Preparing for Smallpox
Edward P. Richards, JD. MPH
Director, Program in Law, Science, and Public Health
Harvey A. Peltier Professor of Law
Louisiana State University Law Center
richards@lsu.edu
http://biotech.law.lsu.edu
What is the Real Risk?
Casualties or a Break
Down in Social Order?
Why TOPOFF is Deceiving
• The two most important variables - the
public and the media - are not involved
• No one is at risk
– No one gets sick, has to get vaccinated, or
even risks political embarrassment
• Everyone shows up at work!
• Medical care capacity is not challanged
Lessons and Limits from SARS
• Excellent compliance with home quarantine
• No panic and overwhelming of hospitals
• Depended on:
–
–
–
–
Comprehensive public medical care system
Most cases were health care workers
No vaccinations or prophylaxis
Government provided compensation and daily
support
– Complete trust in the Health Officer and system
Key Issues in the US
•
•
•
•
Uncertain Information
Inappropriate Expertise
Unreliable Plans
Potential Catastrophic Breakout
Uncertain Information
• There is no good data on smallpox
transmission in a naïve population
• There is no good risk data on mass
immunizations in a naïve population with
significant immunosuppression
• Community reaction to anthrax, which
posed little risk, is not reassuring for
smallpox
Inappropriate Expertise
• Public health directors are chosen for
administrative and political skills
• Most public health physicians are experts
in personal medical care, not disease
control
• Many departments have lost their most
skilled professionals
• Very limited trust of health officials
Unreliable Plans
• States and local government produced
plans to get federal funding
• Plans must show community
preparedness
• Plans assume that all personnel will show
up for work and obey all orders
• Employees who question whether plans
are workable are fired
Potential Catastrophic Breakout
• Epidemics in naïve populations can
spread geometrically
• Underestimating current cases or
transmission rates leads to dramatic errors
in estimates of future cases
• If public cooperation with control efforts
breaks down, it will be very difficult to
reestablish order
Command and Control Issues
• How do you evaluate the reliability of
technical experts you have to depend on?
• How do you deal with questionable
experts and strategies?
• How do you deal with unworkable or
incomplete plans?
Examples of Ignored Issues
• Every police officer, health care worker,
and EMS worker has to be vaccinated
within hours of an outbreak
• Plans say no mandatory vaccinations
• Compensation for time off work, medical
and other costs is critical
• Individual eligibility for vaccination should
be known before an outbreak
• What about illegals and others outside the
system?
Public Participation and Information
• The general public and the media need to
know well before an outbreak what each
individual can expect and will be expected
to do
• What they are told must be what you are
going to do, including the strategy for
managing a breakout
• This forces a discussion of compensation,
health care access, and mandatory or
mass vaccination
Strategic Issues
• How do you anticipate breakout?
• How do you decide when to start mass
immunization?
• Will you shoot the soccer mom and kids to
enforce quarantine?
• Is the CDC's mass immunization plan
workable, or should we use a variant of
the 1947 model?
• How do our plans change if there is
smallpox outside the US?
Wrap-Up
• Smallpox bioterrorism is possible because
of hubris
• Current plans assume there will be no
breakdown in public services and a
compliant public
• There is no fallback if these assumptions
are wrong
• A fallback plan and decision criteria must
be in place before an outbreak