SMALLPOX: SHOULD YOU BE VACCINATED?

BY MARY JANE DITTMAR

President Bush, in his announcement on the national smallpox vaccination program on December 13, 2002, identified three phases for civilian vaccinations. State and local public health agencies will develop and implement all phases of these vaccination programs. All civilian inoculations will be voluntary, including those being made available to first responders.

During Phase I, which began on January 24 in Connecticut, the vaccine was to have been offered to about 500,000 public health investigators and hospital workers designated by state public health departments. These individuals would conduct the initial investigation and treatment of a suspected smallpox case and initiate measures to control an outbreak.

Fire service and other emergency responders, who have a higher risk of exposure to smallpox because of their occupation, will be offered the vaccine during Phase II, which, at press time, was anticipated to begin March 1 (this date is tentative and may vary from state to state). It is anticipated that the vaccine will be made available to adults of the general public who are not at high risk for complications from the vaccine and who insist on being vaccinated sometime in the spring (Phase III). The administration is not recommending vaccination for the general public at this time.

MAKING AN INFORMED DECISION

Whether you should be vaccinated or not is your decision—and one that you should make only after you have become fully informed on all the issues involved. A host of issues must be considered when evaluating the pros and cons of the smallpox vaccination, and they must be viewed not only from your perspective but also from the perspectives of your household members, coworkers, medical services customers, fire department (employer), and municipality.

For starters, the International Association of Fire Fighters (IAFF) suggests you ask yourself the following questions during your prevaccination assessment process.¹ Some of the information that will help you answer some of these questions is given in this article. Your department management should supplement this material and establish an educational program. You should actively participate in the program and keep updated on the issues. A partial list of resources is given at the end of the article.

• Do I live (or work) in an area that is at a perceived risk for a terrorist attack?
• Am I aware that there is no treatment for smallpox?
• Do I know the types of adverse events that might result from the smallpox vaccination?
• Do I have any health conditions (contraindications) that may cause me to suffer adverse effects from the vaccine?
• Does any member of my household or coworker have any of the health condition that are contraindications for receiving the vaccine? In that case, my vaccination would place that person at risk for an adverse reaction to the vaccine.
• Have I fully discussed and reviewed my decision with the members of my household?
• Will I have access to a comprehensive education and training program?
• Are procedures in place for medical screening (before vaccination to determine whether I or others with whom I closely interact have any contraindications for the vaccine), monitoring for adverse reactions, and observing the vaccination site?
• Who will cover my medical expenses if I (or a family member) should have an adverse reaction, or if I must take time off from work because of an adverse reaction?

Questions

“These recommendations are just a first step for our response to smallpox,” says Harold Schaitberger, IAFF president. “We are in unchartered waters and cannot predict the precise effects of these vaccinations, this disease, or any other threats terrorists might unleash on our people.”

The IAFF is advising its members not to be vaccinated if the employer’s vaccination plan does not provide for the following.

• The smallpox vaccination shall be available to all firefighters and emergency medical personnel at no cost, and while on duty.
• Employees may decline the vaccine without being discriminated against in the workplace and shall be able to receive the vaccination without charge at a later date, if desired. [It is highly recommended that an employee who declines the vaccine sign a waiver (see “Waiver of Smallpox Vaccination” on page 68).]
• If the U.S. Public Health Service recommends revaccination for employees who have had the vaccination, the vaccination shall be made available to these employees at no cost.
• The employer shall provide, during working hours, a comprehensive educational program, at no cost, prior to vaccination.
• The employer shall arrange for the appropriate medical screening and monitoring.

EDUCATION/TRAINING

Education is an important component of the vaccination program. State and local health departments will organize and implement the vaccination programs, but, stresses the International Association of Fire Chiefs (IAFC), fire departments should work closely with these agencies.² The IAFC recommends that local public health officials and fire departments join efforts to train fire department employees about the risks associated with the vaccine and in the management of any complications that may develop from immunization. The health agencies should also investigate home situations, as appropriate, to ensure the safety of the members of immunized employees’ households. ⁽²⁾

To better protect the responders’ privacy and avoid liability for the fire department should negligent screening allegations be made or an unforeseen reaction to the vaccine occur, the IAFC recommends that state or local health department employees, not fire department personnel, do the prevaccination medical screening and administer the immunizations. ⁽²⁾

The department’s medical director, in consultation with the public health officials in charge of the vaccination program, should be involved in the vaccination program, assisting in providing department members with educational materials on the risks and benefits of the smallpox vaccination (prevaccination) and giving follow-up medical care to vaccinated department members. (2)

ADDITIONAL IAFC ANDIAFF RFECOMMENDATIONS

As the federal program is currently organized, state and local public health officials will be responsible for numerous administrative and logistical program components, including (but not limited to) the number and locations of clinics, the availability of the vaccine, medical supplies (needles, gauze, and bandages, for example), the informed consent process, human resources and training, and short-term and long-term follow-up of vaccinated individuals.

Fire departments may want to include family members in the prevaccination education program. From the medical perspective, educational materials should cover in sufficient detail at least the following topics:

• The epidemiology and symptoms of smallpox and how it is transmitted, including possible methods of delivery as a weapon of mass destruction.
• What to do if exposed to the smallpox virus. This involves also being familiar with your employer’s control plan.
• How to protect against exposures to smallpox.
• The most current information available on the vaccinia vaccine. [This information may change and will have to be updated as new supplies of the virus are developed; Wyeth Laboratories produced the vaccine now in use; production was discontinued in 1981. Viral titer evaluations have indicated that the vaccine has remained potent, according to the Advisory Committee on Immunization Prac-tices (ACIP).]³
• The method of vaccination and the typical and adverse reactions.
• The risks your vaccination may pose for nonvaccinated family members and fellow employees.
• How to properly care for the vaccination site [preventing vaccination of other areas of your body and other individuals; hand-washing hygiene; disposing of contaminated biohazardous waste (bandages and dressings); and laundering decontamination procedures for clothing, towels, sheets, and other cloth materials that have had contact with the vaccination site, for example].
• That a vaccinated person may not donate blood for at least two months after the date of vaccination, or for 14 days after any complications that may have arisen from the vaccination have been resolved.⁴
• Post-exposure evaluation.
• Selecting the appropriate personal protection equipment and related information such as its availability, doffing, decontamination, and disposal.
• The risks of the disease vs. the risk of the vaccination in both scenarios of vaccination before and after exposure to the smallpox virus.
• Procedures for reporting adverse reactions and proper record-keeping responsibilities.
• Resources for keeping up to date on the subject and making the resources accessible to department members.

In addition, firefighters should be told there is no provision for vaccinating family members in Phase II. Civilians are expected to be offered the vaccine on a voluntary basis in Phase III, which, as noted, was anticipated at press time to begin sometime this spring.

Note: In a “Legal Advisory” in its Fire Chief’s Guide, the IAFC cautions that fire department officials should be “only the conduit of information” for fire department employees, not the source, since fire department personnel are not experts on smallpox vaccination. Such a policy, the IAFC explains, will help protect fire departments and their personnel from the “very possible charge that they gave incorrect information, or not enough information, to a vaccination candidate.” ⁽²⁾ As already noted, state and local health department personnel have the expertise and the responsibility for administering the immunization program.

“The prudent method to disseminate information is through the use of written materials prepared and approved by the health department and through persons trained to provide pre-approved information and answers to questions,” advises the IAFC.

The issue of smallpox vaccination is dynamic and evolving. You and your department must make every attempt to keep up to date on all aspects.

EXPOSURE POTENTIAL

What are the chances that terrorists may use the smallpox virus as a biological weapon? No one can say with certainty. Our government has no specific information concerning an imminent threat of a terrorist attack using the smallpox virus. In its 2001 recommendations pertaining to the smallpox vaccine, the ACIP notes: “The use of smallpox virus as a biological weapon might be less likely than other biological agents because of its restricted availability; however, its use would have substantial public health consequences. A suspected case of smallpox would be considered a public health emergency.” ⁽³⁾

At that time, the ACIP did not recommend vaccination before exposure to the smallpox virus except for groups of laboratory or medical personnel working with specific pox viruses and considered the risk for exposure to the smallpox virus low so that the benefits of vaccination would not outweigh the risk of vaccine complications.

The ACIP explained that if the potential for an intentional release of smallpox virus increased, “preexposure vaccination might become indicated for selected groups (e.g., medical and public health personnel or laboratorians) who would have an identified higher risk for exposure because of work-related contact with smallpox patients or infectious material.” (3)

In the case of an intentional release of the smallpox virus, the ACIP said it would recommend the vaccine for certain groups, including those exposed to the initial release of the virus; persons who had face-to-face, household, or close-proximity contact (about six feet) with a confirmed or suspected smallpox patient at any time from the onset of the patient’s fever until all scabs have separated from the skin; and personnel involved in the direct medical or public health evaluation, care, or transportation of confirmed or suspected smallpox patients. (3)

The ACIP updated its recommendations in October 2002, stating that in the first stages of a preevent smallpox vaccination program, acute care hospitals vaccinate a selected group of healthcare workers (Smallpox Health Care Team) and train them to provide in-room medical care for the first few smallpox patients admitted to the hospital and to evaluate and manage emergency room patients with suspected smallpox.⁵

The ACIP did not recommend that emergency medical technicians (EMTs) as a group be vaccinated in this first phase, but it noted that individual hospitals may want to include on the Smallpox Health Care Team hospital-based EMTs (personnel who would be dispatched to transport patients with suspected smallpox). (5)

THE SMALLPOX DISEASE

Smallpox (variola virus) is a serious, contagious, and sometimes fatal infectious disease. Symptoms, which begin 12 to 14 days after exposure, include high fever, malaise, and prostration with severe headache and backache, followed by the appearance of a rash that appears first on the oral mucosa, face, and forearms and then spreads to the trunk and legs. The rash progresses to papules (small, usually conical, elevations of the skin that generally occur one to two days after the rash appears) and then to vesicles (a type of blister), pustules (small, circumscribed, pus-containing skin elevations with an inflamed base), and scab lesions (14th day). The incubation period is seven to 17 days. The patient is infectious until all scabs have separated, about three to four weeks after the onset of the rash. (3)

The disease is transmitted person-to-person, through direct deposit of infective droplets on the nasal, oral, or pharyngeal mucosal membranes or the alveoli of the lungs from close, face-to-face contact. It can be spread indirectly through fine-particle aerosols or a fomite (an inanimate object or substance that can transmit infectious organisms from one individual to another) containing the virus. During the smallpox era, the overall mortality rate was about 30 percent.

Currently, according to the ACIP, “specific therapies with proven treatment effectiveness for clinical smallpox are unavailable.” (3)

The World Health Assembly certified in May 1980 that the world was free of naturally occurring smallpox. Vaccinations for all military personnel were discontinued in 1990. The ACIP developed its recommendations for the smallpox vaccine because of the concern that terrorists might use the smallpox virus as a bioterrorism agent. (3)

THE VACCINATION

The vaccine (DryvaxT—Wyeth Laboratories, Inc., Marietta Pennsyl-vania) used is a live-virus preparation of the infectious vaccinia virus. It does not contain the smallpox (variola) virus. Its efficacy has not been measured precisely during controlled trials, but epidemiologic studies demonstrate an increased level of protection against smallpox for from three to five years after primary vaccination; substantial, but waning, immunity can persist for greater than 10 years. The vaccine can reduce symptoms or prevent smallpox if administered within the first days (three) after initial exposure. (3)

The Centers for Disease Control and Prevention (CDC) points out, however, that testing at the time the smallpox vaccine was used to eradicate the disease was not as advanced or precise as today; consequently, there may still be things to learn about the vaccine’s effectiveness and length of protection. (3)

The expected response to primary vaccination in a nonimmune person who is not immunosuppressed (see “Contraindications”) is the development of a papule at the site of vaccination (two to five days after vaccination), which reaches its maximum size in eight to 10 days. The evolving pustule dries and forms a scab, which separates within 14 to 21 days after vaccination, leaving a scar. (3)

Based on past experience, it is estimated that one or two people in one million who receive the vaccine may die as a result. Careful screening of potential vaccine recipients is essential to ensure that those at increased risk do not receive the vaccine. About 1,000 people for every one million vaccinated for the first time experienced serious, although not life-threatening, reactions, including a toxic or allergic reaction at the site of the vaccination or a spread of the vaccinia virus to other parts of the body. (3)

Most people will experience mild reactions from the primary vaccination. They would include swelling and tenderness of regional lymph nodes, fever, a sore arm, and body aches. The expected side effects from this vaccine are more significant than those associated with most modern vaccines. Recent research has shown that one in three people vaccinated missed work, school, or recreational activity or had trouble sleeping after receiving the vaccine. It is expected that one in three people who receive the vaccine will miss work for at least one day because of normal reactions to the vaccine. (2)

The IAFC suggests that local fire departments consider staggering the vaccination of firefighters within a shift or fire station so that the continuity of staffing will not be significantly interrupted if members must take sick leave. Statistics show the vaccinated individuals who missed work because of the vaccination generally did so eight to 10 days after vaccination. Since individuals who previously had been vaccinated against smallpox experience fewer side effects when revaccinated, fire departments may want to vaccinate these employees first. (2)

CONTRAINDICATIONS FOR THE VACCINATION (3)

Before administering the vaccine, the physician should complete a thorough patient history to document the absence of vaccination contraindications among the persons being vaccinated and their household members. Individuals at high risk for complications from the vaccine—and who should not receive it for routine nonemergency indications—include the following:

• Individuals who have or have had eczema (even though they may be healed at the time) or atopic dermatitis (even if the condition is not currently active, is mild, or was experienced as a child). Persons with an acute, chronic, or exfoliative skin condition (burns, chickenpox, shingles, impetigo, herpes, severe acne, psoriasis) should not get the vaccine until they have completely healed.
• Individuals with suppressed immune systems, such as those who have had solid organ transplantation; are HIV-positive; have leukemia, lymphoma, generalized malignancy, or cellular or humoral immunity disorders; and received therapies involving alkylating agents (inhibits cell division), antimetabolites, radiation, high-dose corticosteroids, or chemotherapy.
• Individuals under the age of 18.
• Individuals with moderate or severe short-term illnesses, until they are fully recovered.
• Women who are pregnant, plan to become pregnant within one month, or are breast-feeding.
• Individuals who are allergic to the vaccine or any of its ingredients.

DryvaxT contains trace amounts of the antibiotics polymyxin B sulfate, streptomycin sulfate, chlortetracycline hydrochloride, and neomycin sulfate. It does not contain penicillin. Future supplies of the vaccine will be reformulated and might contain other preservatives or stabilizers. Consult with the health professionals running the vaccination program, and read the manufacturer’s package insert for current information about the vaccine used in your program.

If you have any of the above conditions or live with someone who does, and you have not had a direct exposure to smallpox, you should NOT get the vaccine. If you are directly exposed to the smallpox virus, and you have not been vaccinated, you should get the vaccine immediately, regardless of your health status. The risk of the disease outweighs the complications associated with the vaccination. The persons at greatest risk for experiencing serious vaccination complications are also at greatest risk for death from smallpox. If you have had an exposure and you were not vaccinated, you must be quarantined until you are vaccinated and medically released.

If a relative contraindication to vaccination exists, the risk for experiencing serious vaccination complications must be weighed against the risk for experiencing a potentially fatal smallpox infection. When the level of exposure risk is undetermined, you and the clinician should prudently assess the potential risks of the disease vs. the benefits of smallpox vaccination.

DECLINING THE VACCINATION

If you decline the vaccination because you or a member of your family has a condition that contraindicates getting the vaccine, that condition, as in the case of any other medical condition, should be a private matter to the greatest extent possible. (2) In the same vein, only essential personnel should know whether you have been vaccinated or declined vaccination.

If you decline the vaccination, you, as noted, should sign a waiver. The IAFC and the IAFF recommend that language used in the waiver be based on that used by the U.S. Occupational Safety and Health Administration for the hepatitis B vaccination and Section 4(b) (4) of the Occupational Safety and Health Act (see “Waiver of Smallpox Vaccination” on page 68). (1,2)

VACCINATION SITE CARE

The vaccination site is a critical area and must be properly cared for. The virus used in the vaccination can spread from the vaccination site to other parts of the vaccinated person’s body or to other people, beginning two to five days after vaccination—at the time a papule appears—until the scab separates from the body.

Proper site care will also help prevent secondary infection. High-risk individuals in the household or workplace especially may be vulnerable to virus shedding and scab particles from a vaccinated employee during the post-vaccination healing period. Any injury to the vaccination site must be reported to and immediately evaluated by medical personnel.

Hand washing is the most important means of preventing inadvertent contact spread from the vaccination site. Wash hands with soap and water or an alcohol-based waterless antiseptic solution after touching the vaccination site area. As already noted, employees should receive in-depth information on how to properly care for the vaccination site.

Nonvaccinated persons should not come in contact with the site or contaminated materials from the site.

WORKPLACE ADMINISTRATIVE CONSIDERATIONS

“Because of the potential for complications, it is important for fire chiefs to take an active role in planning the vaccination program for their departments,” says Chief Randy R. Bruegman, IAFC president. “While state and local health departments will run the individual vaccination clinics, the operational and administrative issues raised by vaccination demand that fire department management be actively involved in the decision-making process.” He urges department chiefs to supplement the information in the IAFC Guide (a hard-cover copy of which was to have been sent to IAFC members around the end of January) with “regular visits to the federal government’s smallpox vaccination Web site, www. smallpox.gov.”(2)

Bruegman stresses that it is up to the local fire chief to work closely with public health officials to successfully implement a smallpox vaccination program. He also recommends that fire departments consult with their legal department with regard to their specific vaccination program. (2)

Another responsibility of fire department management, the IAFF points out, is to evaluate fire and EMS emergency response and training activities that may affect members’ vaccination site. Rubbing, for example, might cause a pustule to break, and prolonged immersion in water might break down the tissue or precipitate a secondary infection. The vaccination site might be injured by ordinary fire and EMS activities such as donning and doffing heavy protective clothing and SCBA, carrying heavy objects (hose or high-rise packs), and leaning against walls while using hoselines at a fire. ⁽¹⁾

Minimizing contact between newly vaccinated employees and nonvaccinated employees (including those who are pregnant) and members of the public is another issue fire department managers must address. Vaccinated and nonvaccinated employees must be physically separated. Nonvaccinated personnel may have to be exempted from activities during which they might come in contact with recently vaccinated employees and potentially infectious materials. These precautions must be extended to maintaining separate sleeping quarters, bed linens, towels, protective clothing, and equipment (SCBA, for example) for vaccinated and nonvaccinated members. All this must be done while protecting the privacy of the unvaccinated employees. (1,2)

LOCAL OFFICIALS

The chief of the department must make local government officials aware of the public policy and financial aspects of the vaccination program, including the effect the program will have on department operations and the degree of impact vaccination of the general public would have on the department. (2) Officials must be alerted to the legal issues (see below) that might arise and the limited protections currently available under section 304 of the Homeland Security Act.

Section 304 of the Homeland Security Act provides that no claim for liability for injury or death as a result of participation in the smallpox vaccination program can be brought against a manufacturer of the vaccine or the healthcare provider who administered the vaccine. CDC has posted on its Web site at www.bt.cdc.gov/agent/smallpox/vaccination/ pdf/section-304-qa.pdf a legal analysis of section 304.

FINANCIAL ASPECTS

A smallpox vaccination program may have a significant financial impact on a fire department. Fire department management should conduct a fiscal analysis to determine the scope of the impact. There will be costs for education and training, time used for obtaining the vaccinations and transporting employees to and from the vaccination site, sick pay and disability resulting from the vaccine side effects, backfill and overtime pay, anticipated increases in workers’ compensation costs, administrative costs associated with overseeing the program, purchasing dressings, and follow-up care for vaccinated individuals (there may be additional costs also). Then, fire department management must apprise the local officials of the projected costs. Decisions regarding the implementation of the vaccination program also would affect labor negotiations and contracts. Management should consult with the local union representatives. (2)

LEGAL CONSIDERATIONS

There is no federal program to cover the medical costs associated with side effects from the smallpox vaccine. The federal government is recommending that employees considering being vaccinated check with their employer to determine if vaccination reactions will be covered under workers’ compensation. Because the vaccination is voluntary, many states may refuse to cover the expenses. In that case, the vaccinated individuals (and possibly their health insurance companies) will be responsible for the medical costs; the workers would also be responsible for any lost wages.

Fire department management should monitor this issue very closely to determine if their personnel are covered under all provisions of the workers’ compensation system, including disability and wrongful death. They should call their appropriate state agency or workers’ compensation insurance carrier to determine if the costs of medical care caused by a reaction to the vaccine are covered. (2)

RECORDKEEPING

The employer is required to maintain records according to the following schedule:

Medical records. Include the employee’s name, social security number, smallpox vaccination status, all examinations and evaluations, healthcare professionals’ written opinions; information provided to the healthcare professionals should be kept for the duration of employment, plus at least 30 years. Employees who suffer an adverse reaction to the vaccine should immediately file a Vaccine Adverse Event Reporting System (VAERS) form (see www.vaers.org). Medical records are confidential; contents may not be disclosed or reported without the employee’s written consent. Medical records are to be available to employees and, on request, to parties who have the employee’s written consent. ⁽¹⁾

Training records. These records must be retained for three years from the date on which the training occurred. Training records are available to the employee or employee representative on request. ⁽¹⁾

Smallpox education. The fire department should maintain comprehensive and accurate records documenting that all of its firefighters and their family members were educated about the vaccination program and the risks of accepting or declining the vaccination. The educational materials also should be sent home with firefighters and be signed by the family member(s) who would be at risk if the firefighters were vaccinated. (2)

As this article was going to press, news reports were surfacing that some in the medical and labor communities had serious reservations about implementing the smallpox vaccination program. A 15-member Institute of Medicine (IOM) panel, which met December 18-20, 2002, for example, has urged that more time be allowed between Phase I and Phase II so that Phase I could be evaluated and any lessons learned be incorporated in Phase II. The majority of the panel members are medical school professors; the panel was formed at the CDC’s request. One panel member indicated, “There are a lot of reservations and safeguards that need to be put in place.”⁶

Dr. Julie L. Gerberding, director of the CDC, said the CDC and states would monitor safety continuously and make the necessary changes as needed. (6)

The IOM panel also expressed concern about who would cover lost wages and medical expenses for people who have adverse effects from the vaccine. (6) The panel requested that the CDC and state health departments clarify this issue and “make sure that consent forms describe what compensation is available.” (6)

The CDC, Dr. Gerberding said, would provide some guidance but “both compensation and consent forms would ultimately be decided by individual states.” (6)

The panel also recommended that the CDC reconsider the plan that would have the safety board monitoring the vaccination program “connected to a disease centers advisory group.” The panel says the safety board should “be independent of the government” so that public trust would be maintained. Dr. Gerberding noted that the CDC had received input from “a variety of sources” on that issue and “will take whatever input we get from IOM very seriously.” (6)

She added: “We have enormous respect for the IOM. The credibility of their input is always taken very seriously by CDC, and we look forward to seeing the final report. That’s why we wanted to take this issue to the IOM.” (6)

The American Federation of State, County and Municipal Employees and the Service Employees International Union have expressed concern that not enough safeguards are in place to ensure that people with contraindications for the vaccine are not vaccinated and about the lack of compensation for people who may suffer adverse effects from the vaccination. The unions said screenings might not be adequate, especially since many states are experiencing financial difficulties and no federal money has been designated for the smallpox programs.⁷

The IAFF is advising its fire service members to make sure that the employer ensures that the health-care professionals who vaccinate their employees are aware of any modifications in clinical recommendations as the vaccination program progresses. Employers, the IAFF says, “shall implement a quality assurance program to assess techniques of vaccinators.” (1)

Only Four Are Vaccinated in Connecticut

In another update, Phase 1 of the smallpox vaccination program began on January 24 in Connecticut. Only four of the desired 20-health care-worker minimum on the state’s “Genesis Team” were vaccinated. Connecti-cut is anticipating ultimately vaccinating about 6,000 health care workers throughout the state. Some attribute the poor turnout to the concerns about safety and liability voiced by health unions.⁸ Some health care workers, including nurses, and hospitals have declined to participate. Reportedly, Connecticut state legislators are preparing laws that will “clarify that workers’ compensation is available to participants in the vaccine program and that health insurance cannot be denied for any adverse reaction.” The U.S. Department of Health and Human Services is also said to be considering developing a plan to cover individuals who have adverse reactions to the vaccine. (8)

The IAFC and IAFF will continue to consult regularly with federal authorities. Updates will be posted on their Web sites and announced through media alerts and press releases. Look also for updates on the CDC Web site www.bt.cdc.gov/agent/small/pox/index.asp. Check also the Heath Beat column on fireengineering.com.

References

1. Smallpox Vaccination Program Guidance for Fire Fighters, International Association of Fire Fighters, Dec. 24, 2002, full document at www.iaff.org.

2. Fire Chief’s Guide to Smallpox Vaccination, International Association of Fire Chiefs, Jan. 2003, full document at www.iafc.org.

3. Vaccinia (Smallpox) Vaccine, Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001, June 22, 2001.

4. “Smallpox Vaccine Recipients Cautioned,” AP, Yahoo!News, www.yahoo.com, Dec. 31, 2002.

5. “Summary of October 2002 ACIP Smallpox Vaccination Recommendations,” updated Oct. 21, 2002, www.bt.cdc.gov/agent/smallpox/vaccination/acip-recs-oct2002.asp.

6. “Medical Panel Has Doubts About Plan for Smallpox,” Denise Grady, www.nytimes.com/2003/01/16/politics/ 16SMAL.html.

7. “Unions Want Delay on Smallpox Vaccine,” AP, Jan. 16, 2003; http://health.yahoo. com/search/healthnews?lb=s&p=id:34302.

8. “Slim turnout for first smallpox shots,” MSNBC News (contributions from AP and Reuters), www.msnbc.com/news/850537.asp, Jan. 24, 2003.

• IAFC Smallpox Vaccination Working Group formed, IAFC Member News Alert, Dec. 12, 2002.
• IAFC Update: Impact of Smallpox Vaccination Proposal on the Fire Service, IAFC Member News Alert, Dec. 30, 2002.
• CDC Public Health Emergency Preparedness & Response, Smallpox Vaccine Overview, www.cdc.gov, Atlanta, GA (404) 639-3311; public response hotline: 888-246-2675.
• Fire Engineering, Dittmar, Mary Jane, Health Beat, fireengineering.com: January, February, March 2003 columns.

• Agency for Healthcare Research and Quality: Extensive Smallpox Information
  www.bioterrorism.uab.edu/EIPBA/Smallpox/moreExtInfo.html
• American Academy of Dermatology
  www.aad.org/BioInfo/smallpox.html
• American College of Physicians-American Society of Internal Medicine
  www.acponline.org/bioterro/index.html
• American Medical Association
  http://www.ama-assn.org/ama/pub/category/6206.html
• Centers for Disease Control and Prevention

Web Sites

—Main smallpox information index
www.bt.cdc.gov/agent/smallpox/index.asp
—Smallpox vaccination and adverse reaction training module
www.bt.cdc.gov/training/smallpoxvaccine/reactions/
—Smallpox Fact Sheet: People Who Should NOT Get The Smallpox Vaccine (Unless They Are Exposed To The Smallpox Virus)
http://www.bt.cdc.gov/agent/smallpox/vaccination/contraindications-public.asp
—Smallpox Fact Sheet: Vaccine Overview
www.bt.cdc.gov/agent/smallpox/vaccination/facts.com
—Smallpox (basics)
http://www.bt.cdc.gov/agent/smallpox

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• DOD smallpox vaccination program
  www.smallpox.army.mil/
• Johns Hopkins University: smallpox fact sheet
  www.hopkins-biodefense.org/pages/agents/agentsmallpox.html
• Journal of the American Medical Association
  http://jama.ama-assn.org/issues/v281n22/ffull/jst90000.html
• Listing of state immunization program Web sites
  www.immunize.org/states/index.htm
• National Association of County and City Health Officials
  www.naccho.org/Smallpox.html
• National Library of Medicine/National Institutes of Health
  www.nlm.nih.gov/medlineplus/smallpox.html
• National Network for Immunization Information
  www.immunizationinfo.org/vaccineInfo/disease_results.cfm?id=26
• New England Journal of Medicine
  http://nejm.org/earlyrelease/early.asp
  http://nejm.org/specialnotice/special.asp
• Smallpox as a Biological Weapon: Medical and Public Health Management
  http://jama.ama-assn.org/issues/v281n22/ffull/jst90000.html
• U.S. Department of Defense
  —Official site for military vaccinations, www.vaccines.army.mil
  —DOD Smallpox Vaccination Program, www.smallpox.army.mil
• U.S. Department of Health and Human Services
  www.smallpox.gov
• Walter Reed National Vaccine Healthcare Center Network
  www.vhcinfo.org
• World Health Organization Fact Sheet on Smallpox
  www.who.int/emc/diseases/smallpox/factsheet.html

MARY JANE DITTMAR is senior associate editor of Fire Engineering magazine and fireengineering.com. Before joining the magazine in 1991, she served as editor of a trade magazine in the health/nutrition market and held various positions in the educational and medical advertising fields. She has a bachelor’s degree in English/journalism and a master’s degree in communication arts.