The Real Risks and Grave Consequences of Smallpox and Bioterrorism

July 9, 2003 • Commentary
By William J. Bicknell, M.D. and Kenneth D. Bloem
This article was published in the Washington Times, July 9, 2003.

The Iraq war is over, no WMD have yet been found and the administration’s smallpox plan appears to be running out of steam. Instead of being well on the way to vaccinating up to 10 million civilian health, emergency and public safety workers as called for by President Bush, we are stalled at 37,608. Our message to the nation’s health authorities: This is not the time to go wobbly on biodefense.

Bioterrorism is a real risk. Smallpox is easy to hide in any freezer and, whether or not WMD are found in Iraq, it is only one of a number of states on the list of suspects. Of all biological weapons, smallpox has the greatest potential for widespread harm. But the risk of death or serious harm to anyone from any form of terrorism is very low. Therefore, we should live our daily lives normally, not in fear, while government takes steps to reduce chances of terrorism and, when it occurs, to minimize consequences. Have we done this with smallpox? Not yet. There is vaccine for everyone, but we are ill‐​prepared to rapidly contain smallpox after a bioterrorist release. Monkeypox is a timely reminder that the unexpected can happen and take time to recognize.

As we conclude in a forthcoming Cato Institute briefing paper, the president’s December 2002 vaccination plan is sound. The military is on track, with more than 450,000 vaccinated, no deaths, no lasting side effects and no harm to any immuno‐​compromised persons. We do not believe that our government is vaccinating the military just to make a political statement. What’s wrong on the civilian side?

Although CDC guidelines have recently improved, they continue to overstate the risk of vaccine side effects, and erroneously suggest that, after an attack, the techniques used decades ago to eradicate smallpox will work well today.

Here are the facts:

  • Vaccinating healthy adults is low risk, about 1 death per 15 million. If you don’t worry about driving to work or crossing a busy street, don’t worry about getting vaccinated.
  • Smallpox is infectious before there is a visible rash. Anyone infected by a terrorist will be infecting others before they know they have smallpox.
  • If a person is vaccinated up to several days after being infected, disease is not prevented, nor is transmission to others. Illness is likely to be less severe and the risk of death reduced.
  • There is little residual immunity in the U.S. population, and, for persons born after 1972, when routine vaccination stopped, no immunity.
  • We cannot rely on the techniques used to eradicate smallpox 30 years ago, when immunity was high, people were less mobile and there was no malicious dissemination.

We must protect against the unlikely, but very serious, consequence of several highly motivated, well‐​trained terrorists traveling to different cites and infecting 50 to 150 people in each city. Terrorists may be ill, but not so ill that they cannot walk in crowds, cough on us in crowded places and travel to another city. In this scenario, hundreds of Americans would be infected before anyone knows we have been attacked. Rapid control would demand rapid local mass vaccination, and, almost certainly, nationwide vaccination.

The CDC director said the true measure of the president’s plan is whether the entire nation could be vaccinated within 10 days of an attack. We are not close. An attack today would be contained in two or three months, not a few weeks. There would be many preventable deaths, vast avoidable economic loss and, potentially, massive societal disruption. Spread to other countries, where control would be even more difficult, would be excessive.

Homeland Security and the White House should revitalize the National Smallpox Vaccination Program and meet with leaders of medical, hospital, and nursing associations, as well as relevant unions, stressing: This is a national security issue; the risk to healthy adults is minimal; there is a good approach in place for liability and compensation; and the nation needs their help. Protecting hospitals, minimizing societal disruption and rapidly vaccinating the rest of us post‐​attack requires that up to 10 million acute medical care, selected public health, emergency and public safety workers be voluntarily vaccinated pre‐​attack.

As more people are vaccinated pre‐​attack, fewer are at risk post‐​attack. There are fewer to vaccinate and infection of others is more difficult. Therefore, give citizens a choice and promote the voluntary vaccination of all healthy adults.

Citizens should be in the driver’s seat, not only for smallpox, but also for anthrax. N95 masks will be helpful in preventing infection with anthrax and smallpox. A seven‐​day supply of Cipro per person, to be used only if an anthrax release takes place, will shorten by days the distribution of Cipro from government stockpiles. Add potassium iodide to reduce one effect of a dirty bomb, and at modest cost we will have maximized protection against three terrorist threats.

Whether smallpox, anthrax or radiation, control is easier if we have a good national plan. Putting protection in the home strengthens all plans, and in the case of a bad plan or flawed implementation, far fewer people will needlessly die or become ill.

About the Authors
Dr. William Bicknell is a former commissioner of Public Health in Massachusetts and a professor of International Health at Boston University’s School of Public Health. Kenneth Bloem is former CEO of Stanford University Hospital and Georgetown University Medical Center. They are co‐​authors of the forthcoming Cato Briefing Paper, “Smallpox and Bioterrorism: The Plan to Protect the Nation is Stalled.”