Emergency Medical Technicians²⁴

The National Association of Emergency Medical Technicians (NAEMT) represents the professional interests of over 870,000 emergency medical service responders, including EMTs, paramedics, and EMS first responders. A NAEMT position paper published June 7, 2002, describes four protective measures recommended for smallpox vaccination in the event of bioterrorism.

The first measure calls for the active participation of EMS organizations in community threat assessment in conjunction with relevant public health authorities. Participation of EMS organizations in such assessments would ensure accurate and timely communication to EMS organizations about the nature and level of the threat—potentially shortening the implementation time frame for actions necessary to protect the safety of emergency medical personnel—and would provide a mechanism for EMS input into the process.

The second measure calls for amending the EMT and paramedic national standardized curriculum to insure that all EMTs and paramedics are adequately educated about all terrorism responses, their implications, and their impacts on the health, safety, and well being of the EMT community.

The third measure calls for the voluntary smallpox vaccination of EMTs and paramedics in the absence of a confirmed smallpox case or a confirmed smallpox bioterrorism attack. The voluntary smallpox vaccination initiative should be modeled after the past precedents established in the OSHA standard pertaining to blood-borne pathogens.

A combination of tactics and technology allows EMTs and paramedics to operate safely while providing patient care and rescue services in a threatening environment. It is not likely, at least in the early, unrecognized stages of a bioterrorism attack, that those infectious smallpox patients seen as part of an emergency medical response will be appropriately diagnosed in sufficient time to adequately protect the responding personnel. Once there has been a recognition of a bioterrorism attack, it is not likely that a vaccination program could be completed in sufficient time to prevent a significant attenuation, or perhaps a complete collapse of the emergency medical response system. Affording EMT personnel access to the smallpox vaccination before the event is the tactical application of available technology that is both prudent and necessary.

Many EMTs, paramedics, and EMS first responders return home in the same clothing and the same condition that they left work in, which could result in transmission of infection to their families. The fourth protective measure proposes that smallpox vaccination be made available to the immediate family of an emergency medical service member without delay upon recognizing that a smallpox emergency has been identified. The foundation for this proposal is clearly delineated in the NAEMT position paper. Adopting this proposal is logical, if only in limiting the propagation of the disease by eliminating the families of rescuers as potential sources of infection.

Fire Chiefs²⁵

There are 26,000 local fire departments in the United States with variable organizational structures. Perhaps the only unifying component of the vast majority of these systems is that fire services provide EMS first response, as well as the majority of emergency ambulance transport. The anthrax attacks highlighted the role of the fire service in providing hazardous material clean up, placing an enormous strain on local response systems.

At this time, the International Association of Fire Chiefs does not feel it is appropriate to vaccinate fire service personnel pre-exposure, in part due to the risks of the vaccine. Regarding Question 3, the use of ring vaccination as the primary control strategy in the event of a confirmed outbreak, the International Association of Fire Chiefs favors Option 2, that is, supplementing ring vaccination with nationwide vaccination of those who would assist in the containment, including fire service personnel. Any vaccination policy must be supplemented with an aggressive public and health care provider education campaign.

Emergency Services²⁶

The California Governor's Office of Emergency Services (OES) is one of the largest emergency management organizations in the United States. Under the authority of the California Emergency Services Act, as well as other California legislation, OES is responsible for the mitigation, planning, preparation for, and coordination of California's emergency response to, as well as a recovery from, the effects of multi-hazard emergencies that effect lives, property, and the environment. OES works cooperatively primarily with local and regional agencies in California. California also stands ready to assist other states with the resources and expertise of the emergency management communities within California.

While OES does not represent any one class or discipline of responder, it does have extensive experience working with and coordinating the efforts of both traditional and non-traditional emergency responders in various situations. It is not the intent of OES to second guess or judge the risk assessments that have been made by other subject matter experts on these issues.

In reaching its recommendations regarding smallpox vaccination, OES made two additional assumptions surrounding the use of the live vaccinia vaccine. The first is that respect for individual autonomy requires that any use of smallpox vaccine in any situation be voluntary. Alternatives for the protection of individuals, and also the community exist in any situation where an individual refuses smallpox vaccination for whatever reason. It follows from this assumption as a second assumption that absent the re-introduction of smallpox into the wild, individuals, including emergency response members, have a reasonable expectation to remain free from either inadvertent or unwanted exposure to vaccinia virus via transmission from recently vaccinated individuals.

California OES agrees with CDC's risk assessment that the risks of the smallpox vaccine outweigh the benefits for the general public, and that the vaccination of the public should not be undertaken at present. In support of that assessment, OES strongly encourages the public health community to present a unified and unequivocal recommendation regarding this option (Option 1).

It has been the experience of OES that members of the general public respond in a cooperative and constructive manner when presented truthful information by subject matter experts who speak with a consistent message. Since the adoption of a position of no public vaccination will require educating the public about the risk assessment that forms the basis for that recommendation, any perceived equivocation will make successful implementation of such a policy difficult at best.

Question 2, regarding the possible expansion of pre-exposure vaccination, is perhaps the most difficult question to look at from the emergency management perspective. The specific occupational groups that make up the disciplines that are required to investigate, contain, control, and treat a reintroduction of smallpox into the community are heterogeneous, and occupy a spectrum of risk that is intermediate between the orthopox virus laboratory workers and the general public.

In constructing a rational policy regarding this question, OES believes it is useful to focus on the specific missions of the various occupational groups, and consider the time periods and the natural history of the smallpox outbreak involved. Given the existence of alternative and complementary protective measures—such as respiratory protection, isolation, and immediate post-exposure vaccination—it seems prudent to focus pre-exposure vaccination on the groups that could be reasonably expected to be at highest risk of exposure early in a smallpox outbreak. These groups appear to be primarily epidemiologists, public health responders, and others who would be investigating unusual vesicular rashes or disease outbreaks in the population. OES believes it is neither ethical nor realistic to ask these occupational groups to investigate the earliest stages of what may be a smallpox outbreak, given the existence of an effective vaccine, without being offered voluntary pre-exposure vaccination. These higher-risk occupational groups are best identified in the context of an organized, pre-planned smallpox investigation team or smallpox investigation program that has specific tasks and individuals assigned. These teams could variously be located at either regional or state levels, and created in response to a specific state-level risk assessment.

OES supports the development of specific guidelines to assist the states in developing the appropriate response mechanisms that take into account each state's unique risk, the resources available, and the geographic proximity to federal smallpox response resources.

OES recognizes that this pre-exposure vaccination recommendation does not include most traditional first responders such as general fire responders, law enforcement, and paramedical responders, as well as other health care workers. In addition to the lower relative risk that these groups have for an unrecognized exposure to wild smallpox virus, that others have observed, the logistical difficulties of a widespread voluntary vaccination program, the impacts of an already stressed emergency response system resulting from the decreased productivity of these key responders due to local vaccine reactions, as well as the possible logistical and financial costs associated with any restriction on the movement or occupational activity of these recently vaccinated responders, makes a general first responder vaccination program both non-effective and unwarranted at present. Any perceived needs within the first responder community should not allow inadvertent harm to occur to this population through good intentions.

Adoption of any recommendation for a limited pre-exposure responder vaccination must be accompanied by an intensive education process to address: 1) the legitimate concerns of those at lower risk, non-vaccinated first responders; 2) the efficacy of complementary smallpox vaccination strategies; and 3) the distinctions among risks assigned to various occupational groups. Most first responders understand and accept the inherent risks involved in their chosen profession and will respond appropriately to a reasoned explanation of the scientific and public health rationale for this recommendation. Emergency responders understand they cannot function in an absolute risk-free environment, and will respond as long as the risks have been minimized to the lowest practical level.

The recommendation of selected pre-exposure vaccination appears to represent the lowest practical risk level regarding smallpox. OES recognizes that knowledgeable persons may differ in the designation of the relative higher versus lower intermediate risk groups, and strongly urges that to the maximum extent possible, objective and consistent guidelines be used by the states in identification of these occupational groups. It is vital that these pre-exposure smallpox vaccination volunteers be thoroughly educated in the risks and benefits, that appropriate safeguards be in place to reduce inadvertent subjective coercion of the responders' decision to receive a pre-exposure vaccination, and that these persons, because of their vaccinated status, be fully utilized in a smallpox response program in the event of reintroduction of smallpox virus into the population. In addition, mechanisms are needed to insure that rapid post-exposure vaccination is available to all first responders if this recommendation is to have any credibility with the emergency response community.

With regard to Question 3, OES recommends that the fundamental biology of variola be considered in light of the collective human experience, which favors primarily ring containment. However, it is naive to suspect that there would not be a huge public demand for vaccination if a smallpox outbreak were to occur. Therefore, any vaccination plan will have to prioritize levels of community vaccination.

Footnotes

24

This section summarizes the presentation by MacNeil Cross, National Association of Emergency Medical Technicians.

25

This section summarizes the presentation by Matthew Spengler, International Association of Fire Chiefs.

26

This section summarizes the presentation by Steve Tharratt, California Governor's Office of Emergency Services.