``The CDC must be in deep denial,'' stated a Sept. 25 press release from the Association of American Physicians and Surgeons (AAPS), in response to the Smallpox Response Plan and Guidelines released Sept. 23 (see www.bt.cdc.gov).
The CDC plan supplements the ``ring immunization'' strategy with mass immunization-but only after a confirmation of smallpox virus or a large outbreak of clinically compatible illness confirmed by the CDC. This could mean thousands of preventable deaths, even if 1 million people can be vaccinated in 10 days.
While stating that a single case of smallpox could trigger the response, the CDC is reluctant to speak of tens of thousands of index cases manifesting at once. In the Executive Summary of the plan, the CDC states: ``there remains concern that stores of smallpox virus may exist in laboratories other than the two WHO designated repositories.'' It is silent about the tons of weaponized virus known to have been manufactured (CDP Jan 2002). The Dark Winter exercise conducted by the Johns Hopkins Center for Biodefense and others projected 3 million cases and 1 million deaths in the fourth generation of smallpox cases, 2 months after an attack (www.hopkins-biodefense.org), assuming that each case infects 10 others.
Some scientists say the Dark Winter assumptions were overly pessimistic (Science 2002;296:1592-1595). Others note that the number of infected contacts has historically been as high as 38 per infected case (Bicknell WJ. The case for voluntary smallpox vaccination, N Engl J Med 2002;346:1323-1325).
The reality of biowarfare could be much worse than models based on natural smallpox. At the 2002 DDP meeting, Lowell Wood noted that terrorist-type smallpox, featuring deep pulmonary infections vs. classic upper respiratory ones, could be nearly 100% lethal.
Health officials are more worried about the vaccine than megadeaths from smallpox. Based on 1960s data, the vaccine could kill 1 per million and cause encephalitis in 12 per million and serious skin rashes in 39 per million. Vaccinating the entire U.S. population might cause 300 to 350 deaths, according to CDC estimates. Only 600 doses of vaccinia immune globulin (VIG)-made from the serum of recently vaccinated volunteers-are now available to treat severe reactions.
For comparison, at least 440 deaths in association with (though not necessarily caused by) 20 million doses of hepatitis B vaccine had been reported to the Vaccine Adverse Event Reporting System (VAERS) by 1999 (CDP, May 1999). Leaving aside the significant underreporting to VAERS, hepatitis B vaccine could be 22 times as dangerous as smallpox vaccine-yet is required of schoolchildren, to protect them against a disease far less deadly or contagious than smallpox.
Withholding vaccine, rather than giving it to volunteers in an orderly manner, with careful screening and appropriate precautions against spread from the inoculation site, guarantees maximum casualties from both disease and vaccine in the event of a bioterrorist attack. Scenarios to be published in the Proceedings of the National Academy of Sciences support this conclusion (Wall St J 9/10/02).
Israel has begun vaccinating 15,000 emergency workers (AP 9/18/02; Wash Times 8/7/02). It will use their serum to manufacture more VIG.
Pursuant to the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, the Dept of HHS and USDA have sent researchers forms for reporting possession of pathogenic organisms or toxins-or for declaring that one does not possess such things-a mechanism reminiscent of airport ``security questions.'' But detection of actual use of the agents relies on recognizing pock marks or other symptoms and signs days or weeks after a ``nonevent.''
Technology will not be the limiting factor. The increasingly sophisticated analysis of simple molecules could be exploited for presymptomatic screening. For example, the concentration of nitric oxide in exhaled breath increases as the immune system mobilizes to fight an infection. Sensors could be placed near drinking fountains or pay phones, in elevators, on buses, or in other public places (Koonin, Engineering and Science News 2001;LXIV(3/4):23-29, available from the California Institute of Technology, 1200 E. California Blvd., Pasadena, CA 91125). If a problem is detected, the cause can be sought.
U.S. atomic energy facilities, such as Argonne, Sandia, Los Alamos, and Lawrence Livermore National Laboratories have a new priority: quick response to chembiowarfare for the military and Zivilschutz (civil defense) (NZZ am Sonntag 9/8/02). Developments include a ``laboratory on a chip'' for identifying toxins, as from anthrax, within seconds; a portable mass spectrometer for identifying bacteria within five minutes; or rapid polymerase chain reaction (PCR)-``Single Molecule Detection''-for recognizing sequences from bacterial or viral pathogens.
As yet, only two laboratories in the U.S. are equipped to analyze suspected smallpox viruses in an environment safe for investigators. But Mayo Clinic scientists have found that the Lightcycler PCR test can be successfully used on autoclaved specimens, so that the test can be done in local facilities (Science Daily 7/10/02).
The CDC maintains tight control of all existing vaccine, meaning an inevitable time delay in dispersing it even if the transportation system is not paralyzed. It would indeed be ironic if Americans had to resort to the variolation used in the 18th century (CDP Jan 2002), which largely averted disfiguring facial scars and reduced mortality to around 1%. (The disease is much attenuated if virus is introduced through the skin rather than the lungs.) If some vaccine were available, the arm-to-arm method used by the Spanish to bring vaccine across the Atlantic to the New World, without refrigeration or cows, could be an FDA-disapproved expedient to stretch supplies. Two children were inoculated with cowpox just before departure. When pustules developed, material was taken to inoculate two more children, and the process was continued with successive children until they reached Venezuela, with two children providing an aliquot of vaccine for South Americans (Miller DW, Jr., www.lewrockwell.com, 9/26/02).
The Pima County Medical Society (Tucson, Arizona) has written Surgeon General Richard Carmona, M.D., urging him to promote high-tech preparedness for biowarfare and to permit immediate vaccination of volunteers. ``We recognize the importance of not causing panic and hysteria. On the other hand, denial of the possibility of a really, really big threat could result in preventable deaths on an unimaginable scale, in addition to the unavoidable ones occurring as a consequence of the attack.''
Dr. Wood stated: ``The present-time `smallpox affair' may end up the poster-child for how not to do bio-defense.... Vaccination-under-attack plays `you bet your country' with an entirely untested scheme.'' Large appropriations are not reassuring: ``There's no practical limit to the time-&-money that can be expended by large bureaucracies without any worthwhile results being obtained.'' Thus citizens must ``demand emplacement, `live-fire' testing, independent review & periodic upgrading of all civil defensive systems....If you don't see it happening,...be assured that it really isn't happening.''
The 2003 meeting of DDP will be in Phoenix, July 11-12. The CD-ROM update, including the 2000-2001 meetings, is now available (see enclosed form).
DDP, 1601 N. Tucson Blvd. Suite 9, Tucson, AZ 85716, (520)325-2680, www.oism.org/ddp.