Will your employees be willing to take the smallpox vaccine?
Ask now as you prepare for vaccination
Hospitals should start preparing for smallpox vaccination now, even before public health officials have worked out the details, a leading bioterrorism expert tells Hospital Employee Health.
Employee health professionals should set priorities for who would receive the vaccine, screen employees for risk factors for adverse reactions, and even ask health care workers if they would be willing to come to work during a smallpox outbreak, says Michael Bell, MD, a medical epidemiologist who was the lead author for the Centers for Disease Control and Prevention’s (CDC) Bioterrorism Readiness Plan: A Template for Healthcare Facilities. "I would not wait until the last minute and try to figure out whom to vaccinate," advises Bell, who is now chief of the epidemiology unit in CDC’s special pathogens branch. "I would be ready."
In midsummer, speculation arose that the smallpox vaccination plan could ultimately involve as many as 500,000 health care workers — considerably more than the 10,000 to 15,000 initially suggested. However, CDC emphasized that it was still soliciting input before making a recommendation to Health and Human Services Secretary Tommy Thompson.
The Association of Professionals in Infection Control and Epidemiology (APIC) and others have raised serious concerns about the vaccination planning.1 For example, the vaccine contains live vaccinia (cowpox) virus that can be transmitted to others until the vaccination site heals. Will vaccinated health care workers face work restrictions? Will some need to be furloughed? How will vaccinated workers be monitored?
"There are very serious complications that will happen if those concerns are not addressed before [vaccination is] initiated," says Judith English, RN, MSN, CIC, chair of APIC’s Bioterrorism Work Group and director of infection control at the National Naval Medical Center in Bethesda, MD. "Those types of things need to be documented in the guidelines before they’re issued."
In a letter to the advisory panel, APIC and other infection control organizations supported a "tiered approach" to vaccination that gives priority to first-responders and those who triage or diagnose patients, such as emergency departments and freestanding clinics. (A copy of the letter is available at http://www.apic.org/workgroups/btwg/. For excerpt, Vaccination plans raise host of questions in this issue)
In the letter, the infection control groups also recommended beginning vaccination with a pilot study group and stressed that vaccination and follow-up should occur outside the hospital setting.
While hospitals have conducted inservice training on smallpox — as well as other potential biological and chemical terrorism agents — many are adopting a cautious approach on the topic of vaccination.
"We haven’t even talked about vaccination here yet, and I don’t expect we will until we see something a little more forceful or consistent from the powers that be," says Geoff Kelafant, MD, MSPH, FACOEM, medical director of the occupational health department at the Sarah Bush Lincoln Health Center in Mattoon, IL. Kelafant is chairman of the medical center occupational health section of the American College of Occupational and Environmental Medicine in Arlington Heights, IL.
Start with basic preparedness
Preparing for smallpox vaccination actually begins with basic bioterrorism preparedness: educating staff and designating priority services, Bell says. "[Hospitals should determine] what services you would need to prioritize to make sure you can maintain safe and functional health care in the event of an emergency." Those are the personnel who should be on the top of the list for smallpox vaccine, he suggests.
Housekeeping, food services, and engineering should be a part of that discussion, he says. In the event of an outbreak, "You don’t want to find out that the kitchen is shut down and no one is taking out the garbage," he says.
The CDC says that at least 209 million new doses of smallpox vaccine will be available by the end of the year or early 2003. That allows for widespread coverage, although the Advisory Committee on Immunization Practices recommended limited vaccination of key personnel at designated smallpox treatment hospitals. (See HEH, August 2002, p. 85.)
"There’s not clarity yet on whether we’re talking about a skeleton crew for emergency response or coverage of as much health care personnel as possible," Bell says. "I would prepare for both.
"I would start out by identifying the key members that you really need to have vaccinated ahead of time," he says. "First, find out if those people are willing to be there. If they’re willing to be there, [determine] if they’re willing to take the vaccine. That’s an important list to make."
Employee health professionals should discuss the possible adverse effects from smallpox vaccines and, at the end of the inservice program, use a screening tool to gather basic information from employees, Bell suggests.
Key questions include:
• Would you be willing to work during a smallpox outbreak? (Some employees honestly may state that they would stay home out of concern for their families.)
• Would you be willing to have the smallpox vaccine?
• Have you ever had the smallpox vaccine? Did you have an adverse reaction? (Previously vaccinated individuals who did not have a reaction have a lower likelihood of adverse effects from re-vaccination.)
• Do you or anyone in your family have an immune-compromising condition, such as HIV, organ transplant, or other immune deficiency?
• Do you or anyone in your family have eczema, a history of eczema, or other exfoliative skin conditions such as atopic dermatitis? (People with those skin conditions have a greater risk of developing eczema vaccinatum, "a localized or systemic dissemination of vaccinia virus."2
• Are you or could you be pregnant? (Vaccinia vaccination isn’t recommended for nonemergency use in pregnant women.)
• Are you allergic to vaccine components? (The current vaccinia vaccine contains trace amounts of polymyxin B sulfate, streptomycin sulfate, chlortetracycline hydrochloride, and neomycin sulfate.)
You’ll need to ask these questions again when vaccination actually occurs, Bell concedes. But you’ll have a clearer picture of who can and will be vaccinated. Meanwhile, you can use the same questionnaire to capture other employee health information.
For example, you can ask if they have received other vaccinations, such as influenza or varicella.
"I would use it as a chance to make sure the records for my facility were up to date and I had a clear understanding of who was vaccinated for what," Bell says. "It’s only a couple of extra questions, and as long as you’ve got them, it’s a great opportunity."
Employee health professionals have some questions of their own about smallpox vaccination. The vaccinia virus can shed from the vaccination site until the scab separates from the skin, anywhere from four to 14 days after vaccination. That presents a risk of spread to patients.
The furlough of vaccinated employees could be a significant burden for hospitals. Are bandages and other protections sufficient to allow workers to continue to work with restrictions? What should those restrictions be? How should they protect the vaccination site?
"Whoever was vaccinated, she should be compensated for her lost days from work," remarks Cheryl Peterson, RN, nurse and senior policy fellow at the American Nurses Association in Washington, DC. "No cost burden should be borne by the health care worker, and there needs to be significant and close follow-up [after vaccination]."
If a patient contracts vaccinia from a vaccinated health care worker, who is liable? If the employee suffers from a serious adverse reaction to the vaccine, is that a workers’ compensation case?
"I think there are some huge liability issues that haven’t been addressed," says Bruce Cunha, RN, MS, manager of employee health and safety at the Marshfield (WI) Clinic.
Hospitals have some limited experience in dealing with similar issues regarding herpes zoster (shingles), he notes. Recently, when an employee returned to work with zoster, Cunha told her she could not return to the oncology department until the scabs crusted over and dried up.
"We have CDC guidelines [on zoster] that give you some clues [as to how they might handle vaccinia vaccination]," he says. "Most people can work; you just can’t have access to high-risk patients."
Considering the high-risk populations in the emergency department, intensive care, transplant, oncology, HIV, burn units, neonatal, and pediatric departments, Cunha adds: "That eliminates a lot of your employees."
References
1. Letter to the Advisory Committee on Immunization Practices from the Association for Professionals in Infection Control and Epidemiology, the National Foundation for Infectious Diseases, the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Community and Hospital Infection Control Association-Canada; June 13, 2002.
2. Vaccinia (smallpox) vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001. MMWR 2001; 50(RR10):1-25.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.