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U.S. Details Response to Smallpox

Cities Could Be Quarantined and Public Events Banned

By Justin Gillis and Ceci Connolly

Washington Post Staff Writers

Tuesday, November 27, 2001; Page A01

If bioterrorists attack the United States with smallpox virus, health authorities could impose measures as drastic as banning public events, halting regional transport and placing entire cities under quarantine, according to a draft federal plan released yesterday.

The plan, by the Centers for Disease Control and Prevention, calls for stepped-up awareness by doctors, health officials and the public to be able to detect any outbreak of smallpox, a disease officially eradicated from the planet 21 years ago—and to be able to respond quickly enough to stop it before a pandemic can sweep the nation.

Prompted by the terrorist attacks of Sept. 11 and the anthrax scare that followed, the plan is the federal government’s most detailed description since 1972 of how authorities might respond to an outbreak of smallpox. Overall, the plan drew praise from several experts yesterday.

However, one aspect of the plan drew immediate criticism from some state health officers. The CDC has vaccinated 80 to 100 of its employees against smallpox so they can respond to an attack, but the draft plan rules out any broader campaign to vaccinate state workers, who might be the first to respond to an outbreak.

In making that judgment, the CDC noted that vaccine supplies are limited. It said the federal government could rush vaccines to a state and inoculate state employees as soon as an outbreak is confirmed. Vaccination is effective even after exposure to the smallpox virus, if given within a few days.

“The point is that this vaccine works once exposed, so those people who would go out and respond to a confirmed case would in fact be vaccinated essentially as they’re going out the door,” said Harold Margolis, senior adviser for smallpox preparedness at the CDC. “At that point, they are protected.”

But several state health commissioners said yesterday the plan does not take into account the worst-case scenario: simultaneous smallpox attacks in multiple cities, overwhelming the CDC. In such an event, they said, unvaccinated state nurses and state police would be on the front lines trying to contain the epidemic.

“You need to go in and talk to the person who has smallpox” to identify contacts, said Georges C. Benjamin, Maryland’s health secretary, who is president of the Association of State and Territorial Health Officials. “That process starts at 3 o’clock in the morning. That process doesn’t start 24 to 48 hours later, when the team gets there from Atlanta [where the CDC is located].”

In an attack on multiple cities, “CDC in their role as the cavalry will simply not be able to go to all those places,” said Leslie M. Beitsch, Oklahoma’s health commissioner and chairman of a state health officers’ association task force on bioterrorism. “If we can’t have our first responders protected, then we risk chaos and panic.”

The state health officers are expected to press the CDC to reconsider its decision, if not now then in the next few months, as more smallpox vaccine becomes available. At the moment, supplies are limited to an aging national stockpile of about 15 million doses in Pennsylvania. The government has asked companies to re-launch production of the smallpox vaccine, aiming to build a stockpile of 300 million doses in a year.

Although the CDC plan would permit large-scale quarantine, that would be a last resort, employed only if other control measures were failing. The heart of the plan is the classic “ring vaccination” strategy used to eradicate smallpox a generation ago.

That strategy depends on quickly spotting a case of smallpox, isolating the initial patients, and identifying and vaccinating others who might have caught the virus from them. Public health workers would continue to identify possibly infected people by considering ever-larger rings of people centered around the earliest cases.

“The main thing you want to do is try to get as much vaccine used in the place where it’s going to do the most good—that is, around the contact of a case and around the families of those contacts, so if they do come down with a disease, there’s a barrier around them,” said Donald A. Henderson, who led the global campaign that eradicated smallpox and who is now director of health preparedness at the federal Department of Health and Human Services.

Local officials would try to locate people thought to have been exposed on a train or at a sports stadium, Henderson said. Should locating them prove impossible, he said, health officials would be forced to consider a broader vaccination program, such as inoculating a large group—even a whole city.

If early control efforts fail or an initial outbreak is sufficiently large, still more aggressive measures might be necessary, the plan says. In the most extreme case, federal and state authority would be used to erect a “cordon sanitaire”—a sanitary ring—around a city or other large area. Control of a big outbreak “may require suspension of large public gatherings, closing of public places, restriction of travel” and other measures, according to the plan.

The last smallpox case in the United States occurred in 1949, and the last naturally occurring case in the world occurred in Somalia in 1977. The eradication of the disease, which the World Health Organization declared in 1980, is considered to be one of medicine’s greatest achievements.

But as a result of the disease’s eradication, vaccination has stopped. No one under 30 is immune to the disease, and older people who were vaccinated as children are believed to have only limited immunity.

Although a CDC lab in Atlanta and a Russian lab in Siberia are the only official repositories of the virus, many experts fear a handful of countries, such as Iraq and North Korea, may have secret stashes that could wind up in terrorists’ hands.

A single case of smallpox would be an international health emergency of the highest order. The CDC plan makes clear that if an attack occurred in the United States, avoiding mass panic would be a challenge.

“In the event of a bioterrorism event involving smallpox, the level of threat perceived by the public—whether real or imagined—may be extreme,” the guidelines warn. “In these circumstances, state and local health officials should be prepared for a high level of demand for vaccine by the public.”

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