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Image: U.S. Soldiers Train In Fort Benning  
An Army soldier at Fort Benning, Ga. ,wearing nuclear, biological and chemical protection gear. The Bush administration on Friday ordered smallpox vaccination of military personnel and emergency medical workers.
Smallpox response might include quarantine
State and federal authorities could take extraordinary steps to contain an epidemic
By Tom Curry
MSNBC
    Dec. 12 —  If terrorists using smallpox as a weapon started an epidemic in an American city, public health officials might need to consider imposing a quarantine to stop the spread of the fast-moving deadly disease.  


 

     
     
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       GUIDELINES ISSUED in September by the federal Centers for Disease Control and Prevention say that in some cases, the isolation of a small number of smallpox patients may be sufficient to control an epidemic. But in other situations, far-reaching quarantines might be required.
       State governments recently submitted draft plans for responding to a smallpox outbreak but, citing security concerns, most states are saying very little about their plans.
       Professor Lawrence Gostin, director of the Center for Law and the Public’s Health at Georgetown University Law School, said “there are huge logistical problems” with a quarantine, “not to mention the civil liberties implications of taking away people’s liberties en masse.”
 
 
 
 
The smallpox threat
An MSNBC special report
•  Bush receives vaccine
•  The how and why of smallpox shots
•  Questions and answers
•  Outbreak: Would quarantine work?
•  Abroad: Allies taking no chances
•  WP: Areas of concern
 

       Asked whether he can envision troops being called in to enforce a quarantine after an outbreak, Gostin answered, “Sure. Just consider what might happen if a smallpox carrier landed at Kennedy Airport in New York. If you were the governor of New York, would you close down JFK? Would you stop travel between New York and New Jersey? There is a whole range of options.”
       Indeed, the National Guard could be called in to set up roadblocks, as the Yugoslav government did when a smallpox epidemic broke out in that country in 1972.

 
 
 
 
Possible quarantine measures
Suspension of large public gatherings.
Closing of public places.
Restriction of travel.
"Cordon sanitaire," a line around a quarantined area guarded to prevent spread of disease by restricting passage into and out of the area.
Source: CDC Smallpox Response Plan and Guidelines, Sept. 23, 2002


       At the behest of the CDC, Gostin and others have drafted a model emergency medical statute that more than 20 states have already adopted in whole or in part. The law spells out the powers that governors and public health officials would have to impose quarantines, commandeer materials and hospitals, and take other steps to respond to a smallpox epidemic.
       In 1999, a group of leading epidemiologists painted a grim picture of how an epidemic would unfold:
       “A clandestine aerosol release of smallpox, even if it infected only 50 to 100 persons to produce the first generation of cases, would rapidly spread in a now highly susceptible population, expanding by a factor of 10 to 20 times or more with each generation of cases.”
       
WHEN TO IMPOSE QUARANTINE?
       
The experts noted that during the 1960s and 1970s, when natural smallpox outbreaks still occurred in Europe, “widespread concern and sometimes panic occurred, even with outbreaks of fewer than 100 cases, resulting in extensive emergency control measures.”
       When would U.S. officials consider imposing a quarantine if there were an outbreak today? The CDC guidelines say a number of factors would determine whether a city or state had reached that threshold, including:
* The number of cases and the number of people exposed.
* The projected morbidity and mortality of those infected.
* The expected ease and rapidness of the spread of the disease.
* The risk for public panic.
       It is that last factor that is especially difficult to quantify.

 
  Smallpox lesions are shown in this 1973 photograph from an outbreak in Bangladesh.
 
  Image: Aventis Pasteur to Donate Smallpox Vaccine
       Forty years ago, quarantines were not seen as critical to stemming the spread of smallpox. During the international campaign against the virus that culminated in 1977 when the disease was eradicated, health officials used a “surveillance-containment” strategy to combat the disease, isolating infected people and watching them closely for the fever and skin rash that characterize smallpox.
       People who had been in contact with those infected were immediately vaccinated because inoculation within four days of exposure provided some protection against smallpox and prevented people from dying from the disease.
       
TRACING VS. VACCINATING
       But a recent study led by Professor Edward Kaplan at Yale University’s Department of Epidemiology and Public Health concluded that a “race to trace” everyone who had been in contact with an infected person might not stem an epidemic today.
 
 
Smallpox's rise and fall
Time line of a scourge
10000 B.C.
Smallpox appears in settlements in northeast Africa.
1350 B.C.
The first recorded smallpox epidemic occurs during the Egyptian-Hittite war when Egyptian prisoners unwittingly spread the virus among the Hittite population.
1000 B.C.
Variolation, an early form of smallpox inoculation, is developed in China and India. The process involved taking the pus from the pocks of someone suffering from the virus and inoculating healthy people with it. A mild case of smallpox developed, but the process granted lifelong immunity afterwards. The practice would eventually spread to Europe and the New World by the 18th century.
180
The Roman Empire is devastated by the Plague of Antonine which kills millions. The dead include Marcus Aurelius, the reigning emperor.
570
Bishop Marius of Avenches names the virus, "variola", a derivation of the Latin word for "stained." The popular term for the virus, "smallpox", won't come into use in England until the 15th century.
910
Rhazes. a Persian physician, writes the first medical description of smallpox.
1520
Two years after Spanish conquistadors arrive in Mexico, the Aztec emperor Ciutlahuac dies of smallpox. Over the next century of Spanish occupation, Mexico’s population diminishes from an estimated high of 15 to 20 million in 1518 to 1.6 million by 1620. The decimation is repeated throughout the New World as Europeans unknowingly introduce smallpox.
18th century
Smallpox kills four reigning European monarchs including Tsar Peter II of Russia and King Louis XV of France. Other notable victims include the king of Ethiopia and a Japanese emperor. By the last decades of the 18th century an estimated 400,000 Europeans die of smallpox each year.
1754-1767
Smallpox is used as a weapon when British forces distribute blankets used by smallpox patients to Native American tribes during the French-Indian war.
1774
Benjamin Jesty, a farmer from the town of Dorset in the United Kingdom, inoculates his family with material taken from the udders of cows that had cowpox, a virus similar to smallpox. Medical reports begin to appear linking smallpox immunity in those individuals with a previous case of cowpox.
1796
Edward Jenner, a British surgeon, injects the fluid extracted from a postule of a cowpox victim into a healthy child. Eventually, the word "vaccine", derived from the medical name of cowpox, "variolae vaccinae", falls into common usage. Jenner does not invent vaccination, but he does confer scientific status. By 1800, Jenner’s efforts to popularize vaccination results in vaccination campaigns throughout Europe.
1801
President Thomas Jefferson creates the National Vaccine Institute.
1803
Spain begins the first overseas vaccination program when it sends the vaccine to North and South America.
1967
World Health Organization launches global vaccination campaign against smallpox.
1972
Routine smallpox vaccination among the American public ends.
1977
Last naturally occurring case of smallpox reported in Somalia.
1980
The World Health Organization recommendeds that all countries cease vaccination and that all laboratories destroy their stocks of smallpox or transfer them to the Institute of Virus Preparations in Moscow, Russia, or the Centers for Disease Control and Prevention (CDC) in Atlanta, Ga. All countries report compliance. Soviets begin to develop smallpox as a bioweapon.
1982
Vaccine production is discontinued in the United States.
1990
U.S. military discontinues routine vaccinations.
Today
Smallpox vaccinations are generally limited to selected lab workers and military personnel.
 

Source: JAMA
Printable version



 
       Tracing people in isolated villages could be effective, but in a teeming city with millions of residents and visitors this approach could be all but impossible, the study said.
       Kaplan’s study recommends mass vaccination of the local population in the face of a smallpox outbreak.
       In an interview with MSNBC.com, he said that unlike the relatively small isolated outbreaks of 40 years ago, a terrorist attack using smallpox might be widespread and coordinated.
       “At the time the attack is detected you don’t know if it is big or small,” he said. Instead of a couple of infections in any one place there might be a couple of thousand.
       Kaplan also raised what he calls “a nightmare scenario.”
       “What would happen if it were determined that the smallpox vaccinations weren’t working right — if you had been attacked with a strain of smallpox engineered to defeat the vaccine? Then a quarantine becomes of tremendous importance,” Kaplan said, as the only way to contain the disease and let it run its course in those infected, while not allowing it to spread to others.
       
 
 
 
 
 fact file 
Understanding smallpox
 1 / 10  Next: What is smallpox?

The Bush administration is soon expected to announce its policy on smallpox vaccinations, in light of concerns that terrorists might seek to trigger a smallpox epidemic in the United States. At first, only police, emergency medical workers and members of the military are likely to be vaccinated. Here are some questions and answers about smallpox and the vaccine.


Sources: Centers for Disease Control, The Associated Press, American Society for Microbiology
Printable version


       
       

 
 
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Vaccination News Home Page

ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.