Topic: Medical Management Guidelines for Lead-Exposed Adults
Individual AOEC Guidance Documents
Date: Spring 2000
Topic: Asbestos Screening
Date: Summer 2002
Topic: Smallpox Vaccination Strategies
Date: Autumn 2005
Topic: Medical Management Guidelines for Lead-Exposed Adults
The Association of Occupational and Environmental Clinics is concerned that medically inadequate screening tests are being conducted to identify cases of asbestos-related disease for legal action. These tests do not conform to the necessary standards for screening programs conducted for patient care and protection. Screening is only conducted as a preliminary step in determining the presence of asbestos-related disease. AOEC therefore supports the following statement:
Screening on the basis of chest x-ray and work history alone identifies possible cases but does not by itself provide sufficient information to make a firm diagnosis, to assess impairment or to guide patient management.
An appropriate screening program for asbestos-related lung disease includes properly chosen and interpreted chest films, reviewed within one week of screening; a complete exposure history; symptom review; standardized spirometry; and physical examination.
Programs should also include smoking cessation interventions, evaluation for other malignancies and evaluation for immunization against pneumococcal pneumonia.
Timely physician disclosure of results to the patient, appropriate medical follow-up and patient education are essential.
Omission of these important preventive aspects in the clinical assessment of asbestos-related lung disease falls short of the standard of care and ethical practice in occupational health.
April, 2000
AOEC Position on Public Health Response to a Potential Smallpox Attack
The deliberate release of smallpox virus is considered by the Centers for Disease Control and Prevention (CDC) and the U.S. Government to be a feasible mode of terrorist attack, although they rate the potential as "between low and zero". To address the potential threat and means of limiting disease outbreak the CDC and its Advisory Council on Immunization Practices (ACIP) have developed a draft plan. This plan currently under advisement utilizes the "Ring" approach used in the final phases of the worldwide smallpox eradication program. This program utilizes the technique of identifying new cases of smallpox, isolating both the patients and all immediate contacts, then immunizing those people as well as a safety ring of other potential contacts. In conjunction with this plan, the ACIP does not currently recommend vaccinating members of the general public before there is a confirmed smallpox case or a confirmed bioterrorism attack using smallpox.
AOEC strongly recommends that essential health personnel, who would be the initial responders to a smallpox event, be offered vaccination with appropriate discussion of complications and evaluation to assure absence of immunosuppression. These personnel should also be offered personal protective equipment (with appropriate training) and education about precautions beyond vaccination. Essential personnel include those who would be necessary to maintain operations of health care facilities, not just health care providers.
Should an actual event occur, AOEC strongly recommends that vaccination be offered to those in the outbreak areas(s) in addition to implementation of the "Ring" approach. AOEC also recommends that vaccination be offered to the general population when the vaccine is licensed, with appropriate delineation of risks involved.
Rationale for AOEC Policy Statement
AOEC feels these modifications to the CDC policy are needed for several reasons. The "Ring" method has worked very well in underdeveloped and developing countries where migration of citizens is limited. Michael Lane, MD, one of the two who developed the ring approach, has expressed his opinion in the public meetings that the "Ring" would work in the U.S. since they had dealt with 20 to 30,000 patients/contacts in one outbreak and had stopped the disease in that location. However, both the Hopkins' Center for Civilian Biodefense Study, in a scenario presented at its first national conference, and the Dark Winter exercise in June, 2001, demonstrated the difficulties in making an organized, well controlled response to a smallpox event in a mobile urban area. In both situations, the media played a major role in alerting everyone to the event and also detailing breakdowns in efforts to contain the hazard.
During Dark Winter, some state borders were closed without success in stopping the spread. Dr. Lane commented during the May 30-31, 2002 CDC sponsored meeting that Dark Winter was, effectively designed to fail. He also commented that during an incorrect smallpox diagnosis in a Washington, DC hospital, a number of years ago, there was no panic. Others noted that this occurred when the population was still being vaccinated. While the exercises were scenarios, professional experience with very limited mass casualty situations suggests that the results are not unrealistic. The 5 December 2001 JAMA article, 286:2711-2717, clearly delineates the problems with any attempt at large scale quarantine.
It is our concern that the "Ring" approach and immunization only on confirmed events, as outlined in the Vaccinia (Smallpox) section of CDC's ACIP (external link to: http://www.cdc.gov/nip/publications/ACIP-list.htm) will not work if an actual situation should occur due to the panic and demands for immunizations from major population groups. It would not be unreasonable to expect riots if vaccine were not supplied. Another drawback to the "Ring" approach is that the incubation period is such that it would be difficult, if not impossible, to track contacts of index cases and then the secondary, tertiary, etc. contacts due to the mobility of our population.
Were a case to occur, there would be an immediate demand for vaccination across the U.S. This was demonstrated by the numbers of non-exposed people throughout the U.S. demanding Cipro following the anthrax outbreaks in Fall 2001. A more effective approach, and one which would be more acceptable to a worried, demanding public would be the use of public health officials to track contacts and attempt containment, but also supplement these efforts with offering vaccination to all those eligible citizens in affected community(ies).
There is an immediate need for some sort of policy due to the limited vaccine supplies currently available (reportedly about 12 million doses with the potential for 1:5 dilution if the dilution studies are confirmed). However, it is understood that there will be supplies of new vaccine available "soon". If the new vaccine can be made available in the near future, a more reasonable approach for our mobile society would be to make the option of vaccination available to all U.S. citizens. Clearly delineating the hazards and then offering the option would seem an appropriate approach. Offering such an option to the public prior to an event could reduce panic if one or more outbreaks did occur and also, if the herd immunity was sufficiently high, deny a weapon to terrorists. Offering the option would also incorporate the patient in the decision making process, as emphasized in today's socio-political environment. There will need to be a careful balance in communicating to the public with accurate picture of the risk of vaccination versus the risk of disease without panicking large numbers. It must be recognized that serious complications and death can result from immunization. CDC estimated deaths as 5 per million primary vacinees, progressive vaccinia 10 per million. Some at the May 30-31 conference stated they thought the numbers were too low, perhaps by a factor of 10. A very important concern is the increased numbers of immunosuppressed patients in the population today compared to the early seventies. If a vaccinated person has contact with an immunosuppressed patient while still infective, the immunosuppressed patient may be at risk for disseminated vaccinia.
There is no informed consent process adequate for this. It is a public health problem where there will be a calculable and irreducible minimum number of casualties, not all of whom can be identified in advance. Those affected may never be asked to give informed consent, may not have a chance to react to their risk, yet they clearly have a secondary, and very real risk.
Of note is that the old and new vaccine are not predicted to be licensed until 2003 and thus are in the Investigational New Drugs (IND) category. We understand that while the old vaccine is licensed under the old method of inoculation, the current recommendation is to use a new bifurcated needle with it so it too would fall under the IND category. CDC noted each person immunized would have to be immunized under the full IND protocol, which would mean the need for large numbers of personnel to get the informed consent and do all the other interactions needed under IND protocols. This raises the question of whether or not in an actual event CDC plans to adhere to an IND protocol. If not, this needs to be clearly delineated to both health care professionals and the public.
If vaccination of the general public is not allowed, the question then becomes, who should be vaccinated in anticipation of the attack. CDC has currently vaccinated about 160 CDC personnel who would respond to an outbreak as "essential personnel". However, this begs the question of what to do about emergency room department personnel and first responders. These are the medical personnel most likely to come into immediate and unprotected contact with smallpox victims. In contrast, the CDC people would only come after the diagnosis was evident and would be in full protective gear.
If an outbreak occurred, essential workers (fire/rescue/police, hospital workers - physicians/nurses/lab personnel/laundry workers/housekeepers/numerous others), and public health officials investigating the situation, would require protection including vaccination, personal protective equipment (e.g. respirators) and education about precautions. In the absence of these elements, these workers may not come to work or stay at work. Therefore, vaccination should be offered to them in advance of a confirmed case or bio-terrorism attack using smallpox. As side effects of the vaccine would likely cause a number of workers to miss several days of work, lost time must also be taken into account in the planning process. In addition, job protection and medical confidentiality must be considered in advance to protect workers who might decline vaccination, decline vaccination pre-testing (e.g. HIV, CBC and urine pregnancy test) which would render them ineligible for the vaccine, or have medical contraindications to vaccination. In planning, the CDC should accomplish a survey of these essential workers to determine acceptability of such a vaccination program in the absence of a confirmed smallpox case or conformed bio-terrorism attack using smallpox.
August, 2002