o the Editor:

The recent reports in The New England Journal of Medicine summarize the concerns of many public health officials that mass smallpox vaccination is problematic and barely holds up to risk-benefit analysis ("Scientists Favoring Cautious Approach to Smallpox Shots," front page, Dec. 20). Most alarming is the high degree of public misinformation about smallpox and vaccine safety.

It is illogical that parents who know so much about the risks of childhood vaccines are so blindly willing to vaccinate their children for smallpox.

To maintain the public's trust, our national strategy for biodefense needs to be more clearly reasoned and articulated.

DAVID S. PERLIN
Newark, Dec. 21, 2002
The writer is scientific director of the Public Health Research Institute.

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To the Editor:

I am puzzled by the alarm associated with the present version of the smallpox vaccine ("Scientists Favoring Cautious Approach to Smallpox Shots," front page, Dec. 20).

I was vaccinated in childhood in the 1930's (everybody was) and again in the 1960's, as was my wife. We experienced no side effects whatsoever, and were not even warned of such a possibility. Why is today's vaccine so much more dangerous than that available 40 and more years ago, when smallpox vaccination was commonplace?

ANTHONY B. MAUGER
Kensington, Md., Dec. 20, 2002

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To the Editor:

Re "Ducking Smallpox Vaccinations" (editorial, Dec. 22):

The end of worldwide smallpox vaccination preceded the start of the H.I.V. and AIDS epidemic. H.I.V.- infected people, as well as people undergoing chemotherapy, are at risk from exposure to the smallpox vaccine. Such statistics as "roughly two deaths for every million people vaccinated" are from an earlier era.

Today there are almost a million individuals in the United States living with H.I.V., many of whom are unaware of their infection. Because H.I.V.-infected individuals disproportionately live in large cities, they will be disproportionately affected by vaccination campaigns directed at potential terrorist targets.

Your editorial says the risk that hospital workers who are vaccinated might spread vaccinia virus to some of their patients can be controlled. I have little confidence in the "experts" whose "simple protective measures" to prevent contagion were written in the 1960's.

DANIEL E. COHEN, M.D.
Boston, Dec. 23, 2002

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To the Editor:

Re "Scientists Favoring Cautious Approach to Smallpox Shots" (front page, Dec. 20):

There is another group for whom the benefit of smallpox vaccination may outweigh the risk: women who plan to become pregnant within a year. While mothers-to-be don't face the same increased risk of exposure as health care workers, they do risk going unprotected in a smallpox emergency.

A pregnant woman faces high risk of complications to herself and her fetus if she is vaccinated after the infection alarm goes out. Women who hope to conceive soon should have the choice of receiving the smallpox vaccine before pregnancy.

HEATHER SMITH BUCKSER
Pleasant Hill, Calif., Dec. 20, 2002