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IOM: Create a registry of smallpox responders
Panel says responders need training on duties
Smallpox preparedness needs to take a broader focus, with a registry of health care workers and others who have been previously vaccinated, an Institute of Medicine (IOM) panel has advised.1
The 24,000 hospital workers and 455,000 military personnel vaccinated in the smallpox preparedness program could serve as core responders nationwide, the IOM suggested.
"All of these people may be willing to contribute their time and skills to a smallpox response, even if they change their affiliation with their original response teams or the military," says Brian Strom, MD, MPH, chair and professor of biostatistics and epidemiology and of medicine and pharmacology at the University of Pennsylvania School of Medicine in Philadelphia and chair of the IOM Committee on Smallpox Vaccination Program Implementation.
Those responders would need special training, the IOM panel said. The Centers for Disease and Prevention (CDC) also needs to establish a minimum standard of preparedness for states and local communities, and to develop scenarios of possible smallpox attacks that could be used in preparedness training, the committee said.
In fact, the CDC has asked states to maintain a list of immunized response team members, and will likely include that in upcoming performance measures for states on smallpox preparedness. CDC guidelines will emphasize an entire plan for preparedness, including training, communications systems, and drills, says CDC spokesman Von Roebuck.
The current roster of hospital workers isn’t enough, Roebuck says, but CDC will not set a minimum. Instead, the agency will ask states to define their readiness and determine how many health care workers still need to be vaccinated. "We’re always looking for an increase in vaccination numbers. The question comes up, How many is enough?’ We try to have as many people as possible [vaccinated] prior to an incident occurring. There’s not a set number."
The IOM recommendation for a national registry of potential responders fits with the more limited vaccination that has occurred nationwide. Only 235 hospitals have vaccinated a response team of at least 25 employees, far fewer than anticipated when the smallpox vaccination program began. The CDC has released 291,400 doses of vaccine and has asked smallpox vaccination programs to maintain their supply of unopened vials "to assure a readiness to respond to a smallpox outbreak or to continue vaccination activities." Some states, such as Florida and Tennessee, are using some of those doses to vaccinate law enforcement personnel and other "first responders."
"We feel strongly that it’s more important to get the vaccine near people’s arms rather than in their arms, so we’re in a position to vaccinate people if there is a case [of smallpox]," says Bill Borwegen, MPH, health and safety director of the Service Employees International Union.
A focus on readiness, rather than vaccination, is the right approach, he says. "Hospitals need to be doing much more to be prepared to not only deal with smallpox, but other biological as well as chemical and radiological weapons of mass destruction," he says. "Clearly, we need to be not only vaccinating these people but training them about what their duties would be in the event of an attack."
As concerns arose about myocarditis and pericarditis related to the vaccine, some hospitals have postponed the vaccination plans. Reports that immunity may linger many years after vaccination also have led to new questions about the need for widespread immunization.
According to researchers from Oregon Health & Science University Vaccine and Gene Therapy Institute in Beaverton, OR: "Antiviral antibody responses remained stable between one and 75 years after vaccination, whereas antiviral T-cell responses declined slowly, with a half-life of eight to 15 years.
"If these levels of immunity are considered to be at least partially protective, then the morbidity and mortality associated with an intentional smallpox outbreak would be substantially reduced because of pre-existing immunity in a large number of previously vaccinated individuals."2
If the lasting immunity is found to be protective, hospitals may be able to create teams of responders without the risks of re-immunization, notes James Garb, MD, director of occupational health and safety at Baystate Health System in Springfield, MA. Garb created plans to vaccinate staff, then postponed them when the cardiac concerns arose. "I’m still concerned that we don’t know all we need to know to do this [smallpox program] the best way," he says. "I think we need a little more time for the experts to sort this out before proceeding."
Meanwhile, health care workers who suffered from vaccine complications still are waiting to learn details of a federal compensation program. Congress approved the creation of a compensation program in April, but as of late August, the Department of Health and Human Services had not issued the regulations to carry it out.
1. Institute of Medicine, Committee on Smallpox Vaccination Program Implementation. Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation. Washington, DC: National Academies Press; 2003 (www.nap.edu/books/NI000429/html).
2. Hammarlund E, Lewis MW, Hansen SG, et al. Duration of antiviral immunity after smallpox vaccination. Nature Medicine 2003; 9:1,131-1,137.