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More May Be at Risk from Smallpox Inoculations

Study: Half of hospital patients could get secondary infections

TUESDAY, March 25, 2003 (HealthDayNews) -- Many more hospital patients than previously thought may be at risk of getting smallpox-related complications from health-care workers who have recently been vaccinated under the federal government's program.

A survey of New York state hospitals found that at any one point in time, more than half of inpatients have one or more conditions that could put them at increased risk for secondary transmission, says a research letter published in the March 26 issue of the Journal of the American Medical Association.

Live vaccinia virus -- which causes a virus related to smallpox, but milder -- is present at the vaccination site for up to three weeks after inoculation and can be transmitted to other parts of the body or to other individuals via direct contact.

Judging from experiences in the 1960s, the letter says, for every 100,000 people vaccinated, there could be two to six secondary transmissions to unvaccinated contacts with one to two cases of eczema vaccinatum, a skin condition. Certain groups are at heightened risk for this secondary transmission, including children under the age of 5, people with chronic dermatologic conditions, and individuals with compromised immune systems resulting from diseases like HIV or cancer.

Nevertheless, current U.S. Centers for Disease Control and Prevention recommendations advise against hospital personnel taking administrative leave after receiving the vaccine. Instead, those vaccinated are advised to cover the site with a bandage, wear a longer-sleeved shirt as an extra barrier, and to wash their hands meticulously after touching the area.

The problem is that health-care workers do not have a good track record when it comes to frequent and thorough handwashing.

"If we keep [the vaccination site] covered and wash our hands there will be no problem, but, as a health-care community, we haven't washed our hands yet," says Dr. Kent A. Sepkowitz, co-author of the letter and director of hospital infection control at Memorial Sloan Kettering Cancer Center in New York City. "The guidelines are safe and wonderful as long as people follow them."

Health-care workers on the front lines say this is why they are opposed to the vaccination program in the first place.

"There's a reason that there's a rash of hospital-acquired infections. It's because basic infection control measures are not being strictly adhered to simply for the reason that you have to prioritize," says Liz Jacobs, a spokeswoman for the California Nurses Association in Oakland, which is opposed to the vaccination program.

"If you've got two patients in a critical situation, then washing your hands may not be the first thing you do," Jacobs says. "I interpreted this conclusion to be unrealistic. People in the course of the day may absentmindedly be scratching and dislodge the bandage and there could be seepage. I just don't see that as a realistic solution."

The researchers came by their numbers by analyzing New York state hospital discharge files for 2001. Specifically, they looked at people who had conditions that would preclude them from getting a smallpox vaccination and at those who has diagnoses indicating that they were "immunocompromised" or had skin conditions possibly putting them at risk for secondary transmission.

During 2001, there were 1,107,173 hospital discharges in New York City, 228,043 (21 percent) of which were classified as high-risk. This included HIV/AIDS, cancer, dermatitis, and newborn babies. Almost 400,000 patients (36 percent) were considered lower risk, a category that included burns, diabetes, rheumatoid arthritis, and inflammatory bowel disease.

In the rest of New York state, 240,170 (19 percent) of the 1,294,287 total hospital discharges were considered high-risk while 470,739 (36 percent) fell into the lower-risk category.

The estimates are admittedly crude, say the study authors, but overestimates in some categories may have been ruled out by underestimates in other categories.

Jacobs was not particularly surprised that the numbers were so high. "Anyone who's being admitted to an inpatient setting these days is going to be more than likely in a compromised immunity state," she says.

Sepkowitz was surprised. "More people were at risk than we thought," he says. "I hope that health-care workers will think, 'Gee whiz, I'd better take this seriously.' This is actually high-stakes stuff. We are playing with fire. We can do it safely if we do it right. If we do it unsafely, we could have a real problem."

More information

For more on smallpox, visit the Centers for Disease Control and Prevention or the Department of Health and Human Services.

SOURCES: Kent A. Sepkowitz, M.D., director, hospital infection control, Memorial Sloan Kettering Cancer Center, New York City; Liz Jacobs, R.N., spokeswoman, California Nurses Association, Oakland; March 26, 2003, Journal of the American Medical Association
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