Research Story of the Week

Smallpox: Threat, Vaccine, and US Policy
Part VI of a Six-Part Series

View: Parts I & II | Part III | Part IV | Part V | Part VI

View the entire series as a single PDF file.
PDF format, 36 pages, 539 kb.
Illustration
Illustration showing vaccination for smallpox. [Source: World Health Organization]

View the entire series as a single PDF file.
PDF format, 36 pages, 539 kb.

By Richard Pilch, M.D. Co-written with Michelle Baker.

[The authors would like to thank Dr. Raymond A. Zilinskas for his thoughtful review of this article; Dr. Daniel Pinkston for his guidance regarding the economic and budgetary aspects of the smallpox vaccination plan; and Ms. Sarah Diehl and Mr. Dave Steiger for their enduring technical support throughout the writing of this series.]


VI. Consequences of the Smallpox Vaccination Plan

In June 2002, President Bush signed into law "The Public Health Security and Bioterrorism Preparedness and Response Act." This Act pledged 1.08 billion dollars in grants to state and local governments in FY2003 for the specific purpose of bioterrorism planning, the bulk of which--totaling approximately 918 million dollars--was distributed immediately following the signing.[1] States quickly budgeted these funds toward meeting general bioterrorism preparedness objectives, such as correcting universal deficiencies in education and training, upgrading laboratory capabilities and equipment, and hiring specialized personnel with expertise in biological weapons and terrorism.[2]

When President Bush announced his smallpox vaccination plan on December 13, 2002, word was given that the money each state had already received, drawing from the 918 million dollar pot, was to cover this expense as well. Thus, in order to implement phase one of the vaccination plan alone (phases of the plan are discussed in Part IV of this series), states and counties had no choice but to reconstruct their budgets accordingly. This task was accomplished by one of two distinct courses of action: (1) states and counties that had only appropriated or spent a portion of the total federal allotment at the time of President Bush's announcement shifted these resources toward the smallpox vaccinations; and (2) states and counties that had moved forward with their preparedness plans, and spent their grants, were forced to seek resources elsewhere, namely by drawing from finances budgeted toward other public health initiatives.[3]

This article discusses each situational approach in turn, focusing on the potential drawbacks to allocating human, material, and financial resources toward phase one of the smallpox vaccination campaign. This discussion is followed by a review of the potential benefits of phase one of the campaign in order to provide a balanced assessment of its present and future consequences. The article concludes with a brief look ahead at phase two vaccinations, which are scheduled to begin in the next few months (as of March 2003, no specific date has been set for the initiation of phase two vaccinations).

Reallocation of the Federal Grant

When individual states received their portions of the federal aid, two things happened. First, plans were made and implemented on both the state and county level to address the problem of bioterrorism, as described. Second, a number of state and local governments, sensing an opportunity to save money during hard financial times, unexpectedly cut back on public health funding in order to meet deficit requirements, presumably with the understanding that the federal money could be utilized to cover these expenditures as needed.[4] As a result, upon initiation of the smallpox campaign, the reallocation of resources by states that had not already spent their grants affected not only bioterrorism preparedness but, in a number of cases, greater public health efforts as well. Yet these are not distinct consequences. In fact, it can be argued that regardless of where the money comes from, public health systems suffer in the long run.

This touches on one of the major advantages of combating the deliberate release of a biological weapon, and one of the major disadvantages of the smallpox vaccination plan. A portion of available resources must be directed toward biological terrorism-specific training that for the most part has limited application outside of a terrorist action, for example the clinical recognition of inhalational anthrax or the rash of smallpox. However, a major goal when working toward general bioterrorism preparedness is the improvement of surveillance and detection capabilities on a county, state, and federal level. Surveillance is essentially the ability to monitor a given population for signs of an outbreak, using such methods as documenting over-the-counter flu medicine sales at local pharmacies, tabulating absences at elementary schools, tracking the number of animal deaths in the area, and so on. Detection involves the identification of a pathogen's release by terrorists, either in the field or in the laboratory. The important point about such improvements is that they don't simply enhance preparedness against deliberate outbreaks, but protect against natural outbreaks of emerging and re-emerging diseases as well.

Health and Human Services (HHS) Secretary Tommy Thompson noted this "dual-use" of bioterrorism defense when discussing federal aid, emphasizing that the money was to be used to rebuild the US public health infrastructure (see Part III of this series) in order to improve the management of much more realistic threats like influenza virus, E. coli, and West Nile virus.[5] Implementation of the smallpox vaccination plan, the utility of which is limited solely to protection against a single disease that is currently nonexistent in nature, goes directly against this philosophy, however. Therefore, the plan hinders efforts to counter not only bioterrorism threats that, given the extremely low likelihood of an intentional release of the smallpox virus in the US (as outlined in Part III of this series), are much more real than the threat posed by smallpox, but also what is arguably the far greater threat of natural infectious disease.[6]

Shifts from Public Health Funding

States that had spent their grants before the details of the smallpox vaccination campaign were announced were forced to seek funds elsewhere. Officials soon turned to the public health arena, a longtime target for budget reductions, and counties were called on to trim back ongoing public health programs in order to free up enough cash for phase one of the vaccination program. For example, upon receiving 458 thousand dollars from New York State's 60 million dollars in federal bioterrorism grants, Onondaga County (home of Syracuse) spent the money on the development of a preparedness plan, training of personnel, and equipment upgrades. Now, in order to raise enough money for phase one of the vaccination plan alone, the county is considering the elimination of 1,280 maternal and child health care visits; 221 women's health exams, including such proven cancer prevention methods as breast exams and Pap smears; 835 pediatric dental visits; and 260 preschool and early intervention family service visits.[7]

In addition to the nationwide efflux of funding, public health services have been further reduced due to a loss of manpower as phase one vaccinations have proceeded. Shortened staffs are now expected, some as a result of the re-tasking of personnel toward the vaccine's administration and others stemming from side effects following its receipt. In Oregon, for example, personnel deficits have presented challenges to such traditional tasks as tracking regular childhood vaccinations--which are offered in late January, thus coinciding with phase one vaccinations this year--and preparing for natural outbreaks of the most common public health threats.[8]

As a final point, it must be noted that these reductions are occurring at a time when layoffs across the nation have left a growing number of citizens without health insurance. And as war with Iraq looms, and the economy continues to stumble, this number can only be expected to climb in the foreseeable future. Thus, public health program cuts are being made when the need for services is absolutely critical, and still rising. When phase two vaccinations are initiated in the coming months, some areas in the United States may well reach their breaking point unless substantial aid arrives from the federal government.

Potential Benefits of the Campaign

The smallpox vaccination plan of course offers the theoretical advantage of "fire-walling" the United States against a deliberate release of the virus, but is this the full extent of its usefulness?

To answer this question, the introduction of West Nile virus into the United States serves as an appropriate case study.[9] Before 1999, few Americans had ever heard of West Nile fever. When an unusual die-off of birds was noted in certain areas of New York City in July of that year, little attention was paid by the public at large. Approximately one month later, a physician employed in the vicinity of the die-off notified the New York City Department of Health that an unexpected number of her elderly patients had been afflicted with encephalitis (inflammation of the brain) coupled with muscle weakness. It was soon learned that similar cases had been documented around the city, yet it took nearly three months from the time of the initial die-off for federal authorities to correctly identify the causative agent in the outbreak, West Nile virus, and for response efforts to be coordinated. It is now theorized that the source of the outbreak may have been an infected passenger(s) arriving by plane from the Middle East, where the disease was (and is) endemic, or perhaps even a mosquito carrying the virus that had found its way onto a plane and survived the flight overseas.

This experience demonstrated that open lines of communication and willing collaboration between federal, state, and local health departments and agencies are absolutely essential when responding to any disease outbreak, whether familiar or wholly unrecognizable, natural or deliberate. As the events of the West Nile fever outbreak unfolded, authorities of these entities failed to work together in a cohesive fashion, and as a result what had been at first a manageable event was not effectively contained, and a human epidemic was born. The West Nile virus is now endemic in the United States, a permanent reminder of the nation's continued vulnerability to infectious disease.

The smallpox vaccination campaign offers an opportunity to overcome this communication barrier by encouraging interaction between local, state, and federal health authorities. Despite all of its drawbacks, including the weakening of surveillance and detection (that alone may well outweigh any potential benefits), one positive effect of the campaign is that it has in fact enabled this interaction. Individuals, departments, and agencies on all levels of the public health system are now in regular contact, a chain of command has been established, and a national plan has been developed to respond to a large scale outbreak of contagious disease (see the discussion of the Supplemental Strategy in Part V of this series).

Summary

Limitations in both financial and human resources in the face of phase one vaccinations have forced budgetary and management decisions the consequences of which remain to be seen. Still, it appears that at least for the time being, the nation as a whole has made it through phase one relatively unscathed. Further, approximately 80 percent of counties responding to a survey conducted by the National Association of Counties and National Association of County and City Health Officials reported an improved bioterrorism response capability compared to one year ago, whether as a result of the vaccination campaign or despite it.[10]

Phase two, however, carries with it a price-tag of 600 million to 1 billion dollars.[11] Given the record deficit facing the United States, the increasing prospects of war with Iraq (an event that will carry with it a massive financial crunch), the questionable threat posed by smallpox, the uncertain added benefit of phase two vaccinations over the "firewalls" established by phase one, and the need for funding in other areas of public health preparedness rather than the smallpox vaccination campaign should federal funds be made available, it is the authors' opinion that spending this amount of money for phase two is not justifiable, and that the implementation of this next phase of the vaccination plan is therefore not advisable at this time. A stay on the campaign prior to phase two vaccinations is strongly recommended until the situation in Iraq has stabilized and funding issues have been resolved.


[1] See, for example, http://energycommerce.house.gov/107/news/05222002_577.htm; http://www.ncsl.org/statefed/health/PL107-188overview.htm.
[2] See, for example, M. Weiner, "No Aid Set Aside for Pox Vaccines; Onondaga County Alone Faces $475,000 Bill, May Cut Services to Pay for them, The Post-Standard (Syracuse, NY), December 29, 2002; T. Scheck, "State, counties scraping to find money for smallpox vaccinations;" Minnesota Public Radio, January 29, 2003.
[3] See, for example, J. Hopfensperger, "Smallpox prep work is stretching counties, officials say," Star Tribune, January 30, 2003.
[4] For example, in Larimer County, Colorado, 1.4 positions were added in the Department of Health and Environment as a result of the federal bioterrorism grant, but 15 positions were cut due to state reductions. Similarly, the county's 6 million dollar budget grew by 100 thousand dollars thanks to the federal money, yet state reductions took away 700 thousand dollars. As a result, family planning and childhood immunization programs were cut back significantly, such that 1,000 children normally eligible for immunization in the public clinic had no such opportunity. V. Elliot, "Public health funding: Feds giveth but the states taketh away," amednews.com, October 28, 2002.
[5] Elliot, "Public health funding: Feds giveth but the states taketh away," amednews.com, October 28, 2002.
[6] For example, Texas, which in 2002 received 51 million dollars in federal grant money for bioterrorism preparedness, spent the money on acquiring laboratory equipment and hiring and training appropriate personnel, and as a result the 4 million dollars required for phase one vaccinations were drawn from surveillance and detection efforts. M. Mitchell, "Cost of smallpox vaccinations prompts call for a delay in Texas," Star-Telegram, January 1, 2003.
[7] M. Weiner, "No Aid Set Aside for Pox Vaccines; Onondaga County Alone Faces $475,000 Bill, May Cut Services to Pay for them, The Post-Standard (Syracuse, NY), December 29, 2002.
[8] A. Dworkin, "Smallpox Plan Strains County Health Care," The Oregonian, January 10, 2003.
[9] The bulk of this discussion is drawn from J. Tucker, "Improving Infectious Disease Surveillance to Combat Bioterrorism and Natural Emerging Infections," testimony before the Subcommittee on Labor, Health and Human Services, Education, and Related Agencies of the US Senate Committee on Appropriations, October 3, 2001.
[10] "Counties: Funds Needed to Fight Bioterror," Associated Press, January 8, 2003.
[11] M. Mitchell, "Cost of smallpox vaccinations prompts call for a delay in Texas," Star-Telegram, January 1, 2003.


CNS Experts on the Smallpox Threat, Vaccine, and U.S. Policy:

View: Parts I & II | Part III | Part IV | Part V | Part VI

View previous Research Stories.

 

Author(s): Richard Pilch
Related Resources: CBW, Americas, Weekly Story
Date Created: March 10, 2003
Date Updated: -NA-
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