Medical Groups Criticize Bush’s Smallpox Vaccine Plan

WASHINGTON -- Some of the nation’s leading medical organizations warned Thursday that the government’s massive smallpox vaccination program will strain already overburdened public health and emergency medical systems.

Speakers representing state and local public health agencies, nurses, emergency room physicians and the nation’s hospitals said President Bush had not convinced them that the threat of a bioterrorism attack using the smallpox virus was great enough to merit his program’s substantial diversion of public health resources and its health risks to medical personnel.

Their testimony came at the end of a long day of technical presentations to an advisory panel set up by the Institute of Medicine at the request of the Centers for Disease Control and Prevention.

The plan Bush announced Dec. 13 calls for the vaccination of 500,000 military personnel and 439,000 health-care workers who would volunteer to be members of smallpox response teams -- the doctors, nurses and public health workers who would treat and investigate smallpox cases. Vaccine would be made available to all Americans starting in 2004, but Bush stressed that the government was not recommending the vaccine for the public.

The health-care providers reminded committee members that Bush’s vaccination plan will be implemented in the real world, where there is a severe nursing shortage, emergency rooms are overburdened, public health agencies are strapped for cash and Americans face far more common health threats than smallpox.

“As critical as it is that we be prepared to respond to a smallpox attack, it cannot come at the expense” of other public health programs, said Dr. George E. Hardy, executive director of the Assn. of State and Territorial Health Officials.

“Tuberculosis, E. coli and measles are not taking a furlough,” warned Patrick M. Libbey, executive director of the National Assn. of County and City Health Officials.

As of Thursday, the Pentagon had vaccinated 174 people. Vaccination of response team members is expected to begin as soon as late January, and inoculation of up to 10 million fire, police and other medical and emergency personnel is scheduled to begin sometime after that.

All the medical group representatives urged the government to slow down. Hardy warned that moving from the first phase of the program to a broad vaccination plan without taking the time to reevaluate “has the real potential to do more harm than good.”

The American Hospital Assn. and the American Nurses Assn. said the government’s plan failed to protect workers against being sued and to compensate them for medical expenses incurred and work time lost to the vaccine’s side effects. They called on the administration to create a federal compensation fund.

But Thursday marked the first time that health-care providers publicly expressed doubts about the need for the vaccination program and the effect it might have on routine medical care.

Hardy estimated vaccinating health-care workers alone would cost from $600 million to $1 billion. “That money is going to have to be found,” he said.

Dr. Jonathan L. Burstein, an assistant professor at Harvard Medical School who spoke for the American College of Emergency Physicians, said more than 60% of ER doctors would be willing to be vaccinated right away if they were convinced that the threat of a smallpox attack was real.

Short of that, he said, the doctors are worried that the vaccine’s side effects, which might require them to take time off from work, and the necessary safety precautions, which include avoiding close contact with people having weakened immune systems, could jeopardize patient care.

Another cautionary voice was heard Thursday from a group of California scientists who concluded that vaccinating the public against smallpox would kill more people than it saved in all but very large-scale bioterrorist attacks. But vaccinating only health-care workers would save lives in more modest attacks.

“We concluded that as long as there’s not substantial likelihood of attacks across the country, it’s not a good idea to launch a smallpox vaccination campaign,” said Dr. Samuel Bozzette, lead author of the study and an investigator at the Rand Center for Domestic and International Health Security in Santa Monica. “On the other hand, it does seem prudent to vaccinate health-care workers who are at much greater risk.”

Assuming that 60% of the public and 90% of health-care workers would be vaccinated, the scientists estimated that 484 members of the public and 25 health-care workers would die as a result of their vaccinations. But most experts think that many fewer Americans would volunteer to be vaccinated.

The authors found that large-scale vaccination would cause more deaths than smallpox in a case in which an infected terrorist wandered through a city spreading virus.

In another paper released by the New England Journal of Medicine, Dr. Thomas Mack, professor of preventive medicine at USC, argued that given the risks of the vaccine, large-scale vaccination of even health-care workers is a mistake.

Mack said it makes more sense to manage outbreaks through monitoring and isolation and keeping smallpox patients away from hospitals, where infections are most likely to spread.