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http://www.reutershealth.com/archive/2002/06/05/eline/links/20020605elin027.html

Shift in US smallpox vaccination policy recommended

Last Updated: 2002-06-05 10:00:12 -0400 (Reuters Health)

By Todd Zwillich

WASHINGTON (Reuters Health) - Several experts urged federal officials on Tuesday to implement a broad shift in government policy that would include voluntary, preemptive smallpox vaccination for most US citizens.

The plan would also include federal laws requiring healthcare workers and other 'first responders' to a biological attack to be vaccinated against smallpox.

The comments come as federal officials prepare to decide later this month how to use the hundreds of millions of doses of smallpox vaccine the government is stockpiling. The government is currently purchasing massive amounts of stored and newly-manufactured vaccine from private companies and is also busy making diluted vaccine from existing stores.

In all, officials say they expect to have more than 300 million vaccine doses available by the end of the year. The Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention (CDC) is scheduled to meet at the end of June to help the agency finalize a program for how and when the vaccine will be distributed.

The CDC is expected to endorse its current policy of withholding vaccination from the public unless smallpox cases begin to surface. In the event of a biological attack with smallpox, health officials would identify and vaccinate anyone who came into recent contact with an infected person, forming a "ring of immunity" around cases.

The method was effective in eradicating naturally occurring smallpox during the mid-20th century. The policy today could go one step further, calling for mass vaccinations of entire metropolitan areas where cases occur, but not vaccinations of whole states or regions.

But experts speaking at a forum on smallpox vaccination hosted by the Cato Institute, a conservative think-tank, said it would fail miserably against a human-engineered attack.

"In brief, it's a plan that probably cannot work," said William J. Bicknell, a professor at the Boston University School of Public Health. The US population is too mobile and too densely packed to allow the ring vaccination method to work, he said. Assailants could easily spread the virus in several cities simultaneously, distributing smallpox in a way that might overwhelm hospitals and health systems, he said.

Bicknell urged officials to consider allowing adults to opt for the vaccine voluntarily before an attack occurs. The policy would allow millions of Americans to be immunized against smallpox and would help prevent panic if an attack occurs, he said.

"I think (the government) can do a lot better than sitting on the stockpile," said Charles Pena, a senior policy analyst with the Cato Institute.

The argument against preemptive vaccination centers on the risk of side effects. For every million people that are vaccinated, scientists expect about three persons to die from complications--mainly children and people with weakened immune systems. The risk could be reduced by barring such individuals from obtaining the vaccine, experts suggested, and those that do take it could be required to sign informed consent agreements stating that they accept the risks.

These measures did reassure Dr. Jonathan Tucker, of the Monterrey Institute for Nonproliferation Studies. Tucker warned that even a few deaths blamed on voluntary smallpox vaccination would turn millions of frightened people against the idea of vaccination in the event of an actual attack.

"Doing it too early would result in a political backlash that would make it impossible to vaccinate at a later time when the threat is clear and present," he elaborated. "The general public is just not used to that level of risk."

Tucker pointed out that a smallpox threat has been "conspicuous in its absence" from the recent rash of government terrorist alerts, suggesting that the overall risk of an attack is lower than the known risk of vaccination.

Still, at least one expert argued that neither voluntary inoculations nor government-run ring vaccinations would work against a sophisticated attack using smallpox virus modified to increase infectivity. "Immunize everyone as soon as possible," said Dr. Richard Levinson, of the American Public Health Association.

He believes that an education campaign needed to inform people about the risks of voluntary vaccinations would be "marked with massive disinformation" on the Internet and on television. Relying on ring vaccination is risky because terrorists are likely to exploit regional or organizational weaknesses in America's public health infrastructure.

The CDC is currently holding public forums on the issue in four US cities. After that, the agency plans to release its proposals for how to use the vaccine in the event of an attack. Experts agreed that a final decision is unlikely to rest with the physicians and public health experts who usually set vaccine policy.

"Unfortunately, this is a political decision that will be made at a high political level," Tucker said.

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