In 1957, we had Sabin Oral Sundays to inoculate against the scourge of polio. With the current smallpox scare-athon, do we now need Super Smallpox Saturdays?
Dr. Donald A. Henderson, director of the new Office of Public Health Preparedness, and a recognized smallpox expert, says, “no,” it would do more harm than good. But the Centers for Disease Control has proposed state governments set up emergency blanket powers to control citizens in order to control disease. We go with Dr. Henderson.
The facts
Smallpox once spread wildly in fearful epidemics, decimating unfortunate peoples and causing permanent blindness and scarring in many of the survivors. Smallpox spreads from one infected person to the next, mostly by virus particles in the tiny droplets coughed into the air. However, unlike anthrax bacteria, the smallpox virus only multiplies and spreads in human beings and in specialized tissue culture laboratories. Also unlike anthrax, it can’t live more than a few weeks outside a human host.
The last known case occurred 25 years ago in Somalia. The only acknowledged remaining samples of the virus are stored in two laboratories – one in Atlanta and one in Siberia.
Why do people die of smallpox? In 1999, the “Consensus Statement of the Working Group on Civilian Biodefense” wrote that death from smallpox “most likely results from the toxemia associated with circulating immune complexes and soluble variola antigens.” This roughly means that we don’t have a very good understanding of how the smallpox virus kills people. Yet in the decades since smallpox was eradicated, the power of basic supportive medical treatment (such as the use of IV fluids and medicine to help control fever and pain) has exploded. Many of these new treatments would help treat smallpox victims, reduce the severity of infection, and save lives.
Terrorists would most likely release smallpox at a crowded public event or in a densely populated area. We estimate that simultaneous attacks, releasing the virus at several major sports stadiums, would likely infect less than one out of a thousand Americans.
Smallpox patients can be very sick as soon as a week after infection with the virus but – and this is vital – they don’t spread the virus until after they’re sick in bed and the spots on the skin start to develop. One patient may infect two or three others on average, before the disease is recognized and quarantine procedures initiated, but these patients are not out spreading the disease. Advances in hospital construction such as air-flow control and filtering also help prevent spread of the virus.
Antibiotics don’t control the smallpox virus. Other treatments are available, but testing could take years. About half of all living Americans were vaccinated decades ago – no one knows how much residual protection these old vaccinations provide.
If smallpox does break out, vaccination within four days after exposure can prevent or significantly reduce the severity of illness. Over 10 million doses of vaccine are available in this country, although its effectiveness is a bit uncertain because many doses are old and of uncertain activity. The federal government recently ordered 40 million new doses. Delivery of the first batch was originally scheduled for 2004 – officials now hope for earlier delivery.
As with all medical treatments, smallpox vaccination has complications, including death. About one in one thousand people had complications in the past. About two out of a million vaccinated people died of these complications.
The decision
Because of these advances and the relatively small supply of vaccine, we agree with Dr. Henderson. Hold off vaccinating the general public until there is a demonstrated outbreak. If there were enough vaccine to go around, we would leave the choice and decision up to individuals and families, in consultation with their own physicians and local medical officials.
However, because the risk of smallpox exposure, although low and uncertain, is nonetheless real, we conclude that there might be a need for a Super Smallpox Saturday. But only in places where actual cases of smallpox occur. The general public should not be encouraged or required to risk injury or death from treatments for still hypothetical risks.
There they go again
In a recent development the CDC has proposed a “model state emergency health powers act” to all 50 state legislatures. If passed, these laws would authorize everything from forcible vaccination (and rationing of care) to seizure and destruction of private property. Although we recommend that states do review their laws, the blanket powers proposed could do more harm than good.
And governments, like doctors, should “First, do no harm.”
