To Vaccinate Or Not To Vaccinate America's First Responders

Hot and heavy debate centers on whether smallpox vaccinations of first responders should take place in America prior to a terrorist attack - if an attack even occurs. Some have lined up on the side of vaccination of first responders prior to an attack while others advocate holding off until a bioterrorist event occurs.

As debate rages in America, Israel has already begun preparing for a "doomsday" attack by Iraq's Saddam Hussein. Israeli police and paramedics are already being vaccinated against smallpox, and as many as 150,000 other workers could be inoculated soon. Israel is also considering issuing mass amounts of anti-radiation pills. The new measures come amid growing concern that Israel will be struck by Scud missiles carrying biological and chemical agents by Hussein if the U.S. tries to oust the Iraqi dictator.

If used as a biological weapon, smallpox represents a serious threat to civilian populations because of its case-fatality rate of 30% or more among unvaccinated people. Although smallpox has long been feared as the most devastating of all infectious diseases, its potential for devastation today is far greater than at any previous time. There is no treatment for smallpox and it is communicable from person to person. Vaccinations ceased in the U.S. in 1972, and vaccination immunity acquired before that time has undoubtedly waned.

Smallpox probably was first used as a biological weapon during the French and Indian Wars (1754-1767) by British forces in North America. Soldiers distributed blankets that had been used by smallpox patients with the intent of initiating outbreaks among Native Americans. Epidemics occurred, killing more than 50% of many affected tribes.

A worldwide campaign begun in 1967 by the World Health Organization (WHO) succeeded in eradicating smallpox by 1977. In 1980, the World Health Assembly recommended that all countries cease vaccination. A WHO expert committee further recommended that all laboratories destroy their stocks of the virus or transfer them to one of two WHO reference laboratories.

Unfortunately, recent allegations from Ken Alibek, a former deputy director of the Soviet Union's civilian bio-weapons program, reported that beginning in 1980, the Soviet government embarked on a successful program to produce the smallpox virus in large quantities and adapt it for use in bombs and intercontinental ballistic missiles. The program had an industrial capacity capable of producing many tons of smallpox virus annually.

Smallpox spreads directly from person to person, primarily by droplet nuclei expelled from the oropharynx of the infected person or by aerosol. Natural infection occurs following implantation of the virus on the oropharyngeal or respiratory mucosa. Contaminated clothing or bed linen could also spread the virus. Special precautions need to be taken to insure that all bedding and clothing of patients are autoclaved.

A smallpox outbreak poses difficult problems because of the ability of the virus to continue to spread throughout the population unless checked by vaccination and/or isolation of patients and their close contacts. Between the time of an aerosol release of smallpox and diagnosis of the first cases, an interval of as much as two weeks is apt to occur. This is because there is an average incubation period of 12 to 14 days.

In June 2001, the U.S. Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) made recommendations for use of smallpox vaccine to protect persons working with the virus, to prepare for a possible bioterrorism attack and respond to an attack involving smallpox.

The CDC's current primary strategy is not to vaccinate prior to an event but to control an outbreak of smallpox and interrupt disease transmission is through surveillance and containment, which includes ring vaccination and isolation of persons at risk of contracting smallpox. This strategy involves identification of infected persons through intensive surveillance, isolation of infected persons, vaccination of household contacts and other close contacts of infected persons (i.e., primary contacts), and vaccination of household contacts of the primary contacts (i.e., secondary contacts). The CDC points out this strategy was instrumental in the ultimate eradication of smallpox as a naturally occurring disease even in areas that had low vaccination coverage.

A number of factors and assumptions were used in developing these recommendations, including that the risk for smallpox occurring as a result of a deliberate release by terrorists is considered low and the population at risk for such an exposure cannot be determined. It was further assumed that regardless of the mode of a bioterrorism release, the epidemiology of subsequent person-to-person transmission would be consistent with prior experience. These recommendations also assumed that in addition to vaccination, health care workers and others would be afforded protection from infection through appropriate infection control measures, including the use of appropriate personal protective equipment (PPE).

Therein lies the debate. Many advocate not waiting for an outbreak to vaccinate first responders. Some support immediate vaccination of first responders to remove the issue of contamination off the table for terrorist. Others argue that the risk is tremendous since some adverse effects can happen to those getting vaccinated including illness, and in some cases, death. Hopefully, we will never know which side was right.

Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, serves as the director of emergency services for Jefferson County, MO. He retired as chief paramedic from the St. Louis Fire Department after serving the City of St. Louis for 24 years. Ludwig has trained and lectured internationally and nationally on fire and EMS topics. He also operates The Ludwig Group, a professional consulting firm. He can be reached at 314-752-1240 or via