States Lag at Start of Smallpox Program

WASHINGTON -- Just days before President Bush’s smallpox vaccination program was originally set to begin, the number of front-line health-care workers expected to volunteer to be inoculated has shrunk dramatically and some states are still months away from launching their campaigns. A telephone survey by The Times of public health officials in 20 states also revealed several key misunderstandings between state and federal officials on issues as basic as when vaccine supplies will be delivered to the states.

Federal health officials acknowledged the “variability in preparedness” among the states, but expressed confidence that the program was the best way to prepare the nation for a bioterrorism attack with the smallpox virus.

“All of the states have taken enormous steps ... in an incredibly short period of time,” said Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention. “Overall, we’re very pleased and impressed.”

Yet many of the plans described by state health officials differ markedly -- in size and timing -- from the program laid out last month by the Bush administration.

State officials cite a variety of reasons: the lack of additional liability protections for hospitals; the absence of guaranteed compensation for vaccinated health-care workers who lose time on the job; a growing sense that a smallpox attack is not imminent; and a deeper understanding of the vaccine’s risks.

Federal officials and advisory committees have been rushing this week to conduct essential training, complete basic recommendations and broaden their interpretation of liability provisions contained in the Homeland Security Act.

Taken together, the actions indicate that, even as the Bush administration continues to prepare for war against Iraq -- which it says may possess stocks of the smallpox virus -- much of the urgency that had been driving the smallpox plan has dissipated.

“Because the smallpox threat is not imminent,” Gerberding said, “we can put safety as our highest priority.” Last month, however, when the president somberly unveiled the vaccination program, top federal health officials said timeliness was critical. The inoculation of 500,000 military personnel began immediately.

Officials said then that they expected the states to start vaccinating about 450,000 public health workers and hospital emergency-room personnel late this month and to complete the process “as soon as they possibly” could, preferably within 30 days. At that point, they said, state and local health departments would begin inoculating up to 7 million additional health-care workers and 3 million police, fire and other emergency personnel.

Yet several state health officials told The Times this week that they would not begin vaccinating emergency-response team members until mid-February or later. Many others said they did not know when their programs would begin because they were awaiting direction -- and notification of when they would receive supplies of the vaccine -- from the CDC. Officials in Ohio said they were waiting to hear from President Bush.

CDC officials said they were waiting to hear from the states.

“We are prepared to send vaccine as early as next week to states that are ready to receive it,” Gerberding said, adding that the program had no official start date. “We want states to begin the program as soon as they can safely do it.”

Some states still believe they must complete the first phase of the program within 30 days.

“We submitted a plan for 30-day implementation, and we’re sticking with it,” said Ken August, spokesman for the California Department of Health Services, which requested 49,200 doses of vaccine.

But Gerberding called the 30-day deadline “another complete misunderstanding. The bottom line ... is that there is no end date for this program.”

In fact, Kansas and Pennsylvania expect to take up to two months to complete the process. Massachusetts officials said they might need three months.

Of greater concern to some state officials are the large number of health-care workers dropping out of the voluntary program and the impact of the vaccination plan on routine public health services.

In Alabama, the number of health-care workers willing to be inoculated is “declining as we approach the giving of the vaccine,” said Dr. Donald E. Williamson, the state’s top health officer.

Though Alabama requested 12,000 doses of the vaccine, Williamson said, “it’s possible that I may get only one-third or one-half that response.”

In Washington state, the situation is much the same. Asked how many of the 500 vaccine doses requested for a five-county region would be used to inoculate health workers, a top health official laughed.

“It will be considerably less than that,” said Sherri McDonald, director of the Thurston County Public Health and Social Services Department.

Behind the drop-off in the number of volunteers, said Alabama’s Williamson, is a complex set of factors.

Because the vaccine itself carries risks -- studies conducted in the 1960s indicate that one or two of every 1 million people vaccinated will die and many more will suffer serious complications -- health-care workers want to make sure they will be compensated if their reaction to the vaccine causes them to miss work for a time or leaves them with large medical bills.

Vaccinated workers and the hospitals they work in also seek assurances that they will not be sued if they unintentionally infect vulnerable hospital patients with the smallpox virus.

Health and Human Services Secretary Tommy G. Thompson allayed some concerns in a letter to hospitals last week, hospital and state officials said.

But many health-care workers and some hospitals will refrain from participating unless the government offers additional protections. Both state officials and union representatives have called for a federally financed compensation fund.

“A number of hospitals are waiting at the trough but not drinking yet,” said Jim Lott, executive vice president of the Health Care Assn. of Southern California, a hospital trade group.

Potential vaccine volunteers are also trying to balance the threat of a smallpox attack against the risks of the vaccine, Williamson said.

Because the president said there was no imminent threat, “people are less willing to accept the vaccine” if compensation and liability issues are not resolved, Williamson said. If the federal government addressed those concerns, he added, “the fact that the threat is not imminent becomes less of a deterrent to getting vaccinated.”

As with later start dates and longer completion times, the CDC’s Gerberding said she was not concerned about reports of fewer vaccination volunteers.

“We need to get away from this notion of a number,” she said, referring to the government’s original estimate of 450,000 front-line health-care workers to be vaccinated in the first phase of the program.

“We knew full well that we did not need to vaccinate that many people,” she said. Federal officials simply overestimated to ensure there would be enough of the licensed smallpox vaccine, she said.

Aside from the uncertainties about timing and numbers, most states and counties appear well prepared to implement the program. Many have already taught nurses to administer the vaccine, which requires about 15 jabs with a two-pronged needle, and they have planned several vaccination clinics over a period of weeks to avoid taking too many health-care workers away from their normal jobs at any one time.

Gary Cox, director of Tulsa City/County Health Department in Oklahoma, said his agency was ready to begin as soon as it received the vaccine.

One of six already-trained vaccination teams will go to each hospital in the region and complete the job in a few days, he said.

“The president has called on us to do this job to protect national security, and we just look at it as, ‘That’s our job,’ ” Cox said.

“It will be an extra burden, but not a burden we can’t handle,” he said.

Keeping a balance between vaccinating as many as 9,200 health-care workers against smallpox and providing normal health services in Los Angeles County will be “very tricky,” said Dr. Jonathan Fielding, director of public health for the Department of Health Services.

“Outbreaks don’t stop,” he said. “Sexually transmitted diseases, childhood immunizations and the like still go on.”

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Times staff writer Aparna Kumar also contributed to this report.