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Flexibility needed in bioterror response

A public health plan that can apply to an outbreak of SARS as well as to smallpox is the goal, says a new federal report.

By Susan J. Landers, amednews staff. Sept. 1, 2003.

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Washington -- Communities and hospitals should focus on fine-tuning their bioterror response plans rather than on vaccinating large numbers of physicians and other health workers with the sometimes dangerous smallpox vaccine, says a new Institute of Medicine report.

And, given the risks posed by the vaccine, not only to individuals receiving it but to their family members, the general public should only receive the vaccine within the bounds of a research study or other stringent clinical arrangements.

"Preparedness for an attack using smallpox or any other bioterrorist agent depends as much on the availability of a good response plan and the ability to quickly coordinate responders as it does on the number of responders who have been vaccinated in advance," said Brian Strom, MD, MPH, chair of the IOM Committee on Smallpox Vaccination Implementation that prepared the document at the behest of the Centers for Disease Control and Prevention.

The advice is welcomed by some in the public health community who have argued from the start that the risks of a broad vaccination initiative outweigh the benefits. Their views have been strengthened in recent months as evidence of bioterrorist agents in Iraq continues to be elusive.

Meanwhile, there has been a much smaller turnout of civilian volunteers than was anticipated, about 38,000 instead of an estimated 500,000. But the focus shouldn't be on the numbers, said Dr. Strom. "The real question is who needs to be vaccinated."

The report recommends that the CDC establish a minimum standard of preparedness for a smallpox attack, so states will have a baseline against which to measure progress.

The agency should also develop registries of those already vaccinated, including the many members of the military who received smallpox vaccinations, who would be willing to serve in a smallpox emergency response if one is ever necessary.

This is the latest in a series of IOM advisories to the CDC as it implements President Bush's policy on administering smallpox vaccinations before an actual outbreak occurs.

The CDC's initial plan -- put into action last January -- was to vaccinate front-line civilian volunteers, many of them physicians and nurses, who would be called upon to help in the event of a large-scale attack.

Choices made

Hospitals and communities have been making very individual decisions on how many people should be vaccinated. Virginia Commonwealth University Health System in Richmond, Va., decided to vaccinate no one until there was a case of smallpox somewhere in the world that indicated the virus was in the hands of the enemy, said Richard Wenzel, MD, chair of internal medicine at VCU's School of Medicine.

"We came out early and we became visible as the first institution to oppose the vaccine plan for smallpox," said Dr. Wenzel. "That didn't gain us a lot of kind words from newspaper editorialists."

Now the tide has turned, and the IOM report singled out VCU as "a good example" of an organization that attained a high level of preparedness without vaccinating its health care workers before a smallpox attack. "We feel better now," said Dr. Wenzel.

VCU's plan calls for the vaccination of 6,000 of its employees within 24 hours if the need arises. "Unless there was some incredible disaster where someone dumped live virus on the whole metropolitan Richmond area, we thought we would be prepared," said Dr. Wenzel.

VCU also has constructed an entire wing of negative air pressure rooms that could house 10 to 12 infectious patients, a feature that came in handy when suspected SARS cases were admitted recently.

A benefit of focusing on a general plan is its applicability to diseases such as SARS, said Susan Allan, MD, Arlington County, Va., health director. Arlington, a close-in suburb of Washington, D.C., was a test site for a Dept. of Health and Human Services-sponsored test run of a mass vaccination clinic, and Dr. Allan has participated in IOM policy forums.

During the many briefings on bioterror preparedness she has presented in her county, Dr. Allan emphasized the need to learn general principles that can apply to any disease. "Because the disease that is going to come will be the one we aren't looking for," she said.

About 50 staffers in the Arlington health department and in one local hospital have been vaccinated for smallpox. "I do think having small prevaccinated teams is appropriate," said Dr. Allan. "I was not a supporter of a larger expansion. I thought it distracted from the focus on training and plans and on multiple disease approaches."

Planning has made a difference in Arlington. There is now a better understanding by Arlington's physicians and hospitals of public health's role, said Dr. Allan. After the anthrax deaths of 2001, the private physicians and hospitals understood that they were the people "who keep on top of the new and emerging diseases."

But complaints persist that federal bioterrorism preparedness funds aren't always properly targeted to public health. For example, with the exception of CDC funding, federal monies are restricted to equipment and not staff.

"But in public health, staff is what we are," Dr. Allan said. "Other than simple computers, masks, gloves and paper gowns, we don't use any fancy equipment. We use our brains. We need feet on the street."

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