Important note: Information in this article was accurate in 2002. The state of the art may have changed since the publication date.
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Associated Press - Thursday, October 10, 2002
Laura Meckler, Associated Press Writer
The vaccine protects recipients against smallpox, but it can also kill. So the Bush administration is preparing an extensive education plan to help people understand the risks and the benefits as it finalizes plans to provide the shot to the general public.
Already, there are many questions:
Q: What is smallpox and why is it so worrisome?
A: Smallpox is a highly contagious virus that is spread from person to person, historically killing 30 percent of its victims. People can prevent infection if vaccinated within four days of exposure, before symptoms even appear; afterward, it's too late, and there is no known treatment. The last case of smallpox in the United States was in 1949, and routine vaccinations ended in 1972. That means that some 45 percent of the public is totally unprotected. People vaccinated decades ago may have some residual protection, but health officials aren't sure. Bioterrorism experts paint frightening scenarios like this: A dozen people on a suicide mission infect themselves with smallpox and, when they are at their most contagious, walk around airports, infecting hundreds of others who then carry the virus across the country.
Q: Wasn't smallpox wiped out?
A: In 1980, the disease was declared eradicated worldwide, and all samples of the virus were to have been destroyed - except those held by special labs in Atlanta and Moscow. Experts fear some of the Russian sample could have escaped to hostile nations, fears that are amplified as the United States contemplates war with Iraq.
Q: Why not just vaccinate everyone right now?
A: The smallpox vaccine is very effective, so the Bush administration is planning to offer it widely. But many are urging caution because the vaccine itself, made with a live virus called vaccinia, carries rare but serious risks.
Q: How many people could be hurt by taking the vaccine?
A: Based on studies from the 1960s, experts estimate that 15 out of every million people vaccinated for the first time will face life-threatening complications, and one or two will die. If a smallpox attack never comes, that would be a heavy toll to pay. Reactions are less common for those revaccinated. For the approximately 130 million Americans never vaccinated, experts would expect nearly 2,000 to face life-threatening complications and 125-250 of them to die.
For about 158 million people being revaccinated, experts expect nearly 800 life-threatening complications and about 40 deaths.
Q: What sort of reactions and complications?
A: Typical reactions include sore arms, fever and swollen glands. The most common serious reaction comes when vaccinia escapes from the inoculation site, often because people touch the site and then themselves or someone else. For instance, the virus transferred to the eye can cause blindness.
More deadly is encephalitis, which can cause paralysis or permanent neurologic damage. Also fatal though very rare: progressive vaccinia, where the vaccination site does not heal and the virus spreads, eating away at flesh, bone and gut.
Q: Who's at greatest risk of complications?
A: People with weak immune systems - those with HIV, cancer and transplanted organs - face much greater risk, as do pregnant women. People with eczema risk a serious, permanent rash. Officials administering the vaccine will ask detailed questions to try to screen out such people.
Some say the rate of complications is likely to be much higher than it was in the 1960s, when AIDS didn't exist and there were fewer transplants. Still, screening is likely to be tighter, so the two factors could balance out.
Q: How do these side effects compare with other vaccines?
A: Smallpox vaccine is more dangerous than any other. By comparison, the measles-mumps-rubella shot can cause reactions including anaphylaxis, marked by swelling inside the mouth and difficulty breathing. But just 11 cases of anaphylaxis have been reported since 1990, out of more than 30 million vaccinations, and no one has died.
Q: If the vaccine is effective four days after exposure, why not just vaccinate after an attack?
A: Delivering mass vaccinations within days is incredibly complicated, and an attack would be much less deadly if there is more vaccination now. However, planning is also under way for post-attack vaccinations.
Q: Absent an attack, who will get the vaccine?
A: Top federal health officials have recommended offering it in stages, starting with those at greatest risk of encountering a patient. First up would be about 500,0000 people who work in hospital emergency rooms and on special response teams. Next, about 10 million others, including all health care workers and emergency responders. Finally, it would be offered to the general public, but only after the vaccine - which is now experimental - is licensed, probably by early 2004.
Q: What's delaying a decision?
A: Officials are debating the timing of vaccinations. Some in the White House are pushing to vaccinate the public more quickly than the health officials have proposed, possibly before it is licensed. Officials are also considering whether to recommend that people take the vaccine or just to let them decide for themselves. And they must resolve sticky details such as how to compensate people injured by the vaccine and how to screen for HIV.
Q: Is there enough smallpox vaccine for everyone?
Yes. Studies have shown that the already available vaccine can be diluted, meaning there is enough for everyone in the United States. New vaccine is being produced, and it should arrive by the end of the year.
Q: Will the vaccine be mandatory?
A: No. Even in the middle of a smallpox attack, there are no provisions to force vaccinations, though people exposed to the disease who refuse to get vaccinated could be quarantined.
--- On the Net:
Centers for Disease Control and Prevention smallpox page:
http://www.bt.cdc.gov/agent/smallpox/index.asp
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