Slow start for smallpox vaccine plan

Some states have inoculated thousands; others, few or none. Gaps in coverage could result, but these rates are not the only measure of preparedness.

By Victoria Stagg Elliott, AMNews staff. May 5, 2003.

During the past three months, some physicians and health care workers have stood in line, rolled up their sleeves, and received the smallpox shot -- thus becoming part of the cadre of men and women likely to respond in the event of a smallpox outbreak.

The lines, however, have been short.

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More than 285,000 doses of smallpox vaccine were delivered to states for civilian use, as part of the Bush administration efforts to prepare the health system for possible bioterrorist-launched infection. But as of April 11, more than 30,000 vaccinations have been delivered, according to the Centers for Disease Control and Prevention.

"The numbers are definitely not where we would like them to be," said James J. James, MD, DrPH, MHA, director of the AMA Center for Disaster Medicine and Emergency Response. "But they have been increasing. Hopefully, we're dealing with a program that's more of a slow start than one that's not going to get to completion."

Most experts believe that initial expectations for the smallpox vaccination program were much too high, especially when considered in the context of various complicating issues. Liability and compensation questions, for instance, have only recently been resolved in Congress. Before this, some potential recipients opted out or were advised by their unions or employers not to get vaccinated. Others may have decided that the risks of the shot outweighed its benefits, especially for a disease that is not an immediate threat.

"The original estimates were exactly that," said Allen Craig, MD, state epidemiologist for the Tennessee Dept. of Health. "And the thing to keep in mind is that this is completely voluntary, so we don't really have a good sense for what each individual will do." His state received 10,000 doses but vaccinated 2,429 people.

Even when people were willing to receive the shot, not everyone could.

Some states limited their first clinics only to those who had previously been vaccinated. The initial list of contraindications also excluded as many as a quarter of the people who planned to get the inoculation.

"I'm disappointed, but I'm not surprised by the low numbers. I, myself, fully intended to get the shot, but I couldn't because I have a son who has active eczema," said Paul Jarris, MD, commissioner of the Vermont Dept. of Health. His state has used 51 of the 2,000 doses received.

Exclusion categories are expected to become a bigger issue in the months ahead. At the end of March, the CDC expanded the list to include those with common risk factors for heart disease, such as smoking and hypertension. This step was a response to reports possibly linking the vaccine to myopericarditis.

Success or failure in the national effort is pegged to more than simply the vaccination rates.

"The number is important, but the function is much, much more important," said Georges Benjamin, MD, executive director of the American Public Health Assn. "If you vaccinate a lot of people but you haven't vaccinated them in any kind of organized way, you may not really be better off. It was more important to do this carefully than to do this quickly because there isn't a big threat out there."

While numbers do not tell the whole story, some experts say they may reveal areas that are less prepared than others. Florida has provided the most vaccinations thus far with 3,470 people receiving the jab. In comparison, Nevada has yet to vaccinate anyone, primarily because its effort wasn't due to start until mid-April. Like many states, Nevada put clinics on hold until the CDC clarified its heart disease warning.

"For the program to be effective across the country, we obviously would like to avoid having pockets where essentially no one is prepared," Dr. James said.

Experts say the recently passed compensation package and more experience with the vaccine will likely improve coverage rates. "I'm hoping that we'll have a snowballing effect, and the more people that receive this vaccine and do well, the more people will realize maybe the risk-benefit does justify getting it," Dr. Jarris said.

To date, no deaths have been definitively linked to the vaccine, although some have been suspected.

Meanwhile, as some states struggle with phase I, others are moving ahead with phase II -- vaccinations for police, fire, emergency medical technicians and others. Florida planned to start this phase May 1. Many more states have plans ready.

Those in public health say a lot has been learned along the way that may make phase II, or even a future mass vaccination campaign, operate more smoothly. Most workers had never run a smallpox vaccination clinic, but now they know how. Follow-up -- when the jab site is assessed for "take" -- has also improved.

"Initially, we read too many non-takes and probably did some revaccinations that weren't necessary," said Richard Raymond, MD, chief medical officer at the Nebraska Health and Human Services System. "But you know, no one's done this for 30 years." His department delivered 1,388 out of the 4,000 doses received.

Phase II will present its own challenges. The people targeted this time likely will be less medically savvy than the physicians and nurses targeted in the first round and will require different information materials.

There are also more of them, and many in the public health sector fear outreach efforts may further strain already stretched resources. So some states have put phase II on hold.

"We're not in a big hurry," Nebraska's Dr. Raymond said. "We feel we're prepared and don't need to do phase II right away. We took people off various programs and out of local health departments to deliver phase I shots, and we just need some time to catch up with our core functions."

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