It’s a question most doctors thought was behind them:
Should Americans be vaccinated against smallpox, a deadly, highly contagious disease that vanished from the United States a half-century ago?
Today — thanks to fears of terrorism — the U.S. Advisory Committee on Immunization Practices will take up that discussion, deciding who should get the vaccine and when.
“In my medical lifetime, I’ve seen the end of polio in the United States,” said Dr. Robert Stone, a pediatrician and associate chairman of community affairs at Children’s Hospital Medical Center of Akron. “I’ve seen the eradication of smallpox in the world. That is an amazing thing. But I’m chagrined that the world we live in today even allows us to talk about an epidemic of smallpox.”
The disease, which killed about 30 percent of those it infected, has not appeared in the United States since 1949. Childhood vaccinations ended in 1972. And by 1980, the World Health Organization announced the disease’s complete eradication.
The obliteration of this ancient killer — credited with causing devastation as far back as 1157 B.C. in ancient Egypt — is one of the world’s great vaccination successes, sparing 40 million lives and 350 million illnesses over the last 20 years.
The federal government’s current policy is to vaccinate only the handful of technicians and scientists who work with the virus in high-security laboratories. In the event of a confirmed smallpox case, the policy calls for “ring vaccination,” meaning the victim would be isolated, and disease detectives would track down and vaccinate people who had been in contact with the patient.
Americans, however, fearful of bioterrorism, seem to want more.
A Gallup poll released this month found that 77 percent of Americans want everyone vaccinated.
“I think that’s because they don’t know anything about the smallpox vaccine,” said Dr. James Tan, chairman of internal medicine at Summa Health System. “It’s an impure vaccine. It’s not a very good vaccine. It’s associated with a huge number of reactions, even deaths. I wouldn’t do that.”
Neither would Stone. There are just too many adverse reactions to the vaccine, he said.
About one in 10 people will develop swelling or infection at the vaccination site. About one in 100 will get sick, with symptoms like fever or swollen lymph nodes. About one in 1,000 will be hospitalized. And about one in 1 million will die.
“Even if it’s just one in 1,000 that require hospitalization,” Stone said, “that’s a huge impact on the United States and the 300 million people that live here. One in a million doesn’t sound like much, but if that happens to be your mom, that’s a big… deal.”
The risk of the vaccine can’t be measured against the risk of getting the disease, since there’s no way of knowing whether smallpox will ever be anything more than a theoretical threat.
Stone and Tan disagree on how serious that threat could be.
With the contagious nature of the virus and America’s on-the-go lifestyle, Tan sees big trouble because of the difficulty of keeping the virus contained.
Stone, though, sees smallpox as a finicky virus — one that’s hard to manage in less-than-optimal conditions.
“With anthrax, you can put it in an envelope and scare the world and people will get sick,” Stone said. “But the smallpox virus is very fragile.”
Whatever the immunization panel decides, the government expects to stockpile enough doses of smallpox vaccine by 2003 to protect every U.S. citizen in the event of a biological attack.
In the meantime, doctors might want to review their textbooks to be sure they wouldn’t confuse a case of smallpox with chickenpox.
Chickenpox lesions tend to exist at various stages of development all at once, Tan said. In other words, one lesion may look like a red patch, while another may look like a blister, while others look like a “pocket of puss.”
Smallpox lesions, on the other hand, all look the same.
Few, if any, doctors practicing today in the United States have personally witnessed smallpox, Tan said, meaning doctors are left to correlate pictures in a textbook with a real-life patient. That’s a real challenge, he said, since pictures never look quite the same as a patient sitting in an examining room.
“That first case is going to be mighty tough to diagnose,” Stone agreed. “I wouldn’t want to have to diagnose the first one.”