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Faced with growing resistance, the Bush administration's smallpox vaccination plan is off to a slow start.
Eight weeks after the president announced a voluntary program to vaccinate a half-million health care workers, employee unions are balking, big hospitals are opting out and crucial questions about liability and compensation for vaccine side effects remain unanswered.
The Centers for Disease Control and Prevention has so far shipped 204,000 doses to 40 states, but as of Thursday, only 687 volunteers had rolled up their sleeves.
In Florida, the first stage of Operation Vaccinate Florida is scheduled to begin Monday with smallpox response teams at hospitals and county health departments receiving voluntary vaccinations. Some 33,000 doses have been allocated for stage one, which is expected to last one to two months, said Bill Parizek, a spokesman for the Florida Department of Health.
During a telebriefing Thursday, CDC director Julie L. Gerberding repeatedly stressed that initial numbers were only estimates, not targets, and that the goal is to have enough vaccinated workers to care for the sick in the event of a smallpox attack.
"We are just in the very early stages of the vaccination program," she said. "We do not have a target number of people to vaccinate. What we have is the targeted capacity to protect the American people. . . . Our goal is the achievement of a preparedness capacity."
Gerberding said there is a "basement" number for preparedness but did not specify the figure.
The compensation issue has become a significant stumbling block, Gerberding said. Based on historic data, a small number of the people vaccinated will face life-threatening injuries, and federal officials acknowledge they need a way to offer compensation for lost wages and medical expenses.
Reimbursement for lost wages and medical expenses is now available only through the workers' compensation system, which has many holes.
Gerberding said the Bush administration is getting "closer and closer" to proposing a solution. An existing compensation fund helps people injured by other vaccines, but does not include smallpox.
Paul A. Offit, head of the vaccine center at Children's Hospital of Philadelphia, was a member of the CDC's Advisory Committee for Immunization Practices. At a smallpox seminar presented by the College of Physicians of Philadelphia on Wednesday, Offit explained why Children's Hospital won't vaccinate any employees:
The vaccine works when given days or weeks after exposure to smallpox, so mass inoculation could still begin after a first case is identified. The virus is not contagious until pox appear a week or two after infection, so there is time to identify and quarantine exposed people. The traditional strategy of quarantining exposed people and vaccinating their contacts helped eradicate smallpox worldwide by 1980.
Most of all, Offit said, the risks of harm from the old-fashioned vaccine, which is actually a smallpoxlike virus that triggers an immune response, outweigh the theoretical benefit of protection from an unlikely bioterrorist attack.
Offit noted that during the last New York City smallpox emergency in 1947, two people were infected and died of the disease -- and three people died of the emergency vaccinations in the city.
Currently, two U.S. soldiers are recovering from complications of smallpox vaccinations. (Inoculation is mandatory for military personnel.)
Of the nation's 3,000 hospitals, at least 80 have opted out. Last week, the huge St. Barnabas Health Care System, which has its headquarters in northern New Jersey and eight satellites throughout the state, said it "cannot, in good conscience, participate."
In Charlotte, N.C., the Presbyterian Healthcare system is not participating, given the certain risk of the vaccine and the unknown risk of an attack, said spokesman Kevin McCarthy.
The hospital sees "no credible evidence of smallpox threat," he said. "Maybe if we were New York or Washington, D.C., maybe we would. We don't see the risk at this point."
In Atlanta, just two of seven metro trauma centers are participating, but that could change if the threat becomes better defined, said Dr. Kathleen Toomey, director of the Georgia Division of Public Health.
The vaccination program is being conducted by 50 states, the District of Columbia and three large cities -- Los Angeles, New York and Chicago -- as well as U.S. territories.
-- Information from Knight Ridder Newspapers and the Associated Press was used in this report.