President Bush has finally revealed his plans for protecting the nation against the threat of a smallpox attack, starting with vaccinations for the military, emergency medical personnel, and the Commander in Chief, but it's still not clear what the rest of us are supposed to do. Although the President is not recommending vaccinations for the general public (or his family) at this point, the Administration is known to be stockpiling enough vaccine to begin offering it to every man, woman and child by 2004. These vaccinations will be voluntary, which means we have to decide for ourselves whether the small but real risk of complications from the shot is worth the considerable risk of dying from smallpox if an outbreak occurs.
It's a tricky issue because this particular vaccine is one of medicine's most dangerous. It doesn't contain the smallpox virus, but it does use a live version of a related one, called vaccinia, that can make you sick and, in rare instances, kill you. Most people just get a blister at the injection site and maybe some swelling of the arm. Others will feel tired or develop a low-grade fever; about a third will feel ill enough to miss work or school. Out of 1 million people, between 15 and 60 will develop serious complications, including encephalitis (swelling of the brain). If the entire U.S. population were to be vaccinated, 250 to 500 Americans would probably die.
Luckily, doctors can often tell in advance who is most at risk. Pregnant women and small children, for example, are particularly vulnerable. So is anyone whose immune system is compromised--by HIV, cancer, immune disorders or immunosuppressive drugs. People who have ever had eczema, or who live with someone who does, risk widespread skin infections and should avoid the vaccine, unless they know they've been exposed to smallpox. All told, 60 million Americans would probably be well advised to take a pass.
The irony is that most Americans--2 out of 3, according to a Robert Wood Johnson survey--seem to be willing to put their health at risk to protect themselves against a disease that is entirely theoretical. There hasn't been an outbreak of smallpox for 25 years, thanks in large part to Dr. D. A. Henderson, who ran the World Health Organization's smallpox-eradication program and who has been, for the past year, the Administration's chief smallpox adviser. Henderson believes a smallpox outbreak in the U.S. would actually be "very controllable." The strategy he used in the 1960s and '70s was to vaccinate only infected patients and people in contact with those patients, moving outward in concentric circles until the virus stopped spreading. If it's any comfort to procrastinators, the smallpox vaccine will still protect you against the disease after you've been infected--as long as you get your shot within two or three days. That's assuming you can find one in the middle of a smallpox attack.
Dr. Gupta is a neurosurgeon and CNN medical correspondent