Smallpox vaccination begins in U.S.--precautions needed.

On December 13 President Bush announced that the U.S. will begin a smallpox vaccination program. It will be mandatory for about 500,000 military personnel, with voluntary but recommended vaccination for over 400,000 civilian health-care workers most likely to encounter smallpox in case it is spread deliberately. A few in the military started receiving the vaccine immediately; the program for civilian health workers may start in January. Eventually, vaccination might be recommended for as many as 10 million health and emergency workers in the U.S.

People with HIV or certain other medical conditions--probably millions of Americans--cannot be vaccinated safely because the vaccine uses a live virus, called vaccinia. Vaccinia can cause a dangerous infection, especially in persons with immune deficiencies. Persons at risk from vaccination need to be aware of other precautions as well, since one can get this infection not only by being vaccinated, but also by close contact (especially household contact) with someone who has been vaccinated within about three weeks. Vaccinia can be spread by contact with someone's vaccination site, or contact with materials that have touched the site. If vaccinia infection does occur, there are recommended treatments--VIG (vaccinia immune globulin), and cidofovir, an approved drug that can have serious side effects--but the infection can be fatal despite treatment. Hospitals are concerned that their healthcare workers who get vaccinated could infect patients, many of whom have immune deficiencies. Some hospitals may send vacc inated staff home during the two to three weeks they could be contagious, some may decide just to keep them out of certain wards, and a few have refused to participate in the national vaccination program.

In case of actual exposure to smallpox, or cases found anywhere in the world, vaccination might be worth the risk even for many who would otherwise be screened out. Fortunately, vaccination does protect against smallpox even if it is given shortly after exposure (in the first three days if possible). Therefore most people can wait, and decide about vaccination only if a smallpox outbreak occurs.

New kinds of smallpox vaccines are being tested. Some of them may be safe enough for many people with HIV or others who should not get the current one.

A much smaller program is starting in England, vaccinating about 300 healthcare workers against smallpox. Israel recently vaccinated about 17,000 medical and rescue workers in preparation for a U.S. war on Iraq--apparently with little problem from side effects. We have not heard of smallpox vaccination plans in other countries.

For More Information

The U.S. government is planning a massive public education campaign about smallpox vaccination. This information is being prepared by leading experts and will probably be the best available. Until it is ready, those wanting recent information can check the following. (Note: We published these links on December 23, 2002. Be sure to look for more recent information.)

* On December 13 the White House issued a question-and-answer document about the vaccination program; it is at: http://www.whitehouse.gov/news/releases/2002/12/20021213-3.html

* The American Public Health Association published an interim policy statement at: http://www.apha.org/legislative/po1icy/smallpox.htm and a press release on the new White House plan at: http://www.apha.org/news/press/2002/smallpoxresponse.htm

* The New England Journal of Medicine is publishing several articles about smallpox in the January 30, 2003 issue, but has released them early at: http://nejm.org/earlyrelease/early.asp

* Three articles in the December 20 Science (these require a subscription or payment to read online):

"Rough-and-Tumble Behind Bush's Smallpox Policy," http://www.sciencemag.org/cgi/content/summary/298/5602/2312?etoc

"Treating Vaccine Reactions: Two Lifelines, But No Guarantees," http://www.sciencemag.org/cgi/content/summary/298/5602/2313?etoc

"Looking for Vaccines That Pack a Wallop Without the Side Effects," http://www.sciencemag.org/cgi/content/summary/298/5602/2314?etoc

* JAMA (Journal of the American Medical Association) recently published an article on the risk of getting an infection from someone who has recently been vaccinated; see "Contact Vaccinia--Transmission of Vaccinia from Smallpox Vaccination," October 16, 2002. Note that this article is based on experience from before the HIV epidemic.

* For detailed practical information see The Military Vaccines Web Site: http://www.vaccines.army.mil/smallpox.asp

Comment

So far the vaccination program is mostly getting good medical reviews. Public health experts are especially relieved that it is not trying to vaccinate the whole population, as some had proposed.

No one knows the risk of an attack. The case for the program is that if smallpox does occur, there will be teams already vaccinated and ready to respond--and equally important, some current experience in large-scale vaccination and a program that is ready to go, allowing many more people to be protected quickly if necessary. The U.S. already has enough doses to vaccinate everyone in the country, even before new vaccine is manufactured.

The world is not as lucky. "Last year epidemiologists were very concerned to learn that the WHO's vaccine safety net of 200 million doses had been destroyed in the late 1980s when the United States withheld funds and the agency was unable to pay $50,000 to refrigerate the supply." (Lawrence Brilliant, M.D., "Are We Safe? Halting the Next Plague," The Oprah Magazine, June 2002.)

It is strange to plan for smallpox in a vacuum, disconnected from how we got into this situation or how to avoid it in the future. But the vaccination program is a fact, and everyone with HIV or certain other medical conditions will need to consider precautions.

Be sure to get the latest information. This article, published in late December 2002, will soon be obsolete.