- The Washington Times - Friday, September 6, 2002

It has been centuries since native North Americans were so vulnerable to the sickening sword of a smallpox attack. The first time it was so used was when Lord Jefferey Amherst, commander of the British forces in North America during the French and Indian War (1754-1763) approved sending smallpox-infected blankets and handkerchiefs to the Ottawa tribe attacking Fort Pitt. It had the desired effect subsequent epidemics probably killed more than 50 percent of affected tribes, a consequence of Native Americans having practically no immunity to the smallpox-causing variola virus.

The U.S. population now has about that same level of immunity, an unintended consequence of the extremely successful worldwide smallpox eradication campaign. The last known naturally acquired case of the disease was seen in 1977; smallpox vaccinations in the United States ended even earlier (1972). Unfortunately, that has made Americans highly vulnerable to any terrorist or autocrat who dares to use such an indiscriminate weapon.

A bit of background may be useful. Vaccines work because they present the "police" (actually B-cells and T-cells) of the immune system with the equivalent of molecular most-wanted posters. When "criminals" like the variola virus break in, the B-cells and T-cells already know what to look for, so they are able to make the "arrest" destroy the invader, before damage is done, resulting in immunity. Immunity is lost when cells "forget" what invaders look like. It's not clear how long the "forgetting" process takes, so while it is clear that those unvaccinated are vulnerable to smallpox, it's not certain how many of those vaccinated Americans over age 30 retain even partial smallpox resistance.

Given the uncertainties involved, it's almost impossible to determine the casualties that a smallpox attack would cause. Variables range from the climate under which smallpox is released (it survives longer in cooler temperatures) to the number of individuals with compromised immune systems in an exposed population.

However, it is clear that even a small release of the variola virus say aerosols sprayed simultaneously at several major airports would have catastrophic consequences. Under optimum conditions, an infinitesimal amount of the virus can cause an infection, and historical data suggests that a single infected individual can transmit the disease to up to a score of others during their most infectious period (between seven and ten days from the onset of the characteristic rash). Those sickened could also be vulnerable to secondary infections from bacteria, but that is not a common occurrence, according to a consensus statement by smallpox experts published in the Journal of the American Medical Association (JAMA) in 1999. Smallpox will kill about 30 percent of the sickened individuals who fail to receive the vaccine within four days of virus exposure.

Supportive therapy is the only palliative available to those unfortunates who miss the vaccination window. There's no antiviral, and in fact, researchers still aren't exactly certain of the exact method by which the variola virus kills. The vaccine isn't perfectly safe. While the U.S. vaccination campaign was in full swing in 1968, about one in every 300,000 persons vaccinated came down with encephalitis, and about one-quarter of those (that is, one in every 1.2 million) died as a result.

So how should the risks be weighed? A small number of Americans will almost certainly perish in the course of a mandatory vaccination campaign, but a vast number of unvaccinated Americans will certainly die in a smallpox attack. Sen. Bill Frist, a heart and lung transplant surgeon, has made a number of sensible suggestions in this regard.

Mr. Frist proposed permitting each American to make an informed choice on vaccinations as soon as enough licensed vaccine is available. That might be as early as December. The senator has further proposed making vaccinations mandatory for military personnel who might be at high risk, but voluntary for everyone else, beginning with first responders and other health professionals.

Health and Human Services Secretary Tommy Thompson and his top experts have recommended voluntary smallpox vaccinations for first responders health professionals and police officers and firefighters but that proposal does not go far enough. As Mr. Frist has pointed out, voluntary national vaccinations will reduce the number of susceptible Americans and increase the ability of professionals to contain an attack.

Regardless of how many individuals are vaccinated, health professionals will need to be provided with ample doses of vaccine in the case of an attack. The Centers for Disease Control and Prevention plans to apply a "ring" strategy to any smallpox outbreak regardless of how many individuals are initially exposed, but the logistics of such a vaccination campaign remain to be established.

But, as Mr. Frist argues, notwithstanding any other government policy, every American must have the right to decide for his or her family whether to vaccinate or not. Now that there are enough vaccines to go around for every American, it's not up to the government to withhold them from a free people.

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