HHN: Feature: Inoculating for Smallpox




Inoculating for Smallpox
In southern California, a hospital embraces the federal vaccination 
program--while others watch and wai 
By Jan Greene
Thursday
April 3, 2003 
Nestled at the foot of southern California's San Gabriel Mountains and blocks 
from the 210 Freeway, Meth-odist Hospital sits in a pleasant neighborhood of 
well-tended lawns and palm trees. It's hard to imagine bioterrorists choosing 
Arcadia, Calif., as a launching point for smallpox.
But world events have forced Methodist Hospital to confront the frightening 
possibility, and the hospital was among the first in the nation to offer staff 
volunteers for the controversial smallpox vaccination program. "We felt it was 
our duty," says Pauline Lopez, an infection control practitioner and organizer 
of the vaccination campaign at Methodist, a 450-bed community not-for-profit. 
"There are a lot of ways a terrorist could strike, but this is one we can 
prepare for."
Methodist, like every other hospital in the nation, had a short time frame in 
which to weigh a host of questions about vaccination: Will employees want to 
volunteer? What are the risks of the smallpox vaccine? Can a vaccinated worker 
infect another employee or a patient in the weeks after the vaccination? If 
someone has a bad reaction, who pays for time off and medical care?
At Methodist, the planning began last December, when the Bush administration 
announced it would ask hospitals to provide names of staff volunteers to be 
immunized so they could care for smallpox victims in case of an outbreak. The 
hospital assembled a task force including infection control, the hospital's 
safety officer, the vice presidents of nursing and support services, a physician 
and a nurse manager from the emergency department, and representatives of 
occupational health and human re-sources. The group gathered information from 
sources such as the Centers for Disease Control and Prevention and Naval Medical 
Center San Diego, which was conducting a military-sponsored vaccination program. 
They were encouraged by what they heard: the Navy had a low complication rate, 
and the vaccine's risks could be managed without an undue amount of clinicians' 
time off.
Methodist's planners weren't scared off by worries about liability for bad 
reactions to the vaccine. They figured that by screening out staffers with risk 
factors--such as a skin condition or an infant at home--reactions could be kept 
to a minimum. They decided to allow people who need time off because of the 
vaccine to take their regular sick leave. They also decided to take the CDC's 
advice and not require furloughs or keep staffers away from work for the two to 
three weeks it may take for the vaccination site to stop being infectious. If 
the site is covered with dressings and a long-sleeve shirt, it should pose no 
risk, CDC guidelines say.
It didn't take long for the task force to send a "go" signal to CEO Dennis Lee, 
who agreed the vaccinations should take place. "I don't even recall making a 
decision," Lee says. "It just naturally happened because that's a part of who we 
are. It's a part of our culture here to carry out our responsibility to the 
community." Methodist leaders expect their only cost to be for the dressings and 
for staff time to do their educational campaign.
Lee acknowledges that not everyone at the hospital agrees with the decision. 
Some see it as an unnecessary risk, he says, "but we see the risk as small."
After a series of staff education sessions led by Lopez and emergency department 
manager Catherine Kaliel, about 60 people volunteered, their confidentiality 
protected by dropping off a form in a designated box or calling a hot line. 
Kaliel and Lopez were careful to protect everyone's privacy, but the smallpox 
question was soon a hot topic of conversation. "Amongst themselves they've been 
very open," Kaliel says. "They debate it back and forth: 'Why are you doing 
that?' "
Kaliel and Michael Agron, M.D., medical director of emergency services, opted to 
get the immunization. "All of us taking care of patients on the front line are 
most likely to get exposed" in an outbreak, Agron says. "That's an easy decision 
for me." The vaccinations began on March 4. One dose of the vaccine remains 
effective about 10 years.
Cathy Klose, R.N., the hospital's coordinator of health ministries, says she 
chose to be vaccinated because she would want to help sick people in case of 
outbreak. She is confident the government wouldn't ask health care workers to 
get inoculated if it weren't worthwhile. "In my heart I can't believe they would 
advocate or have us do something that was not safe," Klose says. But the feeling 
is far from universal. Kevern McCarthy, R.N., signed up for the vaccination 
initially, but changed her mind later when she heard about the numbers of nurses 
nationally who had chosen not to participate. "Obviously, if there's an 
[outbreak] we'll all do it," McCarthy says. "It just seemed like an unnecessary 
risk at this time."
A Different Conclusion
Methodist's smallpox planners won't criticize hospitals that choose not to 
participate, but they would like more health care organizations to have 
immunized staffers on hand. "I'm kind of disappointed so many hospitals have 
taken a stand against allowing a voluntary program like this," Agron says. But 
one hospital that declined to participate was Huntington Hospital in nearby 
Pasadena, which shares a governing board with Methodist; the two work together 
on contracting and some other business functions, but are run independently.
Like Methodist, Huntington's leaders set up a multidisciplinary group to decide 
how to respond to the vaccination program. The group arrived at the opposite 
conclusion. "Cost was one factor that played into our decision--along with the 
fact that the perception of threat didn't feel it was there to justify this kind 
of risk-taking," says Mary Mendelsohn, infection control coordinator.
An analysis of the scientific and legal issues drove the choice. Huntington's 
leaders were concerned about paying for time off for complications and 
questioned whether the state workers' compensation program would cover employees 
with more severe reactions. They also worried about newly vaccinated staff 
members passing an illness called vaccinia to patients. "All the directions say 
it's not an issue if you have the site covered. But we haven't put that to a 
widespread test."
Another obstacle at Huntington was lack of enthusiasm among the staff. "People 
are not interested," Mendelsohn says. "Had we said 'yes' and gone full-bore, I'd 
be lucky if I had a dozen people." But she's comfortable with the decision that 
her sister hospital made. "We just had key people with different viewpoints," 
Mendelsohn says.
Part of the difference may lie in how likely it is that the region will ever see 
a case of smallpox. Huntington's leaders believed that risk wasn't high enough 
to put its staff through an immunization program, while those at Methodist could 
imagine a traveler exposed to the virus falling ill on the nearby 210 Freeway 
and ending up in their ED. Kaliel has attended some national emergency 
preparedness meetings and expects the worst. "When it comes to terrorism, it's 
not a matter of if, but when," she says.
Jan Greene is a freelance writer based in Alameda, Calif.
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