Smallpox: Attack On American Homeland
America's top public health officials are engaged in a raging debate: how to best prepare for a smallpox attack on the American homeland. Unfortunately, most of this debate focuses on the wrong issue. Instead of arguing about whether we should vaccinate as few as 15,000 or as many as 500,000 medical workers and other first responders before an attack, the debate should focus on how to best prepare for mass vaccination after an attack.
During the Cold War, the most draconian threat to U.S. security was from Soviet nuclear weapons. Today smallpox is a greater threat than nuclear weapons. It is a disease that killed 300 million people in the 20th century. Thanks to the World Health Organization's effort, the naturally occurring form of this disease was eradicated in the 1970s. Unfortunately, the biotechnical revolution has made it possible to use smallpox as a weapon. Like a Cold War Soviet nuclear strike on our homeland, the probability of a smallpox attack is low, but the consequences are so high, we cannot ignore the threat.
Just one year ago, America was woefully unprepared. This was dramatically demonstrated in the Dark Winter exercise. A dozen highly experienced national security leaders watched helplessly as smallpox spread across the nation in this scenario. With a strategic vaccine stockpile of fewer than 15 million doses, there was little they could do to protect 280 million Americans.
Thanks to decisive leadership in both the Administration and Congress, America is better prepared today. There are 160 million doses of vaccine available, and by the end of the year, there will be close to 300 million. This vaccine is highly effective, even if administered as much as four days after exposure to smallpox. The fact that it is so effective, even after exposure, is why our efforts should focus on building the capability for rapid, post-attack mass vaccination. Some level of preattack vaccination is important, but it should not be the central issue of debate.
The current policy of the Centers for Disease Control states that ring vaccination is the preferred response to a smallpox outbreak. This means that health officials would vaccinate only individuals who have had direct contact with those who have become ill. This strategy may be effective in a small-scale attack, just as it worked well during the World Health Organization's smallpox-eradication campaign in villages throughout Africa and India. However, many in these societies were immune to smallpox, either because they had already been vaccinated or because they were survivors of earlier outbreaks. That is not the case in the United States today. No one under the age of 30 has been vaccinated, those of us vaccinated more than 30 years ago are not protected and, with the exception of a few hundred immigrants, there are no smallpox survivors in the United States. Furthermore, the mobility offered by interstate highways and jet travel was not a major factor in the World Health Organization eradication campain.
Many public health officials doubt the effectiveness of ring vaccination in response to a simultaneous attack on a dozen or more major cities. (Dark Winter assumed that only 3,000 were infected, and most were in a single city.) The challenge of several thousand in each of a dozen or more cities would overwhelm the capability of our public health response system to track patients and their contacts. In fact, the current CDC plan calls for two generations (three to four weeks) of ring vaccination. If this does not control the spread, the plan then calls for a transition to mass vaccination. This, however, may be too late for America. According to Dr. Tara O'Toole, Director of the Johns Hopkins Center for Civilian Biodefense Strategies, a major attack with smallpox could take a nation beyond the point of recovery.
The only effective response to a large-scale attack will be mass vaccination. But is America prepared to vaccinate 280 million citizens in less than 96 hours? No. Is it possible? Yes.
In the most recent presidential campaign, close to 100 million Americans went to polling stations in a single day. They were able to do this because they were preregistered and knew where to go to complete a rather simple procedure. In fact, you could even use polling stations as a place to administer the vaccine. They are conveniently spread throughout our communities.
To give America the capability to respond with an effective mass vaccination, Congress would need to pass legislation granting the president specific powers for declaring a "smallpox emergency." Provisions would include indemnification of all involved in the process, from vaccine manufacturers to those administering the vaccine. Under this emergency order, no one should be required to receive the vaccine, but those who refuse should be advised to self-quarantine their families. Many health care workers will say that people must be forcibly quarantined. I disagree. Those who do not receive the vaccine will not be a threat to those of us who choose to vaccinate our families.
It is time to move the debate beyond the issue of preattack vaccination for select members of the medical community and other first responders. The most important factor will be how effectively we can accomplish a postattack mass vaccination. The capability for mass vaccination (or mass distribution of antibiotics in case of an anthrax attack) should be one of the top priorities of our homeland security efforts. It will provide the best protection against the most deadly threat we are likely to face in the next several decades, and it is an approach that does not threaten our civil liberties. It will, however, require prior planning and public education. This is the area where the smallpox debate must focus: what will we do to protect our families if an attack occurs? The answer is clear. The time for action is now.