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Smallpox issue keeps DMS's Modlin in the public eye

In the Fall 2002 Dartmouth Medicine, infectious disease expert John Modlin, M.D., defended a controversial stand on smallpox vaccinations. At that time, he and the national committee that he chairs—the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC)—had recommended vaccinating only some health-care workers, at designated hospitals, in advance of possible bioterrorism.

Since then, the ACIP has expanded its recommendations to include workers at all the nation's 5,100 acute-care hospitals. The revised guidelines encompass some 500,000 health-care workers, instead of only 10,000 to 20,000.

At its June meeting, the 15- member committee, working under the assumption that the likelihood of a smallpox attack was small, judged that the vaccine's risks—side effects like rashes, scarring, encephalitis, and even death—outweighed the benefits of wider administration.

Public debate continued during the summer and fall. The Department of Health and Human Services (DHHS) proposed vaccinating 500,000 health-care workers; then 10 million police, fire, and other emergency personnel; and eventually the entire population. Still, the academic physicians and public health officials of the ACIP stood firm.

Then, in October, the ACIP met again. This time, the group recommended vaccinating workers at all acute-care hospitals.

Why the change of heart? Between June and October, says Modlin, "DHHS, in consulting with state health departments, decided that all acute-care hospitals should be given the opportunity to participate, not just those earlier designated as smallpox hospitals. So the real expansion was the number of participating hospitals."

The CDC asked the ACIP to consider a few other smallpox issues in October, including care of the vaccination site. The panel recommended that it be covered to contain the vaccine —which is made from a live virus that can be transmitted by person-to-person contact.

Plans: Just as this issue went to press, President Bush announced that he was ordering all members of the military to be vaccinated for smallpox and was starting a two-stage plan to vaccinate medical and emergency personnel, but was not recommending mass vaccinations at this time. "In the meantime," says Modlin, "the states are proceeding with developing plans to quickly vaccinate everyone in the event of a widespread smallpox emergency."

The world's last reported smallpox death was in 1978, and the disease was declared eradicated in 1979, so vaccination for it was stopped. Viral specimens were retained by the CDC and the former Soviet Union, although experts fear some terrorists may have samples, too.

Laura Stephenson Carter

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