Big Question About Smallpox: What if . . . ?

By DENISE GRADY

ASHVILLE, Oct. 10 — One recent Saturday at the gym, Dr. William Schaffner looked around at all the other sweaty people working out and playing basketball in tank tops. What would happen, he wondered, if some of them had recent smallpox vaccinations? What if sweat made the dressings fall off their vaccinations and they brushed up against other people?

For about three weeks, the site of a smallpox vaccination can shed the live virus used in the vaccine, vaccinia, a relative of smallpox. Potentially, the virus can infect other people who come into contact with it, and some people can get quite sick from vaccinia.

Dr. Schaffner has been worrying about things like this for much of the past year. He is chairman of the preventive medicine department at Vanderbilt University, and one of the infectious disease experts advising the government as it considers resuming smallpox vaccination to protect against a bioterrorist attack. The United States stopped routine vaccination in 1972. Globally, the disease was eradicated in 1980.

The government has announced that half a million soldiers will be vaccinated, that many health care workers should be and that once the vaccine is approved for widespread use, perhaps by 2004, it should be offered to the public.

On Wednesday and Thursday, health officials and medical advisers will meet in Atlanta to work out the details of how to carry out vaccination programs.

Many difficult issues have yet to be resolved. The greatest concern of public health experts, Dr. Schaffner said, is that vaccinated people may inadvertently infect others who have a high risk of being harmed by the vaccine. That includes pregnant women, babies under a year old and people with H.I.V. or other immune disorders, some types of cancer, organ transplants or a history of skin conditions like eczema.

"No program is truly voluntary," Dr. Schaffner said. "We are establishing a transmissible infection, and there will be instances of transmission. People who did not volunteer, or who were excluded, will acquire this infection."

Studies from the 1960's indicate that transmission rates were low, just a few cases for every 100,000 vaccinations. But, Dr. Schaffner said, it is not clear how reliable that data is — or how applicable it is today. AIDS was unknown when the smallpox vaccine was in routine use, organ transplants were uncommon and rates of eczema were significantly lower than they are today.

Special bandages, now being used in vaccine tests, are thought to cut down on transmission. But, Dr. Schaffner said, health officials have not yet decided whether those bandages will be used when vaccination becomes more widespread.

Government recommendations call for vaccinating health care workers first. But someone has to decide which workers should be immunized, and whether they should be required to take an H.I.V. test or a pregnancy test first. Should recently vaccinated hospital workers be allowed to take care of sick patients, particularly people with lowered immunity? No one knows the answer, Dr. Schaffner said. Similarly, it is not known whether the people giving vaccinations should be required to be vaccinated first themselves.

The proportion of health workers to be vaccinated is turning out to be "a much more elaborate constellation of folks than we first anticipated," Dr. Schaffner said.

A wide range of hospital staff would have to be immunized because if there were an attack, people infected with smallpox would probably receive more complex medical care, involving more workers, than patients did in the past. Twenty-five years ago, there was not much that doctors could do for smallpox, Dr. Schaffner said, describing the treatment as "bed, fluid, T.L.C. and prayer."

But, he said, "anthrax taught us that supportive care can help."

Intensive care helped save 6 of 11 people who contracted inhalational anthrax in last year's attacks; previously, the disease was thought to be 100 percent fatal.

Today, smallpox victims would be put into intensive care units, and many people with different specialties would treat them.

Another problem is that among adults being vaccinated for the first time, 20 percent to 30 percent become ill enough to miss a few days of work. How will hospitals manage if many employees are ill, particularly when a nursing shortage already exists? And who pays for the sick time and any needed treatment? Similarly, who is liable if there are severe reactions that do lasting harm?

"There is increasing appreciation among physicians and politicians that this is an elaborately complex enterprise," Dr. Schaffner said.