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http://www.nytimes.com/2002/06/21/health/21SMAL.html

Panel Rejects Immunizing All Against a Smallpox Outbreak

By LAWRENCE K. ALTMAN

TLANTA, June 20 — A panel of specialists advising the federal government on smallpox vaccinations unanimously rejected a proposal today to offer vaccines to every American. Instead, the panel recommended immunizing only the estimated 15,000 health care and law enforcement workers who would be most likely to respond to a biological attack and come in contact with victims.

In rejecting the idea of starting mass vaccinations for the first time since routine immunization was halted in 1972, the panel said the risks of complications from the vaccine outweighed its benefits in the absence of any known case or confirmed threat of a smallpox attack.

In the event of an attack, the panel said, the government should follow the health care strategy known as ring vaccination, in which victims are isolated and those with whom they had direct contact are vaccinated. In that way, the panel said, state and local health departments "would be able, if necessary, to expand immunization to additional groups, up to and including their entire population, in a timely manner."

After the anthrax attacks last fall, the government ordered millions of doses of smallpox vaccine and the Centers for Disease Control and Prevention asked a 14-member panel to determine whether changes were needed in current recommendations, which limit smallpox vaccine to scientists working with smallpox and related viruses in a laboratory.

The new recommendations from the panel, the Advisory Committee on Immunization Practices, will be sent to the centers' acting director, Dr. David Fleming, and then forwarded to Tommy G. Thompson, the secretary of health and human services.

Dr. Dixie E. Snider, an official at the centers who is executive secretary of the panel, said that in the past its recommendations had not been rejected, though the language was modified in a few cases.

Mr. Thompson said he would review the recommendation with experts "as the administration works toward a policy on the smallpox vaccine."

"We plan to move as expeditiously as possible," he said, "so that we have a policy in place as more vaccine becomes available later this year." The government expects to have enough vaccine to protect every American by early next year.

Charles Pena, a defense policy analyst at the Cato Institute, told The Associated Press that the panel should have chosen mass inoculation. He said those at risk for side effects could choose not to get shots.

"That's the government deciding who gets to live," Mr. Pena said. "They're willing to allow some number of the public to be exposed to the virus if it's used as a bioterror weapon."

Of all the vaccines, smallpox is among the most dangerous. The virus from which it is derived — a cousin of the smallpox virus — can spread from a recipient and can cause life-threatening complications, especially in people with impaired immune systems.

During the two days of the meeting, panel members said their intent was to allow flexibility in administering their recommendations. The panel said it expected to review its recommendations "periodically, or more urgently if necessary," to consider new developments related to smallpox, the vaccine, the risk of an attack and other factors.

Speaking at a news conference, Dr. John F. Modlin, the panel chairman from Dartmouth Medical Schools, and Dr. Julie L. Gerberding, the acting deputy director of the disease control centers, said it would take several months to carry out the recommendations if they became government policy. Dr. Modlin estimated that 10,000 to 20,000 people would be vaccinated under the plan, but said the earliest anybody could receive it would be in the fall.

One reason, said Dr. Natalie J. Smith, an official of the California State Health Department and a panel member, is that her colleagues there and in other states need time to work out the logistics.

While the panel encouraged the nation's 5,000 hospitals to develop plans to respond to a smallpox case, it did not recommend vaccinating all 100,000 or so hospital workers. That would cause logistical problems, the panel said, and would unnecessarily vaccinate many people unlikely to come in contact with any victims.

Today's recommendations allow government officials in each state and territory to designate two sets of selected health care workers to receive smallpox vaccinations. The workers would be part of teams designated to investigate the initial cases in a smallpox outbreak and to directly care for victims.

The number of such teams would vary with the population and geography of each state and would be coordinated with federal, state and local bioterrorism plans. Each state should form at least one such team, the panel said.

The investigative team would include a medical team leader, a public health adviser, medical epidemiologists, disease investigators, diagnostic laboratory scientists, nurses, vaccinators and security and law enforcement workers, the panel said. Such teams would include doctors and nurses who would assist in determining whether suspect cases were indeed smallpox.

Vaccines would also be provided to selected health care workers at hospitals designated by government officials in each state. Each hospital would determine which workers to vaccinate and to train to care for smallpox cases, the panel said.

Dr. Stanley Plotkin, a vaccine expert who is not a member of the panel, said in an interview that the ring vaccination plan would protect the country against large numbers of cases if 10 or so infected bioterrorists spread the virus.

But he added that if terrorists used an aerosol to expose thousands of Americans, the plan would not prevent a significant number of deaths.

Dr. Plotkin urged President Bush to ask President Vladimir V. Putin of Russia whether officials there could account for all their stocks of smallpox assembled during the cold war.

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