A 20-Cent Mask Is the Key to Infection Control

Smallpox is spread two ways, through direct contact and through respiratory secretions. To prevent spread, follow steps from the standard Infection Control Manual. See the isolation requirements from University of Virginia Health Science Center, which covers infection-control requirements for smallpox. (In their previously posted "yellow card", they called for a "standard isolation mask" like the one shown at left. Their new page doesn't specify mask type, but we have to assume appropriate hospital-grade disposables.) The beginnings of a civil defense strategy in case of an attack? Perhaps, but only if enough masks are made available.

Spreading in People -- Started With Exotic Pet Rat

June 8, 2003

The Centers for Disease Control reports an outbreak of Monkeypox in the U.S. Midwest. The disease, previously unseen in the United States, and with symptoms and an incubation period similar to Smallpox, has already sickened 20 people in 3 states. It is likely that others who have been exposed now carry the disease, but will not become infectious until after the incubation period, when they experience the initial symptoms, which include fever and malaise. Infection control precautions are identical to Smallpox, requiring respiratory, fluid, and contact protection.

Black-Tailed Prairie Dogs

Additional story from The Washington Post.
Get the latest from CDC's Monkeypox Page

Vaccinia Virus Linked to Heart Problems

March 28, 2003
By Paul Flint

There are apparently dangers of vaccinating an older population. A second health-care worker has died, apparently from a heart attack following coronary inflammation. Considering the tiny number of healthcare workers who have thus far submitted to voluntary vaccination, this represents a far-greater death rate than the one-in-a-million statistic cited on the basis of previous experience with smallpox vaccinations. This heart inflammation syndrome appears to be the cause of three heart attacks which have now resulted in two deaths. Amongst 350,000 military personnel vaccinated by the Defense Departmnt, there have been 10 cases of heart inflammation observed, none resulting in heart attack or causing death and all of which resolved completely after a period. The population of health-care workers is older than the military population, and is not carefully preselected for physical fitness, which could account for the different outcome.

The smallpox vaccination consists of a transdermal innoculation with live vaccinia virus. A localized infection ensues which, after the patient fights it off, conveys immunity to other members of the Orthopoxviridae genus, including the deadly smallpox virus. Many virus infections can result in generalized inflammation. These are the familiar aches and pains of colds and flu. However, possibly because of the increased monitoring of smallpox vaccinees in this campaign, we are noting for the first time that inflammation in these cases can involve the heart. Health authorities are advising anyone with a heart condition, including narrowing of the coronary arteries, to avoid the vaccination for now.

More on this story, in the New York Times. (free registration required)(free archive not available indefinitely)

No, not of Smallpox. Introducing Severe Acute Respiratory Syndrome (SARS).

March 15, 2003

The World Health Organization has just described and issued travel warnings for SARS (Severe Acute Respiratory Syndrome), a newly emergent disease which has landed hundreds in critical emergency care and killed several. Ominously, doctors say that, to date, no one has fully recovered yet. It is highly contagious, incubation period is three to five days, primary spread is thought to be via respiratory aerosol, and the disease organism is as yet unidentified.

At this time, the only known preventative is general infection control: masks, gloves and gowns. Check here for latest updates.

More: CDC Press Release on SARS.

Are you worrying about the right thing?

December 22, 2002
By Paul Flint

"We have nothing to fear but fear itself," said President Franklin D. Roosevelt as part of his first inaugural address. While he was talking about the Great Depression, the words apply to many other things in life. But maybe not smallpox. When it comes to this subject, there is plenty that an intelligent person SHOULD be afraid of. However, the important thing is that we cannot allow these fears to paralyze us. It is literally a matter of life and death that we understand the various risks and be prepared to take the right measures at the right time.

Smallpox is a spectacularly destructive disease. It kills. It blinds. It disfigures. There is no treatment. It's highly contagious. While most of the reports you will see say that the death toll is typically 30%, this may significantly underestimate what we could expect if there was an outbreak today. Before vaccination was first widely available, populations were periodically exposed to the disease, wiping out those most susceptible and, in a Darwinian sense, strengthening the "herd". Once vaccination was introduced, the adaptive pressure diminished. Over the last 30 years, there have been no outbreaks nor regular innoculations. As a result, today's population is possibly more susceptible than ever.

On their website, the World Health Organization refers to a study of smallpox outbreaks in Europe and Canada from 1950 to 1971. Among those who had not been vaccinated, the death toll was fully 52%. Of those who do survive, most are permanently disfigured, with deep facial scarring, and many are blinded, caused by the virus attacking the eyes.

So, should you be scared? We really don't know. Through concerted effort by the W.H.O. and others, smallpox has been eradicated as a natural disease. Two laboratories, one in the U.S. and one in Russia, are authorized as research depositories to have frozen stocks of the disease organism for study purposes. The bioterrorism fear is that other, unauthorized labs may have stocks of the virus, or that someone in one of the two authorized labs might be tempted by ideology or avarice to steal some and deliver it to terrorists.

Now, about the vaccine: Why do scientists generally advise against introducing large-scale innoculation? Let's look at the risks of the vaccine itself and then weigh them against the disease and the likelihood of bioterrorism.

The smallpox vaccine, as discussed below in other articles, is a live virus that is a gentle member of the same genus as smallpox. Exposure to the vaccine virus, called vaccinia, can impart 5 to 10 years of active immunity from other members of the same genus, including smallpox. But, it is a live virus which can injure some people, and in rare cases, cause death. In prior vaccination campaigns, about one person of every million vaccinated died. Compare that with the 520,000 of every million who could die today from smallpox in the face of a bioterror attack if not vaccinated. The one in a million figure predates many relatively recent medical developments, all of them aggravating risk factors for those affected: AIDS; transplants; cancer, chemotherapy and radiation; growing incidence of eczema, rheumatoid arthritis and other immune problems; and, growing legitimate medical and illegal use of steroids. Healthy infants and pregnant women are also particularly susceptible to vaccine complications. However, compared to the death toll of a smallpox outbreak, vaccinia vaccination looks better. During a widespread outbreak, but not before, even those most at risk from vaccinia might need to then take their chances with the vaccination, as smallpox for them would be an almost certain killer.

Do you need to get vaccinated now, before we know if there will be an attack? Maybe not. If you live somewhere with a strong public health organization which is equipped and prepared to vaccinate you at the first sign of an attack, then you are prepared enough. You need do nothing other than make sure that you will be able to be vaccinated if there is an outbreak. As the incubation period of smallpox (that is, the time it takes to get sick and pass on the disease) is longer than the time it takes for the vaccination to impart immunity, preparedness to give the vaccine is the most important thing. If you are in a high-risk group for the vaccine itself, right now the smart money says to avoid it as long as possible. We don't know if there will be any bioterror attack with smallpox, and we do know the vaccine can be deadly for those most susceptible to it.

If you are not in a high risk group, and you live or work somewhere that might be the first place to be attacked with a smallpox weapon, like Midtown Manhattan or near the Washington Capitol Mall, the decision process shifts more towards getting vaccinated now. This is because those exposed to the virus in an aerosol attack might experience much more rapid onset of the disease and would likely not benefit from vaccination at that point.

Too, if you live somewhere that you feel will be unable to carry out a successful vaccination campaign in response to an attack, you also might want to weigh your options and consider vaccination now.

The complicating factor in all these decisions is that we don't know if anyone in a position to be a bioterrorist even has the virus, or can get it. Also, once released, wherever it is released, the virus would eventually travel around the world, killing friend and foe alike, which prospect might just deter its use.

Government's Proactive Emergency Plan Almost Ready

December 12, New York, NY -- Better late than never, the Bush Administration appears finally to be ready to start a proactive anti-smallpox vaccination plan for healthworkers, and possibly for those members of the general public who wish to voluntarily seek the vaccination. Now the big question is, should you get it?

If you've viewed the links at the bottom of this web page, then you already understand that the smallpox vaccine is an unattenuated live virus, Orthopox vaccinia, which has minimal health implications in most healthy adults, while conveying long-term (but not life-long) immunity to other Orthopox viruses, including Smallpox. Unfortunately, there are also millions of Americans who would be in grave peril if exposed to the vaccinia virus. In particular, this includes a number of immune systems problems, but also those at risk from other factors. For those individuals, the consequences can be truly dire, including the possibility of permanent neurological damage or death.

Here are some of the groups who should probably avoid vaccination unless their physician particularly recommends it:

• Those suffering from AIDS, HIV and other Immune-deficiency problems
• Pregnant women
• Infants
• Anyone with active Eczema or a history of Eczema
• Rheumatoid Arthritis sufferers
• Cancer patients undergoing radiation or chemotherapy
• Patients with Lupus, Leukemia or Lymphoma
• Organ transplant patients and anyone on immunosuppressant therapy for any other reason
• Anyone with a weakened immune system due to current illness, trauma, or certain medications, including having recently stopped prednisone or other corticosteroids

Besides the above high-risk groups, the vaccine may also affect apparently healthy subjects, but at a much lower frequency. For those healthy individuals who do not fall into any of the high-risk categories, those who have been previously vaccinated against Smallpox are believed to be at much lower risk of side effects than those who have never been vaccinated. In both cases, the percentages are still low, but there is a clear risk. Absent an actual outbreak, or the possibility of a Smallpox outbreak, these risks may not be justified. There is an antiviral medication which is believed to be useful in treating those who suffer the side effects of the vaccinia virus, but it is in very short supply at present.

Government Caving in Face of Criticism?

July 7, Washington, DC -- In response to criticism from public health experts around the country, government smallpox vaccination policy may be changing. The currently stated policy of ring-vaccination is widely considered inadequate in the face of a purposeful biological attack. The new policy may involve the advance vaccination of some half-million public health and emergency personnel, and regional mass-vaccination in the event of an attack. A decision is expected by Health and Human Services Secretary Tommy Thompson by August 1.

Read story by William J. Broad in the New York Times, here. (free registration required)(free archive only available until Aug. 6)
Read AP story in the Washington Post.

90 Million Frozen Doses at Aventis Pasteur

March 27, Swiftwater, PA. -- The Washington Post reveals that a large cache of smallpox vaccinations (frozen liquid preparations of live vaccinia virus) had been located in cold storage at a drug company located here. Early tests show that vaccine is still alive and sufficiently potent. This find appears to be at least six times the number of doses formerly available to U.S. public health agencies. Sometimes it's better to be lucky than smart.

Full text of story here. Update: Company announces donation, read story in the Post.

No Need to Disrupt the Economy with These Simple Measures

March 25, 2002
By Paul Flint

Great controversy has surfaced over government contingency planning. Recommendations to shut down all air travel at the first sign of smallpox have butted up against the enormous economic impact of such a move. In our opinion, there is a better solution.

Stopping smallpox from getting on a plane is easier than stopping boxcutters. A fever occurs early in the smallpox cycle, long before any other symptoms. Screening for fever has never been easier or faster thanks to electronic thermal scanners, those thermometers which work in the ear. A small staff could be deployed at airports to screen passengers, or thermometers could be issued to flight personnel, or both, at very low cost.

In a grave crisis, a generalized outbreak, the above alone might not be enough. It then might be a good idea, besides screening for obvious rashes and fevers, to add simple isolation protection, issuing and requiring surgical masks for all passengers and crew. Such a measure can prevent the person-to-person spread of not only smallpox, but Ebola, Plague, and other natural and biowarfare pneumonic diseases. Those with germs won't exhale them into the cabin. Those without germs won't inhale them. That's an effective way to prevent spreading disease via air travel and at a negligible economic impact.

Tommy Thompson's Desire to Soothe Public is No Excuse for Cluelessness

In their press release of 11/28, the U.S. Department of Health and Human Services states, "People who are infected [with smallpox] do not become contagious until the rash appears." Nothing could be further from the truth. Every doctor who ever went to medical school is taught the opposite, that the disease is most contagious during the prodrome. The prodrome is a period of fever and generalized illness which begins before a rash appears. Sources for this are too numerous to cite, but here are two. The government's own CDC Bioterrorism website: "Persons with smallpox are most infectious during the first week of illness, because that is when the largest amount of virus is present in saliva." The article listed in our Recommended Links section below from E-Medicine, edited by JL Mothershead, MD, Special Advisor to the Navy Surgeon General for Prehospital Care, Department of Emergency Medicine, Portsmouth Naval Medical Center, says "[The] prodrome lasts 2-4 days, and during this time, viremia is present and patients are most infectious." Whatever the reason for the misstatement, it is so essentially wrong as to make us wonder what they're up to. In the future, we would advise Secretary Thompson to consider asking a doctor to look over any medical pronouncements before issuing them to the public.

Or, How To Vaccinate Everyone With Limited Vaccine Supplies

December 5, 2001
By Paul Flint

For the first time in a quarter of a century, we again face the threat of smallpox, the first major disease to have ever been eradicated by concerted effort. The fear is that a rogue scientist working in league with terrorists may resurrect this ancient scourge. Our vaccine stores are largely depleted, the remaining stocks long past their expiration dates. While this all seems pretty glum, by simply returning to the roots of the story, there is hope. Have we forgotten that there is something special about smallpox vaccine, something that makes it quite different than other vaccines? If so, this might explain a Public Health unreadiness which is not warranted. The following is not new, not revolutionary, and in part, is over 200 years old.

First and foremost, it seems that collectively we are ignoring what the smallpox vaccine is. Even though it was the first vaccine, and the one from which all other inoculations are named, it's not what we think of today when we think of modern vaccines. I hope to explain, and to demonstrate in this article why it is that while we should be planning, we shouldn't be panicking about not having enough vaccine on hand.

Unlike other virus vaccines, the smallpox vaccine is not a killed or attenuated or partial recombinant form of smallpox. In fact, it's not smallpox at all. Most other vaccines (polio, measles, mumps, hepatitis, influenza, etc.) work by exposing the patient to an immune challenge with the actual disease organism. That organism is either killed or crippled in the vaccine so it can't cause the disease, but the vaccine contains genetic material from the disease organism. Polio vaccine is made from polio. Measles vaccine is made from measles. Influenza vaccine is made from pieces of lots of different strains of influenza, and each year they find new strains and need to make new vaccines.

Smallpox vaccine is not made from smallpox. In fact, originally it was never "made" at all. Edward Jenner instead discovered it in the 18^th century. Smallpox vaccine is, in fact, an entirely different virus. It's natural, live, unattenuated, and best of all for our purposes, contagious. It's a vaccine you can "catch". Let me explain…

Smallpox is a virus which is a member of a genus of closely related viruses, known as Orthopoxes. The Orthopox genus, besides Smallpox (sp. variola), also contains other species, including Monkeypox, Cowpox, Mousepox, Camelpox, and several others, including a species which seems to have only emerged subsequent to large-scale vaccination, dubbed Vaccinia. Edward Jenner discovered, first by deduction and then by experimentation, that cowpox exposure will protect you against smallpox. He observed that milkmaids, women employed to milk cows, rarely seemed to get smallpox, a disease which otherwise ravaged the general population, infecting nearly all and killing one in three. Cowpox, although named for cows, is actually thought to be a disease of rodents, with cows secondarily infected due to poor sanitation. Luckily for us, in the 18^th century, poor sanitation led to endemic cowpox in dairy herds, which then infected milkmaids, and Edward Jenner was able to make the observation which eventually saved the world from a terrible scourge.

Unlike smallpox, cowpox is one member of the Orthopox genus that is not generally very harmful to people, excepting rare complications. In most people, a skin-puncture inoculation will lead only to a small, localized inflammation which begins to resolve in around 4 days. However, it still counts as a disease and it is contagious. People who are vaccinated are instructed to avoid touching the lesion so as to not spread the virus to their eyes or mucus membranes and to have no contact whatsoever with anyone who is immune-compromised or otherwise vulnerable. The virus grows at the site of the inoculation, reaching a peak in about 3 or 4 days, after which the patient's immune system kills it and the lesion heals up, leaving the characteristic vaccination scar. What Jenner discovered was that exposure to one member of the Orthopox genus gives you a large degree of immunity to the others. Purposeful exposure to cowpox, a mild disease, gave you protection from smallpox, a deadly one.

Once vaccination became widely used, and the cowpox virus used in a large population of human hosts, a variant emerged. No longer cowpox, the variant was dubbed "vaccinia". Specifically, and somewhat ironically to this writer who lives in New York City and like my fellow citizens cannot now get a vaccination, the strain of virus used throughout the United States and through large parts of the world during the eradication effort, is known as "New York Board of Health Vaccinia".

One of the reasons regular inoculations were abandoned after the disease was wiped out is that the vaccine carries with it a quantifiable risk. Besides those who are immune-compromised who the vaccine can kill outright with a generalized infection, the vaccine causes central nervous system damage in some people. While it is a low number relative to the number vaccinated, it is clear that without the actual deadly risk of rampant smallpox, it is unwarrantedly risky to expose large numbers of people to the vaccinia virus. Also, as the incubation period for (the time it takes a person to get sick after exposure to) smallpox is 7 or more days, and the vaccine works in 3 or 4, if you are prepared to do mass inoculations on short notice you can actually afford to wait for an outbreak before giving the vaccine. (In public health terms, a smallpox "outbreak" is a single case. One of the greatest triumphs of Public Health occurred in New York City in 1947. Following discovery of a visitor who had contracted smallpox and spread it to a handful of others, two of whom were to die of it, a crisis was declared and the entire population was inoculated before a single other person died.)

So, what do we do if a bioterrorist gets a hold of the smallpox virus and sends "smallpox martyrs" to walk among us? We don't have enough vaccine for everybody. Or do we? Vaccinia is a contagious virus. We know one person can spread it to another. Can we use this to our advantage? Perhaps we can. The virus grows in the tissue at the inoculation site and is present in large quantities in the fluids that form there prior to resolution. The literature is not clear, but a single vaccinia inoculation leaks a large number of live viruses, perhaps even enough to make hundreds or thousands of additional inoculations.

So here is my modest proposal. The vaccine that HHS/CDC have ordered won't be available for another year. Any attempt at smallpox bioterrorism, if it occurs, will (logic dictates) likely occur before then. Public Health authorities should prepare a contingency plan to use in an emergency. I'd like them to consider this:

• Buy enough bifurcated inoculation needles now, and train doctors and nurses in their use. A 1999 FDA survey found that the U.S. only had a stockpile of one million of these special, required, needles and that no one still manufactured them. [Betrayal of Trust, L. Garrett, pp. 524-5.] It doesn't matter how much vaccine you have if you don't have the needles to administer it.
• Experiment with harvesting live vaccinia virus from inoculation lesions. How did they do this before the emergence of large-scale modern production? They did it in the 18^th and 19^th centuries, and we know it worked.
• Line up a bunch of healthy volunteers who are pre-screened for other contagious diseases, such as hepatitis and AIDS. You might start with the nation's regular blood donors.
• Make a plan in which the pool of volunteer donors would receive vaccinations immediately in case of an outbreak and then return in two or three days for harvesting. Each volunteer's donation should be kept separate, not commingled, so that no member of the public receiving subsequent donor vaccinations would receive from more than a single donor, to keep down the risk of transmission of other viral diseases.
• The general public would then receive these rapid-prepared inoculations from fresh-grown vaccinia virus.

Public Health authorities and the medical community might have, and should have, reservations about the sterility and risk of such a vaccination plan. However, before they reject it, they should consider the following. Our surviving stock of 15 million vaccinia doses is long past date. In fact, as of 3 years ago, a survey of the stockpile concluded that fully 11 million were no longer fit for use in humans [NYT, 7Aug98, J. Miller & Wm. Broad]. By now, it's probably worse. Straining the vaccine through a batch of volunteers is just as likely to clean it up and improve its efficacy as to contaminate it. A further possible advantage of using human vaccine hosts is a lower potential for allergic reactions in the recipients.

In the event of a bioterrorist-precipitated smallpox outbreak, one thing is for certain. Public Health authorities must be ready with a response. Smallpox is an extremely contagious and consistently deadly disease. To do nothing is simply not an option. Nineteenth century medical vaccination technology, such as it was, saved millions of lives and gave us the tools to eventually eradicate perhaps the deadliest disease that ever plagued mankind. There is no reason, in the 21st century, not to benefit from those proven techniques.

RECOMMENDED LINKS:
Material Safety Data Sheet on Vaccinia Vaccine, from Government of Canada Office of Laboratory Safety
Differential Diagnosis of Variola (Smallpox), American College of Physicians -- American Society of Internal Medicine
CDC Press Release on Smallpox Readiness, dated 11/04/2001
Reports from 1963 Swedish Outbreak, courtesy CDC
HHS Press Release on Purchase of Vaccinia Vaccine, 11/28/2001
WHO Fact Sheet on Smallpox -- Comprehensive and Highly Recommended
"General Recommendations on Immunization", PDF from CDC, 48pgs, 1994
University of Rochester Vaccinia Policy Page
Information on Vaccinia (smallpox) Vaccine -- Univ. Rochester .pdf of fax
Orthopox Virus Comparisons, Swiss Biosafety Agency B.A.T.S.
Orthopoxvirus Index Virum, Australian National University
Official CDC Bioterrorism Website
MEDLINEplus Smallpox Information Page, from National Library of Medicine, NIH.
Comprehensive Article on Smallpox from E-medicine

READING LIST -- BOOKS AND JOURNALS:
"Clinical Recognition and Management of Patients Exposed to Biological Warfare Agents", JAMA, Aug 6, 1997, Vol 278, No. 5, pp. 399-411. Special Communications written by staff of the US Army Medical Research Institute of Infectious Diseases, Ft. Detrick, MD, and the Walter Reed Army Institute of Research, USAMRMC, Wash., DC.

Laurie Garrett, Betrayal of Trust, NY, NY: Hyperion, 2000.

Tom Mangold and Jeff Goldberg, Plague Wars, NY, NY: St. Martin's Press, 2000.

Edward Regis, The Biology of Doom, NY, NY: H. Holt, 1999.