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    Wednesday, January 08, 2003

    Smallpox Counterpoint: Email from a reader who opposes smallpox vaccine for the public:

    I am an infectious disease physician in practice in Wisconsin. I served in the military and have long had a special interest in biological and chemical warfare, and have lectured on this subject on a number of occasions. I advocate and have received all kinds of vaccinations and have been involved in vaccine trials here at my medical center.

    Yet, I am not in favor of the smallpox vaccine. Why? Because it is a relatively dangerous vaccine for a disease which doesn't exist. The need for smallpox vaccine rests on the possibility of a rogue regime having access to smallpox and deliberating infecting others, and that possibility should be subjected to the greatest possible scrutiny before we embark on a vaccination crusade.

    Let me state my objections.

    The side effects, which in your view have been exaggerated by infectious disease specialists, are real, and the incidence was almost certainly underestimated in the studies from the 1960's. A 1/20,000 chance of a horrible, life-threatening reaction is nothing to take lightly. Moreover, the public reaction to cases of progressive vaccinia or encephalitis probably cannot be overstated. I refer you to Gina Kolata's book "Flu" for a detailed analysis of what can go wrong with a vaccine program. (And swine flu vaccine, which I myself did receive, is a relatively safe vaccine.)

    Please see also opinions of Dr. Vince Fulginiti, probably world's foremost living expert on vaccine side effects.

    Many authorities believe that ring vaccination can control an intentional outbreak, and this approach was used successfully to eradicate smallpox in the past. Virtually every infectious disease expert of note, with a couple of high-profile exceptions, has advocated a go-slow approach on vaccination because of the issues noted above. This includes smallpox experts Donald Henderson (also advising president) and William Foege (head of CDC during
    smallpox eradication).

    While the public health worries about local costs ($800 per person) noted on your website are certainly an exaggeration, believe me, this thing won't get undertaken for free. In my state hundreds of personnel are being pulled from their usual duties to do nothing but this. The supplies alone are very expensive--special "breathable" dressings (?DuoDerm), etc. If we move to Stage 2, I guarantee you'll hear how much it costs. This is the very definition of an unfunded government mandate, even if the vaccine itself is "free". (I haven't heard who will pay for the cidofovir or VIG for vaccine reactions. I do know who'll pay for lost wages, medical care, etc. --workman's comp and private insurance, if the victim has it.)

    Finally, we get down to the issue of duelling experts. I am an infectious disease "expert", for what that's worth. I give antibiotics and vaccines for a living. I respect the opinions of my colleagues the way you would respect those of your mentors and teachers. Those who have publicly disagreed (such as Carlos del Rio, Richard Wenzel, etc.) with the current policy have put themselves on the line. On the other hand, again and again I read of "biowarfare intelligence experts", CIA analysts--who are these anonymous analysts? I have not found a readily accessible CIA or government report which discusses the availability of smallpox outside protected compounds in Russia and the US in terms other than speculation. The CIA's website report on Iraq doesn't even mention it.

    Virtually all bioterrorism news reports quote Ken Alibek, former head of Russia's biowar program. His opinions should be taken with a large grain of salt, as he currently hawks pro-immune-system vitamins and lurid audiotapes on the internet (stating, among other surprising opinions, that West Nile virus is an example of bioterrorism). Most significantly, in his book "Biohazard" he admits to feeling no moral qualms about developing weaponized anthrax and smallpox. And we should trust this guy??

    Well, I've gone on too long, but you see the gist of my disagreement. As a doctor, I do not believe in giving a dangerous medicine for no demonstrably good purpose. Even if a public hyped up over war and terrorism clamors for it. (Would you prescribe an antibiotic for everyone who comes into your office and demands it?) I am skeptical of government authorities who want to tell us how to practice. I disdain federal pronouncements which amount to unfunded mandates. I believe in debating published data by named authors, then coming to a conclusion, not accepting Washington pronouncements at face value.

    First, the smallpox vaccine program as it stands now is by no means an "unfunded mandate." It merely makes the vaccine available for those who want it. Only the military has to have it. For all others, healthcare workers included, it's voluntary. As for the vaccine complications, there's no reason to exclude health insurance companies from covering the care of a complication, just as they would cover the complication of any other medical treatment. Yes, the vaccine has a higher rate of serious complications than our current vaccines, but I believe that each person should be allowed to decide if those risks are something they want to take to protect themselves against a potential bioterrorist attack.

    I've said this before, but I'll repeat it again. The ring vaccination strategy worked at a time when there was a high level of background immunity in the world population. That is no longer the case. It's overly optimistic to think that it would be as effective today. Even back in those days, it required a tremendous amount of effort on the part of those involved in the campaign to eradicate smallpox. It would be infinitely more difficult now. Half the world has absolutely no immunity to the disease, and we travel much more easily from place to place now than we did then.

    As for the Russian biowar guy, I would expect someone who headed a bioweapons program to be of dubious moral quality. And, although I wouldn't trust him with my bank account, it would be hard to ignore his stories about his own work. Worse, there's no reason to think that he's the only person in the world who has "no moral qualms about developing weaponized anthrax and smallpox." Chances are, he knows them. So, while we might not be able to trust him, we certainly shouldn't ignore him.

    I'm less skeptical of the government. I think they have weighed the problem carefully and decided that this is the best approach to take. Certainly, given the amount of brouhaha the public health community has made over giving a voluntary vaccine at a leisurely pace, you have to wonder how on earth they would give it involuntary to people they have to hunt down after an outbreak. That task would be far harder and far more expensive - and the repercussions far more serious.


    posted by Sydney on 1/08/2003 07:13:00 AM 0 comments


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