As health-care workers around the country shy away from the smallpox vaccine, about 35 in Rhode Island attended a Health Department training session last night for the first group of prospective volunteers.
The Health Department intended to start out by vaccinating about 30 people -- two or three from each hospital -- before moving on to an additional 1,200 workers.
Based on last night's turnout, however, the first group is likely to be smaller than 30, because many of those attending are expected to decide against it or discover that a health condition disqualifies them.
The Health Department has already received 1,200 doses of the vaccine from the U.S. Centers for Disease Control and Prevention, which is working with states and counties to vaccinate a cadre of health-care workers who could care for victims if there were a bioterrorist attack.
But Rhode Island's two biggest nurses' unions, concerned about the vaccine's side effects and unanswered questions about who would compensate injured workers, have urged their members not to participate. So it's not clear whether 1,200 will step forward for the second phase.
But that's OK, said John Fulton, associate director of the Health Department's division of disease control and prevention. The state's smallpox response plan can work if fewer than the targeted 1,200 workers agree to get vaccinated, Fulton said.
"We're offering this vaccine," Fulton said, in response to a question from a doctor in the audience. "We're not recruiting people for this vaccine. We're not promoting it."
People exposed to smallpox can avoid getting sick if vaccinated within one to four days of exposure. But the vaccine doesn't take every time, and a patient won't know whether the vaccine induced immunity until seven days after inoculation.
"We need some individuals who are vaccinated up front to mount an appropriate response," Fulton said. "We need some people who we know are immune to smallpox." The exact number needed, however, hasn't been determined, he said.
Robert J. Marshall Jr., associate health director, said after the meeting that the state's smallpox plan would still work even if no health-care workers were vaccinated. If there were a smallpox case, people who came in contact to that person would quickly be vaccinated to contain its spread, he said.
Although the Bush administration planned to vaccinate 500,000 health-care workers, only 1,024 in 19 states had received the vaccine as of Sunday. A survey by The New York Times last week counted 350 hospitals that have declined to participate. Health-care workers' unions in several states, including Rhode Island and Massachusetts, have advised their members that the vaccine could do more harm than good.
Smallpox was eradicated decades ago, but it is feared that laboratory samples of the virus may be used as biological weapons. The risk of the attack is unknown, while the vaccine, made from a live virus, has known risks -- rare but life-threatening complications.
"Ultimately, this type of ambiguity and uncertainty is the very reason why we are in this room today," Dr. Marguerite A. Neill, of the Center for Biodefense at Memorial Hospital of Rhode Island, told last night's gathering.
Neill described the possible side effects of the vaccine.
About half those vaccinated experience mild pain at the site of the injection, and some have severe itching. Roughly one-third have mild headaches or muscle pain, or swollen lymph nodes. In less than 5 percent of cases, the virus will spread widely on the skin or in the lymph system, but without lasting harm.
The more serious complications are much more rare; in the 20th century, smallpox vaccine reactions caused one to two deaths among every million people. People who have a skin disease such as eczema, even if it's not currently active, can develop eczema vaccinatum, a severe skin infection. People whose immune systems are weakened can develop progressive vaccinia, in which the lesion from the inoculation doesn't heal and the virus spreads throughout the body.
And, also rarely, some people who get the vaccine develop encephalitis, a life-threatening swelling of the brain. While the risk factors for eczema vaccinatum and progressive vaccinia are known, no one knows who is more likely to develop encephalitis.
Nevertheless, Neill said, modern-day vaccination programs have experienced few problems. The Israelis immunized 15,000 people, and reported only two adverse reactions -- one involving a person who shouldn't have taken the vaccine, she said. The U.S. Department of Defense immunized tens of thousands of troops, most of them too young to have been vaccinated as babies and therefore more likely to have bad reactions. Yet fewer than 3 percent missed any duty and only two had serious side effects, Neill said. Both recovered.
"We think there are ways to do this safely," Neill said.
Rhode Island is taking the extra precaution of requiring all vaccine volunteers to first get an HIV test, because people whose immune systems are weakened by HIV are likely to get sick from the vaccine. Volunteers can have the test done by their own physicians at their own expense, or at a hospital clinic or state-run HIV testing center for free. Women are also required to get a pregnancy test.
The Health Department plans to vaccinate a couple of people from each hospital first. Those people will act as "vaccination monitors" or "arm checkers" for the other volunteers in their hospital. Their job will be to check the site of the inoculation to make sure that the vaccine took and that the lesion, which is infectious, is being properly covered and cared for.
Fulton said that the first round of vaccinations could begin as early as Feb. 25, but no firm date has been set. Volunteers need to make their decision, make an appointment for an HIV test, wait 7 to 10 days for a test result, and notify the vaccine program's liaison in each hospital. Once 10 to 15 people have volunteered, the first clinic will be scheduled, he said.
Learn more about smallpox and the state of Rhode Island's preparations to battle the disease, at:
http://www.healthri.org/environment/biot/smallpoxprepare.htm
