The Smallpox Vaccination Campaign of 2003: Why Did it Fail and What are the Lessons for Bioterrorism Preparedness?

Abstract

On December 13, 2002, the White House announced a plan to vaccinate active duty military personnel and certain civilian hospital, health care, and emergency services workers against smallpox. This announcement was accompanied by a Smallpox Vaccination FAQ. The goal was to vaccinate 500,000 military personnel as soon as possible, and then to vaccinate 500,000 civilians within a few weeks. There were no specific plans to vaccinate the general population, but there was discussion about making the smallpox vaccine available to the general public in 2004. President Bush was immunized first, with no reported ill effects.

By January 2004, 578,286 military personnel were vaccinated. During the same period, only 39,213 civilian health-care and public health workers were vaccinated, less than ten percent of the original goal. This article analyzes why the civilian smallpox vaccination campaign failed, the impact of this failure, and what it should teach us about future vaccination campaigns for smallpox and other bioterrorism agents. Some of the reasons for failure could have been averted with better planning and legislation, but others are intrinsic to the United States’s medical and legal systems. Addressing these intrinsic problems demands fundamental modifications in the plans for bioterrorism preparedness.

This article does not discuss the control of a smallpox outbreak, beyond the use of smallpox vaccinations. Control measures would include stopping all transportation in and out of the affected area, identifying all cases, persons in contact with those cases or in contact with contacts of those cases, vaccinating and isolating the contacts, and trying to preserve social order and infrastructure in the affected region. Such measures would require military intervention as discussed in other papers in this symposium issue. It is possible that we would see the breakdown of civil order and imposition of martial law. The authors believe that such measures will be nearly impossible to carry out because they pose difficult moral and ethical dilemmas such as whether to shoot the soccer mom with the minivan full of kids trying to get out of the city. As a result, the authors stress the importance of a workable vaccination program which can stop the epidemic even if draconian control measures fail.

This article originated in the Smallpox Vaccine Injury and Legal Guide, an online analysis of the medical and legal issues posed by the smallpox vaccine campaign that was updated as the campaign progressed. Through the guide and discussions with health care institutions, unions, health departments, and reporters, Professor Richards and Dr. Rathbun helped many health care organizations tailor their response to the smallpox vaccine campaign.

Keywords: national security, bioterrorism, smallpox, cdc, vaccine, immunization, quarantine, isolation, H1Ni, public health, public health law, epidemiology, infectious diseases, communicable diseases, contact tracing, disaster planning, Potemkin

JEL Classification: I18, H56