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Last Updated

20 Nov 2002

Source: Washingon Post, November 20, 2001

Scar Search

Amid Smallpox Fear, Many Seek Signs of Childhood Shots

By Carol Vinzant, Special to The Washington Post

Matthew Newman, a 33-year-old from Bethesda, first checked his upper arm to see if he had received the smallpox vaccine as a child. Then, just to be sure the indentation he saw was really a scar from the vaccine, he looked at his childhood medical records.

"I remember when I was little [that] on my shoulder I had a couple little indentations," he said. "That's what I thought it was." The scar, typically on the left arm, looks like a cluster of little craters, similar to an acne scar, Newman said.

Amy Bonawitz, a 24-year-old Potomac native, wishes health officials had not decided to stop giving out smallpox vaccines five years before she was born, and hopes they start again soon. "I'm more scared about smallpox than I am about anthrax," she said. "Everything you see on the news [says] this is contagious and can't be treated."

In New Jersey, Maria Atanasov, 29, already knew she was not inoculated because her parents had long ago explained why her older brother had a spot on his arm and she didn't.

"I was thrilled [at the time] because I hated shots. And I didn't have that ugly spot on my arm," said Atanasov. "That said, I am a bit disconcerted that if in fact smallpox does become a biological weapon, there is only a limited amount of the vaccine," she said. "I think all havoc will break loose at clinics and hospitals as people fight over who gets the shot."

These are some shades of the latest medical parlor game: Did You Ever Get a Smallpox Vaccine and, if So, When? Grab a mirror, roll up your sleeve or try hunting down your childhood health records, and you can play, too.

As people try to nail down their status, medical experts are still wrestling with a bigger question: Will long-ago vaccinations do them any good? Until a few weeks ago, the issue of how long the vaccine offered protection against smallpox was largely theoretical. The new era of bioterrorism, ushered in by the transmission of deadly anthrax spores through the U.S. mail, has suddenly made the issue more pressing. If anthrax is here, public health officials have worried aloud, can smallpox be far behind?

The planet had officially stopped worrying about smallpox in 1980, when the World Health Organization declared the disease eradicated. Relief was short-lived. In the mid-1990s fears were renewed by news that research samples of the virus may have strayed into the wrong hands from its Russian vault, the only repository outside the United States. This fall's terrorist attacks intensified anxiety about bioterrorism and especially smallpox.

Smallpox is even more awful than anthrax because it is contagious and considered untreatable. The disease, which first produces fatigue and fevers and goes on to torment the victim with pustules on the skin, especially the face, is estimated to kill about 30 percent of those who get it. Those who survive are often left disfigured and blind.

The United States got its last routine smallpox vaccines in 1972. But who exactly got the vaccine is often unclear because patients got it at different ages -- anywhere from infancy through age 3 for the first innoculation (actually, more like a scraping than an injection), as recommended by national guidelines, then a booster at grammar school age. In practice the age of vaccination varied widely, said Meg Fisher, a member of the committee on infectious diseases of the American Academy of Pediatrics.

Because boosters used to be recommended five to 10 years after the vaccine, health officials initially regarded as unprotected anyone who had not been vaccinated within the preceding 10 years. However, because actually contracting the disease confers lifetime immunity on survivors, researchers became intrigued by studies that had shown much longer immunity from the vaccine.

In the early 1990s Francis Ennis, a professor of medicine at the University of Massachusetts and director of the university's Center for Infectious Diseases and Vaccine Research, found some patients retained immunity decades after innoculation -- one as much as 50 years later. Ennis, studying the immune reactions of blood cells from HIV-infected people, tested the cells' response to vaccinia, the smallpox virus. He found that the T-cells of patients who had been vaccinated long ago still recognized and killed the smallpox virus. The finding would present an obstacle to those hoping to use the smallpox vaccine as a vehicle for an HIV vaccine, but it shed some light on how long the body remembers a smallpox vaccine.

However, neither Ennis's research nor other studies involved enough patients to show exactly how long some degree of smallpox immunity could be expected to last or how complete that immunity is.

"If a person got a smallpox vaccine as a child, the evidence would suggest they are likely to be protected," Ennis said. "As they get older and farther away from the infection, that immunity might be reduced, but it would still be significantly better than not having the vaccination."

The Centers for Disease Control and Prevention (CDC) now acknowledges that some immunity may indeed be retained by those who got the vaccine even a long time ago. How much immunity, and how long ago, the CDC can't be certain.

The fact that the vaccine might do some good, however, had led to people's asking each other about their smallpox vaccine status: How many "shots" did you get? How long ago was your vaccination? Were you one of the rare people who got the vaccination for travel, work or an offbeat medical treatment? The answers to all these questions figure into any individual's immunity. However, year of birth is still the main factor that defines the various gradations of maybe. About half the country, those too young to get the vaccine in 1972, has no immunity.

Trying to estimate one's personal likelihood of immunity is an exercise in mathematics, probability and futility. For instance, people who received both an initial vaccine and a booster may be the safest -- but their inoculations usually occurred the longest ago, making them presumably less protected. Those born from roughly 1962 to 1972 probably have had just one shot, with no booster. But those born between 1968 and 1972 likely received the most recent vaccinations -- or no vaccinations at all.

Having had any vaccination might make the disease less likely or less severe. Controlled exposure to the smallpox virus itself -- presumably as a result of some terrorist act -- might act like a vaccine booster, conferring additional immunity. "Probably it won't be complete protection, but there may be partial protection," Fisher said. "But we just don't know."

When the vaccine and boosters were still being given, doctors noticed that while the first vaccination usually caused a blister, the second caused only a lump, hinting that the first dose apparently was still working to some degree, Ennis said.

Some people still got vaccinated after 1972, including travelers to developing countries, some soldiers and lab workers who handled related animal diseases.

An unknown number of Americans fall into a special category of higher immunity that they are unlikely to brag about -- patients with herpes and genital warts. For decades, some doctors treated such patients by giving them smallpox vaccines on the sly in hopes of boosting their immunity. As late as 1981, California revoked a doctor's license for giving a smallpox vaccination to treat the cold sores of a 53-year-old leukemia patient.

But why not wipe away all the ambiguity and just start a mass smallpox inoculation program right now?

For one thing, there is currently not enough vaccine. The United States only has about 15 million doses, and they've been in storage for many years. Last year the government ordered up tests to see if it could stretch them out fivefold or tenfold through dilution. Tests of the diluted vaccine, for which many people have enthusiastically volunteered, are currently underway. Meanwhile, Secretary of Health and Human Services Tommy Thompson plans to spend about $500 million -- about $1.25 per dose -- to acquire 300 million doses of modernized vaccine. By the end of next year, he hopes to make all worries about the varying levels of immunity disappear by having a smallpox vaccine "with your name on it," as he has put it.

Another and no lesser concern is that the vaccine itself could kill as many as one in a million patients -- the equivalent of the deaths from a large plane crash. Those most at risk are people who have a compromised immune system or suffer from eczema.

A massive inoculation program is being contemplated, though the government has not yet decided whether to give everyone vaccinations or wait for an outbreak. Vaccination is effective up to four days after exposure to the virus -- about a week before symptoms first show up. If there were an outbreak, the government would use both inoculation and quarantines to curb the spread of the disease.

In Potomac, Amy Bonawitz, still rueful about the absence of a vaccine scar on her arm, is eagerly awaiting the arrival of new vaccine. However it's used, she is glad at least that the government has thought to order it up. "That makes me feel better," she says.

Carol Vinzant is a New York-based writer and frequent contributor to The Post.