The Centers for Disease Control and Prevention (CDC) are meeting behind closed doors on June 19–20 to determine policy about the U.S. stockpile of smallpox vaccine‐this after having four open forums to solicit public opinion and input. First of all, four hastily put together and not well‐advertised (hence, poorly attended) forums in New York, San Francisco, San Antonio, and St. Louis hardly constitutes a wellspring of public input. But the CDC apparently prefers it that way.
Why?
Because most experts agree the CDC will likely continue to recommend some form of the ring‐containment strategy. Ring containment was the strategy used to eradicate smallpox as a disease (at a time when the population was routinely vaccinated, but no one in the U.S. has been vaccinated since 1972). The plan is for teams to respond to an outbreak, isolate those who have contracted smallpox, vaccinate everyone who had recent contact with those persons, and then vaccinate a second ring of people who were exposed to those who had contact with the patients.
While this might be a valid approach for responding to a natural outbreak of smallpox (especially in a rural area), it is less likely to be successful against a bioterrorist attack that might have multiple sources, not all of which would be immediately and easily known, and may not be initially recognized as such (the initial symptoms are flulike and it could be 12 or more days before smallpox is diagnosed).
The experience with anthrax cases after September 11 in the United States demonstrates the shortcomings of using an approach designed for a natural outbreak when a disease is being spread intentionally by a thinking enemy. The initial focus was on the Senate offices and buildings where the anthrax‐infected mail was delivered. The Brentwood mail‐handling facility was initially ignored and, as a result, anthrax spores infected workers at the facility and were also transferred to mail delivered to other locations.
Moreover, in a densely populated and highly mobile society, an intentional introduction of the smallpox virus into the population is likely to spread faster and more widely (including to other countries) than the ring‐containment strategy will be able to keep up with. And in the inevitable post‐attack panic and confusion, the medical infrastructure would buckle under the weight of millions of people demanding immediate vaccination (the vaccine must be administered within four days of exposure to the virus).
The bottom line is that an unvaccinated population is completely vulnerable and an attractive target. A better approach than leaving the population exposed and responding after an attack would be to take preventative measures now (the smallpox vaccine supply should be about 450 million doses by the end of this year).
Supporters of the ring containment strategy claim the threat of a smallpox bioterrorist attack is remote and that there aren’t any significant indicators that such a threat is imminent. Not to put too fine a point on it, the same could be said of jetliners being hijacked and used as missiles flying into buildings before September 11. The supporters also cite the risks associated with the smallpox vaccine, claiming that hundreds of people will die and thousands more will suffer side effects if the population is vaccinated. This would certainly be the case if there was forced mass vaccination (which is probably what would happen in response to an attack).
Because there are known risks with the smallpox vaccination (in particular for those with weakened immune systems), individuals should be allowed to make a voluntary, informed decision (in consultation with a doctor) to understand, manage and mitigate those risks. In all likelihood, those who are most at risk to the vaccine would make the decision to opt out and not be vaccinated, thereby greatly reducing the number of potential deaths and side effects.
Even if only a fraction of the population were vaccinated beforehand (various polls show that 50 percent or more of the public would like to be vaccinated), a “community immunity” effect would occur that lowers the rate of transmission of the disease and significantly increases the chances of success of a ring containment strategy. As a result, the chances of a successful attack would be lowered, which could also have a deterrent effect and thus might prevent such an attack from occurring.
The CDC should just say “no” to the ring containment strategy and make the smallpox vaccine available to the public. Americans are smart enough to decide for themselves.
