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http://www.nytimes.com/2002/12/13/health/13CHIL.html?tntemail1

Citing Dangers, Experts Warn Against Vaccinating Children

By DONALD G. McNEIL Jr.

s smallpox vaccination for the public comes closer, many experts say the risky vaccine should not be offered to children and teenagers, even on a voluntary basis.

While federal health officials have not yet said whether children would be vaccinated under the plan President Bush is to announce today, they and doctors who advise the government on smallpox policy suggested yesterday that in the absence of a smallpox attack, good sense dictated that only adults get preventive vaccinations.

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Vaccinating even part of a population can drastically slow an epidemic, experts said, and children are relatively easy to protect by closing schools and keeping them home. Nor would they be needed, as many adults would be, to serve on the front lines in a smallpox outbreak — running hospitals, giving emergency vaccinations, caring for the sick, delivering medical supplies and food, keeping water and sewer and phone systems running.

At the same time, the smallpox vaccine is the most dangerous in existence, especially to children. It is a cousin of the vaccine developed 200 years ago, when Dr. Edward Jenner pricked the sores of a milkmaid infected with cowpox and jabbed the lancet into the arm of a boy, giving him the virus, which protects humans against smallpox.

Experts say vaccinating children poses major ethical problems and legal liabilities that were unknown decades ago, when schoolchildren were routinely vaccinated. Children under age 18 cannot give informed consent, said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, "and that's an important ethical difference."

Existing stocks of vaccine have been in storage since the 1970's, and the new vaccine expected to be ready by 2004 has not been tested on children. Any child vaccinated would, in effect, be part of a large human experiment. If there were side effects, the government might be held liable.

Although severe reactions to smallpox vaccines are relatively rare — estimates of future reactions range from 1 in every 8,000 vaccinations to 1 in every 67,000 — they are much more common in younger children.

In the past, said Dr. Martin Blaser, chief of medicine at New York University Medical School, children with undetected immune problems were the most likely to suffer or die.

"If you reached 18, you were probably not immuno-deficient," Dr. Blaser said. "Getting a live vaccine was the acid test of immuno-deficiency."

Routine smallpox inoculations stopped in 1972. Today, many more people are vulnerable to complications, including anyone who is H.I.V. positive, is receiving chemotherapy, has had an organ transplant, or has a history of eczema, which has become more common in the last 30 years.

A 1968 study found that the 14 million smallpox vaccinations given that year caused nine deaths, seven of them in children under 10 years old, according to Dr. William Bicknell of the Boston University School of Public Health.

Encephalitis from vaccination, a dangerous inflammation of the brain, occurs almost exclusively in younger children.

If children and teenagers are excluded, the chances of "contact vaccination," in which the vaccine virus is passed from one person to another who touches the sore, are sharply reduced.

Of 114 cases of contact vaccinations in 1968, Dr. Bicknell said, "almost all were in children." The only other two he could remember were of a hospital nurse and between a couple who had had sex.

Contacts between adults in workplaces are rare, Dr. Fauci said. By excluding teen-agers, he said, "you're not vaccinating people who are spending all day horsing around with each other in school."

Experts said that although parents might now be eager to have their children vaccinated, their enthusiasm might wane with the inevitable reports of serious side effects among some military and emergency personnel.

"People are frightened about smallpox because it's in the news a lot," said Dr. Paul Offit of the Children's Hospital of Philadelphia. "It's possible that by 2004, that will settle down."

Dr. Offit opposes vaccination not only of children, but also of emergency personnel on the ground that there is not one case of smallpox in the world. "If you were trying to make a smallpox vaccine today and this was it, it wouldn't be licensed," he argued.

In contrast, he said: "Flu will kill 20,000 people this year, mostly less than 4 years old — and we have a vaccine. It's too bad that Saddam Hussein's not behind influenza. We'd be doing a better job."

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