Smallpox and biological warfare: the case for abandoning vaccination ...

Commentaries Smallpox and Biological Warfare: The Case for Abandoning Vaccination of Military Personnel LINNEA CAPPS, MD, MPH, STEN H. VERMUND, MD, MSC, AND CHRISTINE JOHNSEN, RN, MPH Abstract: Smallpox was officially declared eradicated from the world in 1980. Earlier, in 1972, over 50 nations signed the Biological Weapons Convention renouncing this entire category of weapons. Despite this international agreement, both the United States and the Soviet Union continue to vaccinate their military troops against smallpox, thus implying that each fears the other might still use it in

biological warfare. Vaccination is not a harmless procedure, and vaccinia infections continue to be reported in troops and their contacts. Negotiating an end to the vaccination of troops would be a final step in ending the fear of smallpox. (Am J Public Health 1986; 76:1229-1231.)

Introduction

of causing disease or death in man, animals, or plants.2>22 When the intended victim of biological warfare is man, attempts might be made to infect man through intermediate hosts, such as insects, rodents, or birds.23'24 Biological agents fall into two broad categories, with some overlap: lethal and incapacitating. Incapacitating agents have been of interest since the nineteenth century as a means of waging so-called "humane war", or war without death. Two other presumed advantages of biological warfare are the preservation of property, and the usefulness of biological agents in sabotage through the undetected contamination of air and water supplies. In May 1925, under the auspices of the League of Nations, a conference on the international arms trade was convened in Geneva to tackle the problem of poison gas, which had been used in World War I. After a month of debate, during which time the Polish delegates successfully advocated a ban on germ weapons as well, the Geneva Protocol was signed, on June 7, 1925. The Protocol banned the use of biological weapons but did not explicitly ban stockpiling them.25 Many of the states which ratified the protocol, including France, Great Britain and the Soviet Union, did so only with two reservations: 1) the agreement would not be binding if they were fighting a country which had not ratified the protocol; and 2) if they were attacked using chemical or biological weapons, they reserved the right to reply in kind.26 Merely signing the Protocol was not binding; individual countries had to ratify it. The US Chemical Warfare Service immediately launched a successful lobbying effort and the US Senate did not ratify the Geneva Protocol. It was not resubmitted to the Senate until 1970. In 1972, over 50 nations, including Britain, the US, and the USSR, signed the Biological Weapons Convention. The agreement required them to renounce this entire category of weapons and to destroy their existing stocks. This was the world's first true disarmament agreement, since it required the actual destruction of weapons. In unequivocal terms, the Convention called for the parties never to undertake, in any circumstances, to develop, produce, stockpile, or otherwise retain: microbial or other biologic agents that have no justification for prophylactic, protective or other peaceful purposes; and weapons, equipment or means of delivery designed to use such agents or toxins for hostile purposes or in armed conflict.25'27 United States policy, finally established

On May 8, 1980, the Thirty-third Assembly of the World Health Organization (WHO) certified that smallpox had been eradicated from the world.' Recent control efforts have concentrated on orthopox virus surveillance and on policy initiatives to reduce the risk of reintroduction of the virus. 1-3 All but two of the world's laboratories have destroyed their stocks of variola virus to reduce the risk of accidental dissemination.4 Smallpox virus can live for many years in inanimate material,5'6 and recent attention has been focused upon theoretical risks from archeological finds.7 With the exception of permafrost-preserved specimens,& ° archeological finds will not pose a threat to the public health.' ''3 Dangerous mutations of animal viruses related to smallpox could occur,'4 although the molecular and epidemiological evidence so far suggests no real risk.5",6 A more realistic source of potential reintroduction of smallpox would be the use of the virus as an agent of warfare.'7 The United States and the Soviet Union continue to vaccinate their military troops, each apparently fearing the other will use smallpox in bacteriological warfare. 18 One well known expert goes so far as to state: "There will continue to be a requirement for vaccination of ... military personnel, since smallpox will become an increasingly attractive bacteriological warfare agent...."19 We review here the precedents for use of smallpox as an agent of warfare, current vaccinia use in military personnel, and the public policy option which might eliminate the threat of smallpox use as a biological agent of war. Biological Warfare Biological warfare involves the use of biological agents with or without chemical agents, as weapons for the purpose From the Division of Epidemiology, School of Public Health, and the Departments of Medicine and Pediatrics, College of Physicians and Surgeons, Columbia University; and the Departments of Medicine and Ambulatory Care, Harlem Hospital, NYC. Dr. Capps is currently working with Aesculapius International Medicine in El Salvador; Dr. Vermund is now with the Departments of Epidemiology and Social Medicine, and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center. Address reprint requests to Dr. S. Vermund, Department of Epidemiology & Social Medicine, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467. This paper, submitted to the Journal July 22, 1985, was revised and accepted for publication June 4, 1986. Editor's Note: See also related editorial p 1189 this issue. C 1986 American Journal of Public Health 0090-0036/86$1.50

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by Congress in 1975, bans first use of chemical weapons and any use of biological weapons. After the signing of the Convention, interest and concern about biological warfare among health professionals and scientists appeared to wane. The number of articles listed in the Index Medicus under the heading of biological warfare dropped from a high of 19 in 1970 to zero or one per year in most years after 1972. Recently the subject has generated new concern over the possible use of mycotoxins ("yellow rain") in Southeast Asia and Afghanistan,2830 and indications that the US military is increasing its biological warfare research. President Reagan has sought $8.4 million to expand the US Army's biological warfare research laboratory at Dugway, Utah. Senator James Sasser of Tennessee, in objecting to the President's request, said he saw "potential capabilities for testing and production of offensive lethal biological and toxin weapons" at this facility.3 Smallpox as a Potential Agent

Naturally acquired smallpox has occasionally played a greater role in the outcome of a military campaign than the battles themselves.32'33 While no evidence exists of its successful use as a biological agent, the plan by British Colonial military commanders to use it against the American Indians in the Eighteenth Century is well documented.34'35 Allegations of deliberate use of smallpox in war were made in the Civil War of the United States.36'37 Even the Twentieth Century has testimony of development and possible use of smallpox-containing biological weapons by the Japanese in China during World War 11.26 38 It was only after years of effort by the WHO that several countries finally gave up their stocks of smallpox virus. Since the only non-scientific reason to have smallpox virus would be for offensive purposes, fears of biological warfare were probably among the reasons for the countries' reluctance to give it up.'7 The US Army Medical Research Institute of Infectious Diseases maintained a stock of smallpox virus until April 1980, when it reported transferring its variola virus strains to the Centers for Disease Control (CDC) in Atlanta.'l On December 10, 1983, South Africa destroyed its variola virus stocks, leaving only two known laboratories in the world which maintain smallpox virus, the CDC and the Research Institute for Viral Preparations in Moscow.4 Both are maximum containment facilities and are approved and periodically inspected by WHO. The genetic map and DNA clonal libraries of various strains of variola virus are still the subjects of scientific investigation; destruction of remaining virus would be imprudent prior to the completion of these projects (Z. Jezek, personal communication). Smallpox has poor potential as a weapon. It is potentially lethal and can be produced in quantity, maintained in storage, transported, and disseminated. Like other viruses, however, it is more difficult to produce and maintain than most bacteria. There is some immunity to it among most populations but this is now decreasing in the absence of the disease and routine vaccination. A user of smallpox as a weapon could be protected by the vaccine. However, the vaccine is also the key to controlling smallpox and can be administered quickly and easily.8"6 Unless public health services have completely broken down, any outbreak could be quickly contained with the same surveillance-containment strategy used in the eradication campaigns." 39 The CDC presently maintains 19 million doses of vaccine in storage, ready for use in an outbreak. In storage in Geneva and Lausanne are 1230

vaccines sufficient to protect 200 to 300 million people (Z. Jezek, personal communication).

The American and Soviet Military Unfortunately, despite international agreements against biological warfare and the problems with using smallpox as an agent, the fears are still present. A recent Soviet admission underscores the absurdity of the situation. Professor P.N. Burgasov, Deputy Director of the Ministry of Health, stated at a March 1986 meeting of the WHO that the Soviets had stopped vaccinating their troops in 1979 but began again in 1984 (J.H. Nakano, personal communication). No reason was given for this action; presumably it was related to the fact that the American military has continued to vaccinate its troops. Apparently, the Soviets did not inform the WHO of their decision to cease troop vaccination.40 As of February, 1985, the US military was maintaining approximately 1.3 million doses of smallpox vaccine in stock. In recent years, 1.8 to 2.4 million doses per year have been purchased. From the time of the last case of smallpox in 1978 through 1984, the cost of the vaccine to the US government has been at least $1.5 million (Defense Personnel Support Center, US Department of Defense, Philadelphia, PA, data on file). The total cost of the effort is probably several times higher since this figure does not include shipping and administration. Vaccination of military personnel is generally safe, but is not without risk.41 The vaccine has side effects and can produce vaccinia, an illness characterized by vesicular skin lesions in the person vaccinated, or in a person in contact with the vaccinated individual.42 5 One military recruit developed generalized vaccinia in 1984 and was severely ill (R. Redfield, personal communication). He had human immunodeficiency virus infection and cryptococcosis, illustrating the hazard of vaccinia vaccines in immunosuppressed

hosts./'

Suggestion for Action Only the USSR and US have smallpox virus in culture. Although these nations could still conceivably use it as an agent of sabotage or war, it is precisely the USSR and the US which spearheaded the worldwide eradication of smallpox. The editors of the New York Times noted this superpower collaboration for the benefit of world health, and went on to suggest that "the same two benefactors owe one last contribution" by ceasing the vaccination of their troops.47 Smallpox, like other biological weapons, is inefficient and uncontrollable. "It is difficult to imagine any purpose for which a country would be willing to incur the odium of reintroducing the disease."47 Negotiating an end of the vaccination of troops, with its reassuring implications for reduced biological warfare risk, would be a final step in ending the fear of smallpox 48 REFERENCES 1. World Health Organization: The Global Eradication of Smallpox. Geneva: WHO, 1980. 2. World Health Organization: Smallpox surveillance. Wkly Epidemiol Rec 1978; 53:265-6, 279. 3. Centers for Disease Control: Investigation of a smallpox rumor-Mexico. MMWR 1985; 34:343-344. 4. Centers for Disease Control: Smallpox: post-eradication policy - destruction of variola virus stocks. MMWR 1984; 33:24. 5. Wolff HL, Croon JJAB: The survival of smallpox virus (Variola minor) in natural circumstances. Bull WHO 1968; 38:492-493. 6. Thomas G: Survival of smallpox virus. Lancet 1985; 1:291. 7. Zuckerman AJ: Palaeontology of smallpox. Lancet 1984; 2:1454. 8. Last JM, Jessamine AG: Survival of smallpox virus. Lancet 1985; 1:291.

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COMMENTARY 9. Meers PD: Smallpox still entombed? Lancet 1985; 1:1103. 10. Lewin PK: Mummified, frozen smallpox: Is it a threat? JAMA 1985; 253:3095. 11. Hopkins DR: Smallpox entombed. Lancet 1985; 1:175. 12. Baxby D: Survival of smallpox virus. Lancet 1985; 1:291. 13. El-Mallakh RS: Night of the living dead: Could the mummy strike again? JAMA 1985; 254:3038. 14. Mayr A: Zur Gafahrdung des Menschen durch Tierpocken nach Aufhebung der Pflichtimpfung gegen Pocken. Hautarzt 1985; 36:493-495. 15. Esposito JJ, Nakano JH, Obijeski JF: Can variola-like viruses be derived from monkeypox virus? An investigation based on DNA mapping. Bull WHO 1985; 63:695-703. 16. Henderson DA: The eradication of smallpox. In: Last JM (ed): MaxcyRosenau Public Health and Preventive Medicine, 12th Ed. Norwalk, CT: Appleton-Century-Crofts, 1986; 129-138. 17. Wade N: Biological warfare fears may impede last goal of smallpox eradicators. Science 1978; 201:329-330. 18. Fenner F: The eradication of smallpox. Prog Med Virol 1977; 23:1-21. 19. Benenson AS: Smallpox. In: Evans AS (ed): Viral Infections of Humans: Epidemiology and Control, 2nd Ed. New York: Plenum Medical Book Co., 1982; 541-568. 20. Hersh SM: Chemical and biological warfare: The hidden arsenal. London: Panther Books, 1968; 68-101. 21. Cookson J, Nottingham J: A survey of chemical and biological warfare. New York: Monthly Review Press, 1969. 22. Murphy S, Hay A, Rose S: No fire, No thunder: The threat of chemical and biological weapons. New York: Monthly Review Press, 1984; 26-61. 23. Sidel VW, Goldwyn RM: Chemical and biologic weapons - a primer. N Engl J Med 1966; 274:21-27. 24. Clarke R: The Silent Weapons. New York: David McKay Company, 1968; 87-115. 25. Lambert RW, Mayer JE: International Negotiations on the Biological Weapons and Toxin Convention. Washington, DC: US Arms Control and Disarmament Agency, 1975. 26. Harris R, Paxman J: A Higher Form of Killing. New York: Hill and Wang, 1982; 73-74. 27. Anonymous: Biological warfare banned. Br Med J 1972; 2:180-181. 28. Holden C: 'Unequivocal' evidence of Soviet toxin use. Science 1982; 216:154-155. 29. Harruff RC: Chemical-biological warfare in Asia. JAMA 1983;

250:497-498. 30. Marshall E: A major retreat on the yellow rain battlefront. Science 1984; 223:1046-1047. 31. Biddle W: Fund for Army Biological Warfare Unit Approved. New York Times, Dec. 7, 1984; A-23. 32. Hopkins DR: Princes and Peasants: Smallpox in History. Chicago: University of Chicago Press, 1983. 33. Shurkin JN: The Invisible Fire. New York: GP Putnam and Sons, 1979; 101-143. 34. Parkman F: The Conspiracy of Pontiac. Boston: Little, Brown and Co, 1984; 423-424. 35. Steam EW, Steam AE: The Effects of Smallpox on the Destiny of the Amerindians. Boston: Bruce Humphries, 1945; 39-40. 36. Steiner PE: Disease in the Civil War-Natural Biological Warfare. Springfield, IL: Charles C. Thomas, 1968; 42-43. 37. Kean RGH: Inside the Confederate Government. New York: Oxford University Press, 1957; 89. 38. Ienaga S: The Pacific War. New York: Pantheon Books, 1968; 188-189. 39. Foege WN, Millar JD, Henderson DA: Smallpox eradication in West and Central Africa. Bull WHO 1975; 52:209-222. 40. World Health Organization: Smallpox: Post-eradication surveillance vaccination policy. Wkly Epidemiol Rec 1984; 59:278. 41. Neff JM, Lane JM, Pert JH, Moore R, Millar JD, Henderson DA: Complications of smallpox vaccination. I. National survey in the United States, 1963. N Engl J Med 1967; 276:125-132. 42. Centers for Disease Control: Vaccinia outbreak-Newfoundland. MMWR 1981; 30:453-455. 43. Urdahl P, Rosland JH: Vaccinia genitalis. Tidsskr Nor Laegeforen 1982; 102:1453-1454. 44. Centers for Disease Control: Contact spread of vaccinia from a recently vaccinated Marine-Louisiana. MMWR 1984; 33:37-38. 45. Centers for Disease Control: Contact spread of vaccinia from a National Guard vacinee-Wisconsin. MMWR 1985; 34:182-183. 46. World Health Organization: Recombinant vaccinia viruses as live virus vectors for vaccine antigens: Memorandum from a WHO/USPHS/NIBSC meeting. Bull WHO 1985; 63:471-477. 47. End the fear of smallpox. New York Times, Jan. 30, 1984; A16. 48. Chemical and biological weapons: A matter of medical concern. Lancet 1986; 1:1106.

Johnson Foundation Launches Health Care Program for Uninsured The Robert Wood Johnson Foundation recently announced grants to six state and local demonstration projects, listed below, aimed at bringing health services to people who lack health insurance and cannot afford care. Selected from over 50 applicants, the projects funded under this first round of the Health Care for theUninsured Program are unique in design and in how they address the needs of specific populations at risk. As many as 20 projects will be funded for periods of up to three years under the Program. Total funding for both rounds will be as much as $6.5 million. Round two grants will be announced in January 1987. The University of Alabama at Birmingham Medical Center-Develop a low-cost insurance program allowing the working uninsured to purchase an HMO-like benefit plan providing limited primary (including prevention services) and secondary care benefits. Arizona Health Care Cost Containment System-Develop a program for small businesses and the working uninsured to purchase affordable comprehensive health benefits through the state's established network of HMOs. Puget Sound Health Systems Agency (Seattle, WA)-Provide managed health care to 30,000 uninsured indigent individuals using state-subsidized insurance coverage and networks of primary care providers. San Diego Council of Community Clinics-Develop and implement a low-cost primary care benefit package for working poor and unemployed people through a closed panel network of participating clinics. State of Wisconsin Department of Health and Social Services-Modify the state's Health Insurance Risk Sharing Pool to allow high-risk individuals to be separately insured through the pool to reduce the group's overall risk assessment in the private market. Tennessee Association of Primary Health Care Centers, Inc.-Make low-cost prepaid health care insurance coverage available to small employers and the medically indigent, through a network of community health centers. AJPH October 1986, Vol. 76, No. 10

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