Executive Summary:
Today America faces a strong bioterrorist threat from Al Qaeda. CIA intelligence
estimates a 40% 1 probability that the United States will face an attack using the
infectious and deadly smallpox virus sometime after August 1st, 2004. To protect
America the CDC has developed three possible plans for a national vaccination program.
Alterative A (AltA): Compulsory program to immunize the 90% of Americans not at a
high risk of vaccination side effects. Alternative B (AltB): Voluntary program to
inoculate the U.S. population with an anticipated acceptance level of 80%. Alternative C
(AltC): Vaccination of first-responders only, immunizing a key 7% 2 of the population.
A high level of pre-attack immunity among the U.S. population is crucial to minimizing
both the human and economic damage of an attack. The voluntary vaccination program
achieves a high level of immunization without risking public backlash caused by a
mandatory program, thus AltB is recommended.
Background:
A smallpox attack would expose approximately 1 million Americans to the virus
within a week, leading to the infection of any unvaccinated person who is exposed.
America is currently highly vulnerable to such an attack because only 20% of our
population is vaccinated against the virus. One third of those infected will die unless
vaccinated within five days. Due to a 9-17 day incubation period before recognizable
symptoms occur20, by the time an attack is identified, it is too late to vaccinate those
infected in the first generation and 1/3 of them will die. The long incubation period,
large size of the initially infected population and the highly mobile nature of America’s
population mean that infectious individuals will spread the virus throughout the nation
before containment measures can be enacted 13, 22.
The United States has the following three dominant priorities when considering a
national smallpox vaccination program:
1) Protect public health during and after a potential attack by minimizing the initial
impact of the virus and providing an adequate health services response.
2) Limit the short and long term economic cost of a possible attack.
3) Maintain public confidence and support of the state and federal governments
during the vaccination period and in responding to the smallpox threat.
1) Protect Public Health
A basic goal of any smallpox protection policy is to limit the number of individuals
infected by the virus. Because first generation cases cannot be treated with the vaccine,
one third of those exposed will die, regardless of how effectively the government
responds to the emergency. For the first generation, AltC would result in 243,000 deaths,
AltB would result in 53,000 deaths, and AltA would result in 27,000 deaths4. Because
much of the population is vulnerable with AltC, this plan results in the highest number of
deaths. Likewise, low pre-attack vaccination levels result in a higher rate of virus
transmission to generation two 5, decreasing the likelihood that the outbreak can be
controlled. AltC would lead to 19 times more generation two smallpox cases than AltB
and 74 times more cases than AltA 8.
Providing health services will be critical to containing the outbreak and halting the
spread of the virus. Early detection by individuals and physicians is the best means of
combating a smallpox epidemic10. The widespread nature of the AltA and AltB
vaccination programs allows them to do a better job of putting the threat of smallpox into
the news and the minds of the nation, promoting early detection. The “surge capacity”
of medical facilities to handle an influx of individuals seeking care after an outbreak is
another major concern, since quick and effective care will be critical to minimizing 2nd
generation deaths and containing the outbreak14, 8. The ability of medical facilities to
handle this surge will depend on the number of individuals who were vaccinated prior to
the attack, since higher levels of prior vaccination mean fewer sick individuals and a
lesser need for immediate immunizations. AltA leaves only 10% of the population in
need of either care or vaccination. For AltB this number is 20% and for Alt. C the figure
is 73% 3. AltA results in a population with half the pre-attack vulnerability of AltB, yet
both of these plans are a vast improvement over AltC, which leaves nearly three quarters
of the U.S. population vulnerable to smallpox.
2) Limit Economic Costs
Any bioterrorist attack will have both immediate and long-term costs for the U.S.
economy. Short term costs will directly depend on the number of individuals needing
emergency care. Estimates for an attack using bio-agents less dangerous than smallpox
put emergency and recovery costs in the range of $5-$10 billion / 100,000 vulnerable
individuals exposed 16, 17. Similarly, long term effects are also tied to the number of
infected individuals. As occurred with the SARS virus, the greatest long-term economic
damage will be in regions and cities with a higher numbers of infected residents 15, 18.
Outbreak containment procedures would halt commercial traffic, applying a direct freeze
to many local economies 10. Both points show the value of having less infected
individuals, which is a direct result of higher vaccination levels. In the wake of an
outbreak, panic could lead to a highly unstable economic climate. The population may
hoard vital supplies, avoid work and retailers, or flee cities for fear of infection20, 23. The
possibility of such instability is greatest with AltC, since it leaves over 70% of the
population unvaccinated compared to only 8% and 16% for AltA and AltB respectively 3.
The shock and fear following an attack would also have a strong effect on investors, as it
did following 9-11 12. A widespread immunization plan, such as AltA or AltB, would
make such an attack less shocking and bolster overall confidence that America is
prepared to combat the threat of bioterrorism.
3) Maintain public support and confidence in government
In responding to the threat of terrorism, the government must always balance the
need to provide proactive protection with the goal of avoiding public backlash for new
security measures. Given the 40% likelihood provided by the CIA, AltA and AltB
provide the strongest options to both build confidence prior to an attack and avoid
criticism in the wake of a disaster. Yet the risk of strong public disapproval toward a
smallpox vaccination is significant, since the vaccine would cause deaths and serious
side-effects in non-trivial numbers. Approximately 84 deaths would result from AltA, 74
from AltB, and 8 from AltC 6, in addition to similarly proportionate but larger
occurrences of serious side-effects 7. The existence of this vaccination danger favors
AltC and is a major concern for AltA and AltB. Additionally, adult reactions to the
smallpox vaccine are not entirely understood, as heart disease and other common factors
may place individuals at an elevated risk 24. Again, AltC is advantageous because of the
smaller vaccination population.
Another key consideration is that mandatory programs may vaccinate citizens
against their will, potentially violating their civil liberties. Strong resistance to any
mandatory vaccination program can be expected, as evidenced by both the refusal of
military personal to take similar vaccines 11 and the objection of privacy advocates
including the ACLU and some large medical associations to mandatory smallpox
programs19. Publicity from these groups could undermine public support for mandatory
vaccinations because studies show that the support of medical groups is vital to overall
public support of a smallpox vaccination program 21. Additionally, the deaths caused by
a mandatory program would become high profile, leading to increased criticism of
political decision-makers. This fact is a major liability associated with AltA, and is also a
consideration for AltC, which requires mandatory vaccinations for only a small portion of
the first-responders. Importantly, AltB avoids the criticism involving civil liberties by
making the vaccination voluntary.
Recommendation:
Given the 40% likelihood of a smallpox attack, AltC does not provide adequate levels of
smallpox immunity in the U.S. population to deter devastating social and economic
consequences. Thus the vaccination deaths associated with a majority vaccination
program such as AltA or AltB must be accepted as the cost of protecting America from
smallpox. AltA provides the greatest level of protection, but faces a high possibility of
strong and organized resistance due to its compulsory nature. AltB immunizes only 8%
less of the population than AltA 9, while facing significantly less public criticism.
Additionally, AltB paves the way for a mandatory vaccination process in the future, if
new evidence were to increase the need for protection. Thus, the CDC recommends a
voluntary national smallpox vaccination (AltB) to help protect America from the threat of
bioterrorism.