Five years later, smallpox preparedness improved

A federal initiative launched in 2003 to vaccinate healthcare workers against smallpox reached only a fraction of the people it sought. But veterans of the effort say elements of the Bush administration’s plans, such as stockpiling vaccine and training medical personnel to treat the disease, have made the nation much better prepared to respond to a bioterrorism attack.

The smallpox programs were implemented as part of a broader strategy at the federal, state and local levels to protect the nation after the Sept. 11th terrorist attacks. The federal government has spent billions of dollars on acquiring drugs and vaccines, increasing hospital and laboratory capacity, training healthcare workers and developing detailed plans for reacting to an attack using biological agents such as smallpox or anthrax.

Yet despite all the attention placed on smallpox back in 2003, less than one-tenth of those President Bush proposed inoculated have received the vaccine.

“We are much better prepared than we were,” said Eric Toner, a senior associate at the Center for Biosecurity at the University of Pittsburgh Medical Center in Baltimore who has criticized the vaccination program. The government has stockpiled more than 200 million doses of smallpox vaccine, for example, Toner and others noted.

“If we would have a [single] smallpox case tomorrow … we can probably handle it,” said Georges Benjamin, executive director of the American Public Health Association. “But if we had a terrorist attack with smallpox, it would still be a challenge,” he added.

Congress and the administration dramatically increased public health funding for agencies such as the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health to finance the efforts on multiple fronts. Even though those initiatives were broad, Bush paid special attention to smallpox.

In December 2002, Bush made a high-profile announcement of a program to inoculate as many as 500,000 healthcare workers and other first responders against smallpox, a devastating disease that was officially declared eradicated from the globe in 1979 but is considered a major threat for terrorism. There have been no cases of smallpox in the United States since 1949 and routine vaccinations were halted in 1972.

Bush and federal health officials were concerned about the possibility that terrorist organizations would obtain some of the existing laboratory samples of smallpox kept on hand for research purposes in the United States and the former Soviet Union. The highly contagious pathogen could spread rapidly in an unvaccinated population, especially if healthcare workers themselves were vulnerable to infection. The terrorist attacks, and the anthrax attacks one month later, made the threat more concrete.

“To protect our citizens in the aftermath of September the 11th, we are evaluating old threats in a new light. Our government has no information that a smallpox attack is imminent. Yet it is prudent to prepare for the possibility that terrorists … who kill indiscriminately would use diseases as a weapon,” Bush said in December 2002.

More than five years later, only about 40,000 civilians have actually received the vaccine, a number that has held steady since the middle of 2003. The most recent estimate provided by the CDC, which oversees the program, was from Oct. 31, 2005. The Department of Defense vaccinates military personnel for smallpox and Bush himself was inoculated shortly after his 2002 speech.

The vaccine itself can be dangerous and even fatal. Serious side effects can result, including breathing and heart ailments. During the early months of the program, several civilians and at least one soldier died after receiving the vaccine, though the government never concluded definitively that the fatalities resulted from the vaccine. The live vaccine — derived from cowpox — can be contagious, as well. Last year, a soldier in Chicago infected his son with the vaccine.

According to the Health Resources and Services Administration, 64 people have filed claims with the agency’s smallpox vaccine injury fund. To date, 16 people have received payouts totaling $3.6 million for side effects including respiratory, cardiac, neurological and skin conditions.

Concern among healthcare workers about the serious side effects linked to the smallpox vaccine, along with uncertainty about the likelihood of an outbreak, limited participation in the program.

“That was the reason the program failed,” Toner said.

A former top administration bioterrorism-preparedness official agreed. “The risk [of a smallpox attack] was a very unclear risk, there’s no question about it,” said D.A. Henderson, who headed the World Health Organization program that eradicated smallpox and served in the administration from November 2001 until April 2003. Henderson currently is a distinguished scholar at the Center for Biosecurity.

Despite the fact that the number of people vaccinated is vastly lower than Bush projected, public health experts indicated that there are enough healthcare workers inoculated to respond to an outbreak and enough vaccine on hand to get more protected, along with anyone else exposed to the disease.

“There’s a cadre of people who’ve been vaccinated around the country,” Benjamin said. Unlike in 2001, “you’re not looking at a totally unvaccinated response force,” he said.

During the five years since the smallpox program was launched, the Department of Health and Human Services (HHS) not only stockpiled enough vaccine to administer it to practically the entire population, it completed the conversion of the stockpile from an older version of the vaccine to a newer one. Indeed, the CDC announced on Feb. 29 that it was planning to destroy the remaining supplies of the old vaccine, according to The Associated Press.

The new vaccine is considered somewhat safer, but the public health experts agreed that kick-starting the vaccination program now would be unnecessary and unwise. A CDC spokesman said there are no plans to do so.

Toner said that, although planning for a smallpox outbreak has enhanced the nation’s preparedness, the vaccination component of the program was “ill-conceived from the beginning” and was a poor use of resources.

“The smallpox vaccine program was a distraction, and an unfortunate distraction,” said Toner, who opposed it from the beginning. Likewise, said Benjamin, “The vaccination program had become the center of attention. Many of us were concerned.” Henderson said he strenuously argued for a limited program at HHS.

A 2005 report by the prestigious Institute of Medicine concluded that the emphasis of vaccinating a large number of people called attention away from more important parts of the bioterrorism programs. “If preparedness, not numbers, was the program’s focus, the frenetic pace of vaccination imposed at the beginning of the program was not needed,” the report stated.