- In a historic concession to the new age of bioterrorism,
the Centers for Disease Control and Prevention today recommended that state-based
teams of health care workers and public health officials be immunized against
smallpox.
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- However, the vaccine will not be offered to the public
or health care workers in general, as the potential side effects of the
vaccine outweigh the risk of exposure.
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- The landmark decision - coming three decades after broad-scale
smallpox immunizations were discontinued in the United States - was made
in a unanimous vote by the CDC's Advisory Committee on Immunization Practices
(ACIP). The committee recommended smallpox vaccination "for persons
predesignated by the appropriate bioterrorism and public health authorities
to conduct investigation and follow-up of initial smallpox cases that would
necessitate direct patient contact."
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- The panel also voted to vaccinate "selected personnel
in facilities predesignated to serve as referral centers to provide care
for the initial cases of smallpox. These facilities would be predesignated
by the appropriate bioterrorism and public health authorities, and personnel
within these facilities would be designated by the hospital."
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- These so-called "type C" facilities will determine
who will care for the initial smallpox cases. The committee's decision
essentially delegates the formation of the response teams to bioterrorism
planners in individual states.
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- The result should "catalyze" the public health
and clinical response to bioterrorism, says William Schaffner, MD, a non-voting
liaison member of the committee. Either extreme - offering vaccine to all
or holding it back until an attack - was a flawed strategy, said Schaffner,
chairman, Department of Preventive Medicine, at Vanderbilt University in
Nashville.
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- "This is the direction I was hoping the committee
would go," Schaffner said. "It knits together the public health
response and clinical care. That is very important. This will oblige the
public health network and the major hospitals to collaborate, to have conversations.
And that's a great thing."
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- In making the decision, ACIP members emphasized that
much planning and implementation remains to be done at the national and
state levels. The vote came after a recent workshop meeting, where the
CDC solicited advice and opinion about possibly immunizing people with
vaccinia (cowpox) against variola (smallpox.) The CDC also held a series
of public forums nationwide to receive input on the decision.
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- A disfiguring infectious disease that killed millions
worldwide for ages, smallpox was eradicated decades ago in one of the greatest
public health achievements of all time. The last smallpox immunization
programs in the United States were disbanded in 1972. The known stores
of smallpox virus in the world are officially in Russia and the United
States, but the increasingly broad consensus is that smallpox could be
in the hands of rogue nations and terrorist groups. It is known that the
Soviet Union explored weaponizing smallpox in its former bioweapons program.
With a new vaccine under production and dilution studies showing that existing
vaccine supplies can be greatly expanded, mass immunization is again a
possibility.
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- While some have urged the CDC to recommend voluntary
immunizations for health care workers and the public, others warn about
a host of potential side effects and the fact that there are some 300,000
people in the United States who do not know they are HIV positive. Vaccinating
them and other immune-compromised people could lead to one of the worst
complications of cowpox: progressive vaccinia. In addition, the Food and
Drug Administration warns that widespread use of the live virus vaccine
could imperil the blood supply because those immunized with a live virus
must wait one year before donating blood.
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- However, proponents of immunization argue that the threat
of terrorism is low but real, risk groups can be screened out, and there
are some 157 million people in the United States who were immunized as
children. Whether they have any immunity left is an open question, but
they are much less likely than first-time vaccinees to have any adverse
reaction to the vaccine.
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