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http://www.cnn.com/2002/HEALTH/12/20/smallpox.military.ap/index.html

One in 3 troops exempted from smallpox vaccine

Friday, December 20, 2002 Posted: 9:18 AM EST (1418 GMT)

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WASHINGTON (AP) -- After a week of smallpox vaccinations, more than one in three military troops have been exempted from the mandatory shots because of medical complications, underscoring the importance of careful screening to minimize dangerous side effects.

And in Israel, more than half of 42,000 health and emergency workers offered the vaccine have declined for medical and other reasons, with doctors among the most reluctant, the chief of Israel's program told an expert panel reviewing U.S. plans to resume vaccinations among civilians next month.

It highlights the need for education about both the disease and the vaccine. Routine inoculations ended in 1972, the last natural case of smallpox was in 1977.

For the U.S. military, vaccinations began a week ago. In the first five days of the program, 276 people have been screened for the vaccine, with 102 -- 37 percent -- exempted for medical conditions, said Dr. William Winkenwerder Jr., assistant secretary of defense for health affairs. The others got the inoculation.

Nearly half of those exempted live with someone who would be at risk for a side effect. The vaccine is made with a live virus, and it can escape the inoculation site and infect people who come into close contact with the person vaccinated.

The most common medical conditions were skin conditions, such as eczema.

So far, there have been no serious complications, and Winkenwerder is hoping that careful screening will mean far fewer problems than were found in the U.S. smallpox program in the 1960s. During that time, there were one or two deaths for every million people vaccinated and at least 15 life-threatening complications per million.

"We're paying a whole lot more attention to screening," he said.

The vaccinations began last Friday, targeting about 500 people who would serve on smallpox response teams. In the next stage, beginning in January, the Pentagon will vaccinate about 25,000 medical teams in hospitals and large clinics, and up to a half-million troops in high-risk areas, particularly southwest Asia.

In Israel, 17,500 people have been vaccinated so far, with about 20,000 expected before the program is complete, said Dr. Yehuda L. Danon, a pediatrician at Tel Aviv University who is running the program and was the first to get the smallpox shot in Israel's new program.

About half the doctors have declined to get the vaccination, he said, adding that hospital staff decline the shot as well when the chief physician says no.

THE VACCINE:   The last natural smallpox case was in Somalia in 1977   Vaccine effective if given within 4 days of exposure   Vaccine does not contain the smallpox virus   Vaccine is made from a virus called vaccinia   15 per million vaccinated experience serious complications   1-2 people per million will die from vaccine   Most Americans under 30 haven't been vaccinated   1 case is considered a public health emergency Source: CDC

"The medical personnel (are) the most difficult to educate. The ignorance is really unbelievable," Danon told the panel convened by the Institute of Medicine.

So far, Danon said, four Israelis have been hospitalized with conditions that may have been related to the smallpox vaccination, though only two of them were clearly reactions to the vaccine.

Less serious reactions have been common. Nearly one in three experienced fatigue or weakness, 28 percent had headaches and 18 percent had muscle pain. About one in 10 were nauseated.

The data from Israel and the early experience in the military are helping U.S. health officials prepare for civilian vaccinations to resume after three decades.

First up will be about 440,000 people on hospital and health care response teams. To help educate them, officials are busy preparing detailed information about the smallpox vaccine and its risks, including graphic photographs.

"I think, realistically, a picture is worth a thousand words," said Dr. Julie Gerberding, director of the federal Centers for Disease Control and Prevention.

But she added that people will also be told that the risk of these complications is quite low, particularly for people who do not have skin conditions, compromised immune systems or other risk factors.

CDC officials have asked the Institute of Medicine panel for advice on their education and screening plans, as well as their plans to train doctors about smallpox and to educate the general public.

For the military, where inoculations are mandatory, some half-million troops are likely to be vaccinated, although those at risk for side effects are exempted.

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