Nothing to Fear?

If President Bush's smallpox vaccination program is revived and vaccinations are extended to other health care workers and emergency responders--or to the public--emergency physicians and emergency medical staff will be on the front lines treating people who may suffer complications from them. But until now, emergency departments lacked policies or procedures to handle these complications. Based on the scientific literature available, occupational and environmental medicine physicians and emergency physicians have mapped out a template of policies and procedures in the November 2003 Annals of Emergency Medicine to prepare emergency departments to manage vaccine complications: 'Emergency Medicine Tools to Manage Smallpox [Vaccinia] Vaccination Complications: Clinical Practice Guideline and Policies and Procedures.' 'Considering the U.S. population might be offered smallpox vaccination in the next few years, it's imperative that emergency physicians and nurses be trained to know the likely signs and symptoms from vaccine complications they may encounter and know how to best manage them,' says lead author Craig D. Thorne, MD, MPH, from the Occupational and Environmental Health Program at the University of Maryland in Baltimore. 'Immunized workers need to know how to prevent inadvertent contact with active vaccination sites from their patients and to protect their patients and family members from exposures if the workers themselves have active sites.' Thorne and his team of researchers adapted materials provided by the Centers for Disease Control and Prevention and from additional scientific sources to assist emergency physicians and emergency medical staff in treating possible adverse reactions to the vaccine. The paper outlines the likelihood of complications based on those documented in the international and national literature dating back to the 1960s. 'Priority must be given to protect both our patients and our health care workers,' Thorne says. The study authors suggest that vaccinated physicians and health care workers consider alternative duty, which does not involve direct patient contact, while their vaccination sites are active. They outline several reasons, including the fact that patients in the 21st century may be at increased risk of transmitting the virus because of immune suppression from HIV infection, transplantation, cancer, immunosuppressant medications, and other illnesses. In addition, hospitals and health care workers' liability for vaccine complications, including inadvertent transfer to patients, remains unclear. 'These scientifically based policies and procedures for managing smallpox vaccine complications are something every emergency department has been waiting for,' says Capt. Robert G. Darling, MD, USN, from the Navy Medicine Office of Homeland Security and the U.S. Army Medical Research Institute of Infectious Diseases, which is based out of Fort Detrick, Md. 'We believe all the policies outlined by Thorne make good sense, except for one that recommends health care workers be removed from clinical duties after smallpox vaccination.' In a related editorial, Darling and a team of researchers call this policy recommendation 'unnecessary' because there have been no reported cases of transmission of vaccinia to a patient from the 19,333 civilian and military health care workers who were vaccinated in 2003. There also were no transmissions from vaccinated patients to health care workers. Darling further emphasized these 19,333 health care workers spent nearly 20,000 worker-months caring for patients, including those with a variety of immunocompromised conditions, yet no cases of transfer of the vaccinia virus were reported. 'Following this recommendation would be overly burdensome and expensive to enact and could cause hospitals to further delay or cancel their participation in the pre-event smallpox vaccination program,' Darling says. 'It would inhibit willing volunteers from participating and possibly further exacerbate the nationwide nursing shortage as well as delay the nation's preparedness for a smallpox release. No one can state with certainty what the actual risk of a terrorist release of weaponized smallpox is; however, if smallpox were released back into the world in 2003 the impact could be truly catastrophic. As always, the emergency medicine community will be front and center in any response, and it will be essential to have a cadre of previously vaccinated health care workers in place--ready to respond immediately. The evidence is in. With careful selection and counseling of smallpox vaccine recipients, we can safely vaccinate selected first responders and other members of the health care team while still protecting the health and lives of our other patients. We should begin preparing now.'