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Last Updated

27 Dec 2002

Source: Seattle Post-Intelligencer, December 27, 2002.

Smallpox expert says vaccine should be used only in outbreaks


Washington state health officials received approval this week from the U.S. Centers for Disease Control and Prevention to implement their hastily prepared "stage one" plan for vaccinating about 7,000 hospital and public health workers against smallpox bioterrorism.

One of the world's foremost authorities on smallpox, however, thinks the public health community should be arguing against moving so rapidly ahead. The vaccine can have serious -- and in extremely rare cases deadly -- side effects.

"We are operating with some pretty big unknowns here," said Dr. Bill Foege, former chief of the CDC.

Foege now serves as a global health adviser to the Bill & Melinda Gates Foundation and lives on Vashon Island. He is a big proponent of the power of immunization. But he isn't too crazy about the notion of vaccinating even front-line public health or hospital workers against this theoretical threat using this particular vaccine.

In the 1960s, Foege worked as a CDC physician in Africa. He figured out how to selectively use smallpox vaccination to contain and suppress outbreaks -- a method sometimes known as "ring vaccination" that eventually rid the world of the dreaded disease.

Smallpox vaccines are unique in that they protect against disease up to four days after exposure, Foege noted, so typical pre-emptive immunization is not necessary. And given the risks of this old vaccine, he said, it seems prudent to save the vaccines for an outbreak.

The risks of the smallpox vaccine are too high unless there is an imminent threat of an outbreak, says Dr. William Foege of Vashon Island.

"We seem to be feeling our way along on all this and I think there are still some serious questions that need to be addressed," said Foege, who is a consultant to the National Academy of Sciences' Institute of Medicine panel on bioterrorism preparedness.

Smallpox, which once killed one of every three people it infected, is the only disease ever to be eradicated from the planet. But because samples of live virus are known to exist in labs, at least in the United States and Russia, there is concern that terrorists may have gotten hold of the deadly bug and may try to use it as a weapon.

Earlier this month, the CDC and the Bush administration asked states to submit their plans for vaccinating a small number of emergency health workers should there be a bioterrorism event involving smallpox. The request came with an urgent, but unexplained, short deadline based on the possibility that Iraq may try to use smallpox as a weapon.

"We're prepared to move ahead with this stage, but we still have some questions," said Mary Selecky, secretary for the state Department of Health.

Beyond the still-unanswered question as to why the rush, Selecky said health officials need Congress to establish policy as to liability and compensation concerns. Because the smallpox vaccine can have serious side effects, both those giving the vaccine and those volunteering to get it will need liability protection.

According to the CDC, one or two people of every million vaccinated will die. In addition, about 1,000 out of every million will have serious adverse reactions, and of these maybe 50 will be life-threatening with lasting complications. The smallpox vaccine uses a live virus known as vaccinia, a relative of cow pox, which usually does not cause disease.

The administration's smallpox vaccination plan, if fully expanded beyond this limited stage to include maybe 10 million other "first responders" such as police officers and firefighters, could cost between $600 million and $1 billion, by some estimates.

Selecky, who is also president of the Association of State and Territorial Health Officers, said there has been little discussion about how to pay for the smallpox vaccination program. So far, she said, the states have been told to use some of the $1.5 billion they received last year from the federal government for bioterrorism preparedness.

"We've been trying to build up the public health system in general as part of bioterrorism preparedness," said Dr. Alonzo Plough, director of Public Health -- Seattle & King County. "We've had to divert the entirety of that program to focusing on this one agent."

Still, Selecky and Plough said they believe it is prudent to vaccinate a small number of hospital and public health workers to have ready a group of professionals who can respond to an outbreak without having to worry about their personal safety.

Foege's concern is about the effect this plan could have on the entire community. He recognizes that he's taking a position contrary to many in the health profession, as well as his old agency. But he's concerned that further expansion of the smallpox vaccination plan could have dire consequences and, ultimately, undermine the ability to contain an outbreak.

"If there's a real risk of smallpox, there's no doubt about vaccinating," Foege said. But if enough people get vaccinated now without a real threat and some are harmed by the vaccine, he said, it could be even more difficult to vaccinate the public when it really counts.

"The administration may know something I don't, but they have assured us there is no imminent threat," Foege said. The Israelis have a good track record on intelligence, he said, and Israeli officials yesterday announced that they had decided against doing any mass vaccinations because there's no evidence the Iraqis have a smallpox bioweapon.

The real risk of the smallpox vaccine is unknown, Foege said.

"There are a lot of circumstances today that didn't exist 30 years ago when we were still vaccinating to control the natural spread of the disease," he said.

Today, he said, many people have suppressed immune systems because of cancer treatment or other therapies. Millions of people with skin disorders could be at risk of serious disease if they come into contact with someone vaccinated against smallpox.

Johnese Spisso, chief operating officer at Harborview Medical Center, said all of these are concerns among the staff at the regional trauma center.

"We're still not sure how many will volunteer to be vaccinated," Spisso said. The primary concern of staff, she said, was to make sure the vaccine was readily available if needed.

It's possible, she said, that even with screened and willing volunteers, the hospital might decide not to vaccinate anyone unless there were an outbreak.


Here are answers from the Centers for Disease Control and Prevention to questions about smallpox.

Q: How serious is the smallpox threat?

A: The deliberate release of smallpox is now regarded as a possibility, and the United States is taking precautions.

Q: Can I go to my doctor and get the smallpox vaccine?

A: At the moment, the smallpox vaccine is not available to the general public. In the event of a smallpox outbreak, however, there is enough vaccine for everyone who would need it.

Q: What are the symptoms of smallpox?

A: The symptoms begin with high fever, head and body aches, and sometimes vomiting. A rash follows that progresses to raised bumps and pus-filled blisters. After exposure, it takes seven to 17 days for symptoms to appear. During this time, the infected person feels fine and is not contagious.

Q: Is smallpox fatal?

A: The majority of patients recover, but death can occur in up to 30 percent of cases. Many survivors have permanent scars. Some are left blind.

Q: How is smallpox spread?

A: Smallpox normally spreads from contact with infected persons. Generally, direct and fairly prolonged face-to-face contact is required. Rarely, smallpox has been spread by virus carried in the air in enclosed settings such as buildings, buses and trains.

Q: Is there any treatment for smallpox?

A: Smallpox can be prevented through use of the smallpox vaccine, even after exposure. There is no proven treatment.