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The Bush administration wants the nation to embrace a potentially dangerous mass-vaccination plan to thwart a smallpox attack. But is the threat real, imagined—or concocted?

By Travis Durfee

A box of Marlboros is placed under the hood of a trash can in the food court at the Crossroads Mall in Oklahoma City. Hidden in the cigarette case is an aerosolizer—a credit-card-thin device that emits invisible, odorless bursts of mist over a few hours. Roughly 100 shoppers cross paths with the mist before the device expends its supply. For the purpose of this exercise, that is more than enough.

A week later, officials from the Centers for Disease Control and Prevention are called in from Atlanta to confirm 20 suspected cases of smallpox at Oklahoma City’s Deaconess Hospital. Since the disease was eradicated in nature more than 20 years ago, doctors presume the illnesses are from a biological attack using smallpox—a highly contagious, easily transferable disease known to kill one in every three infected.

As word of the smallpox attack is reported in the local media, emergency rooms citywide are flooded with the infected and those fearful of infection. Many unvaccinated hospital workers begin skipping shifts. Gov. Brad Henry requests that his state’s entire population be vaccinated, and activates the Oklahoma National Guard.

Nine days after the presumed exposure, there are 20 lab-confirmed and 14 suspected smallpox cases in Oklahoma City, along with nine suspected cases in Georgia and 10 in Pennsylvania. As the smallpox vaccine is being delivered, smallpox patients and suspected cases are held in local hospitals that have been converted into quarantine centers. But the isolation is not forcibly imposed. A few of the quarantined, scared and infected, sneak out of the hospital to be with family, bringing the disease with them.

As the scenario progresses, there are 2,000 smallpox cases in 15 states with 300 deaths two weeks after the presumed first exposure. The national news media show mothers carrying their children, screaming for the vaccine before the riot- gear-clad row of national guardsmen defending a vaccination clinic. States have closed their borders to highway and airline travel. Schools close; sporting and other public events are put on hold. Many countries close their borders to incoming shipments of U.S. goods, and the impact to the economy is feared to be in the billions of dollars.

Three weeks after the attack, a second generation of the disease surfaces, and the number of cases skyrockets to 14,000 infected, confined to 25 states, among them densely populated urban centers like New York City and Los Angeles. Smallpox experts project third and fourth generations of the disease and deaths in the millions until it can be contained via vaccination.

But none of this is real. It’s all estimation and speculation. Fiction. It’s Dark Winter, a contrived scenario carried out over a few days in the summer of 2001 by a number of public-health organizations to explore the nation’s preparedness for a smallpox attack. Through the simulation, Dark Winter participants discovered that the United States—with a medical community ignorant of the disease and a highly mobile, unvaccinated population—would be all too susceptible to a smallpox attack.

As stated in Dark Winter, defense analysts and intelligence experts have long speculated that smallpox samples were snuck out of Soviet Union bioweapons labs upon that nation’s collapse a little over a decade ago. Though the Bush administration has been quick to spin the National Security Advisory color wheel and put the public on notice, the president and his men have done little to corroborate any of the alleged smallpox threat publicly.

Though officials in Washington have repeatedly insisted that there is no evidence showing that the United States faces such a smallpox threat, plans to prepare the country for biological attack have sped up dramatically post-Sept. 11.

Last July, federal officials announced that the U.S. government plans on vaccinating 500,000 health care and military workers, up from 15,000 in earlier plans. In September 2002, the CDC instructed every state to be prepared to vaccinate every U.S. citizen within a week’s notice. And in December 2002, President Bush unveiled a highly controversial smallpox vaccination program, asking 10 million U.S. health care and military personnel to volunteer for one of science’s most dangerous vaccines.

The president’s proposal calls for the vaccinations to be carried out in three stages over 90 days, and the first phase began in the handful of complying states a few weeks ago. Sixteen pre-first responders—those who would vaccinate the vaccinators—received their shots in New York earlier this month at undisclosed locations.

As the Bush administration is not being forward with the information, one can only guess that the proposal is based on simulations like Dark Winter and intelligence about leaked smallpox stocks. Skeptics have speculated that the administration might have more sinister motives, such as keeping the American public in a constant state of fright or lining the pockets of drugmakers. Either way, the administration has not been willing to offer evidence to convince the American public that the smallpox scenario described above is plausible.

Presently, smallpox vaccinations are performed in the same manner they were when routine inoculation ceased in the United States in 1971, and are based on the same science that was employed when the vaccine was discovered in the late 1700s.

To boost the immune system’s ability to ward off smallpox, humans are infected with a live virus called vaccinia, a relative of smallpox. Both are family members of the group of viruses referred to as poxviruses, and vaccinia toughens up the human immune system to a smallpox onslaught. Vaccinia is actually smallpox for cows, or cowpox—and cowpox, too, can be dangerous to humans.

According to the most recent information on mass smallpox vaccinations, 14 to 52 life-threatening illnesses and 49 to 935 serious but non-life-threatening illnesses are estimated per million vaccinated. But Karen Ballard, director of practice and government affairs with the New York Nurses Association and the union’s point person on smallpox, says these risk assessments require some reading between the lines.

“All the statistics that you’ve read about the side effects and adverse effects of using the vaccine are based on the experiences of the ’60s and ’70s,” says Ballard. “Look at the footnotes on that data; that information is over 40 years old. The population of the United States is very different. So when they talk about the rates of adverse effects and side effects, no one can guarantee that.”

Ballard refers to statistics from the article “Complications of smallpox vaccinations, 1968” from The New England Journal of Medicine. Not only does the 34-year-old study—quoted by every journalist, politician and medical professional—represent the last risk assessment for mass smallpox vaccinations, it was published at a time when inoculations were still routine. Ballard and a host of others say that the data is seriously outdated and the president’s program is being pursued without adequate information—that it’s a test case in itself.

“I call this the demonstration phase in my own head,” Ballard says. “This is the first phase where we’re going to use the vaccine and we’re going to see what happens.”

The vaccine is introduced to the human body through a number of pricks to the arm with a bifurcated, or two-pronged, needle. Since the smallpox vaccine is itself a live virus, serious and potentially fatal side effects can result. As the vaccination wound heals, it must be cared for properly or there is a risk that others could become infected with vaccinia. Known side effects from the vaccine include encephalitis (swelling of the brain) and severe flulike symptoms.

The CDC, which is administering the president’s program, acknowledges that the U.S. population is much different than it was 30 years ago and has warned a number of people not to participate.

According to the CDC, those most likely to have serious side effects from the vaccine include people who have had, even once, skin conditions like eczema, and people with weakened immune systems—people who are HIV positive or are receiving treatment for cancer or have received an organ transplant. Children and pregnant women also could have side effects from the vaccine. The CDC has cautioned these people against participating in the program, but it has not offered projections of deaths and illnesses that the vaccine might cause today.

Ballard says her union has not yet taken a position on the issue, but the prospect of endorsing the vaccination program for her union’s 34,000 nurses with so many unanswered questions concerns her.

It is still uncertain how those who become sick because of the vaccine will be compensated. Vaccinated workers are to remain on the job, and Ballard says that many of her nurses are concerned about infecting patients. She says that workers in New York will receive compensation if they are still sick and missing work seven days after receiving the vaccine. But she says that gesture may be too little too late.

“If you’re sick more than seven days after the shot, then you’ve had an adverse effect, not a normal side effect,” Ballard says.

Despite all of these concerns, Ballard knows that a number of nurses will volunteer for the smallpox vaccine, seeing it as their duty. But she questions the president’s proposal on the number of health care workers the country needs to vaccinate in order to deal with a smallpox attack.

“I don’t understand phase two [vaccinating 500,000 health care workers],” Ballard says. “I can most certainly understand the country wanting a core population of health care workers who could move out and vaccinate other health care workers if there were a need. There is no doubt that that is a public health need.

“All things said,” she continues, “smallpox is a virulent, deadly disease. If that were to become a biological weapon used against any population, it would be deadly. It is a rock and a hard place.”

Peter Jahrling has seen his share of deadly, infectious diseases. o Jahrling is the principal scientific advisor for the U.S. Army Medical Research Institute of Infectious Diseases in Fort Detrick, Md., the nation’s principal biodefense laboratory. Over the past few decades, Jahrling has spent time in the labs and in the field exploring and curing some of the most deadly diseases our country has seen. This has been no small task.

In 1989, Jahrling discovered, captured and named the strain of the Ebola virus that broke out in Reston, Va. When a number of media outlets and the office of Sen. Tom Daschle (D-S.D.) were mailed envelopes containing anthrax in October 2001, Jahrling was called in to identify the bacterium. He and his colleagues created and perfected Cipro, the anthrax vaccine. With all of his experience working with a number of deadly, infectious diseases, Jahrling maintains that smallpox is the greatest biological threat facing the United States.

“Smallpox is an inherently nasty disease,” Jahrling says, “which produces 30 percent mortality and nearly 100 percent morbidity in populations exposed to the naturally transmitted infection. . . . And of course all morbidity and mortality data from the global eradication era pertained to partially immune populations, either immunized or recovered from authentic disease. Everything would be much worse in a . . . virgin population.”

Smallpox is extremely contagious, and as few as 10 smallpox particles can spread it. The disease is airborne, and an infected person exudes smallpox particles when opening his mouth to speak. It would take three million smallpox particles touching end-to-end to span the period at the end of this sentence.

When someone contracts smallpox, the disease masks itself, and the infected shows flulike symptoms while the virus incubates. The disease is contagious during incubation. Smallpox sufferers see a sharp spike in temperature and general discomfort at the onset of the disease. Soon thereafter, little red spots begin to appear all over the body. The spots begin to rise and form pea-sized blisters, called pustules. The pustules swell and firm with a colored puss. The skin begins to resemble bubble-packing wrap with less symmetry. The pustules are prying the layers of skin apart.

Scientists are unsure of exactly how smallpox kills its victims, but death is often brought on by a breathing or cardiac arrest, or bleeding. Upon infection, the probability of death is relatively easy to gauge. If the individual pustules merge into each other across the skin, smallpox is said to have split the whole skin—encasing the body in a layer of puss—and the victim will most certainly die, usually from an arrest. If the pustules stay separate, they may begin to scab over, and the victim will live with scarring.

The most gruesome variety of smallpox is referred to as black, or hemorrhagic, pox. With black pox, dark spots of unclotted blood form under the skin as the disease deteriorates the linings of the throat, stomach, intestines, vagina, anus and other interior membranes. The remains eventually pass through the body’s orifices, and the person bleeds to death. Black pox is nearly 100-percent fatal.

The effects of the disease can be blunted through vaccination—even prevented if received within four days of exposure. Until the signs of an outbreak are detected, though, the disease has time to spread, which it easily could in a society where a the majority of medical professionals have never seen an actual smallpox patient. Jahrling says it would take only one undiagnosed case of smallpox today to create a catastrophe.

“What makes smallpox scarier than anthrax is that it is a contagion,” Jahrling says. “Each case begets at least three more, via person-to-person contact. Couple that with the increased mobility in industrialized nations, and epidemic spread is virtually ensured.”

For the last few years, it has been Jahrling’s job to work with smallpox and to find better treatments post-exposure, including, possibly, a cure for the disease. Currently he and a group of scientists are working on a number of antiviral drugs, like cidofovir (currently used to treat HIV patients), and other, less-dangerous smallpox vaccines.

“It is unrealistic that we will have a ‘cure,’” Jahrling said. “But there is a 10-day incubation period for smallpox during which time an antiviral drug could supplement the [benefits] of post-exposure vaccination. You can’t just write off the folks who can’t receive vaccine or those who aren’t reached within four days of exposure.”

Jahrling is also concerned about the previously mentioned intelligence about leaked smallpox stocks. In fact, Jahrling, having spent time at dilapidated Soviet laboratories and having spoken with the Russian scientists who worked in them, has contributed to these reports.

One might say, cynically, that Jahrling’s opinion derives from his livelihood, as his work depends on the threat of a smallpox attack. But Jahrling’s concerns about the dangers of a smallpox outbreak and unaccounted-for smallpox stocks are widely shared. In reality, his voice is but one in a chorus.

Yet, critics of the Bush administration’s mass-vaccination program are quick to point out that the one voice that should be ringing clearest in that chorus—President Bush’s—has thus far been filled with little more than empty notes.

The danger of smallpox, the disease—should the U.S. population face an actual outbreak—is inarguable. The threat of smallpox, the weapon—being unleashed on the U.S. population—is still questionable.

“I don’t know that [the Bush administration] has made [the case for smallpox vaccinations] sufficiently well,” said Christopher Hellman, senior analyst for the military watchdog Center for Defense Information. “I think that is one of the reasons why the program is voluntary. I think [the low volunteer turnout] speaks volumes. The people have, in their own minds, done the risk assessments and decided that getting the vaccine is not necessary.”

As of Feb. 11, the CDC reported that 1,043 people had been vaccinated in 19 states nationwide, though it had shipped 250,000 doses of the vaccine to 41 states. On Feb. 7, The New York Times reported that state of Texas pressed its 550 acute-care hospitals to decide whether or not they would comply with the president’s vaccination program, and 175 refused to participate.

Jean McGrath teaches at the Albany College of Pharmacy and is a member Albany’s Healthcare Emergency Operations Coordinating Committee. The group initially was formed in 1997 to coordinate efforts for local officials to prepare for Y2K. Now the group’s focus is smallpox preparedness.

Locally, McGrath says, the smallpox vaccination efforts have generally mirrored the efforts nationally. Preparations to inoculate the inoculators have begun slowly and discreetly. Volunteers have been few at local hospitals. Two area hospitals, Schenectady’s Ellis and Troy’s St. Mary’s, have yet to decide whether they will participate in the vaccination program.

McGrath says the vaccination program is in preliminary stages, but acknowledges that turnout, so far, is less than expected. She said the turnout is linked to hospitals’ and health care workers’ desire for answers to the many unanswered questions surrounding the president’s vaccination program.

“Are hospitals and health care workers going to be personally responsible, or is somebody else going to take care of that?” ponders McGrath. “Is any of this really covered in the Homeland Security Act? It is basically a new document, and nobody knows the answers to that yet.”

McGrath says local hospitals would like to vaccinate roughly 100 people each to prepare for a smallpox event, but she said achieving that goal without a smallpox event is highly unlikely.

The Bush administration has done little to answer the questions posed by hospital officials and health care workers. Nor has the imminence of a smallpox threat been outlined, which would show a need for 10 million vaccinated first responders.

The buck has been passed to the states and, at least in New York, they are saying very little. Federal officials have gone back to spinning the National Security Advisory color wheel (High Risk Orange this week) and touting the domestic security benefits of duct tape and plastic sheeting. None of this is drawing more volunteers to the front line of a speculative battle against one of biology’s deadliest viruses.

“Given that there is no risk at this point from the disease,” says Ballard, “people just feel a little tentative, and they’re waiting to see what happens when other people are vaccinated.”

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