Arm-to-Arm Against Bioterrorism

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Smallpox
is the most deadly disease in our species' history. Variola virus
causes this disease and humans are the virus' only natural host.
It is transmitted person-to-person, most commonly through the air.
Infected people exhale the virus from blisters in their mouth, and
anyone who comes within 10 feet of a smallpox victim can inhale
the aerosolized virus and catch the disease. There are no currently
available anti-viral measures that doctors can use to treat smallpox.
Antibiotics don't work. Vaccination, however, protects a person
from contracting this disease. More than 300 million people died
from smallpox from 1900 to 1978, when the last case in the world
occurred. The last case in the United States was in 1949. Doctors
and public health officials eradicated the disease by mass vaccination.
People in the U.S. stopped being vaccinated for smallpox in 1972,
when more deaths from vaccination occurred than from the now nonexistent
disease. (In 1968, the last year for which data is available, 9
deaths occurred in the 14.2 million people who were vaccinated.)
But laboratory stocks of variola virus, preserved ostensibly for
research, were not destroyed. Before it collapsed in 1991, the Soviet
Union had its state-employed microbiologists grow, in the embryos
of chicken eggs, vast quantities of smallpox virus for use as a
biological weapon – 100 tons of it. There is a high
probability that Iraq has acquired a stockpile of the virus and
has recruited laid-off Soviet scientists to weaponize it.

All
Americans are susceptible to smallpox. Forty percent of the population,
born after 1972, has never been vaccinated. The rest were vaccinated
more than thirty years ago, and they are also susceptible because
smallpox vaccine loses its effectiveness in most people after 5
to 10 years. But if the Federal government, which controls the vaccine
(paid for with tax dollars), releases it and permits mass vaccination
for smallpox on a voluntary basis, Americans would be protected
against smallpox. Should the government decide whether or not to
permit voluntary "pre-event" vaccination, or should Americans
themselves decide whether or not to have the vaccine?

As
conceived by America's Founders, government's main function is to
protect the liberty and property of its citizens. Self-ownership
underpins a truly liberal society. Individuals are free, within
the constraints of honoring their contracts and not encroaching
on other persons and their property, to do what they want. From
this perspective, each citizen should decide whether he or she wants
to be vaccinated. But many people today who call themselves liberals
hold a different view of government and the state. They think the
state must take charge of the health and welfare of its citizens.

The
Advisory Committee on Immunization Practices (ACIP), in the government's
Center for Disease Control and Prevention (CDC), addresses vaccination
policies. This 15-member committee issues "recommendations"
on vaccinations, which more often than not become compulsory state
policy, as, for example, requiring doctors to inoculate newborns
with hepatitis B vaccine. Most states have adopted this policy and
have made hepatitis B vaccination mandatory, even though there are
doctors, Dr. Jane
Orient
among them, who have shown
that children are a hundred times more likely to suffer adverse
effects
from the vaccine, including
death, than they are to catch hepatitis B – a disease that
rarely occurs in children and is found mainly in drug abusers, people
with multiple sex partners, and through occupational exposure to
blood products.

The
ACIP updated its "recommendations" on smallpox vaccination
in its June
2002 Draft
. They are: 10 to 20,000
medical workers "pre-designated by the appropriate bioterrorism
and public health authorities" should be vaccinated for smallpox.
The committee opposes voluntary mass vaccination. Its parent agency,
the CDC, controls all the smallpox vaccine in the country, enough,
properly diluted, to vaccinate all 288 million people in the United
States. The ACIP contends that the vaccine should not be
made available to the general public because, in the committee's
opinion, "the potential benefits of vaccination do not outweigh
the risks of vaccine complications." People who disagree with
this assessment and think that the benefits of vaccination do indeed
outweigh its risks and want to be vaccinated are out of luck. The
CDC keeps a tight lid on its stockpile of smallpox vaccine.

Smallpox
has an ancient lineage. Egyptian writings 5,700 years old describe
this malady, and there is a mummified pharaoh in the Cairo Museum
(who died in 1157 B.C.) that has pustules indicative of smallpox
on its face and hands. According to Jonathan Tucker in Scourge:
The Once and Future Threat of Smallpox
, when Columbus discovered
America in 1492 the native population of North and South America
was around 72 million. By 1800 it had decreased to 600,000, in large
part because of smallpox, which Europeans brought with them. Queen
Elizabeth I, George Washington, and Abraham Lincoln contracted this
disease. Smallpox left Elizabeth with disfiguring facial scars and
bald, requiring her to wear a wig and heavy makeup for the rest
of her life. America fought the Revolutionary War in the midst of
a smallpox epidemic, which British forces exploited to their advantage
(by sending infected civilian refugees into the American lines).

A
person who comes in contact with a smallpox victim need inhale only
a few smallpox virus particles to become infected. Russian scientists
found in their laboratory tests that five viral particles were sufficient
to infect 50 percent of animals exposed to aerosols of smallpox.
Once having gained a foothold in its new human host, the virus utilizes
that person's cellular machinery to make countless copies of its
genome. Following seven to seventeen days of incubation, typically
on the twelfth day, the disease begins with the abrupt onset of
flu-like symptoms of fever, headache, backache, nausea, and vomiting.
These nonspecific symptoms are followed two to three days later
with a skin rash that starts out as red spots, initially on the
face and hands, and then spreads over the entire body. The spots
swell into blisters that over a period of about a week fill with
pus. Scabs form after the pustules swell to the point that they
damage the skin. When the scabs fall off the survivor is left with
pockmarks (pitted scars), which are most severe on the face. Smallpox
is infectious over about a three-week period, beginning either with
the onset of fever or the rash (investigators disagree on this)
until the pockmarks heal. A smallpox victim is likely to be infectious
before the rash appears because throat swabs taken in the
pre-eruptive period contain the virus.

The
overall mortality rate for smallpox in unvaccinated people is 30
percent – 40 percent in young children, 20 percent in adults,
and 30 percent or more in the elderly. (Flat-type smallpox has a
95 percent mortality rate; and a mild form of the disease, variola
minor, has a 1 percent mortality rate.) Boston had its final smallpox
epidemic in 1901 (when the average life expectancy in the U.S. was
47 years and there were fewer elderly and immunosuppressed people
in the population than today). Eighty-two deaths occurred in 754
previously vaccinated people (11 percent) and 188 deaths in 842
unvaccinated people (22 percent). The last two epidemics in the
U.S. occurred in 1946 and 1947 in Seattle and New York, respectively.
In Seattle, 51 people contracted the disease before the outbreak
could be contained and 16 died (31 percent). In New York, where
there had been no cases of smallpox for 20 years, 12 people came
down with the disease and two died. Hourly bulletins were broadcast
on the radio, and frightened New Yorkers queued in blocks-long lines
to be (re)vaccinated at 250 vaccination stations set up at police
stations, schools, offices, and factories. The 250,000 doses of
vaccine that the city had on hand quickly ran out, and city officials
issued urgent appeals for more, which it obtained from military,
pharmaceutical, and other sources from around the country. The Commissioner
of Health reported that health workers vaccinated 6,350,000 people
in the city over a four-week period.

In
1990, when the U.S. was planning to invade Iraq the first time (in
1991), analysts at Armed Forces Military Intelligence reported that
Iraq had a "mature offensive BS [biological weapons] program,"
one that could deliver biological weapons from aerosol generators
carried on trucks, boats, or helicopters; in artillery shells and
missiles; and from aircraft. At the time, according to Judith Miller
and coauthors in Germs:
Biological Weapons and America's Secret War
, the CIA issued
a report titled "Iraq's Biological Warfare Program: Saddam's
Ace in the Hole." In 1990 the bioweapons of greatest concern
to military planners were anthrax and botulinum toxin. Now, in 2002,
it is smallpox.

The
full extent of the Soviet bioweapons program in the 1970s and 80s,
which focused on smallpox, is now known. Ken Alibek (Kanatjan Alibekov),
one of its directors, reveals its extent in Biohazard:
The Chilling True Story of the Largest Covert Biological Weapons
Program in the Worldu2014Told From the Inside by the Man Who Ran It
,
published in 2000. With the breakup of the Soviet Union the thousands
of scientists working in this program became unemployed and some
of them, along with their families, destitute. Both their services
and stocks of variola virus came onto the black market. Richard
Preston in "Demon
in the Freezer
," published in The New Yorker in
1999 (he has written a book with that title that will be published
in October 2002), points out this irony with regard to the eradication
of smallpox: "The eradication [with the Soviet Union's help]
caused the human species to lose its immunity to smallpox, and that
was what made it possible for the Soviets to turn smallpox into
a weapon rivaling the hydrogen bomb." He writes, "The
Central Intelligence Agency has become deeply alarmed about smallpox"
and reveals that the U.S. government keeps a classified list of
states that it suspects has weaponized smallpox. Iraq is on the
list (along with Russia, China, Pakistan, N. Korea, and Cuba).

The
November 16, 2001 issue of Jane's Foreign Report (#2664)
says that a reliable source tells them that Iraq bought smallpox
virus from Russian scientists, who now work there; and "agents
[are] provided with smallpox to spread abroad." Jane reports,
"Our informant reckons that Saddam might try such an attack
only if he felt the game was over and he faced death."

The
Federal government, in its September 16, 2002 Smallpox
Vaccination Clinic Guide
, outlines how state and local public
health authorities can set up and staff clinics to carry out "voluntary,
large-scale, post-event smallpox vaccination" should a "smallpox
outbreak" occur. The 48-page guide states that "once Federal
authorities have authorized release of vaccine" it could distribute
280 million doses around the country within five to seven days,
and by following the template provided in the guide local public
health officials (utilizing a staff of 4,600 people) could vaccinate
1,000,000 people over a seven-day period. This plan would supplement
standard measures of surveillance and control and "ring vaccination"
(tracking down and vaccinating every person who has been within
ten feet of a smallpox victim). Health officials used these techniques
to eradicate smallpox.

Ring
vaccination in natural outbreaks of smallpox worked because people
infected with smallpox virus can escape the full effects of the
disease and not pass it on if they are vaccinated in the first four
days of the infection. "Post-event" mass vaccination is
predicated on this fact. This most likely would not be the case
in a biological attack. The strain of smallpox virus that the Russians
weaponized and what Iraq most likely has is the India-1 strain,
which is highly virulent. Soviet laboratory tests showed that monkeys
exposed to an aerosol of this strain would contract smallpox in
1 to 5 days rather than the usual 7 to 17 days with other strains.

In
the last smallpox outbreak that occurred in this country, the one
in New York in 1947, a man who became infected with smallpox in
Mexico rode a bus to New York while he was in the prodromal phase
of the disease and developed a skin rash (which doctors misdiagnosed)
when he arrived in the city. That single, naturally occurring case,
when it was discovered to be smallpox in people that he had infected,
created havoc. In a biological attack a likely scenario would be
that a terrorist, carrying an aerosolized can like that used for
hair spray, would spray freeze-dried smallpox virus in a shopping
mall, airport, or sports stadium. Aerosolized smallpox sprayed in
the men's rooms of a dozen airports around the country by a group
of terrorists would, two weeks later in an unvaccinated population,
create a crisis of unimaginable proportions and turn "post-event"
mass vaccination into a logistical nightmare.

When
the U.S. invades Iraq the likelihood that America will be attacked
with smallpox will rise substantially. The risk that there will
be a smallpox attack and of dieing in it will be much greater than
one-in-a-million (the mortality rate for revaccination – in
people who have been previously vaccinated – is one in 10 million).
Federal authorities should heed the advice of the Senate's only
doctor, Senator Bill Frist, M.D. (a fellow cardiac surgeon). In
his book When
Every Moment Counts: What You Need to Know About Bioterrorism

he describes smallpox as "the scariest bioterrorism
nightmare." He advocates voluntary, preexposure, mass vaccination
and makes the point that "Americans should be able to decide
for themselves whether to accept the risk of inoculation,"
adding, "I believe the threat of a smallpox attack outweighs
the risk of providing smallpox vaccinations to a well-informed public."

Why
will Federal authorities not release the vaccine to Americans who
want to be vaccinated? They are concerned that people with skin
disorders, like eczema, and people with immune system deficiencies
who have cancer, organ transplants, and AIDS might inadvertently
get vaccinated. Such people are at an increased risk for an adverse
reaction, including death, and should not undergo vaccination. (This
includes pregnant women and young children.) But as Dr. William
Bicknell points out in his article in the New England Journal
of Medicine titled "The
Case for Voluntary Smallpox Vaccination
,"
an increased level of immunity in a vaccinated population
will "reduce the overall risk of infection among immuno-commpromised
persons in the event of an attack." Also, more careful screening
on a patient-by-patient basis can be done in a pre-event setting
to avoid vaccinating people with immune system deficiencies than
would be possible in a crisis atmosphere after a biological attack.
Smallpox vaccine is a live virus (vaccinia virus). People who are
inoculated with it can spread virus particles at their vaccination
site to others in close contact with them, particularly if they
do not observe standard precautions of keeping the site dry and
bandaged until the scab falls off and washing one's hands thoroughly
after changing the bandage. Secondary infection contact rarely happens,
but the CDC obviously does not want to be confronted by an irate
AIDS Lobby protesting its pre-event release of the vaccine if a
person with AIDS should die from a vaccinia infection acquired by
contact with a person who has been recently vaccinated.

If
the government refuses to release smallpox vaccine to the general
public, there is still a way to be inoculated against smallpox.
One can be vaccinated "arm-to-arm." We can, if we have
to, vaccinate ourselves the way people sometimes did it in the 19th
century.

Edward
Jenner discovered smallpox vaccination in 1796 (after a milkmaid
told him that cowpox, which she contracted from a cow's utter, protected
her from smallpox, and he then noticed that milkmaids rarely exhibited
the facial scars of smallpox). Absenting cows with cowpox to provide
material for inoculation or refrigeration to store and transport
stocks of it, people would transfer the vaccine from one person
to the next arm-to-arm. The Spanish brought smallpox vaccine to
the New World this way. A group of orphans were recruited for the
long voyage, and two children were vaccinated shortly before departure.
When cowpox pustules developed on their arms the ship's doctor would
take material from their lesions and use it to vaccinate two more
children, repeating this procedure each time new pustules formed
in successive children until they reached Venezuela, with yet two
more children providing an aliquot of active vaccine for people
in South America.

The
government plans to vaccinate military personnel and health care
workers (officials have not yet decided how many, but it will be
somewhere between 20,000 and 500,000). These people could provide
a source of active vaccine for their family and friends arm-to-arm
reminiscent of those orphan children bringing smallpox vaccine to
the New World. The technique
of vaccination
is fairly simple
(and it does not require a bifurcated needle).

If
you cannot obtain vaccinia vaccine one way or another, a devastating
biological attack has occurred and smallpox is rampant, in a worse
case scenario you can do the kind of vaccination that people employed
for centuries before Jenner. That is variolation. Rather than have
to suffer the disease with its 30 percent mortality rate and disfiguring
facial scars, people inoculated themselves with the smallpox virus
itself obtained from a pustule on a smallpox victim. Smallpox introduced
through the skin rather than the lungs results in a much-attenuated
disease, with only pustules forming around the inoculation site.
Variolation, known as "buying the smallpox," has a fatality
rate of 1 percent, much better odds than with the full-blown disease.

One
thing we must do, especially with the prospect of a biological attack
looming, is to maintain optimum health and to keep our immune system
strong. This will improve the odds that we will survive it. Read
Dr. Russell Blaylock's booklet Bioterrorism:
How You Can Survive
. I summarize
his recommendations, and offer others for good health, in an article
I wrote with Linda Miller.

Let
us hope that our government leaders will release smallpox vaccine
for voluntary, pre-attack, mass vaccination.

September
26, 2002

Donald
Miller (send him mail)
is
a cardiac surgeon in Seattle. He is a director of Prepared
Response, Inc.
and a member of Doctors
for Disaster Preparedness
. His web site is www.donaldmiller.com.

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