Guide for Mass Smallpox Vaccinations: Recipe With Missing Ingredients
By WILLIAM J.
BROAD
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new guidelines for states on mass smallpox vaccinations are most notable for
what was omitted: unanswered and often unaddressed are critical questions
like timing, costs, feasibility and the multiple problems of preparing
health care workers to conduct vaccinations and communicating the plans to
the public.
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The guidelines fit with the Bush administration's recent optimistic
pronouncements about the nation's readiness to confront germ terrorism. But
experts questioned the plan's depth, breadth and realism, warning that
superficiality can sap public confidence and, in a crisis, widen a health
calamity.
Dr. Mohammed Akhter, executive director of the American Public Health
Association, called the plan good but questioned its feasibility.
"This is a huge and massive undertaking, the likes of which we've never
seen in our history," Dr. Akhter said. If a smallpox attack came tonight, he
added, "There's no way the state and local health departments would be able
to implement the plan."
Jonathan B. Tucker, a germ-weapons expert in Washington and author of
"Scourge," a book on the smallpox threat, said public confidence in the plan
was crucial for its success but judged the guidelines and their explanation
by federal officials wanting. "A real potential problem is how you ensure
that a vaccination process is orderly and people don't panic," Mr. Tucker
said. "What we saw last fall with the anthrax attacks, which were much less
threatening than a smallpox outbreak would be, was public hysteria. In the
context of a vaccination campaign, that would be very problematic."
The Centers for Disease Control and Prevention in Atlanta has reassured
the public that federal officials are ready to respond. Dr. Julie Gerberding,
director of the centers, gave a wholehearted "yes" when asked if the agency
was prepared to handle deadly germ attacks.
"C.D.C.'s level of preparedness is very high," she said in a recent
statement. "We have the plans, the policies, the people, the products, and
now we have the practice to make sure we are ready to respond."
In theory, during a deadly outbreak, mass smallpox vaccinations can
protect many people: the vaccine is one of the few immunizations that can
work even if a person is already infected. The vaccine can fully protect
people if given within four days of exposure to the virus.
The new plan addresses only the most comprehensive response to an
outbreak of the contagious disease, which kills about one in three victims.
It does not address giving vaccinations to anyone before an attack or an
outbreak, only afterward.
While the new plan gives a blueprint for how to carry out mass
vaccinations, it says nothing about other precautions that, Dr. Gerberding
said in an interview, would continue to be the first line of defense.
For instance, it is federal policy for health workers first to isolate
infected patients and vaccinate people in close contact with them, forming a
series of rings of immunization around an outbreak and barriers to its
spread.
Federal officials said the smallpox plan, its third revision since last
November, was not a new policy but simply a set of detailed recommendations
for states on how to respond to a worst-case attack.
Dr. Mack Sewell, New Mexico's state epidemiologist, said achieving that
level of readiness "is a matter of time, attention and resources," all of
which are uncertain at this point.
Earlier this summer, federal officials said they would recommend "preattack"
vaccination for up to 500,000 emergency workers, but state officials
complain that they have received little or no guidance on the critical
question of how much vaccine will be made available, and when, or who will
have to be immunized ahead of time so they can carry out the mass
vaccinations.
"They've really been bobbing and weaving on this," said Gary L. Simpson,
director of the New Mexico infectious disease bureau. "We've looked at
numbers that range from 500 up to 50,000 people, and that's just in New
Mexico."
Federal officials said a plan for vaccinating emergency health care
workers, after repeated delays, was to be made public by month's end.
Dr. Tucker, a germ-weapons expert in the Washington office of the
Monterey Institute of International Studies, said the plan was haunted by
uncertainties over whether the states had the financial wherewithal and the
raw organizational skills to carry out mass vaccination quickly. Even though
the federal government has given the states $918 million to build bioterror
defenses, that may not be enough, Dr. Tucker said.
"These plans have to be exercised under realistic scenarios to make sure
they would actually work in a crisis," he said.
Dr. Tucker added that good public communication, vital to the plan's
success, seemed to be an afterthought. "It's very unclear whether C.D.C. or
the states are developing the necessary communication strategy to prevent
panic in the event of an outbreak," he said.
The centers' briefing yesterday on the plan, Dr. Tucker added, was
strikingly lackluster. "It was very bureaucratic and full of jargon, so even
when they were speaking to reporters they were not speaking in plain
language," he said. "If they're going to communicate with the public,
they're going to have to do it in a simpler, more direct way."
The plan says nothing about how ready the federal government is to
distribute the rare vaccine to the states. For security reasons, much of
that information is kept secret to deny terrorists details that might let
them cripple defenses and make smallpox attacks more effective.
Federal officials assert that they can transport vaccine anywhere they
need in a matter of hours, not days. But it is unclear where it is stored
and how quickly it can in fact be distributed. The general goal is to be
ready to vaccinate every American by the end of this year.
Acambis, a company in Cambridge,
England, is making 209 million doses of the vaccine for the federal
government but says it is barred from giving out all but sketchy details of
its progress.
Last week, Acambis said it had produced the first smallpox vaccination
kits for the federal stockpile but would not say how many were available.
Each kit contains the dry vaccine, fluid for its dilution, needles for its
administration and forms to inform the patient of its status as an
investigational new drug.
Dr. Akhter, of the public health group, said an even bigger unknown was
who in Washington would make the decision to begin mass vaccinations and how
that decision would be communicated. "This would be a national emergency,"
he said. "Someone at the national level has to be designated to flip the
switch."
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