Washington Post Staff Writer

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http://www.washingtonpost.com/wp-dyn/articles/A55239-2003Feb23.html

Bush Smallpox Inoculation Plan Near Standstill

Medical Professionals Cite Possible Side Effects, Uncertainty of Threat

By Ceci Connolly

Washington Post Staff Writer

Monday, February 24, 2003; Page A06

When President Bush issued the call for 500,000 volunteer health care workers

to be immunized against smallpox, Health and Human Services Secretary

Tommy G. promised to get the job done in 30 days.

At today's one-month mark, however, the total number of people inoculated

nationwide is just 4,200 -- less than 1 percent of the administration's target

for

the first phase of bioterrorism preparations.

" It is as close to stalled as you can get, " said Bicknell, former

Massachusetts health commissioner and a professor at the Boston University

School of Public Health. " There has not been a sufficient push from senior

administration officials. "

Although the federal government has shipped 274,000 doses of vaccine to states

since the program began Jan. 24, hundreds of hospitals, a half-dozen

major unions and even some public health departments have refused to

participate. Even the states that are vaccinating volunteers report that they

have

drastically scaled back their original plans.

Aside from a few pockets of enthusiasm, the vast majority of medical

professionals remain unconvinced that the threat of a smallpox attack is serious

enough to administer a vaccine known for its serious side effects, especially

when federal officials have refused to create a compensation fund for people

sickened by the vaccine.

" At this point I'm more concerned about seeing a vaccine complication than a

case of smallpox, " said Gordon, hospital epidemiologist at the

Cleveland Clinic, where fewer than 100 of thousands of eligible employees will

be inoculated next month.

The slow start has alarmed many national security experts who fear the looming

war with Iraq will increase the likelihood of a biological attack on the

United States.

" If anything happens in the near term, we will be in serious trouble, " said

Kaplan, who teaches public health management at Yale's School of

Management and School of Medicine. " It seems at a time when the risk is going

up, we're advertising loudly this is one threat we're not ready to deal with. "

Bicknell said that until the government reaches President Bush's ultimate goal

of vaccinating millions of medical personnel and emergency responders,

" we are not protected. " In the event of a smallpox attack, those are the

medical and emergency workers who would be needed to treat early cases and

rapidly open mass vaccination clinics for the rest of the population. Experts

believe that many people can survive a smallpox exposure if they are

vaccinated within 96 hours.

Gerberding, director of the Centers for Disease Control and Prevention,

played down the focus on numbers of people immunized, saying the true

measure of the program is whether the entire nation could be vaccinated within

10 days of an attack.

" We are not there now, " she acknowledged. In an effort to revive the program,

plans to make a personal appeal at today's session of the

National Governors Association, and Gerberding is preparing to send

informational packets to 3.5 million doctors, nurses and nurses' assistants.

When Bush announced his unprecedented immunization program Dec. 13, he said the

goal was to protect the nation's frontlines here and abroad. He

ordered mandatory inoculation of 500,000 military personnel and called for as

many as 10.5 million medical workers and emergency responders to be

vaccinated on a voluntary basis.

Later that afternoon, in a meeting with Washington Post reporters and editors,

outlined an ambitious timetable: One month for the first 500,000

immunizations and an additional 90 days for millions more. At the time, the

Bush administration said anyone who suffered a serious complication could

apply for workers' compensation benefits or sue the federal government for

negligence.

That policy has proved a major obstacle for the program. Some unions that

represent tens of thousands of health care workers advised their members not

to be vaccinated until the government offered compensation for potentially

severe side effects, which include blindness and encephalitis.

" They should be covered the same way a police officer is covered if he is hurt

in the line of duty, " Kaplan said.

Although smallpox has not been seen in this country in five decades, security

experts worry that terrorists could use the highly contagious, deadly germ

as a weapon. Inoculation with the live virus vaccine -- called " vaccinia " --

provides protection but can also cause complications in a small percentage of

people immunized.

That tension has sparked an emotional debate among some of the country's most

respected physicians, who are weighing the unknown risk of attack

against the known risks of vaccination.

" This is a modern version of the first line of the Hippocratic Oath: Do no

harm, " said Schaffner, chairman of preventive medicine at Vanderbilt

University Medical Center. The hospital board's decision not to vaccinate

employees was heavily influenced by concern that immunized workers could

accidentally spread live virus to patients, many of them with already weakened

immune systems, he said.

Gerberding, however, said that she is " a little bit concerned we may have

overstated the adverse effects of vaccination. " She and other experts said that

with careful screening and inoculation site bandaging, adverse effects should

be kept to a minimum. Of the more than 100,000 military personnel recently

vaccinated, five have experienced severe but treatable reactions.

Another major factor was the lack of evidence regarding a possible smallpox

attack. " It is not enough for someone -- whether it is the president or the

secretary of state -- to say, 'I'm worried about this; trust me,' " Schaffner

said. " We need more than that today as a profession and as a society. "

and Gerberding acknowledged that it has been difficult to convey to

the public an imprecise threat based on classified intelligence.

" We have to do a better job of explaining to them this is a possibility and it

will be too late -- if it does happen -- to be able to get people vaccinated, "

said. " We need these individuals to be able to be vaccinated so they

will in turn be able to vaccinate the masses in case there is a smallpox

epidemic. "

Much of the debate centers on the definition of " prepared. " Many

infectious-disease experts said stockpiling vaccine in regional locations,

training staff and

practicing emergency drills would adequately position them to handle an

outbreak. But others said the panic likely to ensue with even a rumored case

makes that unrealistic.

" ly, the more of these workers, along with police and fire personnel, who

are vaccinated before an event occurs, the greater will be our ability to

maintain essential services in the crisis situation of a deliberate smallpox

release, " said Osterholm, director of the Center for Infectious Disease

Research and Policy at the University of Minnesota.

Many physicians said they have been unfairly pilloried as " unpatriotic " because

they have not reached the same conclusion as the president.

" People are not ignoring the government recommendations, but they are trying to

apply them to their own situations, " said Koplan, former CDC

chief and vice president for academic health affairs at Emory University, whose

medical center has decided to vaccinate 20 people.

Officials at nearby Grady Memorial Hospital, for instance, decided not to

inoculate staff in large part because " you can't walk on a ward without being

near

patients who are significantly immuno-compromised, " he said. But at the local

Veterans Administration hospital, staff members have accepted the need to

be immunized because they are already treating military personnel who have been

vaccinated.

For now, states such as Tennessee, Oklahoma, New Jersey, Illinois and

Connecticut have cut in half projections of the number of people they will

vaccinate during the first phase of the program. The CDC, meanwhile, has put

plans for Phase 2 -- inoculating emergency responders -- on hold.

Hundreds of major hospitals -- including Virginia Commonwealth University in

Richmond and Children's in Philadelphia -- do not plan to immunize any

workers unless circumstances change. Several statewide nurses' associations

have advised against vaccination, while the AFL-CIO, the Service

Employees International Union and the American Federation of State, County and

Municipal Employees have urged the Bush administration to postpone

the program.

The health departments of Michigan, Arizona and New York City have not begun

vaccinations while awaiting establishment of a compensation program.

" We're having all kinds of problems with it, " said Doug Campos, medical

director for clinical services at the Maricopa County Department of Health,

which

covers 3.5 million people in the Phoenix area. " The failure to anticipate this

compensation issue was a major mistake. "

Sources on Capitol Hill say the White House has been reluctant to commit money

to a compensation program. But is confident one will be

established. " Once we get the compensation fund out there, I think [the

vaccination program] is going to move quite rapidly, " he said.

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