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http://www.nytimes.com/2003/01/05/national/05VACC.html?tntemail0

Health Officials Fear Local Impact of Smallpox Plan

By LAWRENCE K. ALTMAN with ANAHAD O'CONNOR

ASHINGTON, Jan. 4 — Many local health departments across the nation say they will have to curtail an array of services, including cancer and tuberculosis screening and children's dental examinations, to meet the needs of President Bush's federal smallpox vaccination program.

In interviews, health officials from New York to Seattle said much of the $940 million that Congress allocated to the Department of Health and Human Services last May for bioterrorism preparedness had been spent for steps to respond to the anthrax threats of 2001. Without extra money, they said, they will have to divert time and staff members from traditional programs to smallpox.

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"We understand the need to be prepared, but the load for doing this is falling principally on local health departments, and we're not getting additional funding," said Dr. Lloyd F. Novick, president of the New York State Association of County Health Officials and the commissioner of health for Onondaga County, which includes Syracuse. "We have to transfer staff from other functions to do this. It just cannot be absorbed as business as usual. We need more resources."

But the likelihood of extra federal money is unclear. There is great uncertainty about how much money will be available for federal health programs in the fiscal year that began three months ago. The Department of Health and Human Services, like much of the federal government, is operating under a stopgap spending bill that expires on Jan. 11.

Aides said Congress might eventually provide money to help local officials cover some of the new costs, but it appears unlikely that lawmakers will take any swift action.

The Bush administration has requested that health departments administer smallpox vaccine to health care workers on a voluntary basis. Local health departments are responsible for giving smallpox vaccinations in two stages. In the first, which is expected to begin this month and last about 60 days, up to 500,000 civilian health care and emergency workers will be vaccinated. In the second, up to 10 million health care workers, police officers, firefighters and emergency medical technicians will be offered the vaccine.

But Patrick Libbey, director of the National Association of County and City Health Officials, said many local health departments were already expecting to have trouble carrying out the first phase. "And that is only the first step," he added. "There are no plans in place yet for Phase 2. We don't know what kind of costs or impact Phase 2 will have."

Dr. Thomas R. Frieden, the New York City health commissioner, said he expected the impact to be severe. "While we appreciate the federal government's support for bioterrorism preparedness, the vaccination drive will be extraordinarily disruptive to our day-to-day work of protecting the public's health," Dr. Frieden said. "This is the unfortunate price we are paying for the level of preparedness it appears we need."

The Centers for Disease Control and Prevention, the federal agency responsible for tracking infectious diseases, said the vaccination program will drain resources at some local health departments.

"This is the price of preparedness," said Dr. Ed Thompson, who recently became the agency's deputy director for public health programs and services after serving as Mississippi's health director. "It's going to cause some delays and slow the progress of other public health programs, but it's something we're just going to have to realize — that there's going to be sacrifices."

Dr. Thompson said his agency hoped to ease the problem by providing guidelines on clinic management and, in some areas, extra personnel.

In recent years, many expert panels have warned that budget cuts were causing the nation's public health system to crumble. On top of traditional services for mothers and children, health departments have had to apply more sophisticated laboratory techniques and newer methods to counter the resurgence of tuberculosis and to keep other infectious diseases in check.

The latest demands involve a vaccine that few practicing doctors have ever given because the United States abandoned it as a routine in 1972, eight years before smallpox was eradicated from the world. Now health departments must train workers how to use two-pronged needles to administer the vaccine and recognize its many complications, some rare but potentially lethal.

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The capacity of health departments to carry out the administration's plans varies with the locality.

In Boston, officials are optimistic. The city's $2.6 million share of the $20 million that C.D.C. gave Massachusetts is being used to hire workers and conduct multilingual educational programs on possible bioterrorist attacks. Boston is also expanding a system to monitor information about emergency room visits for early detection of outbreaks.

Maine is diverting resources from other preparedness plans, such as building two-way communication systems with all health care providers, but not from child health and other public health services, said Dr. Dora Anne Mills, the state's chief health officer.

In Syracuse, health officials estimated that they would need $475,000 to vaccinate about 600 health workers at five hospitals in Onondaga County. The $458,000 the county received from the state last year was used for preparing a bioterrorism plan, training staff members and buying communications equipment, Dr. Novick said.

Unless the county gets extra money, he said, it will conduct 221 fewer screening tests for breast and cervical cancer and 835 fewer pediatric dental examinations, among other lost services, in the two months when vaccinations are to be performed.

In Colorado, Jane Anne Hollandsworth, an official of the Pueblo City and County Health Department, said her agency would continue tuberculosis clinics but might temporarily curtail standard immunization clinics for children.

The program has come at a particularly bad time for Seattle. The city is struggling to deal with its largest number of new tuberculosis cases in 20 years and a significant increase in sexually transmitted diseases, said Dr. Alonzo Plough, director of public health for Seattle and King County.

"This has been difficult because other health problems are not getting the attention they deserve," Dr. Plough said. "At the same time that we're dealing with these important public health programs, money is being drawn away for Phase 1."

A sudden demand for protective services nearly always leads to a diversion of resources, said Kevin Hutchinson, the health director in St. Clair County, Ill., which spent $3 million last year to counter an epidemic of West Nile virus.

"We robbed Peter to pay Paul," Mr. Hutchinson said.

In Arlington, Va., Dr. Susan Allan, the county's public health director, says she is concerned about the complexity involved in the first stage of the vaccination program.

"If people think of this as setting up a clinic and giving the vaccine, they're under the wrong impression — the vaccine clinic is the easy part," Dr. Allan said. "There's also the planning and the fairly intense training and education for anyone considering the vaccine. And everyone who has received it has to be monitored daily and then examined seven days later."

The vaccine, which is made from a live virus that is a cousin to smallpox, is the most dangerous human immunization. Experts have predicted that some recipients will have sore arms and suffer flulike symptoms that will keep them home from work, and that a few will have much more serious reactions.

Some people are advised to forgo vaccination unless there is a terrorist attack. Among them are those with weakened immune systems or a history of eczema or atopic dermatitis, two common skin conditions.

In Globe, Ariz., Kevin Kenney, a bioterrorism coordinator for Gila County, said two of the three nurses at the county health department have conditions that make the vaccine inadvisable, and he is searching for volunteer replacements.

Adverse reactions are among a number of reasons the Pima County Health Department in Tucson does not have a formal plan for smallpox vaccinations, said Dr. Elizabeth McNeill, the department's chief medical officer. She said she would be hard pressed to lose staff members even for a day or two of illness.

Dr. McNeill called the prospect of curtailing other services "scary," adding: "Right now we have had a lot of cases of whooping cough, and that can get away from you if you don't stay right on top of it. That kills kids. We don't want to get behind."

Of the resources needed for smallpox vaccinations, Dr. McNeill said: "I have a hard time justifying putting this much energy into this when I don't see a tangible benefit. In other words, there is no case of smallpox out there."

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ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.