NEWS	SUNDAY • June 16, 2002
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Scientists to decide on risky smallpox strategy
M.A.J. McKenna - Staff
Sunday, June 16, 2002
 

Amid heightened concern over bioterrorism, the debate over whether to revaccinate the nation against smallpox comes to Atlanta next week.

Over two days, a group of scientists who set U.S. vaccine policy will decide whether to protect the country against a potential bioterrorist attack by relaunching a program of vaccinations --- an idea some Americans deeply desire but that carries serious risks. The government already has committed to beginning vaccinations in a limited way if a case of smallpox is found. Next week's discussion will deal only with vaccinating before smallpox is recognized, and it will be very complicated.

Vaccination of most Americans ended in 1972. There is little immunity to the disease left in the population, so renewed protection requires a fresh round of vaccination. But the vaccine always caused serious side effects, and many more people might be vulnerable now because a greater percentage of the population has impaired immunity due to organ transplants and AIDS.

"The complications of the vaccine are significant enough that, at this point, it is unclear there is enough risk to justify its use," said Dr. Robert Baltimore, a professor of pediatrics at Yale University School of Medicine.

At the same time, smallpox has an evil reputation: It spreads rapidly, though not as fast as flu or measles, and it kills, blinds and scars for life.

Much of the population is frightened of it: In a survey released 10 days ago, three of five Americans say they would take the vaccination now. That proportion would rise to more than four out of five if a case of smallpox were found.

"I think they ought to make it available," said Barbara Pendley, who lives in north Fulton County and is retired from real estate management. "I had [the vaccination]; I never feared my children getting it. I don't remember anyone dying from it, or even thinking of not taking it."

Smallpox could become a bioterror weapon if the security that has kept it in cold storage for more than 20 years is breached. When the World Health Organization declared the disease eradicated in 1980, most laboratory stocks of the virus were destroyed.

Only two stockpiles remained --- one at the Atlanta-based Centers for Disease Control and Prevention and one in Siberia, in what was then the Soviet Union. For years authorities have feared that rogue states and terrorist groups might obtain access to the Russian stockpile, or had already done so.

The likelihood of smallpox being used as a weapon has been judged low by defense authorities --- but public concern about it is high.

'Opinion varied'

To obtain views on vaccinating, the CDC has held six public meetings around the country since May 30. The most recent, in Washington, was Saturday.

"Among the general public, the opinion varied --- from wanting to have an individual choice to take the vaccine to feeling that nobody should have access to it," said Dr. Joel Kuritsky, director of smallpox planning and response at the CDC. "I think people understood that this is a difficult issue that requires lots of different variables to be thought through."

Reports from the public forums, whose participants included scientists and front-line emergency workers as well as ordinary citizens, will be summarized during the meeting Wednesday at the Marriott Century Center in northeast Atlanta. The meeting runs through Thursday. Public comment will be taken from 2:15 p.m. to 6 p.m. Wednesday.

Committee members, volunteer doctors and researchers appointed by the secretary of health and human services and the director of the CDC, meet quarterly to discuss subjects such as the composition of flu shots and schedules for childhood vaccinations. In a bow to the depth of national concern over smallpox, the group has set aside its entire meeting to explore dealing with the disease.

The panel has many choices. It could make the vaccine freely available, offer it to paramedics and police, or maintain the current situation of restricting it to lab workers who handle smallpox.

Whichever course the committee chooses, it will submit its recommendation to HHS Secretary Tommy Thompson and acting CDC Director David Fleming. They could accept the recommendation, making it government policy, by the end of June.

The committee will hear from what the CDC calls "stakeholders" --- paramedics and emergency room staff who would take care of a smallpox case and state and local health department workers who would mobilize a vaccination campaign. The committee has set aside time for public comment. And committee members will listen to opinions from the major medical associations, many of whose members practiced in the smallpox years.

One of the medical associations concerned about possible resumption of vaccinations is the American Academy of Pediatrics, for which Yale physician Baltimore is a spokesman. "It's pediatricians who are most familiar with the serious side effects," Baltimore said. "In my training, at the tail end of when the vaccine was being used, I certainly saw very serious reactions."

A gap in memory

Some of those reactions can be seen in photographs kept by WHO and the CDC from the smallpox era.

In one, a woman's eyes are squeezed shut by sores, which cover her face. In another, a baby lies in a crib, skin blackened and sloughing away. A girl's cheek is swollen and scarlet. A child's shoulder has been carved out by deep, angry sores --- which later killed him.

Most Americans over 30 carry the ring-shaped scar on one shoulder that marks their childhood smallpox vaccination. A few remember the procedure: not a shot from a hypodermic needle, but jabs into the skin with a slender vaccine-dabbed spike that drew blood. Almost none, according to authorities, recall the events that sometimes followed.

"We didn't have a reporting system for vaccine reactions back then," said Dr. Robert Blendon of the Harvard School of Public Health, whose survey uncovered how many Americans want the vaccine to be available. "We didn't have much television. We didn't make a big point of the problems, and the media didn't focus on them, so the public doesn't remember. That's a real problem."

From scars to death

In most of those who got the vaccine in the smallpox years, reactions were mild: a low fever, a sore arm and the scar-forming pustule that indicated the body had developed immunity.

But according to CDC records, the smallpox vaccine generated larger numbers of reactions than childhood immunizations that are used today. Once in every 5,000 cases, one person transferred the smallpox infection from the inoculation site to another part of the body: the mouth, the eyes or the genitals. Once in every 2,000, someone developed a body rash from the virus in the vaccine, which is not smallpox but a related one called vaccinia. In every 26,000 jabs, a severe, sometimes fatal reaction developed in someone who already had eczema. In every 300,000, the infection settled in the brain, causing paralysis, convulsions and coma, almost always among infants. One in four of those infants died.

Some complications occurred not in those who got the vaccine, but in someone in close contact who had an underlying health problem: the girlfriend of a newly vaccinated sailor, unvaccinated toddlers who used the same crib as a newly vaccinated child. Because there are many more people in the U.S. population today with underlying health problems, such as AIDS patients and those recovering from cancer and organ transplants, the likelihood of passing the vaccine virus on to others is greater.

Nevertheless, researchers say, the public is demanding action, and the panel convening Wednesday will have to acknowledge that demand.

"I think people who are saying they want to be vaccinated right now are not necessarily going to rush off and do it," Blendon said. "But the anxiety levels about bioterrorism are high enough that the public wants some reassurance. They want to know it is a choice that is truly available to them if they feel sufficiently threatened."