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Smallpox Proposal Raises Ethical Issues
New York Times ^ | Saturday, June 22, 2002 | By LAWRENCE K. ALTMAN

Posted on 06/22/2002 1:00:53 AM PDT by JohnHuang2

June 22, 2002

Smallpox Proposal Raises Ethical Issues

By LAWRENCE K. ALTMAN

ATLANTA, June 21 — The decision by a government advisory panel to recommend smallpox vaccination for about 15,000 health care and law enforcement workers raises logistical and ethical issues involving not just the people who will get the vaccine but also those who will come in contact with them.

If experience from the time when smallpox vaccine was routinely administered to the public is a guide, doctors say, some of the 15,000 "first responders" who receive the vaccine may suffer serious — potentially even deadly — complications. Steps may also have to be taken to protect certain people who come in contact with others who receive the vaccine, which infects recipients with live vaccinia virus, a relative of smallpox. Because those vaccinated can shed this virus, they can spread its smallpox protection as well as its complications.

The risk is especially high for people with a history of common skin conditions like eczema and those whose immune systems are weakened by treatment for cancer, infection with the AIDS virus or other conditions. So some doctors say it may be necessary to screen potential recipients before offering them the vaccine.

The panel, the Advisory Committee on Immunization Practices, recommended vaccination for two teams of designated health workers in each state: public health officials who would investigate the initial cases in a smallpox attack and medical personnel in hospitals that government officials would designate to care for smallpox victims.

The number of teams would vary with the population and geography of each state. The plan calls for at least one health care treatment team for every million in population. It was not clear how the policy, if adopted, would deal with workers in these hospitals who chose not to be vaccinated.

Government officials have recommended against widespread vaccination because, in the absence of a known smallpox threat, the vaccine's dangers seem to outweigh its benefits. Smallpox vaccine has a significantly higher risk of serious side effects than other vaccines.

If the panel's recommendations are adopted as policy, the immunizations would be the largest number given in this country since it stopped routine smallpox vaccinations in 1972. Until now, the government has restricted use of smallpox vaccine to scientists who work with smallpox and related viruses in a laboratory. About 11,000 such workers have received the vaccine since 1983, said Dr. Harold Margolis, an official with the Centers for Disease Control and Prevention here.

After the anthrax attacks last fall, the disease centers asked the panel to determine whether more Americans should get the vaccine.

In choosing a relatively small group, the panel did not decide on the logistics for putting the recommendations into effect and left the planning for that up to the government. That, too, will not be an easy task, said the panel's chairman, Dr. John F. Modlin of Dartmouth Medical School. Among problems needing resolution is who will pay compensation to workers who develop vaccine complications.

Dr. Julie L. Gerberding, the acting deputy director of the centers, the federal agency that would have primary responsibility for monitoring the policy, said the C.D.C. would work out the plans "over the next several months."

By early 2003, the government expects to have enough vaccine made from a new technique to protect every American. But until then a high priority is to make sure that available vaccine is used efficiently in case it is needed in an emergency.

Although many states have begun assembling the teams, fall seems the earliest that the first team members would receive vaccinations.

The government owns all smallpox vaccine, which it classifies as "investigational." That means each recipient's written consent would be required after its considerable dangers are explained.

Vaccination will be voluntary, and issues of confidentiality concerning a person's health could pose problems.

"There's no single answer, and the states will have to talk it through," Dr. Margolis said.

Sore arms, swollen lymph nodes and fever can occur in up to 50 percent of recipients. Because the vaccinia is live, it can spread to cause severe skin infections, sometimes destroying tissue and causing permanent disability. Or vaccinia can be spread just to the eye and permanently blind. Vaccinia can also cause brain damage from encephalitis in about 1 in 100,000 vaccination recipients and death in about 1 in 1 million recipients.

Some complications can be modified by injection of a natural substance known as vaccine immune globulin, which is derived from the blood of people who have been vaccinated against smallpox. But there is only enough of the substance to treat about 600 patients.

Although many of the 11,000 vaccine recipients since 1983 have had to stay out of work for a few days, none have needed vaccine immune globulin, Dr. Margolis said.

But when about 125 health workers were vaccinated at the disease centers last fall, doctors who gave the injections were surprised by the number and severity of adverse reactions. Many recipients were treated with antibiotics in the erroneous belief that the site of vaccination had become infected. Older doctors who had given smallpox vaccine in decades past told their younger colleagues that the skin reactions were from the vaccine. Doctors who conducted recent trials to test the safety and effectiveness of diluting the vaccine had a similar experience.

Another potential problem is that a recipient can inadvertently pass on vaccinia to other people who have not consented to a vaccination.

"If you get immunized with vaccinia, you can infect people around you from your vaccinia scab," Dr. Gerberding said. "So while you may accept the risk for yourself, you would be imparting a risk to your contacts."

A question that the panel did not address, but that is likely to arise, is whether to do an H.I.V. blood test before a person is vaccinated.

When the centers immunized a number of workers last fall, the recipients were asked if they were infected with H.I.V., but a blood test was not performed. H.I.V. tests have been required for other smallpox vaccine recipients.


TOPICS: News/Current Events
KEYWORDS: bioterror; biowarfare; smallpox; vaccines
Saturday, June 22, 2002

Quote of the Day by ArGee

1 posted on 06/22/2002 1:00:53 AM PDT by JohnHuang2
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To: JohnHuang2
"Containment" and the practice of "ring vaccination" worked to eradicate smallpox during the 1970's in the Third World BECAUSE those populations are not as mobile as American society. We had mass vaccinations.

This article reads like smallpox will be spread from one point only. Well there won't be just one or two people get smallpox during a concerted terrorist act but probably hundreds or even thousands, since smallpox can be aerosolized and dispersed by aircraft.

2 posted on 06/22/2002 1:14:45 AM PDT by goody2shooz
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To: goody2shooz
Smallpox makes you ugly. It only rarely kills you.
3 posted on 06/22/2002 1:22:47 AM PDT by Lazamataz
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To: goody2shooz
Thusly, not a great terrorism weapon.
4 posted on 06/22/2002 1:23:21 AM PDT by Lazamataz
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To: Lazamataz
Isn't the mortality rate around 38%???

BTW, if it only makes you ugly, how could I tell if my Mother-in-law has it?

NeverGore

5 posted on 06/22/2002 1:34:03 AM PDT by nevergore
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To: Lazamataz
"After someone is exposed to the smallpox virus, the incubation period is between seven and 17 days and usually starts with fever and headache and general fatigue. Then lesions appear that are somewhat similar to chicken pox, usually starting on the face and legs and progressing to the rest of the body. The sores are deeper than chicken pox and leave scars. It becomes communicable from the time of appearance of the first sores until all scabs from the sores have disappeared, which could be two or three weeks."

"The disease is spread by droplets in aerosol form. Usually about 20 to 40 percent of the cases are fatal, though modern intensive care may reduce mortality rates."

http://www.newsmax.com/archive s/articles/2001/5/31/220803.sh tml
6 posted on 06/22/2002 1:40:01 AM PDT by Roscoe
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To: nevergore
Variola Major: 30% mortality rate
Variola Minor: 1-2% mortality rate

7 posted on 06/22/2002 1:43:57 AM PDT by Roscoe
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To: Roscoe
These figures are for a non-weaponized version....A less hardy and dealy virus than the genetic mutants produced in Soviet weapon's labs.....

Correct????

NeverGore

8 posted on 06/22/2002 1:49:13 AM PDT by nevergore
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To: nevergore
I assume the weaponized versions would have significantly higher mortality rates.
9 posted on 06/22/2002 1:59:00 AM PDT by Roscoe
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To: Lazamataz
Indian I, the smallpox variant that struck India in 1967 and which provided the source for the Soviet Union's smallpox stores, had a kill ratio of about 45%. Its hemorrhagic form, which affects approximately 3% of the total cases contracted, has a survival rate of only about 6% -- 94% of those infected die from the disease!
10 posted on 06/22/2002 3:14:24 AM PDT by goody2shooz
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To: goody2shooz
When I was in medical school, I saw a case of vaccinia in a grandmother with leukemia whose grandchild was vaccinated.

Until they get a better vaccine, widespread vaccination would cause thousands of deaths.

The best way to "prevent" smallpox is to hint that a US epidemic would quickly spread to Saudi Arabia, Iran and Iraq.

Saddam Hussein is not dumb enough to wipe out his entire country; alas, I wish I could say the same about other terrorists.

11 posted on 06/22/2002 7:20:39 AM PDT by LadyDoc
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To: Lazamataz
Smallpox makes you ugly. It only rarely kills you.

No, it kills about 30% of its victims. It also leaves people with blindness and other disabilities. Also, if the source of the smallpox is from the Soviet biological weapons program, you can forget the standard mortality estimates. When smallpox was accidentally introduced to the New World, it is estimated that it had up to 90% mortality. Why do you think the Soviets were so eager to erradicate smallpox? They knew that if it were erradicated, immunization programs would disappear, and the vulnerability to smallpox weapons would increase. As one of the major contributors of vaccines, personnel and equipment to the erradication program, the Soviets had opportunities to collect smallpox strains from all over the world. They collected a particularly virulent strain from India in 1967. This strain was the basis for all their weapons development.

12 posted on 06/22/2002 10:32:27 AM PDT by Paleo Conservative
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To: Paleo Conservative
Your facts are not important to me. Have you praised Bush today?
13 posted on 06/22/2002 10:39:08 AM PDT by Lazamataz
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To: Lazamataz
Your facts are not important to me. Have you praised Bush today?

No, did you have him confused with Allah?

14 posted on 06/22/2002 11:16:44 AM PDT by Paleo Conservative
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To: Paleo Conservative
Some people around here seem to.

Hoo boy.

15 posted on 06/22/2002 11:20:32 AM PDT by Lazamataz
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To: Paleo Conservative
Don't confuse him with facts.
16 posted on 06/22/2002 4:00:06 PM PDT by Roscoe
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