Background

The issue of preparedness for a biological threat of smallpox led President Bush to announce a plan in December, 2002 to immunize half a million healthcare workers. The vaccine is being offered on a voluntary basis to those who most likely would respond to a terrorist attack. The Centers for Disease Control and Prevention (CDC) has been designated the lead agency for upgrading public health capabilities for responding to this threat. Smallpox was considered to be eradicated globally in the late 1970s. If an outbreak were to occur, a rapid spread is a possibility due to virtually non-existent immunity to the disease, discontinuation of routine vaccinations in the United States in the early 1970s, and potential for delayed recognition of smallpox by healthcare personnel unfamiliar with the signs and symptoms of the disease. Increased mobility and crowding of the population is another consideration for the early spread of smallpox. The first stage of the program targets smallpox response teams designated by terrorism and public health authorities to investigate and follow up on initial smallpox cases, and healthcare teams whose members are trained to provide medical care for initial smallpox patients. Mandatory immunization of 500,000 military personnel began in December.

Smallpox

Smallpox is caused by the Variola virus. The most frequent mode of transmission is person to person via direct deposit of infected droplets onto the nasal, oral, or pharyngeal mucosal membranes or the alveoli of the lungs due to face-to-face contact with an infectious individual. Indirect spread without direct face-to-face contact is less common. In the majority of cases the symptoms appear within 12–14 (range 7–17) days following the exposure. The symptoms consist of a 2–3 day prodrome of high fever, malaise, and prostration with severe headache and backache. This pre-eruptive stage is followed by the appearance of a maculopapular rash (eruptive stage) that progresses to papules (1–2 days after appearance of the rash), vesicles (fourth to five day), pustules (by the seventh day) and finally scab lesions. The rash is first seen on the oral mucosa, face, and forearms and then spreads to the trunk and legs. Patients are most infectious during the first week of the rash. Once all the scabs have separated (usually 3–4 weeks after the onset) the patient is no longer infectious. The overall mortality rate with smallpox was approximately 30%.¹

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Smallpox Vaccine

The smallpox vaccine contains live vaccinia virus, an orthopoxvirus that induces antibodies to protect against smallpox. It is administered with a bifurcated needle, which is dipped into the vaccine solution and used to prick the skin several times.

The vaccine offers a high level of immunity for three to five years. The protection begins to fade after five years and is probably negligible after 20 years. If the vaccine is given within 2–3 days following exposure to smallpox it can result in protection from the virus. This vaccine, however, does have associated complications. Reports from past experiences reveal that for every one million persons vaccinated, between 14 and 52 individuals vaccinated for the first time could experience serious or life threatening complications, and 1 or 2 could die.²

Certain groups have been identified as having a higher risk for developing complications following vaccination. These are:

• Persons with eczema or other forms of chronic dermatitis
• Persons with altered immune states
• Women who are pregnant
• Children under one year of age
• Older adolescents or young adults³

Additionally, individuals with family members who may be at risk should be screened out.⁴

The Response

Smallpox vaccination of civilian volunteer healthcare workers began on January 24, 2003 for emergency department personnel and special smallpox response teams. As of February 11, 2003, the CDC reported 1,043 persons vaccinated in 19 states.⁵ (See chart above.) However according to Knight Ridder Newspapers, 16 out of 20 health professionals who were to launch the program in Connecticut backed out in late January.⁶

During phase two of the program an additional 10 million people will be offered the vaccine, including other healthcare workers, firefighters, and police. Vaccine would eventually be available to the general public but it is not recommended.

The Bush administration plan has gotten off to a slow start as criticism and skepticism has increased. A number of hospitals across the country are reported to have declined to participate in the program, citing some of the issues described below.⁷

The Issues

One of the key issues for individuals participating in the program has been how healthcare workers will be compensated for expenses and lost time due to complications from the vaccine. Another major concern is the protection of hospital patients whose immune status may be compromised by inadvertent exposure to vaccinia shed by healthcare workers while the immunization is being carried on.

In early February two U.S. soldiers were recovering from complications of smallpox vaccinations.⁸

In mid-January the California Nurses Association urged hospitals in that state not to participate in the smallpox program, indicating that there was no proof of the risk of a smallpox attack.⁹

Sen. Edward Kennedy (D-Mass.) planned to offer an amendment to a spending package that would allocate $750 million for a smallpox vaccine compensation fund and provide $859 million to help states with severe budget shortfalls to run their programs.¹⁰

The Institute of Medicine (IOM) convened a panel at the request of the CDC and unions representing thousands of healthcare workers and asked very pointed questions. The IOM panel urged government to "proceed cautiously."¹¹

Some issues are slowly being resolved. Preliminary approval to have smallpox vaccine-related injuries to first responders covered by workers’ compensation has been granted in several states including Kentucky, New York, and New Jersey, according to Reuters Health.¹² Other hospitals are reportedly screening first responders prior to administering the vaccine. Employee health nurses, infection control nurses, and occupational health nurses trained in the smallpox program are monitoring vaccination sites while healthcare workers are on duty. Their focus is on preventing the spread of infection. They also will assess vaccination site care, reported symptoms, vaccine take, and fitness for duty.

Summary

It is important for occupational health professionals to stay abreast of the issues surrounding the Bush administration’s smallpox plan. Important feedback has been given to the administration and some of the issues are beginning to be addressed. Visit the web sites for updated information and news of professional organizations that are closely monitoring this program.

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Additional Resources

CDC/MMWR Abstracts, Vol. 52, No 5 (February 7, 2003) available at www.acoem.org (click Disaster Preparedness and Bioterrorism button to access).

CDC Public Health Emergency Preparedness and Response web site on smallpox: www.bt.cdc.gov/agent/smallpox/index.asp.

Institute of Medicine, "Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation–Letter Report #1," www.nap.edu/catalog/10601.html.

Footnotes