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Last Updated

02 Jun 2003

Source: Newark Star Ledger (NJ), June 2, 2003

U.S. sees few takers in smallpox vaccine drive

Florida and Jersey vaccination rates vary but both say they're ready for bioterror

BY KITTA MacPHERSON, Star-Ledger Staff

In Florida, 3,605 citizens, including Gov. Jeb Bush, have rolled up their sleeves and submitted to the strange forked-tongue smallpox needle that will render them immune in the event of a bioterror-inspired outbreak.

In New Jersey, a smaller contingent of 657 volunteers has stepped forward for the same ordeal of scraping, poking and infection.

Florida health officials are still recruiting volunteers. New Jersey has stopped. In both cases, state officials contend that their states are prepared for the worst.

Nearly six months after President Bush called for a nationwide plan that would have vaccinated 500,000 volunteers and ultimately 10 million to guard against an outbreak, only a fraction of that number, 36,217 people, has been vaccinated.

"It's not surprising -- the whole program was flawed from the start," said David Perlin, chief scientist at the Public Health Research Institute in Newark and an expert on infectious diseases.

The country's medical, scientific and public health leaders, he said, were never properly consulted by the government authorities who shaped the program. Even scientists at the federal Centers for Disease Control and Prevention in Atlanta were reluctant participants, he added.

The CDC has tacitly acknowledged that the number of volunteers will never reach the president's original expectations. Last month, in instructions forwarded to state officials, CDC officials abandoned the idea of a vaccine program with multiple phases. This means that in places like New Jersey, where recruitment has stopped, police and firefighters will not be asked to undergo vaccinations as they had originally been told.

Prominent health authorities seem positively sanguine about it all.

"When you think about it, the entire country of Canada has vaccinated 500 people to protect against smallpox and that's all they intend to do," said Clifton Lacy, New Jersey's commissioner of Health and Senior Services, who has come to support the idea of smaller "crack" teams that can move to any location to contain an outbreak. "I'm satisfied that the people of New Jersey are now adequately protected," he said.

In Florida, second only to Texas in the number of volunteer vaccinees, officials believe they are well covered but are still reaching out. They have had the strong support of their governor, the president's brother, and have pushed the vaccine as a deterrent to terrorism.

"We have been saying, the more people who are vaccinated, the less likely the event of an attack," said Lindsay Hodges, a spokesperson for the Florida Department of Health. "I mean, there wouldn't be any point if the attack wouldn't make anyone sick, right?"

Smallpox is the most voracious killer ever to stalk the human species. With a victim count in the hundreds of millions, it has killed more than the Black Death and the wars of the 20th century put together.

The last case of smallpox occurred in the U.S. in 1949. General vaccination against smallpox -- accomplished with the injection of a closely related virus, vaccinia virus, stopped in the U.S. in 1972, when the threat of disease disappeared. This was due to eradication efforts, which were declared complete by the World Health Organization on May 8, 1980.

The terrorist attacks on Sept. 11, 2001, and the anthrax scare a month later increased U.S. concerns about all types of possible terrorism, including the potential for biological terrorism. As a result, people started thinking about smallpox and vaccinations again.

Reviewing efforts to institute a smallpox vaccination program over the past six months, health officials said many were forced to reconsider what constituted the notion of "preparedness." That thinking may have been instigated by the fact that so many volunteers balked for safety reasons at the idea of the vaccine.

"It's not the polio sugar cube, it's pretty gross," said Howard Steinberg, Morris County's public health officer, who underwent vaccination himself to inspire others. The vaccination spot oozes for days and has to be bandaged and monitored. "But we've entered the age of terrorism and we're going to have to deal with it," he added.

Steinberg believes that the state did a good job with the vaccine program "considering what they were handed by the feds."

While President Bush and officials at the CDC spoke fervently about the need for protection, a largely private debate swirled behind the scenes for months about the merits of the program, officials said.

Issues that would eventually be rectified, such as compensation -- who would pay if hospital workers became ill from the vaccine -- consumed most of the public's attention. Meanwhile, a private debate among public health leaders ensued over concerns detailed in medical journals over the safety of the vaccine, the rationale for taking on a risk in the absence of a real threat, and the possibilities of transferring infection to a largely immune-compromised hospital population.

Developing a vaccine policy and putting it in place was difficult but illuminating, according to Drew Harris, immediate past president of the New Jersey Public Health Association. "It's an exercise that was worthwhile and prepared us for the future," Harris said.

Health authorities' ardor for a vast program may have waned with the admonitions of Thomas Mack, an esteemed smallpox investigator at the University of Southern California's medical school. His Jan. 30 essay in the New England Journal of Medicine attacked the Bush administration's plan for massive vaccination.

At the very most, he argued, the nation could establish a fractional, mobile coterie of vaccinated health workers numbering about 15,000. And, at the very least, he said, the nation could do nothing.

"The smallpox vaccination plan is a complete waste of time," said Mack, a veteran public health physician who treated smallpox victims in the last known worldwide outbreak three decades ago in Pakistan. "My prediction is that it will prove inefficient."

No one can predict which hospitals will be affected and there is no guarantee that vaccinated workers will be on hand since there is such a high turnover of hospital emergency room personnel anyway, he said. Workers can be quickly vaccinated in the event of an outbreak, he added.

While states such as Florida, Texas and Tennessee have been program stalwarts, enlisting among them more than a quarter of the nation's total vaccine volunteers, their efforts contrast sharply with states like New York, Pennsylvania and New Jersey with volunteers numbering in the hundreds.

With smallpox vaccination, the risk of death is one or two in a million for primary vaccinations, and one in 4 million for revaccinations, although nationally, three of the volunteers vaccinated within the last six months have died.

Between January and April, 657 New Jersey residents received smallpox vaccinations at eight different sites. Hospital workers from 51 acute care hospitals, representing 61 percent of hospitals statewide, participated, according to state health department records.

More hospital workers participated from South Jersey than North Jersey, possibly reflecting the southern region's direct experience with a bioterrorism incident, officials said. The U.S. post office in Hamilton was sealed in October 2001 after workers handled anthrax-tainted letters.

Of the New Jersey smallpox vaccine volunteers, 412 were female and 245 were male. Of them, 158 are public health workers and 499 are hospital employees.

In New Jersey, no one has died from the vaccinations but nine have suffered side effects. In the most serious case, one volunteer suffered myopericarditis, an inflammation of the heart and the membrane covering the heart.