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Bush's Smallpox Boondoggle
By Maria Tomchick,
AlterNet
January 28, 2003
Health experts predict that if 10 million Americans are vaccinated
against smallpox, 20 will die outright from the vaccine alone. What gets
neglected is the 60-million-plus Americans with weakened immune systems who
will be put at risk by widespread vaccination.
The national smallpox vaccination plan rolled out with a whimper last
week. Part of the Bush administration's effort to stave off a bioterrorism
attack, the vaccination plan was to begin with a strong start in the state
of Connecticut by vaccinating 20 or more first-line medical responders who
would then fan out and vaccinate thousands of other doctors, nurses, and
emergency room personnel around the state. In the coming weeks, other states
will join in and inoculate 500,000 first-line medical personnel in all major
medical centers in the country against smallpox. Eventually 10 million more
healthcare workers, firefighters, police, and emergency medical personnel
will receive the vaccine.
But in Connecticut, only four people showed up to get the shot, and 3 of
those were administrative personnel – the state epidemiologist and 2
administrators at the University of Connecticut's Health Center. The numbers
willing to volunteer for the shots had been dwindling all week, as hospital
associations, nursing unions, and other professional groups balked at the
risk of the smallpox vaccine itself and raised important questions about the
true potential for a smallpox terrorist attack. At last count, more than 80
hospitals around the nation, including major teaching hospitals and medical
centers in urban areas, have opted out of the vaccination program.
What's going on here?
The smallpox vaccine is made from a live virus, vaccinia or cow pox,
which is a cousin of smallpox. It can cause illness in a significant number
of vaccine recipients. Experts estimate that about 1,000 out of every every
1 million who receive the vaccine will experience serious side effects,
about 40 of those will be life-threatening illnesses, and 1 or 2 of those
people will die from it. So, of the 10 million expected to get the shots,
10,000 are expected to get sick, 400 will be threatened with death, and 20
are expected to die outright.
But, as critics have pointed out, this is a gross underestimate of the
risks. People who are vaccinated carry an open wound in their arm, which
sheds the live vaccinia virus for up to three weeks. Certain people who come
in close contact with them can become quite ill. At particular risk are
infants under a year old, pregnant women, elderly people, folks with eczema
and skin disorders (who can absorb the disease through breaks in their skin
– an estimated 7 to 20 percent of the general population has had such skin
disorders) and, most ominously, people with lowered immune system response.
There are an estimated 60 million people in the U.S. today living with
weakened immune systems, and most of them are suffering from HIV/AIDS or
undergoing a medical treatment that didn't exist 35 years ago when smallpox
vaccinations were routine. People with AIDS, cancer patients undergoing
chemotherapy or radiation treatments, burn patients, and organ donor
recipients would all be put at an unacceptably high risk of death if their
nurses and doctors are vaccinated for smallpox.
It's a peculiar form of torture to ask a medical person who has dedicated
his or her life to saving other peoples' lives to risk killing patients
because of vague fears of a bioterrorist attack. Doctors and nurses, in
particular, have a good sense of the potential threat various diseases pose
to their patients. As William Schaffner, head of preventive medicine at
Vanderbilt University Medical Center in Nashville, said: "The thing that
stops you from doing this is the complexity of the smallpox vaccine, which
is not a safe vaccine. There's a real disease that kills people
unnecessarily: the flu. Mr. President, I would love to see you endorse a
national flu vaccine campaign with the same vigor." Medical centers around
the country, however, have had to deal with recent flu vaccine shortages.
Smallpox is simply not high on their list of concerns.
Some officials caution that a smallpox attack is a real possibility. All
it would take is one person to infect himself, travel to a major
metropolitan area, and hang out a nearby shopping mall, sports arena, or
other crowded public place to begin infecting people, they argue. There are
many problems with this scenario, including the fact that smallpox has
effectively been eradicated, with no new cases reported since 1977. The only
known laboratory stocks of the disease exist in highly quarantined labs in
the U.S. and Russia. And if smallpox cultures were smuggled out of Russia or
the U.S., it's not at all certain that terrorist groups could get their
hands on them or turn them into usable weapons.
Even in the lone, kamikaze, infected terrorist scenario, the outbreak
might not be as bad as Bush administration advisors assume. Leading smallpox
experts say that nowadays we have conditions that are less conducive to the
massive outbreaks of the past, when people lived in extended families in
crowded rooms, with multiple family members sharing the same bedrooms and
the same beds. People wash their hands more and more people travel alone in
cars and live in less crowded conditions. We use strong disinfectants more
often, and air and water are filtered and treated for contaminants. A
realistic scenario of one person falling ill and then going through his or
her day – even visiting a shopping mall and going to work – shows that only
one or maybe two other people would be infected with smallpox before the
sick person was sent to a hospital. In that kind of scenario, quarantine and
area-specific vaccination would work well to contain the disease.
Joining the critics of the Bush administration's smallpox vaccination
plan is Bill Foege, former chief of the Centers for Disease Control and
consultant to the National Academy of Sciences' Institute of Medicine panel
on bioterrorism preparedness. Foege is a global health adviser to the Bill
and Melinda Gates Foundation, which is spending hundreds of millions of
dollars on major vaccination initiatives in Africa and helping to fund the
search for an AIDS vaccine.
In other words, Foege is definitely not a foe of vaccination in general.
In the 1960s, when he worked for the CDC in Africa, Foege developed a
specific plan of smallpox vaccination that minimized the exposure to the
vaccine and yet helped to wipe out the disease in that part of the world.
His method, called "ring vaccination," relies on a special property of the
smallpox vaccine: It can protect people who have already been exposed to the
disease if they're given the vaccine within four days of their exposure.
Foege argues that ring vaccination should be used here in the United
States, and other medical administrators are beginning to agree with him.
Richard Wenzel, chairman of internal medicine at Virginia Medical College at
the University of Virginia, was faced with a crisis in the fall of 2001.
During the height of the anthrax attacks, he received word that a patient
with smallpox had been found and was being sent to his hospital. He quickly
formulated a plan that would quarantine the patient and assign specific
personnel to treat him who had been vaccinated as children. Wenzel located
some smallpox vaccine for his hospital staff. As it turned out, the patient
didn't have smallpox. But Wenzel now believes that it would be safer and
more cost-effective for hospitals to draw up quarantine plans, stockpile
smallpox vaccines, and use them only in the face of a real outbreak. In the
city where I live (Seattle), the major public hospital, Harborview, is
currently considering this approach.
Cost is also a major issue. The federal government is not providing funds
to hospitals to help them deal with staff shortages if and when their nurses
and doctors fall ill from the vaccinations. Some hospitals are worried about
lawsuits from patients' relatives if they're exposed to the live vaccine and
fall ill. And the cost to vaccinate alone is expected to be between $600
million and $1 billion, and cash-strapped state governments are expected to
pay that bill on their own.
In addition, Bill Foege is worried about public perception in the face of
a real threat. If large numbers of people are vaccinated now, when a threat
doesn't exist, and many fall ill or die, then the public may be resistant to
the vaccine when a real outbreak occurs. That could be disastrous.
The speed with which the Bush administration is pushing the vaccination
plan seems based on political necessity and not public health concerns.
There is currently a safer vaccine being developed and tested in Europe that
doesn't involve the use of live vaccinia. It will be about a year before
that vaccine is made available here in the U.S., but the Bush administration
is pushing ahead with the older, more dangerous vaccine anyway.
In part, it's to prove that the government is doing something about the
threat of terrorism. It's also in response to pressure from vaccine
manufacturers, who want to sell their old stock before the new vaccine hits
the market. In either case – cynical political opportunism or a drive for
corporate profits – expediency should never trump sensible public health
policy. Too many lives are at stake.
Maria Tomchick is co-editor and contributing writer for
Eat the State!, a biweekly
newspaper based in Seattle, Washington.
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