health and Human Services (HHS) announced March 20 that $1.4 billion was to be provided to states this year to help them enhance preparations against terrorism or other public health emergencies. Tommy Thompson, secretary of Health and Human Services, also announced special provisions under which states could get up to 20% of their 2003 funding immediately to support current activities, including smallpox vaccination for selected health workers and emergency responders.

Thompson said some states need a share of their 2003 funds right away, while others will want to receive them later, following their planning process, and the decision will be left to the states.

The funding is part of a total of about $3.5 billion in HHS funding this year for bioterrorism, preparedness, including research into potential bioterror disease agents, and potential treatments and vaccines.

American Public Health Association (APHA) associate executive director for public affairs Kelly O’Brien tells State Health Watch that his group supports the early release of funds.

"But," Ms. O’Brien says, "additional resources are needed to ensure that we proceed without shifting resources from other preparedness requirements and to ensure that we maintain our ongoing programs that protect Americans from everyday health threats. We urge Congress to make sure that adequate dollars are appropriated."

Groups call for legislation

Before that announcement was made, several public health associations joined in a call for passage of national legislation to address impediments to the smallpox preparedness effort. Three critical needs identified by the groups (the American Public Health Association, the Association of State and Territorial Health Officials, and NACCHO) were: (1) a national smallpox vaccination compensation program to provide compensation to those who may be injured as a result of volunteering to be vaccinated; (2) additional liability provisions to provide necessary protection from costly legal action for organizations and individuals who participate in the vaccination program; and (3) new federal funding to support smallpox preparedness efforts at the state and local levels.

The three groups urge Congress and the administration to approve a comprehensive national smallpox injury compensation program to provide easily accessible compensation to anyone who becomes ill, injured, or disabled, or who dies as a result of the vaccine, either through primary or secondary transmission. They also asked for a broader definition of those entities covered by liability protection under the Homeland Security Act.

Addressing the overall funding issue, the groups strongly agree that funding remains a great concern and additional funds will be needed if state and local public health agencies are to carry out all their responsibilities.

At about the same time that the organizations were calling for a smallpox vaccination compensation plan, Thompson said the government would create a program to provide benefits to public health and medical response team members who are injured as a result of receiving the smallpox vaccine. Elements in the plan, said to be similar to one already available to police officers and firefighters, are a permanent and total disability benefits; death benefits; temporary or partial disability benefits; and health care benefits.

HHS also proposes to provide compensation to third parties who contract vaccinia from public health and medical response team workers who have been vaccinated.

Ms. O’Brien from APHA tells State Health Watch of a number of ways a compensation plan could be strengthened:

1. A national program should provide timely first-dollar compensation for medical care and lost wages, rather than function as a system of last resort.

2. The program should not be limited in time. (It currently proposes a 120-day time limit.) There will be a need for full protections for volunteer vaccinees for as long as it is national policy to maintain preparedness for smallpox.

3. Lump-sum payments for death and disability should include lost wages. The incidence of permanent disability and death is likely to be extremely low. Therefore, providing an expanded benefit that more accurately reflects lost income will not be costly and will ensure greater confidence among volunteers that they and their families would be protected.

4. Volunteers who are helping our nation address terrorism preparedness should receive compensation for all lost wages. Compensation should begin immediately without any period of delay, should be 100% rather than 66%, and should not be subject to a cap.

Meanwhile, a coalition of parents and health care providers organized as Americans for Vaccine Safety and Accountability, asked that Congress separate reform of the Child Vaccine Injury Compensation Program from bioterrorism legislation. A coalition news release says the group opposes inclusion of Vaccine Injury Compensation Program reforms in a bill that targets funding for development of new bioterrorism vaccines and compensation for health care workers injured by smallpox vaccine.

"Wedging reform of the federal vaccine injury compensation for children into a fast-tracked bioterrorism bill is no way to get the job done right," said coalition president Barbara Fisher.

"Congress made a social contract with the parents of America in 1986, and that contract was that if parents vaccinated their children, then the government would provide federal compensation if a child was injured. The no-fault, expedited, fair, and generous compensation system that Congress envisioned has not lived up to its promise, and we owe it to all children to do it right this time around," she added.

[To download government information, go to: www.cdc.gov/smallpox and www.hhs.gov. Contact NACCHO at (202) 783-5550; Ms. O’Brien at (202) 777-2501; and Ms. Fisher at (703) 038-0342.]