January NEJM Dedicated Smallpox, Bush Administration Vaccination Plan
The Jan. 30 issue of the New England Journal of Medicine will be entirely devoted to smallpox and the Bush administration's vaccination plans. Under the Bush plan, about 500,000 military personnel and as many as 10 million emergency and health care workers will receive the vaccine. U.S. diplomats in the Middle East also could receive the vaccine, and the State Department will consider requests from U.S. allies for the vaccine. In late spring or early summer of 2003, the federal government will offer the vaccine to U.S. adults in the general population not at high risk for side effects (California Healthline, 12/16). NEJM's editors yesterday released five of the articles planned for the issue. Summaries of the articles appear below:
- "Special Article: The Public and the Smallpox Threat": Most Americans believe that smallpox is less dangerous than it actually is and that the smallpox vaccine is more dangerous than it truly is, a survey conducted by the Harvard School of Public Health indicates. Harvard researchers polled 1,006 adults between Oct. 8 and Dec. 8, finding that 78% of respondents falsely believed there is a treatment for smallpox and that 87% believed they are likely to survive if they contract the disease. About 30% of people in past smallpox outbreaks died (Grady et al., New York Times, 12/20). Although the last case of smallpox worldwide occurred in 1977, 30% of respondents said they thought that there had been a case of smallpox in the United States within the previous five years; 63% believed there had been a case somewhere worldwide in the last five years (Manning, USA Today, 12/19). One-quarter of respondents felt that they would likely die from the vaccine (Haney, AP/Contra Costa Times, 12/20). However, 61% of respondents said they would receive the vaccine if offered; 75% of respondents said they would receive the vaccine if their doctor did, but only 21% of respondents said they would receive the vaccine if their doctors did not. "If people don't know that the vaccine will help them if they get it immediately after exposure, and if they think there is a treatment, they would delay to see if they got sick," Dr. Robert Blendon, a Harvard professor of health policy and the leader of the survey, said. Blendon suggested a "three-pronged" smallpox education effort, including televised appearances by celebrities, pamphlets in doctors' offices and newspaper articles that include basic smallpox facts (New York Times, 12/20).
- "Special Article: A Model for Smallpox-Vaccination Policy": Widespread vaccination of the general public against smallpox is "too dangerous" and would lead to too many deaths, but a plan to vaccinate health care workers immediately is "prudent," according to a study by the RAND Center for Domestic and International Health Security (RAND release, 12/19). The study compares six different possible smallpox attacks to six vaccination policies (New York Times, 12/20). For example, they determined that three smallpox-infected individuals riding mass transit in a large city would kill fewer than 20 people before the disease was contained through vaccination and that 40 people walking through 10 busy airports with nublizers spraying the disease would kill between 40,000 and 55,000 people. Overall, researchers assumed that 2.7 people per one million vaccinated would die as a result of side effects associated with the inoculation, based on analysis of more than 14,000 documents going back 100 years (AP/Contra Costa Times, 12/19). The study estimated that 482 people would die if 60% of all Americans were immunized against smallpox, "too high a price ... if the chance of a major smallpox attack is low," the researchers said (New York Times, 12/20). Researchers also estimated that 25 people would die if nearly 10 million health care workers received the vaccine Researchers said this is a "risk worth taking" because health care workers are "so vulnerable" to coming in contact with smallpox victims and in the smallpox scenarios researchers considered, providers account for as many as half the deaths (Smith, Boston Globe, 12/20). "Vaccinating health care workers presents a modest risk and could pay many benefits. In contrast, a public vaccination campaign is certain to entail significant harm, so it should only be contemplated if the government concludes that the chances of a widespread attack are considerable," Dr. Samuel Bozzettee, the study's lead author, said (New York Times, 12/20). NBC's "Nightly News" yesterday reported on the RAND study (Brokaw, "Nightly News," NBC, 12/19). A transcript of the segment and a video excerpt in Windows Media are available online at http://www.msnbc.com/news/846424.asp?0dm=V11MH. NPR's "Morning Edition" today also reported on the RAND study (Harris, "Morning Edition," NPR, 12/20). The full segment will be available online in RealPlayer at http://discover.npr.org/rundowns/rundown.jhtml?prgId=3&prgDate=December/20/2002.
- "Letter to the Editor: A Smallpox False Alarm": Dealing with a potential smallpox attack may be more difficult for doctors to deal with than expected, based on an experience at Cleveland-based MetroHealth Medical Center detailed in a letter to the NEJM editor. Last May, doctors at the hospital came across a patient with a "severe, mysterious rash" and originally diagnosed the patient as having chicken pox. However, further examination found symptoms fitting the description of smallpox. The letter details some of the "small, maddening details" the hospital experienced attempting to take pictures of the patient and deliver samples of the disease to the CDC in Atlanta, including finding a Federal Express delivery station willing to take biological agents (New York Times, 12/20).
- "Sounding Board: A Different View of Smallpox and Vaccination": The government is "wrong" to urge hospitals to vaccinate health care workers, Thomas Mack, a professor at the University of Southern California and a former smallpox officer with the CDC, writes in the journal, the Wall Street Journal reports. "The key to smallpox control is surveillance and isolation and keeping cases out of the hospital," Mack says (Carrns/Chase, Wall Street Journal, 12/20). Mack states that vaccinating 15,000 health care workers "would be enough," rather than a more widespread vaccination (New York Times, 12/20). Mack concludes, "Only if evidence suggests that a massive attack or sustained biologic warfare is probable can such a [plan to vaccinate 10 million health care workers] be justified" (Mack, NEJM, 1/30).
- "Current Concepts: How Contagious Is Vaccinia?": A "great concern" of public health officials over the Bush administration's vaccination plan is the possibility of health care workers infecting their patients with vaccinia, the virus used to make smallpox vaccine, Dr. Kent Sepkowitz, director of infection control at Memorial Sloan-Kettering Cancer Center, writes in the journal (New York Times, 12/20). Sepkowitz says that many hospitals "remain uncomfortable" with the administration's plan because it recommends against granting administrative leave for recently vaccinated health care workers. Sepkowitz concludes, "Until these controversies are settled, hospitals must be certain that the rush to vaccinate health care workers does not result in a self-inflicted epidemic -- not of smallpox, but of infection with the live, potentially fatal virus, vaccinia" (Sepkowitz, NEJM, 1/30).
In related news, officials from several leading health organizations said yesterday that the Bush administration's smallpox vaccination program has potential to "strain already overburdened" public health systems, the Los Angeles Times reports. Testifying before an advisory panel organized by the Institute of Medicine at the request of the CDC, several providers said that the vaccination program would take place amid nursing shortages, crowded emergency rooms, financially troubled public health agencies and a patient population that faces "far more common health threats" than smallpox. "As critical as it is that we be prepared to respond to a smallpox attack, it cannot come at the expense" of other public health programs, Dr. George Hardy, executive director of the Association of State and Territorial Health Officials, said (Kemper/Mestel, Los Angeles Times, 12/20).