Why Not a Smallpox Choice

President Bush will decide any day now how many Americans will be able to get smallpox vaccinations. Let's hope he is guided by facts and freedom, rather than by the zero-risk mentality that dominates today's public health community.

So far the health bureaucracy has focused only on the risks if it allows Americans to get the vaccine, rather than the risks if it doesn't. Two weeks ago the Advisory Committee on Immunization Practices recommended that Mr. Bush restrict the vaccine to 510,000 hospital workers. This is an improvement from its initial recommendation of 20,000, but barely. What's striking about this is that the people charged with protecting public health are so unwilling to trust the public.

It is true that smallpox is riskier than most other common vaccines. Doctors usually cite a one-per-million death rate and note the serious, if rare, side effects that can accompany the vaccine. Take a closer look at the numbers, though, and the risk to healthy patients looks a lot less severe.

William J. Bicknell, a public health professor at Boston University, recently went back to look at statistics from 1968, the last time the U.S. collected data on mass smallpox vaccination. Of about 14 million people vaccinated, 5.6 million received first-time vaccinations and 8.5 million were re-vaccinated. Of the 14 million, nine died, and another 572 had complications.

When Dr. Bicknell broke out the numbers, however, he found that seven of the nine deaths were in children under the age of 10 -- a traditionally higher-risk category. As for the other two, one had chronic lymphocytic leukemia and another had aplastic anemia -- exactly the sort of people we would expect to screen out in a pre-vaccination program today. As for complications, 81% occurred in kids under age 10.

Dr. Bicknell also notes that 114 of the complications were the result of "contacts," in which those recently vaccinated pass along the virus to unvaccinated people with risk factors. But he notes that medical advances, especially medical dressings that cover the arms, reduce "viral shedding" by 95% to 99%. The former public health commissioner of Massachusetts concludes that by excluding such higher risk categories as younger children or the immuno-compromised, and by utilizing new technologies, the risks drop sharply.

All of this, of course, must be judged against the risk of doing little or nothing in advance of any smallpox terror attack. The advisory committee is suggesting that just 500,000 people -- 100 in each hospital -- would somehow handle the task of vaccinating more than 280 million citizens. Good luck with that. The Centers for Disease Control (CDC) recently released its guidelines for coping with a smallpox attack, and 500,000 won't come close to meeting its standard.

Edward H. Kaplan, a professor at the Yale School of Management and School of Medicine, has done some calculating and figures that it would take 1.25 million workers to vaccinate the nation in 10 days under the CDC plan. Make that 2.5 million if you want to vaccinate everyone in five days.

"This is straightforward: If you've decided you are going with a post-vaccination program, rather than a pre-vaccination one, then you need to have adequate people in place to push the button," says Professor Kaplan. "The panel's recommendations seem to be completely independent from the actual response plan."

By contrast, if even a small percentage of Americans agreed to voluntary vaccinations, the public health system would find it easier to protect everyone else in a crisis. Amid the chaos of an attack is also when the immuno-compromised are least likely to be carefully screened. These are among the reasons that Israel's health minister supports vaccinating his country's entire population before any attack.

One current proposal of merit would begin offering the vaccine in stages. First would come hospital and health workers; if all went well the vaccine would then be made available to paramedics and policemen, as well as to those vital to running the economy, such as pilots and truck drivers. Finally, it would be made available to the public. This sounds good to us -- so long as it doesn't take years to accomplish.

Mr. Bush has a tough call to make, but he might keep in mind that the U.S. coped with the risk of smallpox vaccine for decades before it was phased out in the early 1970s. Our richer, more educated society ought to be able to handle it again. And a free people ought to be able to assess the risks for themselves.

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My view is that smallpox vaccination is a military necessity, or it isn't.

In either event, the competent Public Health authority should be able to make the decision, and be accountable for it.

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