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http://www.nytimes.com/2002/12/17/health/17TROO.html

Pentagon Faces Difficulties in Smallpox Shots for Troops

By DENISE GRADY

s the government begins its program to inoculate half a million troops against smallpox, it is engaged in a delicate balancing act between the military's need for discipline and efficiency and its obligation to protect vulnerable recruits from an unusually risky vaccine.

Military personnel with medical conditions that increase their risk of being harmed by the smallpox vaccine will not be immunized, but may still be deployed anywhere, even to regions where it is feared that smallpox could be used as a weapon, the Department of Defense said in a memorandum dated last Friday.

The memorandum, signed by David S. C. Chu, under secretary of defense for personnel and readiness, said deployment decisions would be left to individual commanders.

But if unvaccinated troops are sent to areas where an attack with smallpox is launched, they will then be inoculated in the field, because at that point the risk of the disease will outweigh those of the vaccine, said James Turner, a spokesman for the Defense Department.

It is not known how many military personnel will be exempted from the vaccine for medical reasons. Among those at increased risk are people with skin rashes like eczema and atopic dermatitis or a history of those conditions, which affect about 15 percent of Americans. They are advised to avoid the vaccine, as are people with burns, certain skin infections, chickenpox, psoriasis and severe or uncontrolled acne.

"I think the number of people with these skin conditions is a minority," Mr. Turner said.

But the presence of people in the military who must avoid the vaccine may pose logistical difficulties. Such people must also avoid close contact with others who have been recently vaccinated, because for two to three weeks the vaccination site can shed the live virus, vaccinia, used in the vaccine. Vaccinia, a relative of smallpox, can infect others, and can cause serious illnesses in pregnant women, babies under a year old, and people with immune problems or skin disorders. People who live with someone in a high-risk group are also advised to avoid the smallpox vaccine, to avoid transmitting vaccinia to the vulnerable person.

What does this mean on a military base or a ship, where personnel live in tight quarters and share showers, and those who should not be vaccinated could be surrounded by those shedding vaccinia?

Another Defense Department memorandum, dated Nov. 26, notes the need for caution, and says, "Exempt individuals should be physically separated and exempt from duties that pose the likelihood of contact with potentially infectious materials (e.g., clothing, towels, linen) from recently vaccinated people."

The memorandum says that vaccinated and unvaccinated people should not take turns sleeping in the same cots, bunks or berths, which is sometimes done on ships.

Asked how the separation might be accomplished on ships or military bases, Mr. Turner said, "Right now I'm not prepared to get into that level of detail."

"It will be interpreted by the services depending upon their unique situations," he said.

Mr. Turner also declined to say whether the military would alter training programs or routines for military personnel who get flu-like illnesses from the vaccine, which has more side effects than most other immunizations. Young people who have not had the smallpox vaccine, the vast majority of military personnel, are more likely than those who were vaccinated as children to have reactions like fever, aches and pains, headaches, swollen lymph nodes and sore arms. In previous studies, about 30 percent of participants have felt sick enough to miss a few days of work or school.

"We give a lot of vaccines to our troops," Mr. Turner said, "and a lot of these vaccines I'm sure cause similar side effects, and we deal with it."

If service members who do not quality for a medical exemption decline the vaccine, they may be disciplined by their commanders, Mr. Turner said.

"We're not expecting that because of events last year and the actual use of anthrax," he said.

During the 1990's, several hundred service members refused to be vaccinated against anthrax, which had been ordered for all military personnel. Some were court-martialed or discharged; others resigned.

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