Israel’s smallpox inoculation should influence U.S. plan

Editor’s note: This is the second of three parts of a commentary on the benefits and risks of the nation’s smallpox vaccination plan.

Israel recently vaccinated 15,000 health care workers, the first responders, against smallpox. The majority had been previously vaccinated. Apparently four individuals in Israel were sick enough to hospitalize and one of the patients was a baby.

It is my understanding that at least two of the hospitalized patients contracted from a recently vaccinated family member. No one died, but apparently a surgeon’s wife was quite sick, according to a report on National Public Radio. For unknown reasons this surgeon was vaccinated despite knowing his wife was immunocompromised, and subsequently she developed a severe complication. So at least half of the hospitalized complications occurred in individuals who were not vaccinated as part of the program.

I have not been able to learn more about the details of the woman’s case. The details coming from Israel are sketchy (at least for me) but the Harvard School of Public Health has a team of investigators in the field in Israel studying the outcome

of the program. Leonard Marcus, M.D. heads the team.

Dr. Marcus has undertaken two trips to Israel. The first, ending in October, generated a marvelous and informative report on all aspects of Israel’s preparedness for all types of terrorist attacks and an overview on operations conducted after attacks. The recent duct tape/-plastic-screening maneuvers in our country may have been partially suggested by Israel’s experience in the Gulf War. Dr Marcus’ second trip, which finished recently, was somewhat productive but the Israelis were unwilling or unable to share the data they have on complications in their smallpox program. This information is critical in evaluating and perhaps even predicting the complications in our military and perhaps civilian population.

So there are risks to smallpox vaccination – that has always been known. There will be complications. How many, how severe, and in whom remains unknown. The program of introduction of a live virus into the community to ward off a bioterroism attack is dangerous; and could well be a public health disaster.

In addition to the medical complications and the need for proper diagnosis And therapy, there are now looming the medico-legal problems of accountability, malpractice, informed consent, compensation and the other matters, which send lawyers and conspiracy devotees flocking to court, and cause hospital administrators and doctors reassessing their obligations to the program, the community and their patients. More on these later.

I will not be vaccinated for various reasons. I would, however, be more than willing to see a case of suspected smallpox – feeling confident that with using precautions, trusting in my past immunity (albeit suspect), and the prompt use of the vaccine if the case is smallpox, I would not be afflicted.

Why won’t I get vaccinated now since I might be on a first responder team? Simply put I would be a public health hazard. I see patients with atopic dermatitis (eczema) and all those other conditions which contraindicate exposure to a smallpox inoculation. I see immunocompromised patients. I see and examine patients at risk. Why

take a chance of infecting them?

Another reason for my remaining unvaccinated at this point is that the Maine’s Bureau of Public Health would not vaccinate me because dermatologists have not been designated as first responders. Only first responders qualify to volunteer to receive smallpox vaccinations for now and the Centers for Disease Control and Prevention does not view dermatologists as first responders! We may not be “first responders,” but we will be making the diagnosis. All of this is rather convoluted.

The CDC’s plan relies on the state health departments to submit post-event (read “attack”) plans to the federal government and the states are required to assemble a plan regarding the make-up of their health response teams. The states in turn contact hospitals to help them develop response teams.

It is my understanding that Maine is ready to vaccinate a number of health workers soon. The Bureau of Health hopes to get 40 of the 60 public health nurses to volunteer to be vaccinated. I know of no one in the bureau who has opposed the plan, despite the fact that instituting it will adversely affect the health of some people in Maine.

The obvious caveat is that there is a chance of a bioterrorism attack and this plan needs to be in place. The fundamental question is what is the chance of such an attack with the smallpox organism. It might be helpful to revisit the Israeli program. What is Israel’s position? As I mentioned, Israel vaccinated 15,000 health workers and others. The majority of the people who were vaccinated in the recent program had had previous vaccinations i.e. they were not first timers. Severe reactions are uncommon in previously vaccinated people, and this might explain the supposed low incidence of reactions.

Israel had an active smallpox vaccination program until 1980. Reacting to the four who required hospitalization as a result, Paanan Gissin, spokesman for Prime Minister Ariel Sharon, said in a Los Angeles Times article that “right now there is no need (for further vaccination). There is more risk when you vaccinate a whole population instead of a control group. Given the intelligence we have and the assessment of the threat at this time, it is not worth anticipatory vaccination.” What do the Israeli’s know that we don’t?

There are rumblings that not all of the medical community in the United States is accepting the program. The New York Times recently reported that the Institute of Medicine has suggested the vaccination program was rushed and lacked important safeguards. The article quotes Dr. Julia Gerberding, the director of the CDC: “We intend to make this program happen on time. We live in a dangerous world these days where a terrorist attack with smallpox is possible. We must be prepared.” What does she know that Israelis and

we should know?

The Institute of Medicine report according to The New York Times made 23 recommendations, calling for certain changes in the program. I gather it did not suggest stopping the program.

Tomorrow: Questions of liability; who can be sued and who pays?

William Gallagher, M.D., is a Bangor dermatologist. He is a member of the American Academy of Dermatology.