Hal Chase, an RN with Iowa's Department of Health, gets a smallpox vaccine as defense against possible bioterror.
		Robert Nandell, Des Moines Register

In New York City, as of the latest posting by the Centers for Disease Control and Prevention, six health workers had been immunized; in Massachusetts, 15.

In the weeks since Dec. 13, when President Bush ordered smallpox vaccinations for U.S. troops who are being sent to high-risk areas and announced that vaccine would be offered to health care workers, more than 100,000 U.S. troops and 7,354 civilians have been immunized.

The civilian plan, which began Jan. 24, is designed to allow groups of immunized health workers to form Smallpox Response Teams who would be able to help people if the nation were attacked.

Initially, states counted 450,000 health workers who could be offered vaccine in a one-month target period suggested by the CDC. That hasn't happened, and now, with so few immunized, the question arises: If smallpox were unleashed, is the nation ready?

Health officials say we're getting there.

Though the number of immunized workers is low, programs are just getting started in some states. In others, they're well underway. Nebraska has vaccinated 1,018 people, and Tennessee has immunized 1,488.

But many medical workers are balking at getting vaccinated, partly because of concerns that the vaccine itself can cause severe illness. It contains a live vaccinia virus, a relative of the smallpox virus, that can be passed from the vaccine site to other parts of the body or to other people and cause infection.

For instance, California health officials are investigating a case in which someone who had contact with a recently vaccinated person has an eye infection caused by the virus in the vaccine.

Experts say vaccine reactions are to be expected, despite careful screening to assure that people at highest risk are excluded. Still, the number of health care workers who have volunteered for vaccination is lower than expected, experts concede.

Citing unresolved questions about who might be held liable if the vaccine makes people sick and concerns over whether health workers will be paid for sick time taken to recover from vaccination, some medical unions have urged their members to hold back. Some hospitals are not offering vaccine to their employees because they fear that recently immunized health workers could pass the vaccine virus to patients.

And when stacked up against the vaccine's very real risks, many believe that the threat of a smallpox attack is a distant, theoretical possibility.

That's a mistake, says Julie Gerberding, director of the CDC, one of the medical leaders who helped shape the president's plan.

"One of the big changes since 9/11 is that the CDC is in the loop of communication on classified information that deals with threat assessment," Gerberding says. "I have been in rooms where this has been discussed. I can tell you for sure that I believe these steps for preparation are absolutely essential. The steps we're taking to assure our smallpox teams can protect the nation are essential."

But Gerberding would not go into detail. She falls back on a comment repeated often by a number of top health officials: "The president has said there is no imminent threat of smallpox. We know the risk is not zero, and we know the consequence of an attack could be devastating. The only way to prevent that risk is to take the steps for preparedness we're taking right now."

But whether it will take 15,000 or 500,000 immunized health care workers to stand between the smallpox virus and a vulnerable public is not known.

"We have said from the beginning that the focus on numbers was wrong," says George Hardy, director of the Association of State and Territorial Health Officials, so the initial target of vaccinating up to half a million public health and medical workers was never the "measure of success." Success would be "that we have offered vaccine in as safe a way as we can to people to serve on public health response teams, and that we have adequate preparedness teams in place.

"At this point in time, there are probably fewer people immunized than we would have expected or hoped," Hardy says.

'All hazards' approach

Once questions of liability and compensation are resolved, a huge hurdle will be removed, but other obstacles remain, Hardy says.

"There are people who think this vaccine is a greater risk to themselves and their patients than they are willing to take," he says. Some people question the focus on smallpox alone when there are dozens of other weapons that could be used by terrorists.

One reason for the attention to smallpox, Hardy says, is that "it's something you can do something about. You can vaccinate."

There are no vaccines yet against Ebola or plague, and short of duct tape and plastic sheeting, not much anyone can do about a chemical attack. But even though less publicity surrounds these threats, the CDC is taking an "all hazards" approach to preparedness, Gerberding says.

"You are hearing most about smallpox because we have a vaccine program for it, but our whole preparedness system is focusing on all biological threat agents, as well as chemical and nuclear."

A bioweapons attack could take any number of forms, experts say, though when it comes to smallpox, there is some disagreement about how easy it would be for terrorists to infect a lot of people, especially now that the USA has a huge supply of the vaccine and every state has a plan to implement a mass-vaccination campaign if needed. The vaccine is effective up to four days after exposure.

"We know the Soviets prepared it in a form that could be aerosolized," says Ronald Atlas, co-director of the Center for Deterrence of Biowarfare and Bioterrorism at the University of Louisville.

Many experts believe spreading the virus from an airplane or bomb would be technically difficult, but not impossible. Another scenario is that one or more suicide bombers infected with smallpox could board planes or ride subways in big cities. A detonation could infect travelers, who would then infect their families, co-workers and friends in increasing numbers.

That could occur, says William Schaffner, an infectious-disease specialist at Vanderbilt University, but there are reasons it might not be very effective.

For one thing, he says, people who have smallpox can't pass the disease to someone else until they develop fever or rash, seven to 14 days after being infected. Though it's true that the first lesions may form in the throat or mouth, where they're not visible, by that time the infected person is very sick, Schaffner says.

"You're not in the mood, nor do you have the capacity, to dance through a mall or take long trips on the subway," he says.

And, he says, smallpox is not as contagious as the common cold or flu. It generally requires close and prolonged contact to spread, he says. "This means, even if you encounter a slumping person on the subway and bend over and say, 'How are you?' with that brief exposure, it's highly likely you weren't infected. We'd like to vaccinate you, but that's a very brief exposure, so the risk is small."

The trouble is that even a single case of smallpox could prompt national panic, experts say. State and federal response plans provide for teams of immunized people who could quickly respond to investigate the first cases and care for the victims, then to quickly vaccinate tens or hundreds of thousands.

It has been done before. In 1947, a single smallpox case in New York City prompted vaccination of 6.35 million people in four weeks, a strategy that quickly contained what might have been a major outbreak.

Because most practicing doctors and nurses have little or no experience with smallpox, because there hasn't been a natural case anywhere since 1977, the CDC has launched a massive education campaign. It includes satellite broadcasts, in-person training for state and local health agencies and extensive information on its Web site. This week, the CDC sent 3.5 million doctors information about the vaccine and the disease.

'Vigilant and prepared'

Most medical leaders say they do not believe there is a need to vaccinate the general public before a smallpox attack. "Given the potential side effects," Atlas says, "for the mass population we remain best described as vigilant and prepared to vaccinate."

He says he worries that reports of reactions to the vaccine among health care workers and military personnel could cause a backlash.

"If we do get attacked, we need a public willing to stand online to get vaccinated. If the public is afraid because they've seen some adverse reactions, we have a worse situation" than if no vaccinations had been given before the attack.

Americans have high expectations of public health effectiveness that could prove unrealistic if smallpox is ever released into the world, Schaffner says.

"We're less tolerant. There is an unstated expectation of no transmission. Zero. My first response to that, as a real-world public health person, is 'get over it.' "

An attack probably would result in some deaths, Schaffner says, and no smallpox preparedness plan could avert that.

That's why it's so important to have response teams ready to go, Atlas says. A significant number of people vaccinated for the first time have reactions, including rash or fever, that cause them to miss a day or two of work.

That won't do in an emergency, Atlas says. "You want a group of responders who won't need to go home for a day or two. You want people able to respond without hesitation at the point we might have an attack."