MPH, werdell’oo@hawau:r.com 3224 Authors: C’hnen— Werdell Coresponderce (B.W.) of Honolulu. Medical Burns University Department

Burns of mass IlI’Jh

Ring W. C Assistant University School 1999, ‘L. K.S,F.i Waia.ae School School cli MS Center KS. Hospitalisf, of Yen HI of KS. Clinical

Public a of of 96816-5357 Hawaii Foo of of I..au Ave. Hawaii Berkeley, Fuo Medicine MD Health, Su:te Professor MD,

John Alta Jonn MD

5-3 Sates A. CA UCLA Class

vaccination A. 1 Abstract biological that tember population exists ary harbor Since used play populations? mass both, tion much are also tion sequelae as exposure. bioterrorism. Articles in for health historical formulated. island situational; Since identified Methodology involve United Introduction during In was Vaccination preventing event a both contacts, immunization terrorists are weapon of in know used as vaccination infected the vaccination concern populations capabilities in selecting undocumented States the targeted II bioterrorism the pertaininv the strategies of of bombing h’ . onlx n factors, vaccination weapons. to 2001 in entire a mass following two a as of searching Which smallpox smallpox. What might spread smallpox mdi evaluate the and will has surveillance two hioterror. a immunization major and would event vaccination strategy? population is one to is plavacentral equally and attack of iduals such arisen smallpox role use critical strategy smallpox secure unclear. of the preparedness. Thus, the H1UVAi string: in stores tactics attack, strategies PubMed. major hypothetical smallpox. attack. vaccination entail of these does as subsequent Russia. World would Though regarding a feasible? Given M.%U in Oahu. plans laboratories, and smallpox would (bioterror of 1ss while responding illicit under characteristics, indiscriminate versus may vaccination the vaccination of iCL the The he Trade the role

in containment, prinuary Key other resource especially risk must smallpox JUU6 optimal isolated. for be optimum and stores he virus. and ring consideration. cases in attack use words Information Center best attack of controlling protecting countries most OR 34 be ring

event of vaccination. and vaccination policy tosmaffoox one to of It strategy strategies. limitation, evaluated scenarios However. bioterror— for hioterror. smallpox officially L. effective is generate v vaccina in anthrax. must strategy second on 64, ac public feared would in dense island 6888 cina— were were Sep max the the the on be In is U 444 extracted evaluate Oahu’s promote cination capabilities declared of consideration established also feared point were factors, v for sequentlv. vaccine. His ring shown strategy. 242 in significant Discussion follows website tion Boston. ing History Historical Results Based : sm) as The Pros historical 1853. smallpox the work articles obtained . and limited AND was selected All first disease, in on late population and provides belovv. smallpox and The vaccination strategies. Ring eradicated However, major It Table eventually mass arduous. from article the titles case numbers Lessons eighteenth reportedly were (smallpox) as textbooks. and cons subsequent experience to in vaccination legislature from for for the which vaccination of 1. vaccination. identified and 1854. English. identilied clues hypothetical types Discussion viral smallpox of of use responding major Smallpox epidemics in the with of led available 19. each killed century, 19.0. originated Despite as in people. This characteristics, AND Centers to were 126. cowpox epidemic mandated and to vaccination further and Information a using articles. vaccination in strategies. the vaccinia in the information with Though had of hypothetical (vaccine considered. continued mass Hawaii epidemic attack this Edward abstracts to effectiveness struggle the these for to long evaluation from 5.74$ smallpox afflicted prevent mass measure. delineated vaccination Information Disease based factors was scenarios policies smallpox been Jenner public on a OR deaths. .32 strategy waves. to to vaccination was ship diagnosed Language reach smallpox. scenarios historical smallpox decimate a 9.082 vaccina Control attacks. of articles I deadl\. used of in search law out health began under Con were Dur light both vac was vvas was that are au of of to ______

experienced three more smaller smallpox outbreaks Table1.— MassVaccinationVersusRingVaccinationInthe Eventofa Smallpox in 1861. 1873. and 1882. These epidemics. with 282 Attack additional deaths, were likely caused by failure to MASS VACCINATION RING VACCINATION achieve a IOOU accination rate.- In 1967. the World Health Organization launched PROS PROS:

the intensified Smallpox Eradication Program. The • Entire population is prepared Efficient use ot resources

program initially also relied upon mass vaccination, Higher iikelihood intended recipients are ‘ which proved efficacious in Western countries. How vaccinated

ever, again. 100% vaccination rates were impossible to •Less intense surveillance required Effective up to 4 days post-exposure achieve and smallpox continued to plague developing Incubation non-contagious: Prodrome sometimes • Public sense of security nations. particularl\ those with dense populations. contagious . Meanwhile, events in Nigeria stimulated e olution of Likely ettective for less populated Neighbor Islands. • Special advantages to dense island po5uiations a new strategy. Though most of Nigeria’s population especially more geographically isolated communities such as on Oahu had been vaccinated, a religious sect that had resisted .-.—______sucn as Hana vaccination developed an outbreak. Faced with limited resources and delivery delays, eradication campaign CONS: .-- CONS: staff learned quickly to isolate infected individuals • Resource requirements for survelliance after • Resource requirements for administering vaccine and vaccinate others to control disease spread. Within attack a few years, this method of surveillance and contain Time required to trace primary ; secondary • Pockets of susceptibility may be overlooked ment, known as ring vaccination, had successfully contacts controlled several outbreaks in India and become a • Everyone must consent Risk of overlooking high-risk individuals worldwide standard:n • Adverse reactions; contrandications Pubii.c demand With these two major vaccination strategies. smallpox was controlled over several decades. The last US case occulTed in l949. Nonetheless, vac tion in response to a known exposure. rather than prophylactically. cine was still administered to all children, military recruits and tourists until 1972. Routine smallpox Vaccination Strategies immunizations were subsequently discontinued in the Once a known smallpox event has occurred, agencies must be prepared to vaccinate US, as the risks of vaccine adverse reactions were felt at-risk individuals. This can be accomplished by either mass or ring vaccination. to outweigh the risk of a future smallpox epidemic. Each strategy has pros and eons. However, high-risk individuals continued 6to receive vaceine,i Worldwide, the last natural case occurred in Mass l%iccination Somalia in 1977. Successful smallpox management A mass vaccination response would ensure that the entire population is prepared thus relied initially upon mass vaccination, and later for subsequent contact with infected individuals as well as for future attacks. Thus ring vaccination strategies. it would decrease the need for surveillance of contacts and reduce the extent of vigilance necessary. It would also provide herd immunity. reducing propagation The Smallpox Threat of infection if contagious individuals did interact with the uninfected. Thus, this Though natural smallpox outbreaks are no longer a strategy would likely reduce the impact of future attacks. It might also give the threat, officials fear that the virus may public a sense of security, decreasing the probability of popular hysteria in re be employed as a weapon of bioterror. Given this sponse to perceived risk. scenario, selection of a vaccination strategy cannot be Nonetheless, mass vaccination has significant drawbacks, It requires tremen based solely upon historical factors. Smallpox was not clous resources. Not only would we need sufficient stocks of vaccine fbr an entire traditionally considered a biological weapon: it didn’t population. but also adequate trained personnel to administer it. ‘Fhecosts associ startfrom a point-source: and infectious characteristics ated with such an undertaking would be staggering. Another problem with mass were more predictable. At present. we do not knoy vaccination is its potential to inadvertentl overlook certain groups of individuals. whether smallpox will be re-introduced to our now thus resulting in pockets of susceptihilits. Along the same lines, at least 90’ll of naïve population. if smallpox were re-introduced, individuals must submit to vaccination for this strategE to be effecti e. Manda would it be a mutated, more deadly form? Would it tory vaccination ma\ infringe on the individual’s right to informed consent and spread similarly to historical smallpox? And would it to refuse medical care. Thus initiation of mass vaccination could be delayed by be suddenly introduced in one location or simultane legal proceedings or formulation of guidelines. ously in multiple locales’?All of these issues influence Furthermore, the presently used vaccinia-based vaccine has side effects. Though decisions regarding a vaccine strategy. rare, the risks associated with vaccination may outweigh potential benefits if the Since the probability ofa smallpox bioterroristevem threat of smallpox exposure is low. Constitutional symptoms, eczema vaccinatum. is low. pre-event vaccination ot the general popula mopericarditis. generalized vaccinia. progressive vaccinia and postvaccinial en— tion is not recommended. Only individuals likel to cephal itis are potential adverse react ions, but are more common among primar palticipate in an initial response to a smallpox event vaccinees than re_vaccinees.F In 450.293 healthy military vaccinees. one case of have been immunized, Others will receive vaccina encephalitis and thirt -seven cases of acute myopericardilis developed after vac

FABiAn MEDICALJOURNAL. VOL 64, FEBRUARY2005 35 cination: there were no eases of eczema vacc inatum or progressive of attack sustained. If an attack or few attacks were localized, ring vaccinia.’ However, adverse reactions may he more common in the vaccination ssould be a more reasonable strategy. It would facilitate general population. In a study on smallpox vaccine dilutions. fifteen efficient use of resources, appropriate protection and minimization of 14$ vaccinees developed dermatologic 10reactions, of adverse reactions. Howeser, in the event of multiple attacks or Under normal circumstances, contraindications to smallpox high risk of multiple subsequent attacks, mass vaccination would (vaccinia) vaccine include dermatidities. irnmunodetIciencs, im be n7ore appropriate. Mass vaccination would provide protection munosuppressiofl. pregnancy. to vaccine component. age to the large numbers at risk and reduce the need for intensive sur under IX ‘ ears, concurrent illness. and breastfeeding. For pre-event veillance. This situation—basedapproach would maximize resource prophvlaxis. people ithcontraindications are not vaccinated because utilization while minimizing morhidit and mortalit. Moreover. the risk of adverse reaction outs emhs potential benefit. However. mass vaccination max be especiall ads antageous in dense island in the es en!,ofan actual attack, the benefIts of accination outweigh populations such as Oahu. to best avoid a reprisal of the devastating the risks. Since there are no contraindications to post—exposure effect the virus had in Hawaiis sn7allpox- naïve population in the vaccination, the likelihood of adverse reactions increases, Mass 19th century. In contrast, ring vaccination may be preferred on the vaccination could thus result in increased morbidity and mortality less populous neighbor islands, especial] in more geographicalE in people with pre-exposure contraindications. isolated communities such as Hana where surveillance may be conducted more readil and efticientl”,. Rine 1íic nation Mathematical models e aluatine smallpox vaccination policy Rim’ vaccination also has its pros and cons On the positive side, ring options are in agreement with this situational approach. Modeling vaccination strateg ma\ utilize resources more eflicientI. Because takes into account several possible scenarios. characteristics of the only primary and secondary contacts of infected individuals would virus. response logistics and varying probability of attack.’ In be vaccinated, less vaccine and labor would be required to perform general, models support a ring vaccination strategy so4 long as the the actual immunizations. Focused surveillance with targeted vac probability of attack remains low. Once the probability of attack cination would probably also increase the likelihood that intended exceeds a particular threshold. which varies amongst models, mass recipients are vaccinated. vaccination ma\ be more practical. Were accination effective only if given prior to exposure. sur Regardless of vaccination 5 trategv employed, education of the veillance and containment might not he a prudent option. However lay public must be addressed. The public should understand the vaccination is reportedl\ effective for four days post-exposure and mechanisms and implications of hioterror. specifically smallpox. can be supplemented with vaccinia immunoglobulin. Although before an event occurs. Studies have shosvn that the public is not there are no FDA-approved antiviral medications indicated for knowledgeable about smallpox. In one survey, the majority of re smallpox at this time, the experimental compound hexadecyloxy spondents believed there exists an effective treatment for smallpox. propyl-cidofovir (HDP-cidofovir), has reportedly inhibited smallpox that there have been cases of smallpox within the past fIveyears and lO viral replication in early in vitro and mice studies. 3 Lastly. people that there is not enough vaccine for everybody in the US. Such are not infectious during the incubation period. Some become misconceptions could propagate in the community. contributing contagious when the prodrornal symptoms begin, while others are to inappropriate reactions, for example hysteria. Education would non—contagiousuntil the rash occurs. This course facilitates timely prepare the public to respond calmly and aptly. identification. Given these circumstances, at-risk individuals would still receive vaccination within a safe period. Thus surveillance and Conclusion containment is a reasonable tactic. In conclusion, mass vaccination and ring vaccination are thetwo major On the other hand, there are drawbacks to ring vaccination. It vaccination strategies that may be used in response to a smallpox requires rapid identification of exposed individuals, and thus more hioterrorevent. Mass vaccination, which entails indiscriminate vac intense surveillance than mass vaccination once an attack is recoo’— cination of the entire population. ssould he appropriate for multiple nized. This sudden demand for labor and resources could become attacks.if risk of subsequent attacks is high. and in dense urban island a serious problem in the event of multiple attacks within a brief populations such as Oahu. Ring vaccination, which entails surveil period. Furthermore, ring vaccination would onE protect primary lance with subsequent vaccination of high—riskindividuals would and secondary contacts of knoss n exposures. Given the possibility be more appropriate for a localized smallpox attack and low risk for that some cases might not be detected in a tin7ely manner, this could subsequent attack. such as on less populated, more geographicall increase the risk of non-immunized individuals developing small isolated communities on the Neighbor Islands. Thus, both ring and pox. Another problem is that members of the non-exposed general mass vaccination have a place in response to smallpox exposure. public would likel demand vaccination. Public opinion polls has e The choice hetsseen the tss0 is situational. suggested that approximately half of US adults would want to be vaccinated svhenthe smallpox vaccine is axailable.’ Such exigency Acknowledgements would lead to des iations from protocol and confusion recarding The authorsthank Dr.RobertKim-Farleyand Susan Foo.MAEfortheirinvaluable feedbackregardingthis manuscript. vaccine administration.

Best of Both Worlds Given the assumed characteristics of smallpox, the optimal method of ,? vaccinating the general public would depend primarily upon the t’. pe See “Refrrei,ees” p.

36 “References... “ jrorn p. 36 Classified Notices References 1 HendersonDA,IngiesbyTV.Bartlett AncherMS. Jahrling PB. e1aLSma:lpox JG. EitzenE. as a BiologcalWeapon.In:Henderson DA. Toplacea classifiednotice: inglesbyTV.O’TooleT editors,Bioterrorism:GuidelmesforMedicalann PzoiicHea.tnManagement.ChmagoliL):AMAPress: 2002.p. 99-120. HMAmembers—Asa benefitofmembership.HMA 2. MillsGH.Hawaiiansand Medicine,Hawal:MedJ 1981:40)lOi:272-276 membersmayplacea complimentaryone-timeclas 3 Hcpb:nnJW.The eradication of smallpox:organizationallearrng and inncsation xi .nrernatxisI nealth administration.J Des Areas sifiedad inHMJas space isavailable. I 988’22i3):321-32. Nonmembers.—Ratesare $1.50 a wordwitha 4 Strassburg MA.Theglobaleradicabonof smailpox.AmJ InfectCo’trol 198210:2 53-9 minimumof20 wordsorS30.Notcommissionable. 5. Centers forDiseaseControl.SmallpoxFactSheer. Deoartmeniof HealS and Harlan Se’vices.CentersforDiseaseControl[online].2002 Dec.Axa.labiefrom’http::.www.bt.cdc.govagentnmallpoxoverviewoisenne-factn.auo Formoreinformationcall(8081536-7702. 6. Cnntinueor endsnialipoxvaccination[Editorial].Hawai’MedJ 192 31’ :36 MahoneyMCSvmonnAB,KimmelSP Smallpox:Cincal Highlghtnann Connideratic.s to Vsccinaron,J PcntgraoMed2003:49:141C. 8 AdxisoryCornnritlesonlmmuniza1on.OracbcesVaccsaSmal’ocsVaccncAecon’merida:icnxoxthe Advino’yCzmmt:eeonlrrrrnunizaton. Office Space Pay ACP c 12z 9 Gracerstein JD.Winx.enwerde.rWiUS.M.litarvSmallpoxVaccinationProgramEszerence JAMAB9OO 3278-82. TA iaF. ‘0 Tanict Brecen,beroHf,.SniilLM.5.r BJ.BoySA.EdwardsKM.Focaland Generalizes Eoilcal’t.s234 Folow’ngSmaiccxVaccination FULLYFURNISHEDOFFICEINMOILIILI—AVAILABLE .1 4” a V i a t 28° 4 9 INOCTOBER2005. 1000 sq. ft.includes three eaaminaton ‘I Cm’-J. Color ControlofD.c.mmjricab:eDiseasss Manna:Wsshn-gton.AmencanPvblpcHealthAssociation:2700.. rooms,spaciousworkareafor personneland multipleshelving 12. Lear AG Smalpox ann VaccxiatWrilerter:.NewEngi Smalloc.x J Med2003.348:191.t920-1 torcharts. Largedoctor’soffice.Interiordecorated-designed 13. Bradbury.J. Ora.lyavallattecidcfcxiroerivat’xnactise agains: sr-ia.lpox.Lancet2002:359i931’:“ cat waitingroom.Forfurther informationcall l808i 949-6665. 4 BozzetreSA.Boe’ A BnaniaoarC Browe:JL. KeelerER.MortonSC Slob MAAmodelforsmallpox-xaccxrationpoilcy.NewEncIJ Med 2003,348l5::4t6-425. ‘5. Kap.anEH.CraftDL.WeinLM.Analyz:ngoroterrorresponse iog’nlics:te5 case ofsmallpox Ma:hBrosci2003:185U :33-72. B ndnn AJ C A CM 2 nn JM Hnr v’s n MJ Th Ca K Wenon K 9T 0uoic aru S’-ta ooxThe NE Med 2063:348’5:426-32 Welcome To Our Newest Tenant

Dr. Greigh I. Hirata “Using The fl VV1...’iro,n p. 47 Fetal Diagnostic Institute an actual experience in scholarly writing which is not ordinarily available to junior faculty. and a tangible academic achievement in completing a chapter a successful endeavor), to of the Pacific promote faculty development utilizing fewer resources than other programs described in • Convenient Location the literature. The use of the WWW greatly facilitated the editing process. reducing the • Attractive Offices amount of work for each editor. Secretarial support staff was not required for the editing process. • Easy Access parking The WWW version of this book could standalone as an electronic book. It is an electronic publication with no cost if one has access to a server and web site domain. Electronic journals and electronic books can be published and circulated through the WWW. The online documents can be continuously updated. as opposed to a paper book which requires an enormous effort and a substantial expense to publish a new edition. Despite the ubiq uity and acceptance of electronic online reference materials, having a book in hand is an academic/professional accomplishment. The cost of on demand publishing has declined substantially, making both paper and electronic publishing more feasible for individuals and smaller department programs. In conclusion, the WWW can be used to facilitate the editing process of organizing a textbook, It is also a new medium for academic publishing, which can be used to facilitate BUILDINtl the professional and academic development of faculty. 1600 Kapiolani Blvd. References Corner of Kapiolani and Kaheka 1. PololiL,Knight.S.DunnK.Facilitatingscholarlywritinginacademicmedicine.J Ge’-InternMed.2004:19)1):64-68. 2. MorzinskijA,SimpsonDE.Ovtcomesofacomprnhen.nivefacoltydevwopmenrorocrarnfv’local.full-timefaculty.FamMed.2003:35l6):434- For leasing information call 439. 3 CoatesWC.HobgoodCD.B:rnbaumA.FarrellSE.Facultydexeioome’-t.academiczpocrtunitienfoemergencymeoiclnefacultyoneduca 944-8100 tioncarvertracks.AcadEmergMed.2003:tol’lO):l113-1117.

Any questions, comments, or concerns? Contact the Hawaii Medical Journal at: [email protected]