Smallpox, the bioterror du jour: Or is it?

February 2003

One year ago it was anthrax. This year, it is unquestionably smallpox. What will it be in the year(s) ahead? The title to these comments reflect my impression that our concerns for bioterrorism events simply reflect what is presently being served to us — by the President, the popular media, the medical literature, the availability of preventive measures and the like — all with seemingly little appreciation for the likelihood of specific bioterrorist events actually taking place.

If we were going to spend a lot of time worrying about bioterrorism (which we have been doing a great deal recently), would smallpox be the agent we would worry about the most? I doubt it. There is a vaccine which we are beginning to use again; there are effective antibiotics; there are potentially useful antiviral drugs, and there are modern hospitals with contemporary care facilities. I doubt, therefore, that we would experience the 25%-30% mortality rate so widely quoted, which was derived from experience in the 1960s in developing countries. Furthermore, it is really not as highly contagious as some might think; measles and varicella, for example, are far more contagious than smallpox.

Anthrax in the fall of 2001 was a frightening experience, to be sure. Yet when all was said and done there were only a very small number of deaths. Furthermore, anthrax has a major drawback as an agent of bioterror in that it is not transmissable from person to person.

My point is simply this: there are far more frightening agents than smallpox or anthrax that we have not yet considered in a systematic fashion, at least not in public. Think of botulinum toxin, for example, in an aerosol release. How about biotoxins such as ricin or nerve gases, all in crowded settings. Think of a rerun of the 1917-1918 influenza epidemic that killed 20 million to 40 million people worldwide. Or, think of what we could be referred to as the “mad scientist scenario” — where using present technology, “designer” agents could be produced that would carry us well into a world of new or emerging bioterror agents.

Thus, although we must deal with the issue at hand — smallpox immunization — we need to maintain a more balanced and open perspective on the etiologic agents that should concern us. In a sense, that is what the special emphasis in this issue of Infectious Disease News is really about.

On to the issues at hand.

The Society of Healthcare Epidemiologists of America (SHEA) just released the results of an e-mail survey carried out among its approximately 1,000 members on issues concerning the phase-1 pre-event program to vaccinate volunteer smallpox health care teams. A total of 198 members participated in the survey, a 20% response rate. Overall, 56% of responding SHEA members supported the program, 27% opposed it and 17% remained undecided. Among those who did not support the phase 1 plan, about two-thirds of respondents cited vaccine-associated adverse events, the possibility of transmitting vaccinia to patients and a lack of conviction that a smallpox release was a credible threat. Over half of the respondents who did not support the plan expressed concerns about liability protection for vaccinated health care professionals and concerns about spreading vaccinia virus to their household contacts.

Overall, two-thirds of the hospitals represented by SHEA members who responded to the survey planned to participate in the phase-1 program.

Among the respondents who did not plan to get smallpox vaccine themselves, the two most commonly cited reasons were the existence of contraindications, or a belief that the possibility of a smallpox release was simply not sufficiently credible to justify taking the vaccine.

Questions raised

Of particular interest were questions about continuing work of vaccinated personnel. Would daily site inspection of the evolving “primary take” and covering the site with a semi-permeable dressing be sufficient to continue caring for specified kinds of patients? Forty percent of respondents thought such personnel should not care for HIV-positive patients, oncology patients, transplant patients, other immunocompromised patients or children under 1 year of age. The remaining 60% either were undecided or believed those vaccinated personnel could safely continue care of even high-risk patients. Seventy-five percent of those who opposed continuing care of high-risk patients believed vaccinated personnel should refrain until after the scab separated.

A substantial majority (80%), of respondents believed that only vaccinated personnel should care for patients with progressive vaccinia or eczema vaccinatum. Two-thirds believed that issues relating to insurance, liability coverage and workers compensation had not yet been resolved at the hospital level. Thus, at the very least, there was certainly not unanimity of opinion among SHEA members about the phase-1 smallpox immunization plan.

That divergence of opinion is reflected in media reports about the number of hospitals that are participating in the plan and those that have opted out. For our part, at my own hospital, we have decided to opt out, at least for the time being, while continuing to monitor events closely. Our reasons were similar to those of other centers who also opted out, as well as concerns about transmission of vaccinia virus to our patients and to household contacts of health care personnel, many of whom have contraindications to the vaccine.

Our decision was by no means unanimous, however and the dissenters were of two minds. They were the patriotic feeling that we should support the President’s plan and the feeling that we (University of Colorado Hospital) ought to take a leadership role in bioterrorism readiness and be prepared for any eventuality. I suspect we will have continuing discussions into the foreseeable future.

Finally, on a lighter note and in keeping with our interest in the history of medicine, I ran across a curious paper by following a few interesting electronics links on the internet recently, one that I would commend to your attention. The reference is as follows: Ben-Noun LL. Figs — the earliest known ancient drug for cutaneous anthrax. Annals of Pharmacotherapy. 2003;37(2):297-300. In this opinion article, the author, who is from the Ben-Gurion University of the Negev, notes that anthrax, in all its forms, was common in Mediterranean countries in biblical times, and was believed to be one of the plagues of Egypt and in its cutaneous form, a major affliction of Job. Furthermore, there was clearly described belief in the book of Leviticus that some cutaneous anthrax could be cured.

Ben-Noun went on to describe texts in 2 Kings and Isaiah that indicate that figs were used as a native remedy in efforts to heal cutaneous anthrax. Fig trees are common in that part of the world, and are prominently mentioned in many biblical writings. Figs are said to be rich in calcium, iron and vitamin A, and contain niacin and riboflavin in goodly amounts, as well. The article goes on to describe present treatments of anthrax, and concludes making the inevitable plea for the pharmaceutical industry and the (Israeli?) National Institutes of Health to take a closer look at figs to see if there are any compounds there that possibly might be worth commercial development as modern treatment of anthrax.

If you have the opportunity, do read it; it will be a pleasant diversion from more pressing matters.