On December 9, Utah Department of Health (UDOH)submitted a plan for pre-event vaccination against smallpox to the Centers for Disease Control and Prevention (CDC), targeting public health and health care response teams. This pre-event smallpox plan is designed to offer guidance to Utah's public health agencies, officials, community healthcare institutions and providers in preparing for the possible introduction of variola virus into Utah's population as a weapon of bioterrorism. The plan will be used in support of the Utah Smallpox Post Event Response Plan. CDC will need to review and approve each of the plans before the actual vaccination process can begin.

Questions and answers:

The key points:

Why not just go ahead and make the vaccine available to everybody?

Is there anyone who can't - or shouldn't - be vaccinated?

If vaccination is voluntary - and that many people may be excluded from vaccination for health or other reasons - how can we be sure that we'll have enough vaccinated people to mount an effective response during an outbreak?

Can people get smallpox from the vaccine?

How long has it been since anyone was immunized against smallpox?

If I was vaccinated before they stopped giving the vaccine in 1972, would I still be protected against smallpox?

Why the rush to get this done? How big is the threat - really?

The key points:

• CDC has asked each of the states to develop a plan for vaccinating a limited number of medical and public health personnel against smallpox.

• The proposed vaccination effort would be part of each state's advance preparation for a possible smallpox bioterrorism attack.

• Any proposed vaccination program will be completely voluntary. No one will be required to get vaccinated.

• The UDOH is working with local public health agencies, hospitals, and other health care providers to develop a vaccination plan for Utah. This phase of the plan does not include all first responders such as firefighters and police.

• A separate plan, describing in detail how Utah would respond to a smallpox attack, has also been developed. That plan was submitted to CDC on Dec. 1.

• The pre-event vaccination plan is intended to supplement the broader response plan. The vaccination plan will provide additional detail about how we would prepare key personnel to respond to a smallpox attack.

• Utah's pre-event plan will closely follow the guidelines set up by the Advisory Committee on Immunization Practice (ACIP), which recommended to identify medical care and public health Smallpox response teams. These teams would include people who would:
  • investigate the outbreak
  • care for the sick
  • take steps to control the outbreak
  • coordinate and managing our overall response to the outbreak
  • maintain public order
    
    
• Initially, the groups being considered for vaccination would include:
  • patient care teams in hospitals that are equipped to handle smallpox patients
  • infectious disease investigation teams
  • teams of people to administer the vaccine
  • other critical public health personnel
  • a limited number of critical emergency management and law enforcement personnel.

• It's been estimated that initially, under the plan being proposed for Utah between 2,000 - 5,000 medical and public health responders would be offered the opportunity to be vaccinated. This may occur as soon as mid-February.

• The number of people to be vaccinated during the initial phase of this effort has been purposely limited. The goal is to prepare response teams of health care providers and public health workers, so they can respond quickly and safely if an actual case of smallpox is ever reported in the state.

• If that situation ever does arise, only those who have already been vaccinated will be able to safely vaccinate others, or provide care to patients with smallpox. By vaccinating a limited number of people in advance, we will immediately be able to begin vaccinating other emergency response personnel and members of the public as well as caring for the sick. The small number of people needed to perform those critical tasks will be able to begin right away, without taking time out to be vaccinated themselves.

• Any decision about expanding the vaccination effort beyond these groups - or even making the vaccine available to the general public - would have to be made at the federal level. Federal officials currently control all available supplies of the smallpox vaccine.

• The UDOH, along with the CDC and President Bush, does not advise the public to be vaccinated until a legitimate case of small pox is identified in Utah. The UDOH does not intend to make the vaccine available to the general public until such a case is identified. Any decision about making the vaccine more widely available would have to take into account both the risks and benefits of vaccination. For those Utahns who want the unlicensed vaccine, they may be able to participate in vaccine research studies. For more information, visit www.clinicaltrials.gov

• The vaccine can cause serious, potentially fatal reactions in some people. At a minimum, it's been estimated that roughly one out of every million people who receive the vaccine will die - and 15 will become very seriously ill. In addition, about one in three will become ill enough to miss work or school for a few days and up to 1 in 1,000 will have serious but not life-threatening complications.

• Unless and until there is an actual smallpox attack, the risk of becoming ill or dying from smallpox is zero. If an attack did occur, the vaccine can still protect people even after they've already been exposed to smallpox. Vaccinating up to 4 days after first exposure provides substantial protection against smallpox or would at least lesson the severity of the illness.

• The "need for speed" is the primary reason for vaccinating some people in advance of any terrorist attack using smallpox. People in critical positions may not have time to get vaccinated once an outbreak occurs. They'll need to go into action immediately.

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Is there anyone who can't - or shouldn't - be vaccinated?

• Yes! Some people will not be considered for vaccination, in advance of an actual smallpox outbreak, because they face a higher-than-normal risk of having a bad reaction to the vaccine. Those groups include:
  • people who may be allergic to the vaccine
  • people who have health problems - or are receiving medical treatments - that may weaken the immune system (cancer patients, organ transplant patients, people with HIV, people taking steroid medications, etc.)
  • pregnant women, women who plan to become pregnant, and nursing mothers
  • people with eczema or certain other skin conditions

• Others who should not be vaccinated include people who share living quarters - or are otherwise in close, daily contact - with people in the groups listed above. For a short period of time, people who've just been vaccinated have the potential to expose others to the vaccinia virus. Smallpox vaccine doesn't contain Smallpox virus, it contains a related virus called Vaccinia.

• Based on these criteria, it's been estimated that up to a third of the population may not be eligible for vaccination, unless there is an actual smallpox outbreak.

• During an actual smallpox attack the picture could change dramatically. We would want to offer vaccination to anyone who had actually been exposed to the illness. No one would be excluded on the basis of the criteria listed above, because the risk of severe illness from Smallpox would far exceed the risk of the vaccine.

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If vaccination is voluntary - and that many people may be excluded from vaccination for health or other reasons - how can we be sure that we'll have enough vaccinated people to mount an effective response during an outbreak?

• The number of people needed initially to fill critical roles during an outbreak is actually relatively small. We believe that we can identify and vaccinate enough people to do those critical jobs.

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Can people get smallpox from the vaccine?

• No! The vaccine is made using a live virus, and that partly accounts for some of the risks involved in getting vaccinated. But the virus used in the vaccine is not smallpox - it's vaccinia, a different virus from the same family as smallpox.

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How long has it been since anyone was immunized against smallpox?

• Routine Smallpox vaccination was discontinued in the U.S. thirty years ago - in 1972. Vaccination was discontinued worldwide after smallpox was successfully eradicated, in the late 1970s.

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If I was vaccinated before they stopped giving the vaccine in 1972, would I still be protected against smallpox?

• There is some evidence that people vaccinated that long ago may still have some immunity, especially if they were vaccinated more than once. However, that residual immunity won't protect you against getting the disease - although it may make the disease less severe.

• People who have previously been vaccinated will still need to be revaccinated, if they want to be protected against smallpox.

• If you were immunized previously, there is also evidence that any reaction to the vaccine would be milder - and you would be less likely to spread the vaccinia virus to others.

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Why the rush to get this done? How big is the threat - really?

• The likelihood of a bioterrorism attack involving smallpox is believed to be very low. However, there is a risk - and the consequences of a bioterrorism attack would be extremely serious.

• Federal officials would be responsible for launching any vaccination effort, when and if they believe there is a credible threat that smallpox could be used as a terror weapon. They have access to the information and expertise needed to make that assessment, and we are relying on them to perform that function.
  

For more information, visit www.cdc.gov/bt

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