Wednesday, December 18, 2002
Smallpox vaccine risks outweigh benefits
Since President Bush announced the smallpox vaccine would likely be made available to the American public in 2004, my patients have all been asking me the same question: Should they get the smallpox vaccine?
Anyone who has ever seen a picture of what smallpox can do -- the lesions practically exploding over the face and body -- can understand why the level of fear is so high.
But a medical or public health analysis must, as always, weigh risks and benefits. And for now the vaccine's risks outweigh its benefits for the general population.
For military personnel and health care and emergency workers, immediate vaccination is probably prudent. The old live-virus vaccine offers temporary immunity against smallpox.
In fact those who received this vaccine more than 30 years ago probably still have some protection.
But the old vaccine has a real downside. It can cause brain swelling, skin problems and infection, problems that are not insignificant when millions of people are being vaccinated.
Further, there are other smallpox vaccines in the works that appear to be safer. In two of these vaccines the viral particles used are not live.
One version is undergoing clinical trials at the National Institutes of Health. Another version has been used in Japan to immunize hundreds of thousands of people.
It would be foolish to vaccinate millions of people here in a panic, only to discover that a better, safer vaccine is on the verge of being approved.
If smallpox hits, the most important response will be to quarantine those who have been infected, since smallpox generally spreads from person to person via airborne droplets.
The second most important response will be to administer the live vaccine in areas where the disease has appeared, for immunization after infection reduces the mortality rate to less than 10 percent. No matter how smallpox arrives -- if it does arrive -- there will be plenty of time to react before a large population is affected.
Which is why President Bush's intention to make the old smallpox vaccine available to the entire population by 2004 might not be so wise. It could raise false hopes because there's no way to vaccinate everyone overnight. It could also limit the ability of doctors to counsel their patients on whether they should subject themselves to a somewhat risky vaccine.
In my experience, if people know that a vaccine or a treatment is out there, they are probably going to want it -- whether it will be helpful or not. With new, safer vaccines around the corner, wouldn't it make sense to give physicians as much leverage as possible in convincing people who are not at risk to refrain from using the live vaccine?
Smallpox is one of our oldest scourges. It should scare us. But we would do well to remember that even before there was a vaccine, smallpox never took over a whole region the way polio or influenza did. And smallpox isn't about to do that now.
This isn't the first time a vaccine has been offered to inoculate against fear as much as disease. But in this case the vaccine offered isn't risk free.
Instead of taking it, we must treat our fear with reason -- and we must wait.
Marc Siegel is associate professor of medicine at the New York University School of Medicine. Copyright 2002 The New York Times.
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