Aftermath News

New Plan for Smallpox Attack

Tue Sep 24 23:56:55 2002
208.152.73.86


New Plan for Smallpox Attack
By SHERYL GAY STOLBERG with LAWRENCE K. ALTMAN


WASHINGTON, Sept. 23 — Federal health officials today instructed states to
prepare to vaccinate every American in the event of a biological attack
using smallpox, and issued a detailed plan showing how each state could
quickly inoculate as many as one million people in the first 10 days.

In releasing their most comprehensive smallpox preparedness plan to date,
officials at the federal Centers for Disease Control and Prevention said
publicly for the first time that even one case of smallpox might result in a
nationwide program of voluntary vaccinations. That is in part because even a
single case could be a harbinger of a larger outbreak and in part because
even one case would undoubtedly spark panic and a clamor for vaccine.


"We want to step up preparedness," Julie Gerberding, the director of the
disease control agency, said in an interview. "If there is actually exposure
and risk, we want to be able to vaccinate quickly. If there is anxiety, we
also want to do it quickly."

But the new guidance for states is far from encyclopedic, and experts
complained that the center's 48-page document failed to answer questions
about the timing, cost and logistical hurdles of preparing thousands of
health professionals and volunteers to conduct mass vaccinations while
keeping the public calm. Critics said a superficial plan could sap public
confidence, worsening the effects of a smallpox crisis.

"It's putting a lot of responsibility in a short time on local clinics,
which will be untested," said Caroline B. Hall, a professor of infectious
diseases at the University of Rochester's School of Medicine. "The quilt is
only as good as the stitches. One tiny thread breaks, and the whole thing
unravels."

Smallpox, which was eradicated worldwide two decades ago, is highly
contagious and kills roughly a third of its victims, making it a potentially
fearsome biological weapon. Officially, the virus is supposed to exist only
in repositories in Moscow and the disease control center's headquarters in
Atlanta, but experts have long suspected that some nations harbor secret
stocks of smallpox to use as a biological weapon.

Today's release of the "Smallpox Vaccination Clinic Guide" comes as the
United States is mobilizing for a possible attack on one of those nations,
Iraq. Dr. Gerberding described this as "an unfortunate coincidence of
timing," and said the guide was simply an update of a preparedness plan
first issued two years ago, before the attacks on New York and the Pentagon
and the subsequent anthrax attacks.

Bioterrorism experts said the administration's timing could not be ignored.

"They know the best time for Saddam to hit us, if he has the smallpox
weapon, would be before we go in so he can terrify the American people,"
said an adviser to the Bush administration on smallpox policy. "In that
case, it is definitely good to have these guidelines out there."

The plan does not specify what kind of attack would spur a mass vaccination
campaign, or who would make the decision to initiate one. Agency officials
said that absent a declaration of a national emergency by the president they
would make the decision in consultation with state health officials.

The vaccine is one of the few that can work even if a person is already
infected, and experts say it can protect people if given within four days of
exposure to the virus.

The guide says up to 75 million doses of the nation's vaccine stockpile
could be shipped in a single day and 280 million doses, enough to cover
every American, in five to seven days.

The guidelines call for states to run 20 clinics 16 hours a day, an effort
that the government estimates would require 4,680 public health workers and
volunteers. Depending on the size and severity of the outbreak and where it
is, the guidelines said more or fewer participating clinics could be needed.
In state capitols around the country, health commissioners said they
welcomed the advice but fretted about whether they would be able to carry it
out.

In Maryland, Dr. Georges Benjamin, secretary of the Department of Health and
Mental Hygiene, said he had already told his staff to integrate the document
into the existing bioterrorism preparedness plan.

"What is astounding is the number of people it would take to actually make
this thing happen," Dr. Benjamin said. Asked if he could conduct a mass
vaccination right away, he said, "We would do what we had to do, but it
would be tough. I would hate to try to do this tomorrow."

There is no set timetable by which states must comply, Dr. Gerberding said,
adding that the disease control agency hoped that states would conduct
preparedness exercises as they develop their own plans.

Replete with flowcharts and checklists, the center's guide covers things
like many security officers would be needed for each clinic to contain an
unruly crowd (two per clinic per day) and how many minutes it would take
people to fill out the medical history screening forms (two to three).

It deals with how clinics should handle people who refuse to be vaccinated
and reminds states that they must plan for huge numbers of fatalities. "Plan
for vaccinating mortuary personnel and their families," the guide says.

But the plan does not address the vexing, and politically delicate, issueof
whether to vaccinate public health workers and emergency personnel before a
terrorist attack.

The White House is weighing whether to permit such vaccinations. Tommy G.
Thompson, the secretary of health and human services, has said a decision is
expected by the end of this month.

Many public health experts say the precautionary vaccinations are necessary.
"These people need to be protected," said Dr. Mohammed Akhter, the executive
director of the American Public Health Association. "If we do not do that,
and we just go to this plan, then these workers will be standing in line to
get their vaccination rather than helping us" vaccinate others.

But the issue is complicated because the vaccine, made from a live virus,
carries risks to patients with skin disorders and immune system
deficiencies, including people with AIDS. And those who are vulnerable are
endangered not only by being inoculated, but also by contact with others who
have been inoculated.

"It's very hard to say without a clear threat who should and who shouldn't
be vaccinated," said Tara O'Toole, director of the Johns Hopkins Center for
Civilian Biodefense Strategies. "Some analyses suggest that if you have ever
had eczema or live with someone who has, you shouldn't get vaccinated, and
by some estimates that eliminates 30 million Americans."

Dr. O'Toole said she thought the plan "makes great good sense," because it
assumes that the nation must be ready to vaccinate a large number of people
on short notice.

The center's previous smallpox preparedness plan revolved around a strategy
in which public health workers would track down and vaccinate infected
people and those who came into contact with them, working in concentric
circles until the outbreak was contained.

The new document does not supplant the "ring vaccination" plan, Dr.
Gerberding said. But Dr. Bill Bicknell, a professor of international health
at Boston University critical of that strategy, said the guide was
undoubtedly influenced by recent studies showing that ring vaccination would
not contain a large outbreak. He said studies had found that if 1,000 people
were infected in a large city like New York and ring vaccination were used,
within three months there would be 300,000 cases of smallpox and 100,000
deaths and the epidemic would not be contained. But mass vaccination, he
said, would contain such an epidemic in 40 to 45 days, with 1,500 cases and
500 deaths.

"If they do it correctly, with the proper planning, you can vaccinate
millions and millions of people in a very short time," Dr. Bicknell said.

And he noted that until recently, a mass vaccination policy would have been
implausible, because the nation did not have a big enough vaccine stockpile
to carry it out.

Federal officials began building a smallpox vaccine stockpile after last
year's anthrax attacks. Mr. Thompson, the health secretary, signed contracts
with two companies to buy 209 million doses to add to the existing stockpile
of vaccine, some of which dates to the 1950's. In the interim, studies have
shown that the existing stockpile could be diluted.

Government officials have offered differing assessments of whether there is
now enough vaccine for every American. In a recent interview, Dr. Anthony S.
Fauci, director of the National Institute for Allergy and Infectious
Diseases, said there was, adding, "If we had an emergency tomorrow, we'd be
good to go."

During a briefing today to discuss the state guidance, Dr. Joseph Henderson,
the center's associate director for terrorism preparedness, said, "On an
emergency basis, if we saw smallpox tomorrow and felt the need to do mass
vaccination, we could vaccinate 155 million individuals."
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