PHILADELPHIA - In its eagerness to prepare a plan to vaccinate 500,000 hospital workers against smallpox, the government neglected one thing: Nobody alerted the people who are supposed to get the inoculations.
Tomorrow is the deadline for states to submit their smallpox-vaccination plans to Washington. President Bush is expected to approve an inoculation program any day now, and vaccinations are supposed to begin next month.
The program is designed to inoculate enough doctors, nurses and other emergency workers to deal with a smallpox outbreak in the United States if the deadly virus becomes a bioterrorist weapon.
But no one knows how many of the health care workers who will be asked to voluntarily roll up their sleeves are willing to do it, or even whether they think the plan is prudent.
If large numbers refuse to be vaccinated, the entire effort to set up a national first-response force could be in jeopardy.
"Unfortunately, there hasn't been a lot of outreach from the government to the people who are going to be asked to be immunized," said Robert McNamara, Temple University Hospital's chair of emergency medicine and past president of the American Academy of Emergency Medicine.
"There's a lot of concern about getting the vaccine. This [disease] is still a very intangible threat. Unless they can make a strong case, it's going to be difficult to sell."
McNamara is part of a smallpox task force recently formed by five national professional organizations of emergency-medicine workers. It was convened, he said, because "no one has asked our advice" about vaccination.
Smallpox is a disfiguring disease that cannot be treated and that kills about a third of its victims. No one can accurately gauge the risk of an outbreak. The vaccine's risks, however, are well-known: It can be dangerous or deadly for pregnant women, those with chronic skin problems, and people with weakened immune systems.
In studies from the 1960s, about 15 of every million people vaccinated had life-threatening complications and one or two died; today, the rates would likely be higher because of HIV, cancer therapy and immune-system-suppressing drugs.
Even when all goes well, the vaccine - first created in 1796 and primitive by today's standards - causes a sore, itchy wound that takes weeks to heal, and, in rare cases, can accidentally spread the vaccine to persons who are not immunized.
Roger D. Pomerantz, a Thomas Jefferson University infectious-disease specialist and an expert on smallpox, was not inoculated as a child, as most Americans were until 1972. He recently received the vaccine's 15 needle pricks in his arm.
"It was not fun," he said. "I had huge pustules, a swollen arm, swollen lymph nodes, and a fever for two days. As I testified before Congress, this is an 18th-century vaccine in a 21st-century population."
Pomerantz endorses the precautionary immunization program because, even though the only known smallpox stocks are locked in Russian and U.S. government labs, he believes the threat of a bioterror attack is real.
But he expects that "there will be resistance" to inoculation.
"Even with the anthrax vaccine, some people in the military refused it and were thrown out," he said. "What will we do with first responders who refuse to take the smallpox vaccine? It's a real problem, but you can't force people to take it."
Federal officials have stressed that smallpox immunization will be strictly voluntary. The Bush administration has no plan yet for mass vaccinations, although the possibility of inoculating anyone who wants it is being discussed.
A government advisory committee led by the federal Centers for Disease Control and Prevention has recommended that every major hospital have a vaccinated team of about 100 workers who could deliver round-the-clock medical care to smallpox patients for a week after an outbreak. This team would include emergency-room staff; intensive-care-unit staff; pediatricians, obstetricians and family physicians; surgeons and anesthesiologists; infection-control personnel; and, various technicians, transporters, security guards and janitorial workers.
One small indicator of the attitudes of emergency-room nurses comes from a recent survey of 80 nurses by William Chiang, an emergency-medicine specialist at Bellevue Hospital in New York. Half were willing to be vaccinated, 11 percent were unwilling, and the rest were unsure.
Most hospitals have not begun to educate employees about the call to arms.
"I think, below the federal level, everyone has been waiting for guidance," said Patrick J. Brennan, chief of health care quality and patient safety at Penn Health Systems.
Pennsylvania's plan estimates that 25,000 to 30,000 health care workers will be vaccinated, while New Jersey's plan calls for 15,000.
Already, there are signs that unionized workers want certain assurances before volunteering.
Hospital administrators and doctors are also worried about their liability if workers are harmed by the vaccine.
The Homeland Security Act recently passed by Congress includes a section on liability that takes effect Jan. 24. In general, doctors and others who administer the vaccine are protected against lawsuits, but claims may be filed against the federal government and, in more limited situations, against the vaccine makers. But the details are unclear.