U.S. smallpox preparedness improves, even if not quite according to plan

contagious pathogen could spread rapidly in an unvaccinated population, especially if healthcare workers themselves were vulnerable to infection. The terrorist attacks, and the anthrax attacks one month later, made the threat more concrete. “To protect our citizens in the aftermath of September the 11th, we are evaluating old threats in a new light. Our government has no information that a smallpox attack is imminent. Yet it is prudent to prepare for the possibility that terrorists … who kill indiscriminately would use diseases as a weapon,” Bush said in December 2002.

More than five years later, only about 40,000 civilians have actually received the vaccine, a number that has held steady since the middle of 2003. The most recent estimate provided by the CDC, which oversees the program, was from 31 October 2005. The Department of Defense vaccinates military personnel for smallpox and Bush himself was inoculated shortly after his 2002 speech. The vaccine itself can be dangerous and even fatal. Serious side effects can result, including breathing and heart ailments. During the early months of the program, several civilians and at least one soldier died after receiving the vaccine, though the government never concluded definitively that the fatalities resulted from the vaccine. The live vaccine — derived from cowpox — can be contagious, as well. Last year, a soldier in Chicago infected his son with the vaccine. According to the Health Resources and Services Administration, 64 people have filed claims with the agency’s smallpox vaccine injury fund. To date, 16 people have received payouts totaling $3.6 million for side effects including respiratory, cardiac, neurological and skin conditions.

Concern among healthcare workers about the serious side effects linked to the smallpox vaccine, along with uncertainty about the likelihood of an outbreak, limited participation in the program. “That was the reason the program failed,” Toner said. A former top administration bioterrorism-preparedness official agreed. “The risk [of a smallpox attack] was a very unclear risk, there’s no question about it,” said D.A. Henderson, who headed the World Health Organization program that eradicated smallpox and served in the administration from November 2001 until April 2003. Henderson currently is a distinguished scholar at the Center for Biosecurity.

Despite the fact that the number of people vaccinated is vastly lower than Bush projected, public health experts indicated that there are enough healthcare workers inoculated to respond to an outbreak and enough vaccine on hand to get more protected, along with anyone else exposed to the disease. “There’s a cadre of people who’ve been vaccinated around the country,” Benjamin said. Unlike in 2001, “you’re not looking at a totally unvaccinated response force,” he said. During the five years since the smallpox program was launched, the Department of Health and Human Services (HHS) not only stockpiled enough vaccine to administer it to practically the entire population, it completed the conversion of the stockpile from an older version of the vaccine to a newer one. Indeed, the CDC announced on 29 February that it was planning to destroy the remaining supplies of the old vaccine, according to the AP. The new vaccine is considered somewhat safer, but the public health experts agreed that kick-starting the vaccination program now would be unnecessary and unwise. A CDC spokesman said there are no plans to do so. Toner said that, although planning for a smallpox outbreak has enhanced the nation’s preparedness, the vaccination component of the program was “ill-conceived from the beginning” and was a poor use of resources. “The smallpox vaccine program was a distraction, and an unfortunate distraction,” said Toner, who opposed it from the beginning. Likewise, said Benjamin, “The vaccination program had become the center of attention. Many of us were concerned.” Henderson said he strenuously argued for a limited program at HHS.

A 2005 report by the prestigious Institute of Medicine concluded that the emphasis of vaccinating a large number of people called attention away from more important parts of the bioterrorism programs. “If preparedness, not numbers, was the program’s focus, the frenetic pace of vaccination imposed at the beginning of the program was not needed,” the report stated.