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Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation, Letter Report #1

January 16, 2003

Dr. Julie Gerberding

Director

Centers for Disease Control and Prevention

1600 Clifton Road, NE Atlanta, GA 30333

Dear Dr. Gerberding:

The Centers for Disease Control and Prevention (CDC) asked the Institute of Medicine (IOM) to convene an expert committee to advise it and its public health colleagues on the implementation of a pre-event smallpox vaccination program. The IOM agreed to provide this advice through a series of timely reports. We are pleased to communicate to CDC observations, conclusions, and recommendations from the first meeting of the committee of volunteer experts who have agreed to serve the IOM in this effort. The committee’s areas of expertise include internal medicine, infectious diseases (including smallpox), dermatology, pediatrics, nursing, epidemiology, public health law and ethics, public health practice, emergency medicine, and pharmacology.

CDC charged the IOM committee with providing guidance on how to best implement the president’s policy regarding pre-event smallpox vaccination, addressing the following eight areas:



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The Smallpox Vaccination Program: Public Health in an Age of Terrorism B Review of the Centers for Disease Control and Prevention’s Smallpox Vaccination Program Implementation, Letter Report #1 January 16, 2003 Dr. Julie Gerberding Director Centers for Disease Control and Prevention 1600 Clifton Road, NE Atlanta, GA 30333 Dear Dr. Gerberding: The Centers for Disease Control and Prevention (CDC) asked the Institute of Medicine (IOM) to convene an expert committee to advise it and its public health colleagues on the implementation of a pre-event smallpox vaccination program. The IOM agreed to provide this advice through a series of timely reports. We are pleased to communicate to CDC observations, conclusions, and recommendations from the first meeting of the committee of volunteer experts who have agreed to serve the IOM in this effort. The committee’s areas of expertise include internal medicine, infectious diseases (including smallpox), dermatology, pediatrics, nursing, epidemiology, public health law and ethics, public health practice, emergency medicine, and pharmacology. CDC charged the IOM committee with providing guidance on how to best implement the president’s policy regarding pre-event smallpox vaccination, addressing the following eight areas:

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism the informed consent process; contraindications screening; the system in place to assess the safety profile of the smallpox vaccine; guidance for the treatment of vaccine complications; professional training programs CDC is developing; the communications efforts; guidance CDC offers to states in developing their implementation plans; and overall progress at achieving the goals of the program. Given the rapid pace of planning for the smallpox vaccination program, the committee realizes that while it has been working on this report, CDC has been moving ahead, and at the time of the report’s release, it is possible that CDC has already accomplished some of the components the committee is recommending. In addition to CDC’s partners, many in the general public will be interested in this communication. Moreover, all reports of IOM committees are released to the public. We thus provide some background information directed at readers less familiar with the issue. This letter is divided into general statements about implementing the recently announced pre-event smallpox vaccination program, followed by targeted recommendations on the specific components of the committee’s charge. Our intent is to help CDC and its partners across the country implement President Bush’s pre-event smallpox vaccination policy as safely as possible. We begin by offering our professional admiration for the hard work of CDC staff and their public health partners in our states and territories, major metropolitan areas, counties, and local communities who have been working under conditions of many uncertainties to prepare for this program. We hope we can help make these efforts even more successful. BACKGROUND INFORMATION AND COMMITTEE PROCESS On September 30, 2002, the Centers for Disease Control and Prevention (CDC) entered into a contract with the Institute of Medicine (IOM) of the National Academies to provide targeted advice on the implementation of a “pre-event” or precautionary smallpox vaccination program. An independent, nongovernmental, nonprofit organization operating under the 1863 congressional charter to the National Academy of Sciences, the IOM has provided advice on matters of health and medicine for over 30 years. The IOM often tackles issues of importance to CDC’s public health mission, including matters of vaccine financing, supply, development, and—

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism perhaps most relevant to this project—safety. The IOM operates by convening ad hoc committees of the nation’s experts, invoking policies and procedures developed over many years to ensure the advice is free from sponsor or other interested-party influence, unbiased with respect to the questions at hand, and based on evidence. The last case of smallpox in the United States occurred in 1949. General vaccination against smallpox—accomplished with cutaneous administration of a closely related virus, vaccinia virus—ceased in the United States in 1972, when the threat of smallpox disease disappeared due to eradication efforts, which were declared complete by the World Health Organization on May 8, 1980. Only two official stocks of smallpox (variola) virus remained—under the auspices of the governments of the United States and the Soviet Union. It has often been rumored and suggested that some of the virus possessed by the Soviet Union could have been given illegally to people attempting to use the virus as a biological weapon, though factual evidence to support this concern has not been made public. The events of September and October 2001 increased U.S. concerns about all types of possible terrorism, including the potential for biological terrorism. Thus, attention turned to considerations of initiating vaccination against smallpox. CDC has been concurrently developing “post-event” vaccination plans (mass vaccinations after a smallpox release) and—the focus of this committee—“pre-event” plans (precautionary vaccination of smallpox response teams, first responders, and the general public). On December 13, 2002, President Bush announced his policy on pre-event vaccination against smallpox (White House, 2002). Vaccination of select military personnel, including the president in his role as Commander-in-Chief, began immediately thereafter. At the time of this writing, voluntary vaccination of state-based teams of public health disease investigators and of hospital-based teams of health care workers (who would respond to the first case of smallpox, should it ever appear) is scheduled to begin in late January 2003. The president has asked that this round of vaccinations be completed as quickly as possible and that a broader vaccination effort commence thereafter. As currently understood, the subsequent vaccinations will encompass the voluntary vaccination of all health care workers and those commonly defined as first responders, such as firefighters, police, and emergency medical personnel. Vaccination of the general public is specifically not recommended, but the president also announced the intent to provide vaccinations to those members of the public who request the intervention. The IOM’s Committee on Smallpox Vaccination Program Implementation met for the first time December 18-20, 2002, to begin addressing their charge, stated most succinctly as providing advice on how best to implement the policy as announced by President Bush. The committee has not been asked to, and will not, comment on the

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism president’s policy decision to recommend voluntary smallpox vaccination to health care, public health, and emergency personnel under a precautionary program, and to allow but not recommend access to the vaccine by people not included within those groups. The extensive expertise the committee brings to this issue will focus on program implementation. The committee realizes that this is an atypical vaccination campaign, and that it is neither a research study nor an ideal public health program. Rather, it is a public health component of bioterrorism preparedness. The committee was constituted to help CDC and its partners at state and local health departments, hospitals, health clinics, and private medical offices throughout the country implement a program with inherent serious risks and with publicly unknown and unstated benefits, and to do so rapidly, within a timeline that has not been explicitly outlined. Thus, the committee has chosen to address to the best of its ability at this time questions specifically posed to it by CDC and, when evidence or time does not permit a reasoned answer, to pose questions that, if answered, might allow for better and more evidence-based advice. Due to the time pressures inherent in this vaccination campaign, this report presents the committee’s recommendations on the first set of vaccinations described in the President’s policy announcement. Subsequent reports will provide recommendations relevant to further vaccination efforts, hopefully informed by experience gained from the initial effort. For practical reasons, the committee uses the term “phase I” to describe the planned vaccination of 500,000 public health and health care workers who volunteer to be part of smallpox response teams, and “phase II” to refer to the subsequent vaccination of 10 million health care and public health workers and other emergency responders. However, it is unclear what the rounds of vaccination are being called by CDC (“phases” seems most frequently used) and clarification also is needed about the target population for later vaccination efforts. Much of the evidence on which the committee bases its conclusions derives from two sources—the historical medical literature on the effects of smallpox vaccine (vaccinia virus), and presentations from and material prepared by CDC at the time of the first committee meeting (noting that the committee has not received updated drafts of materials, such as consent forms). In addition, these sources are supplemented by material presented to the committee by interested partners in the vaccination program and anecdotal information about state, local, and hospital-level response around the country available in recent print media. A list of all materials reviewed by the committee is available to the general public through the National Academies’ Public Access and Records Office (http://www4.nationalacademies.org/onpi/paro.nsf; phone: (202) 334-3543; e-mail: publicac@nas.edu). Before addressing the specific items in its

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism charge, the committee summarizes its key messages and then addresses some general considerations. SUMMARY OF KEY MESSAGES The committee urges CDC to: Highlight the unique nature of the smallpox vaccination program as a public health component of a national bioterrorism preparedness policy, focusing on the delivery of clear, consistent, science-based information. Proceed cautiously, allowing continuous opportunity for adequate and thoughtful deliberation, analysis, and evaluation. Embark on phase II only after adequate evaluation of phase I has occurred. Use a wide range of methods for proactive communication, training, and education, and customize it to reach diverse audiences, including potential vaccinees, all health care providers, and the general public. Designate one credible, trusted scientist as key national spokesperson for the campaign, and sharpen and expand communication plans and strategies to ensure rapid, transparent, and sustained contact with the media throughout implementation. GENERAL CONSIDERATIONS National Security Concerns and the Unknown Balance of Risks and Benefits The smallpox vaccination program has been competently planned by public health authorities, and decades of experience in vaccination programs and in clinical medicine have been brought to bear on this process. The planning of public health interventions, particularly immunization programs, includes cautioned and deliberate consideration of the risks of the intervention compared to its benefit. The benefit of this public health program is the likelihood that the vaccine will prevent morbidity and mortality from smallpox viral infection, if smallpox reappears. Nevertheless, there is evidence that the risks of the intervention are significant (Neff et al., 1967; Lane et al., 1969, 1970—citation used by CDC to explain adverse reaction rates); the smallpox vaccine may be the least safe vaccine ever used on a wide scale. Although the vaccine to be used in the first two phases of the program is the same calf lymph–derived vaccine stored since the 1970s, the host characteristics on a population level have changed significantly. First, a high proportion of the population has not been immunized against smallpox, and there is evidence that primary vaccinees are more likely to experi-

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism ence serious adverse reactions compared to those being revaccinated (Lane et al., 1969). The vaccine also carries significant risks for some members of the population—those with various types of immune suppression, such as HIV infection or due to cancer chemotherapy, those with certain diseases such as eczema and atopic dermatitis, and close personal contacts of vaccinees who have such contraindications. The U.S. population has many more people at high risk for serious adverse reactions now compared to the 1960s, when most data concerning the safety profile of the vaccine were collected. Furthermore, it is assumed that with rigorous efforts at screening those at risk and with intensive efforts at educating vaccinees about caring for the vaccination site, accidental inoculation of high-risk contacts of vaccinees can be minimized. However, the actual risks will only be known after the vaccination program is operative. The benefit of the vaccine also is unknown at this time. There is no reason to believe that the efficacy of the vaccine at preventing smallpox infection has changed, both in its protection of individual vaccinees and the additional protection it offers to others by blocking smallpox transmission to the unvaccinated, although there is no way to ascertain whether the vaccine would be effective against bioengineered smallpox. However, the assumed benefit of the vaccine includes an estimate of the risk of encountering smallpox virus; this estimate was derived by the President and his advisors with a view to national security issues, facts and considerations not communicated to the committee. Based on the administration’s statement that the risk of a smallpox attack is indeterminate (not zero but currently assumed to be very low) (White House, 2002), the benefit of the vaccination program to the public also is not zero but is assumed to be very low. The benefit to any individual might indeed be zero if the individual never encounters the smallpox virus. However, in the event of exposure to smallpox virus, the benefit to individuals may be very high. Given this profile of high vaccination risk and likely very low to zero benefit, the administration’s policy to offer vaccination to public health, medical, and emergency workers must be implemented in a most prudent and cautious manner. In general, public health interventions are undertaken with recognition of some benefit to some individuals, no effect on others, and the possibility of some risk to a small percentage of the population (e.g., folic acid supplementation of the food supply), with expectation of overall benefit to the population receiving the intervention. This precautionary program is a public health component of national bioterrorism preparedness, and those who assume the vaccine’s risks may have a small likelihood of individually benefiting from it. In this context, it is imperative to highlight the voluntary nature of this vaccination campaign and the paramount importance of safety, to protect

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism the volunteers assuming this risk. The sense of urgency required by national security considerations should be kept in balance with the President’s stated goal of safety. Therefore, learning from experience, making midcourse corrections on every aspect of the program, and maintaining constant and consistent communications with the public are integral to developing the safest program possible. Like all Americans, the committee hopes that the risk of smallpox disease reappearing approaches zero and that an abundance of caution can prevail. Therefore, information on the progress and outcomes of implementation—including but not limited to safety concerns and the experience of states and local communities—needs to be shared, analyzed, and discussed at every step before proceeding further. If the risk of smallpox disease (and thus the benefit of the vaccine) is truly very low, deliberation is key to ensuring the safest program possible. Issues of Timing The pre-event smallpox vaccination program is a complicated and enormous task. Given the presidential directive for rapid implementation, the states, major metropolitan areas, and territories charged with developing plans for implementing the first phase of the program had very little time to respond to the guidance CDC issued for developing a program. At the time of the committee’s December 2002 meeting and in subsequent media accounts, several states expressed concern that the original ambitious time frame was not realistic (Young, 2003). Concurrently, CDC revealed that it would relax the 30-day timeline for the first phase of vaccination, but without providing specifics about the changed timeline (CDC, 2002a; Orenstein, 2002; Strikas, 2002). At the time of writing this report, the committee had not received written confirmation of this change. The committee hopes that local health department and hospital readiness will dictate the launch date for phase I in each state or community, and duration of each state vaccination program. Furthermore, sufficient time should be allowed between the two phases to ensure adequate assessment and plan revision by CDC and its partners at the state and local levels. Although advising deliberate and careful planning and implementation, the committee recognizes that the unique context of this program may change at any time, as new information about the nature and extent of threats to the public’s health may become available to public health authorities. For example, the confirmation of a suspected smallpox case would immediately signal a change in policy and mandate the rapid implementation of vaccination plans. As phase I, and ultimately, phase II are completed, it is advisable that CDC evaluate the long-term sustainability of the vaccinated smallpox response teams. There will be some turnover among the first vaccinated

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism cohort of response team members, and CDC would need to determine how it can ensure that public health and health care smallpox response teams maintain an adequate number of vaccinated members with the necessary expertise for each team. The commencement of phase II vaccinations may help eliminate the concern over the immediate sustainability of response teams vaccinated during phase I, but the need for new rounds of vaccinations for newly designated members of response teams should be considered once phase I and phase II vaccinations have been completed. An important task for CDC and its medical and public health partners will be to develop an agreed-upon set of questions that must be answered satisfactorily throughout phase I and before phase II can begin. The questions, borrowed from analyses of the Swine Flu program of the late 1970s (GAO, 1977), are “What evidence on which things, when and why, would make us change the course we now propose, and to what?” (Neustadt and Fineberg, 1978). Should a deliberation about the fundamental nature of the policy not be possible, at a minimum the committee recommends that CDC develop and communicate the criteria (e.g., types and rates of adverse reactions) that would trigger a reconsideration of the current systems in place to protect vaccinees and their contacts (e.g., the October 2002 Advisory Committee on Immunization Practices [ACIP] recommendations on contraindications, screening, care of the vaccination site, and administrative leave). For example, CDC might wish to consider from how many vaccinees it will require data and at what rate of specific serious adverse reactions (in vaccinees or their contacts) CDC would consider the program riskier than currently expected and the contraindication screening less adequate than needed (or safer than currently expected). Hospitals and health departments will implement the first phase of the pre-event vaccination program in slightly different ways, depending upon the circumstances and needs of their communities. Much could be learned from this differential administration of the program. Since this program is a very unusual public health intervention, it will be important to gather data on which practices and techniques are most effective in different types of settings. To most effectively evaluate the progress and outcomes of the first phase, the committee recommends that CDC utilize the variation in implementation by hospitals and health departments (e.g., differences in granting administrative leave, types of bandages used, different site care instructions, degree of patient contact, adverse reaction investigation) to obtain safety data and to analyze these data before embarking on subsequent phases of the vaccination program.

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism Clarity The committee urges that CDC and the Department of Health and Human Services (DHHS) proceed in their public discussions and program guidance with attention to clarity, focusing on issues such as timelines and terminology. First, there has been confusion on the part of the committee, and likely others as indicated by media reports on the subject (Altman and O’Connor, 2003; Young, 2003), about the characteristics of program phases, the numbers of people estimated to be vaccinated, when vaccinations will begin, and the estimated duration of each phase. Specific wording should be chosen (e.g., waves, phases, stages), clearly defined, and then used consistently in all communications from CDC and DHHS. In addition, all communications should be clear about whether particular guidance refers to pre-event (precautionary) smallpox vaccination or to post-event (response and control) vaccination. This is particularly important for any discussion of contraindications, which are very different under the situation of postexposure vaccination. In this regard, the pre-event program must be explained as part of a general program of public health preparedness for bioterrorism and other threats to the public’s health. It is clear to the committee and other interested parties that the stated policy of the president is an absolutely voluntary vaccination program for hospitals that may choose whether to have a smallpox response team and for public health and health care workers who may volunteer to be members of a response team, but this matter bears continual emphasis in communications and planning. Finally, some administration and other policy statements about the early part of vaccination implementation have described the group to be vaccinated as “first responders” or “response teams.” The committee believes there is a need to more clearly explain in policy and planning materials that in the event of a smallpox release, the first responders (i.e., those who are likely to first encounter or identify smallpox) will be public health and health care teams. Fire, police, and emergency personnel commonly described as first responders may have a role to play in mass vaccination, in addition to law enforcement’s role in investigating the criminal aspects of a smallpox virus release. Compensation for Adverse Reactions to the Smallpox Vaccine Although not a specific “line-item” within its contractual charge, the committee interprets general issues of compensation for adverse reactions as integral to its stated charge to assess the overall progress at achieving the goals of the program. [The committee will use the term “adverse reactions”

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism to describe both the common (i.e., local and systemic reactions) and serious adverse reactions (e.g., generalized vaccinia, serious cases of accidental inoculation, eczema vaccinatum, progressive vaccinia, vaccinia keratitis, and encephalitis). There may be some suspected adverse reactions that are not yet recognized as being causally associated with the vaccine. If these suspected adverse reactions are determined to be causally associated with the smallpox vaccine, then compensation should address these reactions as well.] It does so because it believes that the currently stated plans for compensation for adverse reactions could seriously affect achievement of the stated goal of the program—to increase the nation’s bioterrorism preparedness. A number of hospitals have said that they will not participate in the pre-event vaccination program until these issues are resolved (McKenna, 2002; Price, 2002). The committee believes that resolution of the adverse reaction compensation issues is important for the informed consent process, clearly a part of the committee’s charge. Concerns about lifelong disability resulting from the vaccine (particularly neurological disability from postvaccinal encephalitis) also may arise, and the committee encourages consideration of how to address disability issues. Implications of the pre-event vaccination program for issues related to health insurance, disability insurance, and life insurance also should be considered. The committee notes that the Homeland Security Act of 2002 (Public Law No. 107-296) provides a federal mechanism to compensate vaccinees who are injured due to negligent manufacture or administration of the smallpox vaccine (but does not cover adverse reactions that occur despite non-negligent manufacture and administration). This has encouraged manufacturers and vaccine administration sites to participate in the pre-event vaccination program, as it reduces their liability exposure for adverse reactions. The Homeland Security Act does not, however, provide reimbursement to vaccinees for costs associated with participating in the program when there are no instances of negligence. These costs may include administrative leave (with possible loss of salary) in order to avoid accidental infection of vulnerable patients in their workplace; lost income due to time away from work while recuperating from adverse reactions that occur despite non-negligent manufacture and administration of the vaccine, particularly for nonsalaried workers; and unreimbursed medical expenses associated with treating adverse reactions that occur despite non-negligent manufacture and administration of the vaccine. In addition, the committee notes with concern that there may be some people, such as patients and family members, who are infected accidentally by contact with a vaccinee, despite efforts to care for the vaccination site appropriately. Recognizing this, contacts should be considered part of the population that is vulnerable to adverse reactions and, thus, losses from the vaccine. This is not unlike the policy of vaccine-associated paralytic polio

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism in contacts of people who received the oral polio vaccine in the National Vaccine Injury Compensation Program. Without reimbursement for these losses, the committee fears that some, perhaps many, public health and health care workers will decline vaccination, thus undermining the effectiveness of the program’s implementation. Some of these adverse reactions may be covered by state worker’s compensation programs. However, there is much uncertainty surrounding the types of vaccine adverse reactions and circumstances leading to those vaccine adverse reactions that would be coverable under each state’s worker’s compensation law. Public health and health care workers who are considering vaccination need accurate information about the rights and protections that are available to them under their state’s worker’s compensation law. The committee recommends that CDC and its state and local public health partners immediately work to clarify each state’s worker’s compensation program’s position on coverage for smallpox vaccine–related injuries and illnesses for workers covered under their programs. At the time of the issuance of this report, the implications of the Homeland Security Act were not fully understood by many of the state and local public health and health care partners in the smallpox vaccination program. This led to confusion and concern that individuals who have volunteered to be part of the nation’s defense against bioterrorism—the public health and health care workers who participate in precautionary vaccination and their family members who are at risk of accidental inoculation—are inadequately protected financially from liability, compared to the much smaller group of public health and health care workers who agree to administer the vaccine (AHA, 2002; McDonough, 2003). The committee heard during discussion that these concerns have been raised with DHHS and other administration officials (SEIU, 2002). These concerns may change as more is learned about the adverse reaction rates during phase I of the vaccination program. The committee also understands that the 108th Congress might address these issues. The committee urges timely attention and communication about the progress of these deliberations. Without this, concerns about the financial burden for caring for the adverse reactions of the smallpox vaccine (and the sobering consideration that some small but real number of vaccinees or their contacts could die or suffer permanent disability subsequent to vaccination) could greatly decrease the number of people who volunteer for smallpox vaccination. This could seriously affect the program’s achievement of its overall goals of increasing U.S. terrorism preparedness. The committee recommends that CDC and DHHS support all efforts, some of which might be administratively or legislatively bold and creative, to bring this issue of compensation for smallpox vaccine adverse reactions—including those reactions that oc-

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism gency department nurse), literacy level, and culturally diverse needs of vaccinees. Also, both vaccination clinics and the workplaces of vaccinees might contribute to supporting vaccinee site care knowledge and practices by making plans to reinforce information, given that repeated exposure to educational messages may be more successful in ensuring protective behaviors, like hand washing and site care. Both health care workers who are vaccinees and the public health personnel vaccinating them may be engaged in training and retraining efforts. The second training focus area refers to adverse reactions training for physician experts. Rapid and accurate identification of adverse reactions depends upon the ability of all clinicians—infectious disease specialists, primary care physicians, nurse practitioners, and others—to identify common and serious adverse reactions to the smallpox vaccine in their patients. The committee recommends that CDC expand the scope of their training and education regarding the identification, treatment, and reporting of serious adverse reactions to all clinicians. Education and training also should provide clear guidance about how adverse reactions should be reported and what resources are available to aid in their management and treatment. Webcasts for clinicians are not enough; outreach must be conducted through multiple modes. The committee commends CDC on the development of the 16-page color brochure providing information on smallpox vaccination and common and serious adverse reactions to the vaccine, and encourages CDC to distribute this brochure as widely as possible. Furthermore, if guidance has not been developed already, the committee encourages CDC to develop guidance for vaccination clinics (some of which may not be located in hospitals) on how to respond to anaphylactic reactions immediately following vaccination. The committee also was asked to provide advice on what smallpox vaccine safety information practicing physicians need and how this can be most efficiently transmitted. The committee would first like to encourage CDC to think more broadly about who needs this information, and any plan to accomplish this should include sufficient reiteration to answer the problems of busy clinicians being able to attend single sessions. Rather than just focusing on “practicing physicians,” this information should be provided to all types of health care providers—physicians, physician assistants, nurse practitioners, nurses. The committee recommends that the first communication clinicians should receive is basic information about the details of the pre-event smallpox vaccination program.

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism Although CDC has recognized a need to reach out to clinicians throughout the country and develop specific training materials for them, the committee believes that CDC has possibly underestimated the importance of the primary care system in the implementation of the pre-event smallpox vaccination program. The committee has limited information of plans to provide training about the vaccine to all primary health care providers (e.g., physicians and nurse practitioners), in addition to specialists and others. Given that CDC is encouraging health care workers contemplating vaccination to discuss their questions and concerns with their own health care providers (Rotz, 2002), the committee notes the need to provide some basic training and education to all providers, not just to those selected to address serious adverse reactions. The committee encourages CDC to expand their consideration of how the primary care system may become involved in the vaccination program, and the variety of modes (in addition to website-based) that can be used to provide training to the primary care community. Much confusion and misinformation exist in both the general public (Blendon et al., 2003) and the health care community (Everett et al., 2002) about multiple components of the smallpox vaccination program. The committee encourages CDC to provide more consistent and comprehensive information to as wide a distribution of clinicians as possible, enabling them, at a minimum, to: Counsel potential vaccinees when they are seeking information and assistance in deciding whether to be vaccinated; Effectively and sufficiently screen potential vaccinees (or their household contacts) who have contraindications to vaccination; Recognize adverse reactions, both common and serious; Report serious adverse reactions; Seek assistance with managing serious adverse reactions; Identify types of dressings to use on the vaccination site (and effectively educate their patients); and Care for the vaccination site, including proper hand washing technique (and effectively educate their patients). Methods for training and communicating with providers may include, but not be limited to: communiques to all health care providers (e.g., state-based fax rapid delivery systems); take-home video and audio cassettes; website and telephone-based information as a backup to brochures and other written materials; and training trainers at the local level to conduct workshops on components of local implementation. Frequently asked questions (FAQs) or similar tools also may be useful for practicing clinicians, and such material may be disseminated electronically and in print. Data management for safety, the third training focus area is discussed in an earlier section of this report. The fourth and fifth focus areas of the

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism CDC training plan refer to laboratory diagnostics for smallpox and rash illness and training for rash illness surveillance. The committee was unable to address these areas directly at this time, but believes that they are of great importance, and that the training principles outlined by CDC and the guidance provided in this report should be applied to these components of the training plan. Additional Training Areas and Training-Related Planning Activities The committee expressed concern that many aspects of smallpox vaccination planning seem to have occurred in isolation from broader public health activity, reinforcing the programmatic separation characteristic of much public health planning and funding (Boufford and Lee, 2001; IOM, 2002). Although this is an atypical program, similar preparedness and large-scale implementation would be expected to characterize local public health readiness to respond to other public health crises, such as other bioterror threats and emerging infectious diseases. Ideally, smallpox activities would be integrated into overall bioterrorism preparedness, and as much as possible, measures taken to strengthen surveillance, staff training, and communication would be more broadly conceived as dually applicable to smallpox and other public health efforts. A possible strategy to optimize resources and broaden the impact of smallpox vaccination preparations may be collaboration with Centers for Public Health Preparedness to enhance various dimensions of the smallpox program, an opportunity not explicitly considered by CDC planners at the time of the committee’s first meeting (Strikas, 2002). Over the next 2-6 months, in anticipation of phase II of training and education, CDC should provide additional guidance and models/templates for training and education materials to be used at the state and local levels and should develop a database of findings and evaluation materials. This may require activities such as conducting a survey or maintaining an evaluation site to assess the experience of vaccination clinics, hospitals, and health departments around the country. Furthermore, the committee hopes that CDC has been reviewing lessons learned from other mass events with public health implications (e.g., local governments’ experience with mass campaigns, the expertise of organizations that routinely plan large events and the movement of large numbers of people). The first phase of smallpox vaccination will provide unprecedented information about the training and education needs of vaccinators, public health and health care workers, prospective vaccinees and their close contacts. CDC may benefit from establishing mechanisms to collect such information throughout phase I that would be useful in the planning and implementation of expanded vaccination efforts.

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism Communication Communication Planning The committee agrees with the assumptions behind CDC’s pre-event communication planning, and has noted that CDC has provided a substantial outline of the communication objectives to be met and activities to be conducted prior to beginning vaccination. However, the committee has noted the need for a more comprehensive, detailed, and strategic communications plan and, in the following pages, identifies some additional broad areas or issues that should be considered in communication planning, including: Timing; A single, expert voice to represent CDC in presenting science-based public health messages regarding smallpox; Audience specificity; and Clarity, appropriateness, and mode of delivery of messages (e.g., literacy level, pretesting, Internet). First, communicating to the public about the vaccine, its benefits and risks should occur before vaccination of health care workers begins. Now is the time to shape messages and influence perceptions with honest answers and scientific evidence; once a serious adverse reaction occurs, attempts to control information or change public opinion will likely be too little, too late. The next steps in the development of a pre-event communication plan require greater clarity and more specific details about the methods and channels to be used and the outcomes expected. Second, the committee believes it is important that the CDC communications effort strictly address the public health aspects of the smallpox vaccination policy and focus on providing public health and health care workers and the general public with the most complete and scientifically accurate information, while supporting informed decision-making regarding vaccination. Also, the committee recommends that CDC’s communication efforts about smallpox vaccination clearly separate public health issues from national security matters. The latter are best addressed by representatives of the administration more directly involved in such matters, and not by representatives of scientific agencies. Therefore, the responsibility of CDC is to deliver clear, consistent, and science-based public health communications. There is evidence from the risk-perception literature that the public expresses less fear when it receives its information from people it trusts (Gray and Ropeik, 2002), and trust is facilitated by honesty, transparency,

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism and the transmission of consistently accurate, science-based information. The committee recommends that CDC identify a single “voice” for the national vaccination program, a credible individual with a strong scientific background and an experienced communicator who can serve as the key CDC spokesperson. Additionally, the agency should develop several backup sources for the media who can offer the same level of informed comment and thoughtful observation as the program’s primary “voice.” Such spokespersons should be trained in media techniques, as necessary, to respond to the wide variety of difficult questions that are going to arise during this challenging enterprise. Since the media also will refer to many well-informed critics of the vaccination effort, it is crucial that CDC’s communications are based in strong science and communicated with authority. These are essential ingredients to foster public confidence in the program’s direction and ultimate outcome. This cadre of health communicators must be able to speak authoritatively to both members of the general public and to health care providers who have anxieties and concerns that must be addressed. To safeguard the separation between political and public health communications, the key spokesperson should not be a politician. This spokesperson (and other key public health communicators) should address the public and be available for the media immediately and regularly after the occurrence of a serious adverse reaction or smallpox release crisis. Such a spokesperson may gain the public’s confidence by constituting a credible and consistent source of information and reflecting the expert management of a public health crisis. Third, if CDC has not done so already, its communication planning may be enhanced by developing specific objectives and strategies targeting each of the audiences that have been identified. As an example, the media, which itself informs the public and needs access to the best, science-based evidence, requires information and transparency that will enable their reporting on program status. Based on their enormous influence in shaping public opinion and disseminating information to the public, the committee believes that state and local efforts would be benefited by CDC-prepared communication objectives focused specifically on communicating with media professionals at the national, state, and local levels, with strategies intended to increase communication between the media and health officials at all levels. The nation’s ability to prepare and respond to a smallpox attack or other potential bioterror threat depends heavily on the content and influence of media outputs before an outbreak occurs. A well-informed public also is essential to the success of the smallpox vaccination program, and to public health preparedness in general. Community leaders, community-based organizations, and local civic associations possess human and communications resources that can prove invaluable in assisting the CDC

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism to develop, evaluate, and disseminate targeted public health information to the public. The objectives outlined in CDC’s Smallpox Response Plan and Guidelines (2002d: E-6) appear to combine the information needs of the general public, policy makers, and media, and the communication standards needed by health care workers. Some of the broad communication areas mentioned pertain to the knowledge and understanding of smallpox and immunizations concepts among health care workers and the public; ability of health care worker, public, media and policy maker audiences to respond appropriately to a smallpox case or outbreak; and protocols for surveillance and the communication of data needed after a smallpox case or outbreak. The first two areas are too broad, requiring much more detailed discussion of individual audiences and approaches, and the third is more accurately described as a matter of health informatics (e.g., surveillance, VAERS), discussed to some extent in this report. A fourth area of great importance to communicating about smallpox has to do with message development and the delivery of information to the public. Methods for communicating to and with the public seem overly reliant on the Internet. Not all health care workers, and certainly not all members of the public, obtain their information online. Print materials should be made available through a variety of outlets, including professional associations, community organizations, and others. Information should be disseminated to the public broadly through a variety of methods, ranging from print materials tested for readability and cultural appropriateness, to public service announcements on television and radio. Given the public’s limited and often incorrect knowledge about vaccines, communicating well and early about the smallpox vaccine is essential to support public confidence in the public health system. The public should be provided with pretested, targeted information about vaccines in general (how they are developed, how they work, their benefits and potential side effects), and about the smallpox vaccinia immunization in particular (i.e., the reality that the smallpox vaccine is different from other vaccines in its greater risk of adverse reactions and even death, though such risk is relatively low and may be minimized if appropriate screening, site care, and other precautions are taken). Primary care providers and nurses should be well-informed through communication activities since they are trusted sources of information for individuals and communities. Transparent, culturally competent, accessible, and understandable presentation of what is known and unknown is needed. In general, CDC’s communication plans reflect a greater focus on crisis management than on broader communication strategies. More emphasis should be placed on communications to help frame the public’s initial awareness and knowledge and to build trust, which will be essential in

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism dealing with a potential crisis. CDC has outlined four communication principles: (1) consistency and consensus; (2) acknowledgement of and tolerance for uncertainty; (3) communication research; and (4) importance of addressing diversity of communication needs. In addition to these principles, and as previously noted, the committee finds a need to differentiate between political and public health communications and to position CDC firmly in the realm of evidence-based public health communications. Finally, but perhaps most important, there is the principle of informed consent, mentioned above. All communication materials and strategies targeting potential vaccinees and the general public should emphasize the voluntary nature of the vaccination program. The second through fourth communication principles are addressed to some extent throughout the report. In regard to the first communication principle of consensus and consistency, the committee was unclear about how communication between CDC communicators and their state and local health communicators will occur. What strategies will be employed to ensure standard language is used and that local, state, and national decisions and plans are well aligned? The committee has concluded that CDC’s communication strategy seems well developed in two broad areas: passive information (e.g., training materials, fact sheets) about the disease, the vaccine, and the vaccination campaign, available on the website; and crisis material, prepared to respond to a news event/vaccine crisis or smallpox release. Although the first phase of the vaccination program involves only health care workers, it is never too soon to begin educating the general public; therefore, the committee recommends that more attention be given to developing a variety of materials and channels to inform and educate the public about the immunization program before vaccinations begin. Furthermore, communication planning and tools should differentiate between pre- and post-event information needs. Current training needs and news events are different from potential crisis response, and planning must take place to address each area individually. A wide range of channels should be used to communicate to and with various audiences, from the media to the general public, from health care workers to policy makers. As the time to make the vaccine available to the general public nears, CDC may wish to consider a mass mailing to every U.S. household, in the style of former Surgeon General Koop’s mailing on HIV/AIDS. Some of the communications questions submitted by CDC to the committee were not answered, as they require empirical and formative communications research (e.g., message development, literacy-level testing). Other than recommending a candid, transparent communications approach that is sensitive to and appropriate for the range of literacy levels and cultural

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism backgrounds among potential vaccinees and the general public, the committee hopes that CDC will seek other types of expert advice and resources. The committee advises CDC to communicate frequently with the public focusing on consistency, transparency, and a balanced representation of what is known and not known. CDC should be very clear about its jurisdiction—questions about the likelihood of attack are national security issues that CDC is not able/qualified to answer. If asked about the risk of the smallpox vaccine, however, the agency should answer with the facts—that the risk of serious adverse reactions is relatively low, but still higher than any other vaccine in routine and mass use. Guidance to States With the exception of guidance on safety system issues, the committee is unable to comment on CDC’s guidance to states due to lack of access to certain materials. The committee hopes to provide comments on other components of guidance to states in a future report, when it has received further information. Overall Progress at Achieving the Goals of the Program CDC’s overall goal seems to be the successful implementation of an immunization program that is truly voluntary and as safe as possible but that establishes the response capacity necessary to protect the public’s health in the event of a smallpox attack. Success would mean securing an adequate set of vaccinated teams of health care workers willing to participate in responding to such an attack. The committee is unable to assess CDC’s progress at this time, but will do so as program implementation experience allows. Areas of Potential Future Inquiry There are a number of important matters the committee recognized but was unable to address in this report and some additional areas on which CDC may wish to request guidance as the implementation of the vaccination program begins and progresses. These matters and areas include, but are not limited to: Discussion of the optimal response to an immediate change in the determination of smallpox threat, with a focus on state and local preparedness; A review of local readiness for implementation and an assessment of opportunity costs and resource allocation issues;

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism Assessment of the adequacy of the screening materials, based on experiences during the first phase; Assessment of the adequacy of the informed consent materials (particularly the information provided to vaccinees on the relation of risks to benefits and the range of possibilities for adverse reactions), based on experiences during the first phase; Assessment of secondary transmission to contacts, including an assessment of site care guidance and vaccinee’s adherence to that guidance; Occupational safety issues, particularly related to bifurcated needles; A review of the organization and function of the DSMB; and Prioritization of recommendations, recognizing that multiple demands may be necessary and some of the committee’s recommendations require resources. CLOSING REMARKS In closing, the committee wishes to thank you for the opportunity to be of assistance to the Centers for Disease Control and Prevention as it implements this important vaccination program. We look forward to finding out how the committee can help CDC address other program components as it works with state and local partners to move forward with implementation. Brian L. Strom, Committee Chair Kristine M. Gebbie, Committee Vice Chair Robert B. Wallace, Committee Vice Chair Committee on Smallpox Vaccination Program Implementation REFERENCES AHA (American Hospital Association). 2002. Statement to the IOM’s Committtee on Smallpox Vaccination Program Implementation on December 19, 2002. Notes: Statement presented by Roslyne Schulman (Senior Associate Director for Policy Development, American Hospital Association). Altman LK. 2002, December 10. Health Care Workers Union Wary of Smallpox Vaccinations. New York Times, A23. Altman LK, O’Connor A. 2003, January 5. Health Officials Fear Local Impact of Smallpox Plan. New York Times, A1. ANA (American Nurses Association). Statement to the IOM’s Committee on Smallpox Vaccination Program Implementation on December 19, 2002. Notes: Statement presented by Cheryl Peterson (Senior Policy Analyst, American Nurses Association). Associated Press. 2003, January 2. Texas Official Wants Delay in Smallpox Vaccinations. Amarillo Globe-News. Blendon RJ, DesRoches CM, Benson JM, Herrmann MJ, Taylor-Clark K, Weldon KJ. 2003. The public and the smallpox threat. New England Journal of Medicine 348(5):1-7.

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism Boufford JI, Lee P. 2001. Health Policies for the 21st Century: Challenges and Recommendations for the U.S. Department of Health and Human Services. New York: Milbank Memorial Fund. Burstein J. 2002. Statement of the American College of Emergency Physicians. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting One on December 19, 2002, Washington, DC: 267-271. CDC (Centers for Disease Control and Prevention). 2002a. CDC Telebriefing Transcript: HHS Teleconference on Smallpox Policy. [Online] Available at htpp://www.cdc.gov/od/oc/media/transcripts/t021214.htm. Accessed January 10, 2003. CDC. 2002b. Epidemiology and Prevention of Vaccine-Preventable Diseases, 7th Edition. [Online] Available at http://www.cdc.gov/nip/publications/pink/Full.htm. Accessed January 10, 2003. CDC. 2002c. Pre-Event Vaccination System Webcast Questions and Answers. [Online} Available at http://www.bt.cdc.gov/agent/smallpox/vaccination/vaccination-program-qa-pvs.asp. Accessed January 8, 2003. CDC. 2002d. Smallpox Response Plan and Guidelines (Version 3.0). [Online] Available at http://www.bt.cdc.gov/agent/smallpox/response-plan/. Accessed January 9, 2003. CDC. 2002e. Summary of October 2002 ACIP Smallpox Vaccination Recommendations. [Online] Available at HtmlResAnchor http://www.bt.cdc.gov/agent/smallpox/vaccination/acip-recs-oct2002.asp. Accessed January 9, 2003. Connolly C. 2002a, December 15. Bush Plan for Smallpox Vaccine Raises Medical, Fiscal Worries. Washington Post, A33. Connolly C. 2002b, December 24. Smallpox Plan May Force Other Health Cuts. Washington Post, A01. Everett W, Coffin S, Zaoutis T, Halpern S, Kim J, Strom B. 2002. Smallpox Willingness: A National Study of Emergency Department Personnel. Presented to the IOM’s Committee on Smallpox Vaccination Program Implementation on December 19, 2002. GAO (General Accounting Office). 1977. The Swine Flu Program: An Unprecedented Venture in Preventive Medicine. Washington, DC: GAO. Gray GM, Ropeik DP. 2002. Dealing with the dangers of fear: the role of risk communication. Health Affairs 21(6):106-116. Hardy G. 2002. Statement of the Association of State and Territorial Health Officials. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting One on December 19, 2002, Washington, DC: 284-291. IOM (Institute of Medicine). 2002. The Future of the Public’s Health in the 21st Century. Washington, DC: The National Academies Press. Lane JM, Ruben FL, Neff JM, Millar JD. 1969. Complications of smallpox vaccination, 1968: national surveillance in the United States. New England Journal of Medicine 281(22):1201-1208. Lane JM, Ruben FL, Neff JM, Millar JD. 1970. Complications of smallpox vaccination, 1968: results of ten statewide surveys. Journal of Infectious Diseases 122:303-309. McDonough M. 2003. A Pox on It! Health Lawyers Worry About Smallpox Vaccine Liability. American Bar Association Journal eReport. [Online] Available at http://www.abanet.org/journal/ereport/j10pox.html. Accessed January 10, 2003. McKenna MAJ. 2002, December 17. Atlanta Hospital Declines to Vaccinate Workers Against Smallpox. Atlanta Journal-Constitution. Mitchell M. 2003, January 2. Cost of Smallpox Vaccinations Prompts Call for Delay in Texas. Fort Worth Star Telegram, Metro, 1. NACCHO (National Association of County and City Health Officials). 2001. Local Public Health Agency Infrastructure: A Chartbook, 51.

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The Smallpox Vaccination Program: Public Health in an Age of Terrorism NACCHO. 2002. Statement to the IOM’s Committee on Smallpox Vaccination Program Implementation on December 19, 2002. Notes: Statement presented by Patrick M. Libbey (Executive Director, NACCHO). Nakamura D, Weiss EM. 2002. Local Workers Weigh Benefits and Risks of Vaccination. Washington Post, A9. Neff JM, Lane JM, Pert JH, Moore R, Millar JD, Henderson DH. 1967. Complications of smallpox vaccination: national survey in the United States, 1963. New England Journal of Medicine 276(3):125-132. Neff JM, Lane JM, Fulginiti VA, Henderson DA. 2002. Contact vaccinia—transmission of vaccinia from smallpox vaccination. Journal of the American Medical Association 288(15):1901. Neustadt RE, Fineberg HF. 1978. The Swine Flu Affair: Decision-Making on a Slippery Disease. U.S. Department of Health, Education, and Welfare. Orenstein W. 2002. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting One on December 19, 2002, Washington, DC: 311-318. Price JH. 2002, December 20. Health Workers Resist Smallpox Vaccinations. The Washington Times, A1. Quick L, Nelson R, Strikas R. 2002. Training and Education Overview. Presented to the IOM’s Committee on Smallpox Vaccination Program Implementation on December 19, 2002. Richmond T. 2003. Money Needed for Vaccinations. The Duluth Superior [Minnesota]. Rotz L. 2002. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting One on December 19, 2002, Washington, DC: 112-147. SEIU (Service Employees International Union). 2002. As Bush Plan for Mass Smallpox Vaccination Stirs Controversy … Nation’s Largest Health Care Organization Says Hospital Workers, Patients Will Face Unnecessary Risk. [Online] Available at http://www.seiu.org/media/press_releases/press.cfm?ID=1096. Accessed January 8, 2003. Strikas R. 2002. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting One on December 19, 2002, Washington, DC: 38-81, 172-173. Vogel S. 2003. No Serious Problems in Military Inoculations. Washington Post, A7. White House. 2002, December 13. President Delivers Remarks on Smallpox. [Online] Available at http://www.whitehouse.gov/news/releases/2002/12/20021213-7.html. Accessed January 8, 2003. Winkenwerder W, Grabenstein J. 2002. DOD Smallpox Vaccination Program. Transcript from the IOM’s Committee on Smallpox Vaccination Program Implementation Meeting One on December 19, 2002, Washington, DC: 235-267. Young J. 2003. Public Health Departments Will Offer Vaccine Directly to Hospital Workers if Employers Decline. Washington Fax.