Smallpox Vaccination Program Fizzles

The thud you heard was the federal government program to vaccinate against smallpox coming to an abrupt halt. By the time of this writing, we should have been well into Phase III, which would have made the vaccine available to the general public. Instead the program faltered in Phase I, with only about 38,000 health care workers and approximately 450,000 military personnel being vaccinated.

Launched in December 2002 with great fanfare and expectations, the first phase of the campaign aimed to vaccinate about 500,000 civilian health care workers, all volunteers. As many as 10 million police, fire and EMS personnel were to have been vaccinated in the second phase. The initial goal was to have enough immune people on hand to care for the ill and to vaccinate quickly those who were not yet sick, in case of a smallpox outbreak. The federal Centers for Disease Control and Prevention (CDC) collected and distributed enough vaccine for every American in a remarkably short period of time.

Unfortunately, some of the vaccine is going to waste. In Indiana, state officials are discarding hundreds of doses of smallpox vaccine that went unused after the vaccination program was halted last spring. Reports from Illinois, Oregon and Pennsylvania paint the same picture.

Smallpox is one of the deadliest diseases known to mankind. It is estimated that over 300 million people worldwide have died of disease through the ages. The last United States case of smallpox occurred in 1949 and the last case of smallpox in the world was reported in Somalia in 1977. Routine smallpox inoculations ceased in the United States in 1972 and the World Health Organization declared the disease eradicated in 1980. But stockpiles of the virus were maintained in laboratories by the United States and the former Soviet Union. Other countries are suspected of having stockpiles of smallpox, including North Korea, Iran, France, and China. Iraq was suspected of also having smallpox, but as of this writing, none has been found by our troops. In 1989, a defector from the Soviet Union told U.S. officials of an elaborate bio-weapons program in the Soviet Union, where approximately 100 tons of smallpox was produced each year. Some of the smallpox was even loaded into warheads that could be launched on the United States in the event of a war.

With the breakup of the Soviet Union, terrorism experts feared that the smallpox samples could have fallen into the wrong hands and then could be turned into a weapon of germ warfare. Since childhood vaccinations ceased 31 years ago, much of the U.S. population would have no immunity if terrorists deliberately released the virus.

The mortality rate for smallpox averages about 30%. However, this figure is over 30 years old and some conjecture that it would be much lower today because of our advances in medicine from 30 years ago.

On June 18, government officials said the civilian and military smallpox vaccination programs had virtually come to a halt. Why? First, all military personnel who could be vaccinated for high-risk overseas duty had been vaccinated. Second, there was a lack of interest in the civilian sector.

Why the lack of interest in the civilian sector? Some theorize that one cause is that the smallpox vaccine, Vaccinia, is the most dangerous vaccine around, since it is actually a live virus. Experts predicted that the vaccine would cause serious adverse reactions in one in 19,000 to one in 71,000 people and would kill one or two in a million. They also predicted brain inflammations.

But one thing happened that they did not predict: heart attacks and heart complications! Eight people suffered heart attacks after immunization and three died. What was unclear was if the deaths were coincidental or were attributed to the vaccination. Most of those who suffered heart attacks were middle age, and several had clogged arteries, diabetes or other risk factors such as smoking.

Another cardiac complication that arose and was unsuspected was cases of heart inflammation. The number was 3.6 times the number that might have been expected to develop myocarditis and pericarditis anyway based on data from Australia and Finland, where a stronger strain of the vaccine was used. The heart attacks and heart inflammation caused the CDC to ban any immunizations for anyone with heart disease on March 25 of this year.

Others theorize that the vaccination program faltered because of the quick victory in Iraq and that many Americans felt the threat had faded. Other speculation includes resistance because there was no law to compensate people if they were hurt or became ill after being vaccinated. The bill to compensate them was not signed until April 30. There also was conjecture that SARS and monkeypox competed for state health resources and public attention.

Still others, especially in the fire service, did not promote Phase II because of the adverse impact that vaccination would have on the workforce. Common reactions to the smallpox vaccine include rashes and swelling and tenderness of the lymph nodes that could last one month; 20% of adults inoculated develop a fever that lasts two or more days. When employees of CDC were vaccinated, one-third called in sick for at least two days. Could your fire department sustain these types of absences?

In response to many questions and concerns, the International Association of Fire Chiefs (IAFC) issued a Fire Chief's Guide to Smallpox Vaccination to all its members. The guide makes reference to scheduling concerns because of members who become ill after receiving the vaccine and recommends staggering vaccinations of firefighters within a shift or fire station in order to minimize the number of personnel who would be on sick leave concurrently.

While some in the fire service did not promote vaccination, there were still others who strongly advocated fire department personnel be inoculated. As one ranking chief officer in Chicago told me, "Everybody should be vaccinated, since it would remove one weapon from a terrorist's arsenal of weapons."

The chief concern for the fire service is personnel who may come into contact with a person who is contagious with smallpox. A smallpox outbreak will not be some high-intensity event such as an explosion, building collapse, or warehouse fire. Just like the outbreak of monkeypox, people will start showing up at their doctors' offices or in some cases calling for an ambulance because of a rash that has become progressively worse. Only after five days will the classic signs of the smallpox be evident on the person's body. By that time, it would be too late. Fire personnel may have been exposed to the disease.

Although the issue of smallpox vaccination seems to be off the table at this point, just one reported case of smallpox in the United States would see a flurry of activity of even greater magnitude than last year's anthrax scare.

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Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is the chief of Special Operations for Jefferson County, MO. He retired in 2001 as the chief paramedic for the St. Louis Fire Department after serving the City of St. Louis for 25 years. He is also vice chairman of the EMS Section of the International Association of Fire Chiefs (IAFC). He is a frequent speaker at EMS and fire conferences nationally and internationally, and is on the faculty of three colleges. Ludwig has a master's degree in management and business and a bachelor's degree in business administration, and is a licensed paramedic. He also operates The Ludwig Group, a professional consulting firm. He can be reached at 636-789-5660 or via