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nerdgirl

Bioterrorism, smallpox vaccines, & another WMD Commission report

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Yesterday I was at Emory University (in Atlanta) for a table-top exercise on bioterrorism response. I got to play DHS Secretary. B| Stan Foster, who led WHO smallpox eradication efforts in Bangladesh, played head of CDC. The exercise was modeled on the Atlantic Storm exercise of a few years back.

If terrorist use of smallpox occurred in Europe (e.g., Netherlands, Sweden, and Germany in the exercise); Turkey; and the US (NYC & LA), what would you recommend the response be?

Particularly w/r/t sharing vaccines?

The US currently has the largest stockpile of smallpox vaccine (>300M doses), which is about half the world’s stockpile. The US also has among the most vulnerable population in the developed world: we stopped mandatory smallpox vaccination in early 1973. States like Russia continued into the 1990s and most of Europe continued into the late 1970s or early 1980s. Many developing nations continued vaccinations into the 1990s, but our public health system is much better.

Otoh, ring vaccination (basically, giving the vaccine only to people in close contact or secondary contact with an isolated infected individual) was used in the real world and shown to be effective without the potential problems/contraindications of mass vaccination. The smallpox vaccine is also effective up to 3 or 4 days *after* exposure … a couple days longer if a weak strain. The science and the real-world success of ring vaccination is sound. But science rarely drives policy.

If states like Turkey (~70M population) with less than 1M doses of the smallpox vaccine stockpiled, should the US share some portion of our vaccine stockpile if requested?

I asserted that once a single smallpox case was discovered in the US, it would be exceedingly unlikely that any US vaccine doses would be shared with other countries. Not because it’s counter to science and not because of other strategic considerations (of which there are quite a few) but because of domestic politics. Most of the folks in the room didn’t like that for various reasons.

This isn’t just policy wonk/academic. On Tuesday, the (latest) WMD Commission released their findings in which they assert that a biological terrorism attack (not necessarily smallpox) is “more than likely” within the next 5 years.

Would you get vaccinated today if it was available? The efficacy of the vaccine for those who were born before 1973 is low today. (NB: In December 2002, President Bush ordered smallpox vaccines be made available for all American citizens. Less than 50k were vaccinated.)

VR/Marg

Act as if everything you do matters, while laughing at yourself for thinking anything you do matters.
Tibetan Buddhist saying

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Hi Marg,

I think your position was correct (in that it was the most likely political response) in the early stages of the exercise. I'd suspect that the short-stockpiled nations would use those stockpiles in defence of their respective governments while the US would fudge the issue until they could raise production of CowPox.

I doubt if there would be a sudden mass vaccination in response to a bio-war. No government would be that responsive within the required time frame.

Mike.

Taking the piss out of the FrenchAmericans since before it was fashionable.

Prenait la pisse hors du FrançaisCanadiens méridionaux puisqu'avant lui à la mode.

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Whether or not we "should" share is moot. There's no way the public would allow the government to "give away" our vaccine. I would bet a large amount of money that even reports of smallpox being used as a weapon anywhere in the world would result in mass panic and overwhelming demand from the public to be vaccinated right now. Look at the panic around the SARS out break a couple years ago.
Our vulnerability to these kind of attacks is frightnening. Moreso psychologically than physically.

And no, I probably wouldn't get vaccinated. If there was an outbreak, I'm isolated enough, and able to be self-sufficient enough that I think I'd be ok.
"There are NO situations which do not call for a French Maid outfit." Lucky McSwervy

"~ya don't GET old by being weak & stupid!" - Airtwardo

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Incidentally, why Smallpox?

Wouldn't the terrorist bio-weapon of choice be pneumonic or bubonic for it's greater mortality & spread wheras smallpox is more of a debilitator?

Just a thought...

Mike.

Taking the piss out of the FrenchAmericans since before it was fashionable.

Prenait la pisse hors du FrançaisCanadiens méridionaux puisqu'avant lui à la mode.

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I agree with your question and point I can think of a far more likely scenario which is allot easier to perpetrate and would have far wider consequences.
When an author is too meticulous about his style, you may presume that his mind is frivolous and his content flimsy.
Lucius Annaeus Seneca

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Incidentally, why Smallpox?

Wouldn't the terrorist bio-weapon of choice be pneumonic or bubonic for it's greater mortality & spread wheras smallpox is more of a debilitator?

Just a thought...

Mike.



It probably doesn't matter which bio-weapon you imagine for the excercise, in general principle the govermnent response is likely to be similar for all of them.

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Incidentally, why Smallpox?..



It probably doesn't matter which bio-weapon you imagine for the excercise, in general principle the govermnent response is likely to be similar for all of them.



One of the issues raised was the sharing of limited quantities of vaccines which only applies to the smallpox scenario.

This ties in to the terrorist scenario offered - given that the purpose of terrorism is to terrorise, and the purpose of a religious war is to exterminate the unbelievers, why use a innoculable incapacitant rather than a more lethal and less preventible agent with a similar virulence?

Mike.

Taking the piss out of the FrenchAmericans since before it was fashionable.

Prenait la pisse hors du FrançaisCanadiens méridionaux puisqu'avant lui à la mode.

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I dunno, maybe this particular excercise was specifically meant to investigate a smallpox outbreak but was only one of many excercises that together cover many threats.

Anyway, pneumonic and bubonic plague are both curable with early treatment and there are only limited supplies of antiboiotics available. In general, I think many of the responses to smallpox would be applicable to lots of other outbreaks too. But I'm no expert.

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I dunno.... I'm no expert.



Me neither. I assume MArg can answer this stuff, but since it's only 8am her time, she must still be recovering from last night's party.>:(

Mike.[

Taking the piss out of the FrenchAmericans since before it was fashionable.

Prenait la pisse hors du FrançaisCanadiens méridionaux puisqu'avant lui à la mode.

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On Tuesday, the (latest) WMD Commission released their findings in which they assert that a biological terrorism attack (not necessarily smallpox) is “more than likely” within the next 5 years.



I read this report when it came out, and I was unimpressed. One need only look at the title page, with a 72-point font screaming "WORLD AT RISK" to get a sense that it's just more of the same fearmongering agenda of the political right. Even the preface references the recent attacks in India - attacks that were neither biological or nuclear, which was supposedly the intention of the report. And the report is chalk full of neo-con, PNAC-spewing rhetoric, such as "soft power", and direct references to Pakistan as the major threat to America.

Not that the report is wrong - it's just that it's so incredibly broad that it must be correct!

"It is more likely than not that a wmd will be used in a terrorist attack somewhere in the world by the end of 2013".

First weapons of mass destruction - biological OR nuclear attacks. Chemical is de facto included, but the focus of the report was bio or nukes. How about machine-guns? Yes, I believe that it's likely that somewhere, on this whole planet with hundreds of unstable governments, that at least one of them will figure out, in the next five years, a way to unleash a biological weapon on their own people, or their neighbors that kills a few hundred or thousand people. It's already been done - even Saddam Hussein launched chemical weapons (one form of wmd) againt the Kurds. It's a pretty broad statement, and easily justified (because it will happen eventually). Nuclear isn't that hard to justify either - you've got "real" nukes, and "dirty nukes" (which are much easier to make). Since Iraq had yellow-cake, they could have made a dirty nuke. But none of these scenarios means that a terrorist state has the capability to launch an ICBM across the ocean to the middle of an American city and cause WW3.

As Jane Harman said, "It's time to retire the fear card." Should we continue to fund anti-terrorism efforts to stop WMDs? Absolutely. If we have irrefutable proof that America is about to be attacked, should we take efforts to stop it? Yes. Is this a justification to invade Pakistan? No! This report is one more building block leading to another unjustifiable invasion for the Bush administration. From the report - "were one to map terrorism and WMDs today, all roads would intersect in Pakistan." Didn't we say something similar about North Korea, Iran and Iraq? Another example of fearmongering - "the public must be made aware of what activities are suspicious and of their responsibility to inform authorities."

Second, "discouraging, to the extent possible, the use of financial incentives in the promotion of civil nuclear power." Of course, we don't want other countries to use any energy resource except oil :S That would be a direct conflict to the stock prices of the wealthy corporations that dictate policy in this country. More of the Bush agenda here. But it directly conflicts with the later statement "ensuring access to nuclear fuel, at market prices to the extent possible, for non-nuclear states that agree not to develop sensitive fuel-cycle capabilities and are in full compliance with international obligations". I guess that leaves out just about every poor country that has defaulted on debt from having nuclear power. Most of the nuclear agenda of this report points alludes to America selling nuclear rods to other countries, but prohibiting them from making the rods themselves.

I do agree with the report's recommendations on biological controls, most of which center on securing America's own laboratories, within our own borders, and working with other countries to do the same. But much of the report praises George W Bush and criticizes Congress - a republican agenda for sure.
Trapped on the surface of a sphere. XKCD

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Incidentally, why Smallpox?

Wouldn't the terrorist bio-weapon of choice be pneumonic or bubonic for it's greater mortality & spread wheras smallpox is more of a debilitator?

Just a thought...

Mike.




If you're talking about the plague, I doubt terrorists would use that, since antibiotics usually clear it up pretty quickly. It got out of control in the middle ages because antibiotics hadn't been invented and people didn't understand about the spread of disease, so a lot of the things they were doing to prevent it were actually spreading it.

Smallpox is probably a much better weapon of choice, since the point of terrorism is to, well, terrorize, and even a single case of smallpox in the USA would send the entire nation into a panic, while plague would be more of the subject of a Monty Python sketch.

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Would you get vaccinated today if it was available?
VR/Marg



Nope. It's a live virus vaccine, and has been known to cause complications even in healthy people, and you shed virus while you're healing, so you getting vaccinated can cause problems for people around you (babies, elderly, immunocompromised). I'm not going to risk those kinds of problems when the odds of a smallpox outbreak are so low, and when we're not even sure that the vaccine we do have would be effective on smallpox virus that has been engineered for biological warfare. If there was a possibility of exposure, I'd go get vaccinated.

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Being an old geezer, I was vaccinated against smallpox as a child.



Same here, but as Marg says, there's a distinct possibility that those vaccinations have expired.

Incidentally, how did they administer the Cow-Pox Vaccine when you were a child? Did you, like, have to visit a farm, or did they bring a cow to your school?

Mike.

Taking the piss out of the FrenchAmericans since before it was fashionable.

Prenait la pisse hors du FrançaisCanadiens méridionaux puisqu'avant lui à la mode.

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Smallpox is probably a much better weapon of choice, since the point of terrorism is to, well, terrorize....



Yes. But the purpose of a "Religious War" (the current most likely cause of such a terrorist incident) is to exterminate the unbeliever. Not incapacitate him.

Smallpox was the favoured scenario when "playing" Bio-War against the Soviets. It's virulent but non persistent, with high incapacitance and relatively low mortality. Ideal when you want to invade a relatively intact country.

I just believe that a current terrorist group would have different preferences, so would seek a different agent. Of course, their primary choice would be what they can obtain and culture, but I believe they would go for the highest mortality, and Smallpox doesn't do it. Even Anthrax may be better from the religious point of view.

Vaccination or Treatment in early diagnosis is largely irrelevant in the early stages of such a "game", when the agent used isn't known. In the later stages, knowledge of the agent determines the response tactics, and ultimately the response strategy.

Mike.

Taking the piss out of the FrenchAmericans since before it was fashionable.

Prenait la pisse hors du FrançaisCanadiens méridionaux puisqu'avant lui à la mode.

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Would you get vaccinated today if it was available?
VR/Marg



Nope. It's a live virus vaccine, and has been known to cause complications even in healthy people, and you shed virus while you're healing, so you getting vaccinated can cause problems for people around you (babies, elderly, immunocompromised). I'm not going to risk those kinds of problems when the odds of a smallpox outbreak are so low, and when we're not even sure that the vaccine we do have would be effective on smallpox virus that has been engineered for biological warfare. If there was a possibility of exposure, I'd go get vaccinated.


Not a medical proffessional in any way here, but I have been vacinated for small pox, when I was young. Have the scar on my upper right arm. My understanding that the vaccine is actually for cow pox and the antibodies your body makes to fight that also are effective on small pox. So would that not mean that the only thing you 'could' possibly spread is cow pox?
"I'm not lost. I don't know where I'm going, but there's no sense in being late."
Mathew Quigley

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Not a medical proffessional in any way here, but I have been vacinated for small pox, when I was young. Have the scar on my upper right arm. My understanding that the vaccine is actually for cow pox and the antibodies your body makes to fight that also are effective on small pox. So would that not mean that the only thing you 'could' possibly spread is cow pox?



Yep, what you'd be spreading is cow pox, but it can still be dangerous to people around you that are immunocompromised. The CDC ran into that problem when they planned to vaccinate the first responders... these are the people who work with sick people every day! That's one of the reasons they scrapped the program.


-the below is snipped from the cdc website-
Is it possible for people to get smallpox from the vaccination?
No. The smallpox vaccine does not contain smallpox virus and cannot spread or cause smallpox. However the vaccine does contain another virus called vaccinia, which is “live” in the vaccine. Because the virus is live, it can spread to other parts of the body or to other people from the vaccine site. This can be prevented through proper care of the vaccination site (e.g., hand washing and careful disposal of used bandages). (added Nov 13, 2002)

Is it possible to get vaccinia, the virus in the vaccine, from someone who has recently been vaccinated?
Yes. Vaccinia is spread by touching a vaccination site before it has healed or by touching bandages or clothing that have become contaminated with live virus from the vaccination site. Vaccinia is not spread through airborne contagion. The vaccinia virus may cause rash, fever, and head and body aches. (updated Dec 9, 2002)
....
People most likely to have side effects are people who have, or even once had, skin conditions, (especially eczema or atopic dermatitis) and people with weakened immune systems, such as those who have received a transplant, are HIV positive, or are receiving treatment for cancer. Anyone who falls within these categories, or lives with someone who falls into one of these categories, should NOT get the smallpox vaccine unless they are exposed to the disease. Pregnant women should not get the vaccine because of the risk it poses to the fetus. Women who are breastfeeding should not get the vaccine. Children younger than 12 months of age should not get the vaccine. Also, the Advisory Committee on Immunization Practices (ACIP) advises against non-emergency use of smallpox vaccine in children younger than 18 years of age. In addition, the vaccine manufacturer’s package insert states that the vaccine is not recommended for use in geriatric populations in non-emergency situations. The term geriatric generally applies to those people age 65 and above. Also, people who are using steroid drops in their eyes should wait until they are no longer using the medication to get the vaccine. Also, people who have been diagnosed by a doctor as having heart disease with or without symptoms, including conditions such as previous myocardial infarction (heart attack), angina (chest pain caused by lack of blood flow to the heart), congestive heart failure, and cardiomyopathy, stroke or transient ischemic attack (a “mini-stroke” that produces stroke-like symptoms but no lasting damage), chest pain or shortness of breath with activity (such as walking up stairs), or other heart conditions being treated by a doctor should not get the vaccine at this time. (Heart disease may be a temporary exclusion and may change as more information is gathered.) In addition, individuals who have 3 or more of the following risk factors should not get the vaccine at this time: high blood pressure diagnosed by a doctor; high blood cholesterol diagnosed by a doctor; diabetes or high blood sugar diagnosed by a doctor; a first degree relative (for example, mother, father, brother or sister) with a heart condition before the age of 50; and/or, currently a cigarette smoker.


http://www.bt.cdc.gov/agent/smallpox/vaccination/faq.asp

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Thanks for the information. What about the claim I saw in the thread that the vacination I received, about 45 years ago, could have lost it's effectiveness? Does the body 'forget' that it once had the antibodies and thus is now vulnerable?
"I'm not lost. I don't know where I'm going, but there's no sense in being late."
Mathew Quigley

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... the vacination I received, about 45 years ago, could have lost it's effectiveness?...



Yes. The vaccination would need to have been repeated to maintain immunity. In effect, at present it's as if no-one in America or Europe has ever been vaccinated.

Why mass vaccinate against something which no longer exists. Now it's ring vaccination post diagnosis.

Mike.

Taking the piss out of the FrenchAmericans since before it was fashionable.

Prenait la pisse hors du FrançaisCanadiens méridionaux puisqu'avant lui à la mode.

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Thanks for the information. What about the claim I saw in the thread that the vacination I received, about 45 years ago, could have lost it's effectiveness? Does the body 'forget' that it once had the antibodies and thus is now vulnerable?



How long does a smallpox vaccination last?
Past experience indicates that the first dose of the vaccine offers protection from smallpox for 3 to 5 years, with decreasing immunity thereafter. If a person is vaccinated again later, immunity lasts longer.

http://www.bt.cdc.gov/agent/smallpox/vaccination/faq.asp

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Would you get vaccinated today if it was available? The efficacy of the vaccine for those who were born before 1973 is low today.



Why is the efficacy low?

edit: clarification - do you mean the dose received in childhood is now ineffective, or that getting a new dose would be? I had read it as the latter.

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Incidentally, why Smallpox?



Smallpox is EXTREMELY contagious for starters. What's more, infected people become contagious a good day or two before they begin to get sick - so the disease would have a tremendous head start. And while the mortality is "only" something like 30%, the pain and suffering is terrible. The face and entire body are covered with excruciating sores. And finally, the survivors are disfigured for life.

I've always thought it was a mistake for smallpox vaccinations to have ended. The last natural case was in 1977, but since the US and USSR/Russia have both hung on to their live weapon stocks for "research" purposes, I think people should be vaccinated. I had the series as a child and think I'll ask my doctor about getting another one sometime soon.

Your humble servant.....Professor Gravity !

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