The Bush administration is asking health care workers to volunteer to be vaccinated against smallpox so that they may participate in community and hospital smallpox response teams. No case of smallpox disease has occurred in the world for 25 years. However, the government’s smallpox preparedness program is based on the fear that the disease could be reintroduced in a bioterrorist attack. PEF is providing this factsheet to make sure that our members have as much information as possible in making a decision on whether to volunteer.
Historically, smallpox has killed 30% of those infected and 300 million people died from it in the 20 th century. However, it is not as easily transmitted as the common cold and you have a 90% chance of preventing or slowing the disease if you are vaccinated within four days after exposure.
In past smallpox epidemics, vaccinators were vaccinated at the time of the outbreaks. The theory behind vaccinating large groups of health care workers prior to an actual attack is that this would save lives by reducing the time involved in vaccinating the vaccinators. In case of a large-scale attack, it is estimated that thousands of health care workers would be needed to immunize the affected population. Vaccination has significant risks and health care workers have a right-to-know about them.
Public health authorities tell us that they are not aware of any increased risk of a smallpox attack. If others within the government are aware of such risks, they are not sharing this information. We know that the former Soviet Union manufactured tons of smallpox virus, and that some of this stockpile is unaccounted for. Recent news reports speculate that Iraq and North Korea could possess smallpox. All that federal public health officials will say is that they assume that the risk is very low, but that is it not "zero."
Newspaper reports indicate that the Bush Administration will soon announce plans to start this process by working with state and county health departments and hospital employers to seek 500,000 front line hospital health care and public health workers to volunteer as the first wave to be offered smallpox vaccinations.
It is your decision and your decision alone
It is important to remember that the decision to volunteer to be vaccinated is up to you and you alone. Therefore, it is critical that you learn as much as possible about this vaccine to enable you to balance the risks and benefits in advance of participating in any smallpox vaccination program.
Basic Facts about Smallpox and Vaccination
Below are key facts you should know about smallpox vaccination and your rights should you decide to volunteer.
Tell me about smallpox
Smallpox is a virus transmitted person-to-person. While not as contagious as the common cold or influenza (the "flu"), it is spread through the air during close face-to-face contact when smallpox patients cough. It can also be spread through direct contact with smallpox lesions, infected bodily fluids, or contaminated objects such as clothing or bed linen. There have been a few cases where smallpox has been spread in the air in enclosed settings such as hospitals that did not properly isolate contagious patients. Humans are the only natural hosts of variola, the smallpox virus. It is not known to be transmitted by insects or animals.
Historically, the disease kills one of three smallpox patients. However, with the advent of newer anti-viral drugs in the past 25 years, medical experts wonder whether the death rate might be reduced.
Is the smallpox vaccine effective?
The smallpox vaccine is extremely effective in preventing the disease. It is effective in preventing the disease for 3-5 years after it has been given and is also effective if given within four days of exposure to someone with smallpox, there is a 90% chance that you will be protected from developing smallpox disease or the course of the disease will be less severe.
The vaccine is made from a weakened form of a live microbe called the vaccinia virus, which is a much weaker "pox" type virus related to smallpox. The vaccine does not contain the smallpox virus and cannot give you smallpox. It is the same type of vaccine that was used to wipe out smallpox worldwide more than two decades ago.
But, because smallpox was eradicated in the 1970s many persons living in the U.S. (especially those born in the 1970s, 80s or 90s) have never been vaccinated against smallpox. Persons who have been vaccinated in the past (meaning more than 5 years ago) may be protected from dying if they get smallpox; they will not be protected from getting the disease.
How safe is the smallpox vaccine?
This vaccine has been described as the "least safe human vaccine," and its poor safety performance is the main reason why the US stopped administering it in 1972. While the risk of a smallpox attack is unknown, the dangers of the vaccine are well documented.
Because the smallpox vaccine contains the "live" vaccinia virus, it carries more risk than many other vaccines. It can cause severe reactions, complications, and even death. Medical experts believe that 15 people out of every 1 million people vaccinated for the first time will face life-threatening complications.
Many more will fall sick, suffering from fever, malaise, and swollen lymph nodes. One third of those vaccinated may become sick enough to miss at least one day of work. Severe side effects usually appear within three weeks. One or two people in every 1 million people vaccinated are expected to die.
Reactions to the vaccine are less common for those being revaccinated.
Who should not volunteer for the vaccine?
About one in six individuals should not receive the vaccine due to pre-existing medical conditions that weaken their immune system.
Don’t volunteer to get vaccinated if you or a family member:
- have HIV or do not know your HIV status;
- have recently undergone chemotherapy, have been diagnosed with cancer, or have had an organ transplant;
- have any condition that compromises your immune system;
- have ever had skin conditions such as eczema or dermatitis;
- have allergies to certain antibiotics used to prepare the vaccine;
- have to take high doses of steroids; or
- have become pregnant, or are considering it soon.
How do I protect others and myself from the spread of the vaccinia virus beyond the inoculation site?
Remember, since the vaccine is made with the live vaccinia virus, it can spread to other parts of your body and even infect family members, co- workers, and patients. Studies indicate that health care workers who are vaccinated may shred vaccinia virus for up to 19 days. Extensive hand washing is necessary whenever you come in contact with the inoculation site. The CDC believes that this risk can be reduced substantially if the vaccine inoculation site is carefully covered according to their recommendations using gauze and special tape. It is important that the vaccine inoculation site be examined and rebandaged at least on a daily basis at your worksite by a designated individual trained to care for inoculations and detect any vaccine related complications.
The Rights of Health Care Workers
The Bush vaccination plan contains a number of serious gaps and raises a host of complex issues that have not been adequately addressed. We must demand that smallpox vaccination programs provide the necessary safeguards to protect health care workers, their patients, and families.
- Written Smallpox Emergency Preparedness Plan
Before your employer solicits healthcare workers to be vaccinated they should have a written smallpox emergency preparedness plan. These plans should detail the procedures for preventing a negative impact of the vaccination program on patients and workers’ families. Hospitals must also have functional negative pressure isolation rooms, appropriate personal protective equipment, decontamination, and security procedures in place. The plan should also document the hospital’s role in the community response plan. The number of volunteers should match the number of isolation rooms a hospital is equipped with.
Thorough Education and Training
Health care workers need to be educated on all aspects of the vaccinia vaccine, including the possible dangers of the vaccine. Training should be during working hours, by a qualified trainer, and allow for questions and answers.
Medical Screening
Health care workers should be screened to ensure they are not at risk for adverse side effects due to existing medical conditions. The screening should include filling out a questionnaire on possible medical conditions that could put health care workers at risk. Health care workers should be offered free and confidential off-site medical testing to ensure they have no conditions related to adverse vaccine reactions such as HIV infection, pregnancy, antibiotic allergies, eczema and other skin conditions—It is estimated that 300,000 people in the U.S. are infected with HIV and do not even know it.
Unfortunately, so far the federal government is only recommending that HIV and pregnancy testing be offered, but is not saying how it should be done, by whom, and who should pay for it. This is a critical question to ask your employer before you agree to even consider volunteer for this vaccine.
As part of the screening process, PEF believes, workers need to be offered free, on-the-clock counseling to help them decide whether they should be vaccinated against smallpox. This is especially critical for those in high-risk groups or whose household members or patients are in high-risk groups.
Daily Onsite Monitoring, Tracking, and Reporting
Health care workers who have volunteers to be vaccinated should be monitored daily, on-site. Monitoring should include observation of the inoculation site and bandage. If a health care worker has a strong reaction to the vaccination, she/he should have access to an expert physician, who can refer them for the appropriate diagnoses and treatment regimens.
Any complications, mild or severe, should be tracked and reported to the health department overseeing the vaccination program for your hospital.
Compensation for Lost Work Time
It appears likely that large percentages of newly vaccinated health care workers will have to take time off. In a recent government study reported in The Washington Post (12/5/02), 200 young college students received the vaccinia vaccine. One third of them—66 of the students—missed at least one day of work/school; 75 had high fevers and several were put on antibiotics because physicians worried that they had bacterial infections in their vaccination sites. Others had swollen arms.
CDC advisors are now recommending that health care workers do not have to be off of work while they are shedding the vaccinia virus if the inoculation site is properly bandaged. Previous recommendations stated that recently vaccinated persons posed a risk to unvaccinated at-risk populations for up to 19 days.
PEF’s position is that employers should provide up to seven paid administrative leave days to volunteers with fever and malaise. The seven days is the same as the one-week waiting period for workers’ compensation. Ask your employer, do I have to use my own sick leave, or will there be a special agreement for paid administrative leave or some other approach?
It would be unfair to ask health care workers, already volunteering to be vaccinated with a risky vaccine, to lose pay if they have to take time off after being vaccinated.
Coverage of Medical Costs and Lost Wages
Medical care and lost wages for health care workers who develop complications from the smallpox vaccine, either mild or severe, should have medical costs covered. Unfortunately, at this point, health care workers who get sick from the vaccine need to know that they are on their own. The federal government is not planning to set up a compensation program like the one currently run for children who suffer from other vaccine related illnesses. A provision to compensate workers was taken out of the recently passed Homeland Security Act. It is important that you find out in advance from your employer what he/she plans to cover.
Workers should not have to use their health insurance and make co-payments if they experience complications from the vaccine.
Ask your employer:
- If I or any of my family members get seriously ill from the vaccine who will pay for the health insurance costs?
- If I am sick for an extended period of time, will the state workers’ compensation system cover my medical expenses? What is the benefit for lost wages and how long is the waiting period? Will the employer provide up to one week of paid administrative leave if I have fever, malaise, or disabling pain? Will the employer write a letter to the workers’ compensation insurance carrier telling them that they want any such cases to be covered?
Health Care Workers Have a Right to Say "No" to this "Voluntary" Vaccine without Fear of Discrimination
Federal government officials have repeatedly stated that the smallpox vaccination program is strictly voluntary and that no workers will be required to be vaccinated. But, some workers are worried that they will be unduly pressured to participate.
We are concerned that employers might transfer a "refuser" to another shift or a less desirable or lower paying position. If employers engage in any of this type of discriminatory activity they would be violating the union’s right to bargain over the terms and conditions of employment. You should contact your union representative if you experience any form of discrimination for refusing to participate in the smallpox vaccination program.
Health Care Workers Have a Right to Safer Needles
Special needles called bifurcated needles that look like miniature two-prong "cocktail shrimp forks" are used to administer the smallpox vaccine. Under the federal Needlestick Prevention and Safety Act, employers are required to use needles with integrated safety features. Unfortunately, the CDC has already purchased and packaged millions of conventional bifurcated needles with the vaccine, ready for distribution. However, the federal government has agreed that employers and health departments can choose to purchase and use needles with safety features if they so choose. They should be strongly encouraged to do so because use of the conventional, bifurcated needle exposes the vaccinator to vaccinia and potentially to HIV, hepatitis B and other bloodborne pathogens. It is our position, that use of needles without safety devices is a violation of the OSHA Bloodborne pathogens standard. If your employer refuses to use safe bifurcated needles, a complaint may be filed with the NYS Department of Labor Public Employee Safety and Health Program for violation of the bloodborne pathogens standard.
Conclusion
The decision on whether to participate in the vaccination program is complex and multi-faceted. Of course, if there were a true emergency PEF members would be on the front lines responding. However, this program is unusual since the risks of pre-event vaccination may outweigh the threat of a real bioterrorist attack. Contact your local elected union representatives about your concerns so that they can sit down with management to address them item by item.
Information on the vaccination program grows and changes everyday. What doesn’t change is the dedication of health care workers to their patients, their willingness to respond to the needs of the public health, or the rights they have to accurate information and the safest tools available.
As information about the White House plan to offer vaccinations to health care workers becomes available, additional details will be available on CDC’s website at www.bt.cdc.gov/agent/smallpox/index.asp Additional information and updates will also be posted on PEF Health & Safety website at www.pef.org/healthandsafety/index.htm
Adapted from a draft factsheet developed by the Service Employees International Union, December 2002
