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By David Brown
Washington Post Staff Writer
Saturday, December 14, 2002; Page A01

The announcement yesterday that as many as 11 million Americans will soon be vaccinated against a disease that nobody on Earth has contracted in 24 years marks a strange and unique moment in the history of American public health.

It is the first time a U.S. vaccination campaign has been launched not simply in the name of disease prevention, but to advance "homeland security" -- the still-evolving amalgam of military and civil preparedness, psychological reassurance and personal health. In fact, for the first time it may be impossible to say whether anyone benefited from a mass inoculation.

The Bush administration recognizes the policy is unprecedented, and its implementation fraught with uncertainty.

"We're going to learn a lot, and there's going to be some bumps along the way," Health and Human Services Secretary Tommy G. Thompson said yesterday.

Nevertheless, the administration has concluded that by vaccinating about 450,000 hospital workers starting in January -- and as many as 10 million police, fire and paramedic workers by early summer -- the United States will be prepared for a smallpox attack.

By late summer, vaccine may be available to any citizen -- although not recommended -- further building "herd immunity" in the U.S. population. Some experts believe that the plan may help take smallpox virus out of the arsenal of terrorists -- if it's there, which nobody seems to know for certain.

What is certain is that many people in state, city and county public health departments and in the country's approximately 5,000 hospitals aren't a bit enthusiastic about the program. That's not simply because they must implement the enormously complicated program. It's because they'll be the ones forced to deal with its problems, which are certain to emerge in short order even if the benefits remain forever unknown.

State health officials, epidemiologists, hospital administrators, emergency room doctors and public health nurses will do what the federal government asks. Patriotism is involved, after all. But their reluctance is evident in the tone and choice of words that creeps into discussion of the plans.

"Because of our duties to respond, we need to be prepared, and the best available evidence is that the vaccine is how we get prepared. That is how we are convincing ourselves to sort of accept the vaccine," said Thomas Terndrup, head of emergency medicine at the University of Alabama at Birmingham, who has an interest in bioterrorism planning.

Patricia Quinlisk, medical director of the Iowa Department of Public Health and vice president of the Council of State and Territorial Epidemiologists, has participated in innumerable conference calls in recent weeks. Colleagues from around the country are voicing lots of semi-rhetorical questions.

"What I am hearing from others is, 'I wonder why? How did [government policymakers] come to make that decision? What are the pieces of information they're using?' " she said.

This is an unusual state of affairs for public health officers, who are normally the apostles of disease prevention and the great promoters of vaccines. In the case of smallpox vaccine, the prevailing -- but not unanimous -- view is that the less it gets around, the better.

In a poll taken in June, 91 percent of members of the Association of State and Territorial Health Officials opposed any policy that would allow the general public to get vaccinated against smallpox before an attack. In October, the Advisory Committee on Immunization Practices (ACIP), a body of epidemiologists and academic physicians that is the chief adviser to the government on vaccine matters, rejected the proposal to vaccinate 10 million people, backing only the plan to immunize 500,000 hospital workers.

Opposition to wide use of smallpox vaccine bubbles up from three wellsprings -- one psychological, one medical, one sociological.

The psychological one involves the history of smallpox itself. It's the only human disease to have been eradicated -- a feat that many epidemiologists feel has never been fully appreciated by the public.

To reverse that achievement through the intentional release of smallpox virus would be "a crime against humanity of unimagined proportions," says Georges C. Benjamin, executive director of the American Public Health Association and former head of the Maryland health department. Bringing back vaccination makes such an event thinkable -- and that's something many people have a very, very hard time accepting.

The medical reason for opposing widespread vaccination is the relative riskiness of the vaccine and the difficulty of minimizing that risk. At least one-quarter of the potential pool of recipients -- and possibly a lot more -- will need to be screened out. This includes anyone who is infected with the AIDS virus, is pregnant, is on immunosuppressive drugs or has any of the skin diseases known collectively as eczema.

Because the vaccine is a live virus that can be transmitted to others, anyone in close contact with a person in those categories must also be excluded. That will be an even harder task, and one more vulnerable to mistakes. Even if everything goes perfectly, there will be thousands of people with hot, swollen, sore arms. More likely, there will be complications and a few deaths.

What has public health officials most worried are the sociological consequences of a vaccination campaign that is badly handled, or even just unlucky.

Although vaccines are perhaps medicine's greatest accomplishment, their acceptance is regularly under threat. Health officials and practitioners wage a constant campaign to convince the public of their value. That's because vaccination has made most of the diseases they protect against rare and, consequently, no longer feared. At the same time, it's easy to attribute all kinds of bad things to vaccines.

In recent years, both autism and the symptoms known as "Gulf War syndrome" have been blamed on vaccines, although there is little or no scientific evidence to support the contention. Skepticism about vaccines is fueled by the fact that occasionally one does cause harm, as in the case of the rotavirus vaccine against a common intestinal illness. The vaccine was abandoned after it was found to have triggered an intestinal defect in some people.

Mere coincidence can be damaging. This occurred in the ill-fated swine flu vaccination campaign mounted in 1976 to protect Americans against what was believed to be an extremely dangerous strain of influenza. Three elderly people, all heart patients, dropped dead on one day (Oct. 11) after getting shots at a Pittsburgh clinic. Experts concluded the vaccine was not responsible, but it took President Gerald Ford and his family getting swine flu shots on national TV to restore confidence in the program -- and even then only for a while.

The greatest fear of public health officials is that something will happen during widespread smallpox vaccination that will sour the public on vaccines in general -- including the ones against diseases that are still around and not, as with smallpox, only theoretical risks.

Asked last week why public health doctors fear the worst from smallpox vaccination despite politicians' enthusiasm, Benjamin, the former health secretary of Maryland, said:

"The difference can be summed up in a word -- experience."

With millions of Americans now preparing to roll up their sleeves -- some eagerly, others out of duty -- Benjamin's world-weary view will be put to the test.

Staff writer Rick Weiss contributed to this report.