The initial round of vaccinations will be targeted at making sure the dread disease does not spread past the emergency room and infect entire hospitals in the event of a terrorist attack and in protecting the personnel assigned to any later mass inoculations of the public.
"During this first phase, we will receive only enough doses to vaccinate those health care workers who would be needed to begin vaccinating Los Angeles County residents, should that become necessary, or those who may be first to investigate or care for a case of smallpox," said the county health officer, Dr. Jonathan Fielding, who unveiled the plan at a news conference Monday.
With 81 hospital emergency rooms and a population of nearly 10 million, Los Angeles County is one of three urban areas in the nation -- along with Chicago and New York -- required to draft a smallpox plan separate from the plans each state must to the Centers for Disease Control by next week.
The federal government must approve the plan before it can be implemented, and no date has been set for the initial vaccinations to begin.
Terrorism experts are concerned that smallpox may have fallen into the hands of terrorist organizations, posing the threat of millions of Americans being exposed to a highly contagious plague that proves fatal 25 percent to
35 percent of the time.
Smallpox also poses containment problems in a health-care system in which patients may come in contact with family members, paramedics and emergency room staff. The Los Angeles County plan calls for vaccinations to be focused first on E.R. personnel -- ranging from doctors and nurses to technicians, security guards and foreign-language translators; between 13,000 and 20,000 individuals would be eligible for the shots.
The plan is based on the concept of "ring vaccination," in which individuals who would be in close contact with a patient are inoculated so that the infection is bottled up in the emergency room.
"In order to be prepared to respond to a smallpox case or outbreak, it is critical that we have public health and medical response teams pre-vaccinated," Fielding said.
Los Angeles County, however, has a hospital system that is being squeezed between a growing population and a continuing financial squeeze that has hospitals running at consistently high occupancy rates and could be quickly overwhelmed by a surge in contagious smallpox patients.
"There are not enough isolation beds or rooms to deal with a highly contagious disease in any mass quantities in Los Angeles County," said Jim Lott, vice president of the Hospital Association of Southern California. "Contagious vectors like smallpox don't confine themselves to specific areas of a hospital if introduced into the environment."
Lott told a news conference Monday that he had serious concerns about vaccinating emergency room workers and not every employee.
"Here we are asking employees to work where we know now that there is a hazard, and we're only inoculating certain employees and not others," said Lott "Who is going to play God here?"
Dividing up the available vaccines appeared to also be a dilemma in New York, where newspaper reports Tuesday indicated that the shots might be limited to 100 doctors at each city hospital.
The Los Angeles Times said some bioterrorism experts have said smallpox vaccines should be given not only to medical and emergency personnel, but also to utility workers and employees who provide other vital services.
Dr. William Bicknell, former director of the Massachusetts Department of Public Health, told the newspaper the Los Angeles plan would not "not make it worse, but it's a day late and a dollar short."
Fielding said the second phase of the vaccination plan would cover a "broader" group of health care workers, including paramedics, firefighters and some police officers. The third and final phase would vaccinate the general public.