1. Child Health Evaluation and Research Unit
Division of General Pediatrics, University of Michigan
Factors Related to the Formation of Smallpox Response Teams in US Hospitals
                                                                                                              
UM Research Team:
Alex R. Kemper, MD, MS; Anne E. Cowan, MPH; Matthew M. Davis, MD, MAPP; Emily J. Kennedy, MPH; Sarah J. Clark, MPH; and Gary L. Freed, MD, MPH
CDC Collaborator: Pamela L.Y.H. Ching, MS, SD, RD, LD
National Immunization Conference
May 13, 2004

2. Background
October 2002: ACIP/HICPAC recommended that hospitals vaccinate teams of healthcare workers to prepare for a potential smallpox outbreak
January 2003: Smallpox Pre-Event Vaccination Program (SPVP) implemented at state and local levels with CDC assistance
Hospital participation lower than expected

3. Objectives
Understand factors influencing hospitals’ decisions to participate in the SPVP
Identify factors that would lead non-participants to change their decision
Describe policies developed by participating hospitals to implement vaccination program

4. Methods: Hospital Selection
Smallpox preparedness coordinators from 24 states with estimated hospital participation of 25-75% were contacted by CDC
9 states provided hospital contact information: CA, KY, ME, MI, MS, MN, UT, VA, and WY
Acute care hospitals chosen to represent variation in size, county, affiliation, and decision to participate in SPVP
148 hospitals in final sample
Ranged from 5 in MS to 21 in UT

5. Methods: Interview Process
Semi-structured telephone interviews were conducted with hospital decision-makers between June-November 2003
Interview protocol (~20 minutes):
Individuals involved in decision
Hospital’s ultimate decision
Whether specific factors considered
Key factor(s) in decision
SPVP participants: program implementation
SPVP non-participants: factors that would change decision

6. Specific Factors Addressed in Interview
Perceived risk of smallpox outbreak
Risks of vaccination
Safety for vaccinees
Exposure of patients/close contacts of employees
Policies for vaccinated employees
Costs to hospital
Compensation for adverse events
Liability
Other costs
Stakeholder influences
Employees
General public
Other outside parties

7. Results Decision-makers at 123 of 148 hospitals (83%) were interviewed
Response rates ranged from 60-94% across states
88 of 123 hospitals (72%) decided to participate in SPVP
No staff were vaccinated at 22 of these 88 hospitals

8. Factors Considered in Decision
Chose to Participate in SPVP
(n=88)
Chose Not to Participate in SPVP
(n=35)
Risk of a Smallpox Outbreak
88% (77)
91% (32)
Risks of Vaccination
90% (79)
100% (35)
Potential for adverse events in vaccinees
82% (72)
97% (34)
Exposure of close contacts of vaccinees
63% (55)
80% (28)
Need for policies for vaccinated employees
57% (50)
60% (21)
Costs to the Hospital
91% (80)
94% (33)
Compensation for adverse events
78% (69)
89% (31)
Liability
77% (68)
83% (29)
Other financial or opportunity costs
28% (25)
26% (10)
Stakeholder Influences
72% (63)
74% (26)
Employees
38% (33)
37% (13)
General public
34% (30)
26% (9)
Other outside parties
44% (39)
49% (17)

9. Factors Considered in Decision (continued)
Risk of Smallpox Outbreak
Hospitals made own assessment of risk of a smallpox outbreak
Many also assessed their perceived risk of exposure
e.g., proximity to urban areas, likelihood of receiving case as transfer patient
Almost all felt the risk of outbreak was low
“The risk of an outbreak didn’t seem likely, but if it were to happen, it would be devastating and we felt we needed to be prepared ahead of time.”

10. Factors Considered in Decision (continued)
Risks of Vaccination
Participating hospitals found ways to address safety concerns
e.g., employee education, screening protocols
Those that decided not to participate had unresolved concerns about vaccine safety or determined that risks too great
Many hospitals struggled over need to develop employee policies to protect contacts of vaccinees

11. Factors Considered in Decision (continued)
Costs to Hospital
Regardless of decision, liability and workers’ compensation major concerns
federal legislation did not necessarily alleviate concerns
Workers’ compensation addressed in varying ways
A few smaller hospitals concerned with cost of lost work time (e.g., nursing shortages)

12. Factors Considered in Decision (continued)
Stakeholder Influences
Employees not a significant influence
though unions very influential in some cases
Public opinion not a major consideration
balance between positive view of being prepared with stigma of “smallpox hospital” label
Main outside stakeholders: local and state health departments, federal government, and other hospitals within community or corporate network

13. Factors Considered in Decision (continued)
Stakeholder Influences (continued)
Influence of state and local public health officials overwhelmingly positive
“Local public health officials worked along side us and we developed a better relationship regarding the entire disaster planning program”
In a few cases, influence of public health officials was negative
“The main reason we ended up not participating was due to the lack of preparedness and technical support from the local health department.”

14. Key Factors

15. Key Factors for Participation
Hospitals that Chose
to Participate in the SPVP
(n=88)
Responsibility to Be Prepared
75% (66)
Option for Employees to be Vaccinated
12% (11)
Risk of Outbreak
7% (6)
Other
6% (5)

16. Key Factors for Non-Participation
Hospitals that Chose Not to Participate in SPVP
(n=35)
Risk of Vaccination Greater than Risk of Outbreak
57% (20)
Logistical / Cost Issues
23% (8)
Unknowns Surrounding SPVP
9% (3)
Other
11% (4)

17. Factors That Would Change Non-Participants’ Decision
Outbreak of smallpox somewhere in world most commonly cited
Other factors included:
more adequate compensation
comprehensive information on safety of vaccine
more/better information risk of outbreak

18. Program Participants: Recruitment Strategies
Healthcare worker participation voluntary in all cases
About 50% of hospitals offered vaccination to all employees
Others offered vaccination only to certain personnel, with wide variability across hospitals:
“We concentrated on ED staff due to their high skill level. We also tried to get volunteers from Infectious Disease, Dermatology, and Psychiatry.”
“Vaccine was offered only to patient care providers (RNs, MDs, ED staff), security officers, and infection control.”
“Vaccine was offered to everyone except personnel in obstetrics and oncology.”

19. Program Participants: Recruitment Strategies (continued)
Given occupational mix of vaccinees, few hospitals developed specific smallpox response teams
At the vast majority of hospitals, only nurses or physicians were vaccinated
Ancillary staff (e.g., housekeeping, security), laboratory personnel, respiratory therapists, and radiology technicians were rarely vaccinated

20. Program Participants: Site Care
Almost all hospitals developed a policy for care of the vaccination site
Most designated staff to perform site checks, usually an employee health or infection control nurse
Several hospitals allowed vaccinated staff to check their sites themselves
Most adhered to recommendation that site checks be conducted daily

21. Program Participants: Policies for Vaccinated Staff
Some hospitals went above and beyond guidelines with respect to employee leave / reassignment policies
One hospital furloughed vaccinees (3-day, paid)
Several hospitals reassigned employees, though specific policies varied
Some hospitals offered paid leave in the event of an adverse reaction to vaccination

22. Discussion
Hospitals considered many complex issues in (1) deciding whether to participate in SPVP and (2) implementing vaccination program
available information not always complete/consistent
variation across hospitals even within same community
State/local public health played key role in addressing–or failing to address–uncertainty

23. Discussion (continued)
Future smallpox preparedness efforts can benefit from:
consistent messages conveyed across all levels of public health
a more collaborative approach between local public health officials and individual hospitals
buy-in from national level stakeholders (e.g., American Hospital Association)