Smallpox: Would You Get The Shot?

Some say this vaccine could save your life—others say it could kill you.

Blood and guts have never particularly fazed Michelle Maron and Jacquelyn Heiserman. As nurses with the City of Allentown Bureau of Health in Pennsylvania, they've seen their share of infirmity and disease; they're steel-stomached enough to deal with just about anything. That turned out to be a blessing when, a few months ago, they sat down to study the medical literature about smallpox.

The clinical journals and government pamphlets were packed with grisly photos of what the disease can do to you: flesh erupting with angry red boils, dimpled pustules sprouting from ears, lips and fingertips, until eventually the skin is covered with so many blisters that it appears encased in corn kernels. Smallpox, the women learned, killed 300 million people in the 20th century alone and may be responsible for more fatalities than any other infectious disease in history.

The material about the smallpox vaccine wasn't exactly reassuring, however. The shot, too, can kill you. Alarming statistics on the vaccine's risks were illustrated with photographs of eyes glued shut with pus and bacterial infections that transformed skin into something resembling pizza sauce. Massive scarring, blindness, brain swelling—it was enough to make even the most seasoned nurse feel uneasy.

"You can't help but wonder," says Heiserman, "is this going to be me?"

Like millions of Americans, the two women were struggling to decide whether to be vaccinated. Last December, with bioterrorism fears mounting, President Bush ordered 500,000 military personnel to get the shot and asked another 450,000 "first responders" (civilian health-care workers who would be among the first to encounter an infected patient) to volunteer. Those vaccinated as kids were asked to get it again because the shot wears off after five years. The plan was to have 10 million health-care and emergency workers vaccinated as soon as possible, enough to carry out mass inoculations of the general public if there's an outbreak.

There was just one glitch: When the civilian vaccinations began in late January, hardly anyone showed up. Though the U.S. Department of Health and Human Services vowed to vaccinate nearly half a million doctors, nurses and paramedics within the first month, by the 30-day mark only around 10,000 people had been inoculated. What's more, a handful of unions advised their members not to participate, and hundreds of hospitals and many health departments refused to get involved. They complained that the government had no firm plans to compensate those harmed by the vaccine, and that vaccinated health-care workers might infect vulnerable patients and family members. And then came the heart attacks—medical workers mysteriously dying of cardiac failure within weeks of getting the pinpricks. Even the scientists who study smallpox can't seem to agree: Could the dangers of this vaccine be greater than its benefits?

The moment smallpox broke out in more than one city, the entire country would have to be vaccinated.

"From a public health standpoint, this is a campaign that doesn't make sense. You don't give a vaccination that could kill people, against a disease that doesn't exist, to large numbers of people," asserts Brian Strom, M.D., director of the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania in Philadelphia. After all, he points out, the World Health Organization declared smallpox eradicated in 1979; there hasn't been a case in the United States since 1949 or anywhere in the world since 1977. In the years before routine vaccination of Americans was stopped in 1972, the chance of catching smallpox was greater and the case for risking the shot stronger. Today, says Dr. Strom, "there's no reason people should want the vaccine, except purely to be patriotic."

That's a dangerous view, says William Bicknell, M.D., a smallpox expert at the Boston University School of Public Health. "We have no choice but to plan for a worst-case scenario," he says. Extremely contagious, virtually untreatable and fatal for nearly a third of those who catch it, smallpox is so terrifying that if only one case were to strike anywhere on earth, it would qualify as a public health emergency, according to the Centers for Disease Control and Prevention (CDC) in Atlanta. Bioterrorism experts suspect as many as nine countries, including Iraq, Iran, Pakistan and North Korea, have secretly stockpiled the virus for use as a weapon. If terrorists unleashed it tomorrow, Dr. Bicknell says, many thousands of Americans could die. "The more people who get vaccinated beforehand, the better we can stop an epidemic," he says. "Until we reach 8 to 10 million [vaccinees], we will not be prepared to respond to a smallpox attack."

The potential terrorist attacks that experts are batting around are something out of a horror movie. A recent New England Journal of Medicine article poses the two most devastating possibilities: a bioterrorist spraying an aerosol canister of liquid smallpox into an office building's ventilation system and 40 terrorists spraying the virus inside the country's 10 largest airports. The projected fatalities paint a fearsome picture. Dr. Bicknell predicts five infected terrorists could spread the disease to as many as 114,000 people, culminating in 28,500 deaths. In the aerosolized airport attack, The New England Journal of Medicine predicted 53,000 deaths.

An outbreak would put health-care workers like Maron and Heiserman, who work in Allentown's infectious disease clinics, on the front lines. But in the absence of definite answers, they were left to sort out the matter for themselves. "It was stressed to us, over and over again, that this was voluntary," recalls Maron, 39, a clinical manager who shuttles in and out of several infectious-disease clinics, overseeing a staff of 20. "The health department kept telling us, 'Do whatever you think is best for you. It's a very personal decision.'" It's a decision more and more people will have to consider as the vaccination plan evolves—and, perhaps, a choice we all will eventually have to make for ourselves.

It didn't take long for Maron to make up her mind. Having helped beat back an outbreak of tuberculosis in Allentown in 1996, she and her team know how quickly a deadly germ can spread. Last winter, they stood in one of the clinic's waiting rooms and watched President Bush's televised appeal for volunteers. "I was already beginning to wonder, What will my role be?" Maron remembers. By the time the press conference ended, she was seriously contemplating getting vaccinated.

At home, Maron talked it over with her husband, Greg, a telephone technician. Both of them had been vaccinated as kids, and Greg still bears a small circular scar on his arm. The fact that the vaccine leaves a scar at all shows how potent it is and underscores why there's such concern about its use. Unlike modern vaccines, which contain dead or weakened viruses, the smallpox vaccine is made of an active, live virus—not the variola virus that causes smallpox, but a close relative called vaccinia. The "technology"—that is, scraping the hides of infected calf bellies—dates back to the 1700s. No one ever developed more advanced techniques, because by the time scientists could have done so, smallpox had been declared extinct. In 1968, one of the last years the virus was administered, the vaccine caused about a thousand serious reactions, and one or two deaths, for every million vaccinees. Safer vaccines are in the works but won't be ready for at least two years. In the meantime, doctors need to keep a close eye on those who get the shot, to make sure the feisty vaccinia doesn't make trouble. A virus's goal in life is to multiply and spread in living cells—and given any opportunity, it will.

Maron knew the outcome might be bad. The vaccination site in her arm could grow red and sore, and she might develop swollen glands and a low fever; these are among the mildest and most common side effects. If she forgot to wash her hands after touching the site, she might transfer grayish pustules to any other body part she touched; if she rubbed her eye, it could blind her. If the vaccinia overpowered Maron's immune response, it could spread through her system, a condition known as generalized vaccinia; her face and arms would sprout pustules that could then spread to other parts of her body, turn scaly with scabs and leave her skin pocked with scars. Worst of all, she could develop progressive vaccinia, an often lethal condition in which the virus devours the skin, breaking down its tissues into a bloody pulp. Or, in a rare scenario, Maron's immune system would turn on itself, causing encephalitis—inflammation of the brain—which could kill her or leave her comatose.

As of this writing, of the 32,644 civilians inoculated so far, 57 have had serious reactions, among them a 39-year-old woman who showed signs of generalized vaccinia, and a 38-year-old woman hospitalized for a severe headache and dizziness. That number includes a slew of heart-related problems, a development that has floored experts. It's sometimes difficult to know for sure which adverse reactions the vaccine actually causes, cautions Dr. Bicknell: "If you get vaccinated and then get hit by a car, you can't say the two were related." But 17 civilian vaccinees experienced cardiac problems, including five heart attacks—two fatal—worrying the CDC enough that on March 31, it began urging hospitals to turn away potential vaccinees with heart conditions or risk factors such as high cholesterol, smoking and hypertension.

The design of the vaccination program has made an already anxious situation worse, say critics. (Senator Edward M. Kennedy, D—Mass., for one, has called the program "an absolute disaster.") If someone is injured by a childhood vaccine for measles, rubella or another disease, the government pays restitution from the national Vaccine Injury Compensation Trust Fund. But the Bush plan originally had no provisions to compensate an adult harmed by a smallpox vaccine. In April, Congress passed a bill providing up to $50,000 a year to anyone permanently or totally disabled by the vaccine, ending at age 65, and $262,100 to the family of someone who dies. Still, complains Christopher Donnellan, associate director of government affairs for the American Nurses Association in Washington, D.C., there's little money for states to screen workers for risk factors or to track their health after they get the shot.

Maron says compensation was never an issue for her. "Nurses face health risks every day," she says breezily. And she assured her husband that her chances of an adverse reaction were low. The two vaccines she received as a child gave her a significant measure of protection. In addition, Maron never had any skin conditions such as eczema or atopic dermatitis, which increase the odds the vaccine will cause severe skin infections and rashes.

Her immune system is robust, which is key. Unless there's a smallpox outbreak, hospitals won't vaccinate people who are HIV positive, are undergoing cancer treatments, have received an organ transplant or are taking medications that suppress the immune system (such as steroids, which treat diseases like asthma or lupus). In fact, this precaution helps explain why experts are so nervous about reintroducing the vaccine. The shot hasn't changed since the '60s, but the population has: Many more of us live with compromised immune systems and would be vulnerable to catching vaccinia, perhaps from our own doctors. The risk of accidentally transmitting the virus to others is real.

This, finally, is what gave Michelle and Greg Maron pause—the chance that the vaccine would put their two sons, ages 11 and 9, in danger. Maron knows children are especially vulnerable to complications. "Obviously, I would never do anything that would put my children in harm's way," she says. She thought about the dozens of daily exchanges that could bring her kids in contact with the virus. It could be as simple as a sloppily applied bandage and a child barreling in for a bear hug, or if the kids handled a piece of clothing that had touched the vaccine scab. Maron is far from alone in her concern, because immunizing health workers means immunizing a lot of women; according to the CDC, the civilian program has vaccinated some 16,500 women so far, twice the number of men who've participated.

Being a mom and a nurse, Maron was well versed in her kids' medical histories. She concluded that the danger to the boys was low, as long as everyone was careful during the three to four weeks her vaccine would be contagious. "This is what I want to do," she finally told Greg in their kitchen one December evening, and he agreed that if she felt that strongly, she should do it. And so over the dinner table just after Christmas, Michelle Maron told her children as gently and, she hoped, unalarmingly as possible that Mom was going to get inoculated for smallpox.

"Our hospitals don't have enough nurses to handle even large car accidents, let alone a smallpox attack," says a bioterrorism expert.

For Jacqui Heiserman, 36, the decision was harder. Heiserman, who works in the tuberculosis clinic, had never been vaccinated for smallpox before, which she knew increased the risk she would react badly to the shot. Because she was adopted, she couldn't be sure that she didn't have a family history of heart disease, which might also put her in danger. And she worried about infecting her three kids, ages 11, 6 and 5. "They climb all over you at that age," she explains. Plus, her youngest child has a risk factor: Due to an asthmalike condition, he sometimes takes steroids.

Over a period of weeks, Heiserman read everything she could on the issue and talked it over with coworkers. She even attended a daylong state health department seminar to learn all about the vaccine, including how to administer it; attendees practiced the skin-pricking technique on each other, using a special two-pronged needle. Driving home, Heiserman kept thinking about one remark that had struck her: If you have any doubt at all as to whether you have a risk factor, do not get the shot. "When I heard it put that seriously, I thought, This is not for me," Heiserman recalls.

It's a decision thousands of others have made in the absence of an immediate threat. But if a single patient with smallpox arrived at any of the Allentown health clinics, which are all in the same building, the sneaky virus could make its way to Heiserman without her knowing it. Although she could still be vaccinated up to five days after this exposure, she would first have to realize she'd been infected. It could be two full weeks before she developed the obvious symptoms of smallpox.

For about 12 days, the virus would replicate and spread, during which time Heiserman would be totally symptom-free and not contagious. When the incubation became complete, she'd suddenly be laid low with a fever, body aches and vomiting spells, like the worst flu she'd ever had. At that point she'd be somewhat contagious but probably too sick to do anything but lie in bed. Three or four days later, spots would appear on her tongue and mouth, becoming open sores; then a rash would bloom on her face and arms. Oddly, at that point her fever would subside, and she'd begin to feel better.

"You'd feel well enough that you might go to work to check your messages, or go to the pharmacy, or to the doctor," says Dr. Bicknell. "But you're actually at your most infectious." Heiserman would spread the virus wherever she went, until 2 to 4 days later—about 17 days after exposure—her symptoms would return with a vengeance, and the nature of her illness would at last be clear. The bumps, now covering her body, would plump up and turn pearly with pus, each with a cleft in the center. From there, her illness could go one of two ways. Her pustules could form crusts and scab over, leaving her scarred and perhaps blind. Or she could die. Epidemiologists don't understand exactly how smallpox kills, but death usually comes by way of toxic shock or a total immune system overload.

It's a horrible thing to contemplate, of course. Worse, Heiserman's illness could only be the result of terrorism, meaning others had been exposed. What would happen in such a crisis if not enough health-care workers were prevaccinated? Many experts, including Dr. Strom, feel that because the vaccine starts kicking in the moment it's administered, "if we're well organized, we could handle it if we vaccinated post-event." Others point out that while the vaccine can save your life if given within the five-day window, it may not be strong enough to prevent every symptom of the disease. If doctors fell ill, they'd be unable to treat the public.

Brace yourself for the worst-case scenario. Let's say, as Dr. Bicknell suggested in Reviews in Medical Virology, that an attack is performed by five smallpox-infected terrorists, each in a different U.S. city. During the two to four days when they're highly contagious but mobile, they'd infect as many people as possible—riding mass transit, visiting shopping malls—then do the same in two more cities. We'll assume that rather than wind up in hospitals, where their smallpox would be detected, each terrorist would die in seclusion, undiscovered for days.

Each terrorist could infect 120 to 1,000 people, totaling 600 to 5,000 unknowing victims, Dr. Bicknell told SELF. When this first wave of victims starts feeling sick, most will think they have a raging flu; they'd probably only stagger to the hospital after the rash develops. (Conceivably, the recent emergence of severe acute respiratory syndrome, or SARS, could improve smallpox response time by making people more likely to seek treatment for fluish symptoms.) By that time, not only would it be too late to protect them with the vaccine—they would be beyond the five-day postexposure window—but also they would have infected others, most likely their family, friends and coworkers. At the hospital, they'd infect the unvaccinated doctors, nurses and EMTs caring for them.

Some astute doctor would surely suspect smallpox, says Dr. Strom. "The CDC would immediately swoop in," he says. "They'd send a team of people with vaccination kits, and they'd do the workup" to make sure it really is smallpox. Once it's confirmed, all hospital staff who dealt with infected patients—and perhaps, to be cautious, all staff, period—would be vaccinated. Everyone would start working the phones, tracking down the people who had contact with the victims in the week or two prior and summon them in. But because those people might be contagious, too, investigators would also seek out and vaccinate everyone they had contact with, creating two concentric circles of immunity around each victim.

But how do you find the strangers who sat beside an infected person on the subway, or stood next to her at the supermarket checkout? "In some situations, you can't be sure that there aren't other cases out there, so you'd go ahead and vaccinate the whole metropolitan area," says Dr. Strom. The message would be broadcast over the media; health officials would go knocking on doors. And every hospital in the nation would be on alert, because the moment a case cropped up in a second city—in our scenario, a mere matter of time—it would become clear that the virus was loose, and the entire country would probably have to be vaccinated.

"Medical facilities would be completely overwhelmed," predicts Elin Gursky, D.Sc., a senior fellow for biodefense and public health programs at the ANSER Institute for Homeland Security in Arlington, Virginia. "Our hospitals don't have enough beds or nurses to handle even large car accidents, let alone a smallpox attack." With many infected health-care workers, this understaffing would only get worse. Having never encountered a crisis of this nature before, the system would be unfamiliar, and it would take precious hours or days to get each clinic up and running smoothly. Meanwhile, the longer it takes to vaccinate the public, the more havoc smallpox would wreak.

Vaccinating a sufficient number of health-care workers is crucial, then, but it's only half the battle. This past December, each state was required to submit its own plan of action, outlining exactly how it would respond to a smallpox outbreak, to the U.S. Department of Health and Human Services. It's a start. But, says Gursky, "these plans need to be rehearsed. We have learned from the anthrax attack just how much work needs to be done. We have huge gaps we need to fill to meet the threat of bioterrorism." Which is why, even though the smallpox vaccination campaign is relatively well funded—the Bush administration has allocated $1.4 billion for bioterror preparedness this fiscal year—Gursky is still deeply skeptical about our readiness. "The most expensive computers aren't going to help us if the foundations of our public health system are weak. We can't afford complacency," she adds. "That will be our undoing."

Maron was vaccinated the day before Valentine's Day, a Thursday. By Saturday she had an itchy blister. "That was probably the worst part for me, the itching," says Maron. By Monday it had become a grayish pustule. Her sons wanted a look, so Maron took off the gauze, and they peered at it from a few feet away, while the older one teased, "Ooh, I'm gonna touch it!" Each evening, Maron put on a sleeveless shirt and shut herself in her bedroom for a while to get some air to the wound. She wore latex gloves to change the dressing, sealed the dirty bandages in a Ziploc bag before throwing them away and scrubbed her hands obsessively. By day seven, the site had scabbed over, and three weeks later the ordeal was finished. Maron is low-key about the whole thing, saying, "It didn't really disrupt any part of my life," not even her daily 4-mile run.

Jacqui Heiserman stands by her decision to decline the vaccine, especially after the spate of heart-related problems among people who took it. "For a while I was thinking I might reconsider, but I don't think I'll ever get the vaccine now," she says. "Two women have died. I have three children. I'm not going to take that chance." Even so, as she watched the war in Iraq play out on television, Heiserman realized that despite having made up her mind, she still can't rule out a vaccination in her future. "Right now there's no reason to take that risk, but two hours from now there could be a confirmed smallpox case reported, and everything would change. All bets are off then," she says. "It's a frightening world."

Sabrina Rubin Erdely is a National Magazine Award—nominated journalist in Philadelphia.