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Real Risks of Smallpox Debated
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Dec. 19, 2002
The real risks from smallpox are addressed in several reports released online
early today, to be published in the Jan. 30, 2003, issue of the New England
Journal of Medicine (NEJM).
The messages
of the reports can be summarized as:
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Justifying mass smallpox vaccination is
difficult without evidence of an impending bioterrorist attack.
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The great majority of Americans do not know
basic smallpox facts.
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The decades-old smallpox vaccine now in the
U.S. stockpile is not as safe as modern vaccines. But the risk of spreading
the live virus from the vaccine to unvaccinated people has been greatly
exaggerated.
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78% of Americans think there is an effective
treatment for smallpox. The reality: there is no such treatment.
Risk of
Smallpox Bioterrorism
A smallpox
attack on an unvaccinated U.S. public would be "catastrophic," according to D.
A. Henderson, MD, MPH, Johns Hopkins University distinguished service professor
and senior science advisor to the secretary of the Department of Health and
Human Services. Dr. Henderson's standing he was a leading force in the global
eradication of smallpox convinces some bioterrorism experts that a smallpox
attack is a worst-case scenario.
Others are not
so sure. One is Kent A. Sepkowitz, MD, director of infection control at Memorial
Sloan Kettering Cancer Center and associate professor of medicine at Weill
Medical College, Cornel University, New York.
"Remember Y2K.
This is a comparable nonevent," Dr. Sepkowitz told Medscape.
Another is
Thomas Mack, MD, MPH, professor of preventive medicine at Keck School of
Medicine, University of Southern California, Los Angeles. Like Dr. Henderson,
Dr. Mack is a veteran of the world war on smallpox. He led teams that
investigated some 100 smallpox outbreaks. His NEJM Sounding Board article
argues that smallpox is overrated as a bioterrorist weapon.
"A smallpox
attack is not a worst-case bioterror scenario," Dr. Mack told Medscape. "People
greatly exaggerate the danger to the population not directly affected. They
picture smallpox being transmitted like wildfire, and that doesn't actually
happen. It is more like a grenade than like a dirty bomb. Once the initial wave
of infections is over, mopping up is relatively simple."
Unlike many
other diseases, people with smallpox can't infect other people until they start
to feel ill a couple of weeks after infection. And if people know they've been
exposed, getting vaccinated within a few days often can keep them from getting
sick. Both these facts mean that health workers have time to stop a smallpox
epidemic before it gets out of hand.
"Suppose the
worst case: the aerosolization of live smallpox virus applied to a substantial
population, say into a shopping center," Dr. Mack said. "Maybe if there was some
way to keep it in the air, then, yes, under very extreme circumstances you could
infect a large number of people. But the average number of people they
infect is not going to change [from what we've seen in natural epidemics]. They
don't get smallpox from weaponized virus any more, but from somebody's mouth. If
they are put in hospitals, they will be dangerous. But once a first case
appears, every community will find a place to put people away from the general
hospital population."
Another NEJM
article calculates the risks from various smallpox-attack scenarios. It
considers a range of smallpox outbreaks ranging from an accidental laboratory
release to a major bioterrorist attack on a large airport. The researchers found
that even a worst-case scenario does not justify mass public vaccination before
there is an attack.
Samuel A.
Bozzette, MD, PhD, is senior scientist for RAND Health Care and the Veterans
Affairs San Diego Healthcare System. Dr. Bozzette and colleagues estimate that a
large airport smallpox attack could kill more than 40,000 people if the public
wasn't vaccinated. It would kill nearly 13,000 people if the public were
vaccinated beforehand. All these deaths would happen only in a "what if"
scenario; nobody really knows whether such smallpox weapons even exist. But
vaccination against smallpox would result in nearly 500 very real deaths.
"The main issues
are that smallpox isn't an instant killer, and that there is a lot of vaccine on
hand," Dr. Bozzette told Medscape. "If there is an attack, there will be time to
carry out a widespread vaccination program."
The study finds
that advance vaccination of healthcare workers is worthwhile -- but mass public
vaccination is not. So would Dr. Bozzette get the smallpox vaccine? What about
his family?
"I think we can
look to the example of what the President is doing with his family as what an
informed judgment might look like," Dr. Bozzette said. "I am an
infectious-disease specialist; I am going to be vaccinated. My wife is a
pathologist; she is going to be vaccinated. But my children, my parents, my
sisters and their children are not going to be vaccinated. Our family knows they
are not helping the nation by getting vaccinated. They understand that even if
there is an outbreak they are not likely to be infected and that there will be
time to get vaccinated."
Learning
About Smallpox
One of the most
striking of the NEJM articles is a survey of what Americans know and,
mostly, don't know about smallpox and smallpox vaccination. Robert J. Blendon,
ScD, professor of health policy and political analysis at the Harvard School of
Public Health, and colleagues conducted telephone interviews with a national
sample of 1,006 adults. Dr. Blendon said there is a serious lack of knowledge,
which means most people aren't able to make informed choices about whether to
get vaccinated.
"There hasn't
been a smallpox case in the U.S. or in the world in recent years," Dr.
Blendon told Medscape. "Many people think there's been a recent case and it
makes them more nervous. And people have to understand that there is not an
effective treatment some 80% think there is so they may not understand the
importance of early vaccination. They are not aware of the biggest public health
message. That is, if you think you are exposed and get vaccinated in two or
three days, you won't get symptoms."
Smallpox
Vaccine Risks
It is known
that many people will suffer adverse effects from the smallpox vaccine, and some
an estimated one to five in a million will die. If the entire U.S.
population is vaccinated, about 150 people are likely to die.
One adverse
effect of mass vaccination could be the accidental spread of the live-virus
vaccine from a vaccinated person to an unvaccinated person. Immunosupressed
people such as transplant recipients, people taking immunosuppressants for
arthritis and other conditions, and cancer patients on chemotherapy are at
enormous risk of vaccine complications.
But are these
people at risk from vaccinated people? Not much, according to the NEJM
report by Dr. Sepkowitz. The Weill Medical College professor took a careful look
at all the medical literature on the topic.
"The vaccine
virus is very uncontagious," Dr. Sepkowitz told Medscape. "It would take the
wrong person being in the wrong place at the wrong time and a [break with]
standard infection control practices in hospitals for a person to get secondary
disease. The risk will be small but not zero."
Dr. Mack,
however, argues against mass public vaccination.
"This is the
most dangerous live vaccine we have," he says. "It is going to kill people. It
may be just a few people in a million, but it still will kill people. Overall,
vaccinating people in general is not cost-effective. It will hurt more people
than it helps. I think even vaccinating people who work in hospitals is not
effective. We will hurt more people than we save. If someone would show me
evidence that someone is planning sustained multiple attacks, I would change my
mind."
Questions
About Mass Vaccination
Smallpox
vaccination likely will be available for all Americans by 2004, including
nonemergency healthcare professionals. Deciding whether to get vaccinated
involves weighing whether the benefit is worth the risk.
"Decisions are
best made on a rational, factual basis and not on the basis of fear," Edward W.
Campion, MD, NEJM senior deputy editor, told Medscape. "Physicians do
have a major role. If there is going to be any type of widespread vaccination,
patients are going to be coming to doctors to ask, 'Should I be vaccinated or
not, what is your opinion?' "
This makes it
more important than ever for physicians to be informed and to be aware that they
are role models.
"At this moment
I am making the decision as [a] front-line person to get vaccinated, but I am
not having my family vaccinated," Dr. Blendon said. "That is important for
people to know. It is more important for patients to know what their doctor says
than what a cabinet secretary says. Physicians are critical. People are going to
be watching what they say."
- What this
tells me is that regardless of your local or current well-being or your
intention to vaccinate or not to vaccinate. My suggestion for prevention
therefore would be the following:
-
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DO NOT take regular or broad spectrum antibiotics as a precautionary measure
since many strains of bacteria are becoming resistant to antibiotics. You do
not want to expose any bacteria or virus to an antibiotic on entry; this will
increase the probability of resiliency for the microbes.
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This is a weapon against mankind, and they shall come together, but not by
God. Pray and stand on Isaiah 54:17
No weapon
that is formed against thee shall prosper; and every tongue that shall rise
against thee in judgment thou shalt condemn. This is the heritage of the
servants of the LORD, and their righteousness is of me, saith the LORD.
Bioterrorism from a
Christian Perspective
Learn
More about Body Detoxing
Ref:
N Engl J Med.
Published online Dec. 19, 2002.
Daniel J. DeNoon
Anthony Reinglas
Reviewed by Gary D. Vogin, MD
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