Profile: Smallpox Preparedness Of Israel And The U.S.

All Things Considered: November 1, 2002

Israel - Smallpox Vaccine


This is ALL THINGS CONSIDERED from NPR News. I'm Robert Siegel.


And I'm John Ydstie.

With a possible war in Iraq looming and the war on terrorism still at the fore of the global agenda, many governments are worried about how to prepare for a chemical or biological weapons attack. In the more-prepared category, Israel. Already Israel issues gas masks to protect residents, and in early October, it began vaccinating thousands of health-care workers against smallpox. In the US, meanwhile, the debate over smallpox is moving more slowly and centers around the question: Who gets the vaccine first? We have two reports tonight, the first from Tel Aviv and NPR's Jackie Northam.


Given the proximity and relationship to most of its Arab neighbors, Israel has long held the assumption that smallpox is a real threat and that the country needs to be prepared in the event of an attack. As part of that, Israel has launched a program to vaccinate about 15,000 of what it calls first responders, medical and rescue workers who could have contact with smallpox victims. Professor Dan Mahaley(ph) is the chairman of Clalit, Israel's largest HMO. He says prevaccinating health-care workers means they'll be protected while they treat and immunize other Israelis in the event of an attack. But more important, Mahaley says, prevaccination will help build up a badly needed supply of antibodies to the virus.

Professor DAN MAHALEY (Chairman, Clalit): Those antibodies, you can extract them from blood and then inject them to somebody who has a deficient immune system, and then he will be able to act against the side effects of the virus.

NORTHAM: And it's those side effects that are at the core of an ongoing debate in Israel about who to vaccinate and when. It's a question of risk vs. benefit. Smallpox can kill between 30 to 40 percent of unvaccinated people exposed to the disease. The vaccination can kill about one to two people per one million. Professor Mahaley says the highly contagious disease could quickly spread through Israel's population of six million people, so he believes it's better to use a blanket approach when it comes to smallpox.

Prof. MAHALEY: Once you have vaccinated the population, then you can sleep, as they say in French, on both your ears because you're not afraid anymore.

NORTHAM: But many health officials disagree. Professor Manfred Green, the director of Israel's Center for Disease Control, says that if all Israeli residents were vaccinated, then anywhere from six to 12 people could die from the vaccine. Green says even that small death toll could be psychologically damaging if there wasn't a smallpox outbreak at the time.

Professor MANFRED GREEN (Director, Israel's Center for Disease Control): When people do not see any disease around, then even one death from a vaccine is considered by a population to be one too many.

NORTHAM: And Green points out that there are other serious side effects besides death associated with the smallpox vaccine, including encephalitis, a swelling of the brain which can leave a person paralyzed. The Israeli Ministry of Health has carefully screened the 15,000 people it plans to vaccinate to limit any potential problems, says Dr. Yehuda Danon with Tel Aviv's School of Medicine(ph).

Dr. YEHUDA DANON (Tel Aviv's School of Medicine): We are not vaccinating people that are on steroids, people that have immune deficiency, people that had organ and bone marrow transplant.

NORTHAM: Nor, Danon says, are they vaccinating anyone who's never been inoculated against smallpox before. The Ministry of Health is monitoring the health-care workers who have been immunized. He says so far, there haven't been any serious side effects to the vaccine. But that could change if millions of Israelis are immunized in a mass vaccination. That would happen if military intelligence felt the threat of a smallpox attack was imminent or if the disease was detected on Israeli soil. Vaccination clinics would be open round the clock at 200 schools, and logistical experts with the Ministry of Health say the entire country could be inoculated within four days of an attack. That includes both Israel's Jewish and Arab residents, but not necessarily the Palestinians living under occupation in the West Bank and Gaza Strip. Professor Green of the Israeli Center for Disease Control says while it's government policy to try to get vaccines to those Palestinians, politics could get in the way.

Prof. GREEN: We have cooperated in terms of vaccines and in terms of exchange of information regarding infectious diseases. That doesn't mean that the political situation ...(unintelligible) makes things easy. It makes the exchange of information more problematic.

NORTHAM: And if there's a smallpox outbreak, the time frame for getting a vaccine to people is limited. Jackie Northam, NPR News, Tel Aviv.

RICHARD KNOX reporting:

I'm Richard Knox in Boston.

The sense of urgency in Israel stands in sharp contrast to smallpox preparedness in this country. While Israel is beginning to vaccinate health-care workers and defense forces, the Bush administration has been pondering for months how many and whom to vaccinate. Most striking: Israel has decided to vaccinate its entire population within four days if a smallpox attack occurs anywhere in the world. Professor Edward Kaplan of Yale University says that should be a deterrent to anyone thinking of unleashing smallpox on Israel.

Professor EDWARD KAPLAN (Yale University): Basically it's a signal that says `If we are attacked with this particular bioweapon, we will be able to respond sufficiently quickly to minimize any harm that would come from it.'

KNOX: Kaplan says Israel has also paid closer attention to the details of implementing a vaccination plan. It's decided to vaccinate not only hospital workers who might have to care for smallpox cases, but also people who would vaccinate the public in the event of an attack. In the United States, the only proposal so far is to vaccinate a half-million hospital workers.

Prof. KAPLAN: That number would actually not be sufficient to implement the CDC's mass vaccination plan as they have stated it.

KNOX: Kaplan says it would take one and a quarter million more health-care workers to vaccinate everybody within 10 days, the current US goal. It would take more than twice that many to meet Israel's four-day goal. Many state health officials think it'll be necessary to vaccinate the vaccinators beforehand, as the Israelis are doing. Dr. Alfred DeMaria is with the Massachusetts Department of Public Health.

Dr. ALFRED DEMARIA (Massachusetts Department of Public Health): We've sort of taken that for granted, that the vaccinators would have to be vaccinated. I think most of us just made that assumption. The public health nurses that I work with immediately understood that and have been talking about the need to have some of them vaccinated and prepared.

KNOX: This important detail hasn't made it onto the federal agenda so far. Administration officials declined to comment. Dr. John Modlin of Dartmouth University chairs the federal committee that's been advising the government on smallpox vaccination.

Dr. JOHN MODLIN (Dartmouth University): We haven't had much public discussion about immunizing a large number of vaccinators on a pre-event basis so far.

KNOX: Modlin says part of the reason is that federal smallpox policy has not been well-coordinated.

Dr. MODLIN: This whole business of smallpox--you have to understand that it's moving so fast that it's kind of like a bunch of trains traveling down several parallel tracks at the same time. And I've been amazed at how often something is happening on one track that people on the train on another track are not entirely aware of.

KNOX: That apparently hasn't been a problem in Israel. A report this week contrasts Israel's smallpox preparedness and America's. Leonard Marcus is a professor at the Harvard School of Public Health.

Professor LEONARD MARCUS (Harvard School of Public Health): In Israel, they'll talk about `We have to have this plan in place by this time.' We're still involved in the committee process, we're still deliberating about preparedness, `We need to be ready to vaccinate this number of people by this date in this period of time,' and right now, we're not ready to be able to do that.

KNOX: Marcus says the differences grow out of both history and everyday reality.

Prof. MARCUS: For the Israelis, terrorism is a very real thing. They experience it and they're vulnerable to it every day. In the United States, we'd like to, in some ways, pretend that we're not vulnerable to it. And in part, that's contributed to our reluctance to fully engage in preparedness as we see it.

KNOX: That won't change, many state health officials say, until they get a clear signal from the White House on smallpox preparedness. Richard Knox, NPR News, Boston.


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