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The stand: Sometimes the truth is told by an outlier
Health care epidemiologists must resist intimidation
In the turbulent days after 9/11 and the anthrax attacks, during the buildup to war in Iraq, the federal government undertook an ambitious plan to vaccinate half a million health care workers against smallpox. The vaccine to be used was not without risk to recipients and could possibly endanger patient contacts. Smallpox remains eradicated in the wild, but is frozen in repositories in the United States, Russia — and the thinking then was — possibly Iraq.
Richard Wenzel, MD, professor and chairman of the department of internal medicine at the Medical College of Virginia in Richmond, stood up and said, "No." He paid for it by having his patriotism questioned and being blasted by major media outlets for undermining the war against bioterror.
Wenzel suggested the alternative of preparing to vaccinate workers within 24 hours should smallpox appear anywhere in the world.
"We had a plan to immunize all 6,000 health care workers within 24 hours with the announcement of a single case anywhere in the world," he recalls, "but we weren't going to immunize anybody until we knew there was smallpox. I also knew, with smallpox vaccine, even after exposure you still have about five days [to immunize], so that gave us a level of confidence."
Factored into the decision by Wenzel and others that took a similar stance was the low but potentially serious risk to the person vaccinated, and beyond that the threat to any immunocompromised (e.g., HIV) or otherwise contraindicated (e.g., atopic dermatitis) potential contacts of vaccinees.
"Remember that the vaccine was officially stopped in 1980, and that was prior to a lot of things, the AIDS epidemic for example," he says. Moreover, many more patients were on chemotherapy and powerful immune suppressants since the last time smallpox vaccine was being broadly administered, notes Wenzel, a 35-year veteran of health care epidemiology.
"The patient population in our hospital again was highly immune suppressed," he recalls. "There was a risk there would be transmission from health care workers, and even a single case or two could have been devastating."
Then came the backlash. An irate editorial in The Washington Post was followed by a similar piece in The New York Times, which branded the action as "deplorable" and warned "the refusal to participate raises needless suspicions about the nation's smallpox preparations and could, if dropout fever spreads too widely, undermine efforts to prepare for bioterrorism."1
Wenzel was, to say the least, taken aback and disappointed. He had the full support of his hospital president, but there were undercurrents of concern that federal funding could be withdrawn from the university. He was clearly out of step with the public and political mindset of the time. "I think there was a general fervor in the country that we were in imminent danger of bioterror — that even in the absence of data, we should go ahead," he says. "A preparation for war took over the thinking of a lot of people."
Wenzel's position was vindicated by history. When no weapons of mass destruction were found after the invasion of Iraq, the smallpox vaccination program ground to a halt with 38,000 health care workers immunized. In addition to reports of encephalitis, myocarditis, eye infections and assorted rashes and reactions, two fatal heart attacks following smallpox vaccination of health care workers occurred in 2003. The point remains, however, that Wenzel and his team were ready to immunize workers if smallpox was unleashed on the world.
"If you really think you have done a fair assessment of the risk and the benefit and then somehow yielded to political pressure, to me that would have been horrible," he says. "For me, it would have been very difficult to do anything other than what we did."