Director, Program in Law, Science, and Public Health. Harve

1
Preparing for Smallpox

• Edward P. Richards, JD. MPH
• Director, Program in Law, Science, and Public
  Health
• Harvey A. Peltier Professor of Law
• Louisiana State University Law Center
• richards_at_lsu.edu
• http//biotech.law.lsu.edu

2
What is the Real Risk?

• Casualties or a Break Down in Social Order?

3
Why TOPOFF is Deceiving

• The two most important variables - the public and
  the media - are not involved
• No one is at risk
• No one gets sick, has to get vaccinated, or even
  risks political embarrassment
• Everyone shows up at work!
• Medical care capacity is not challanged

4
Lessons and Limits from SARS

• Excellent compliance with home quarantine
• No panic and overwhelming of hospitals
• Depended on
• Comprehensive public medical care system
• Most cases were health care workers
• No vaccinations or prophylaxis
• Government provided compensation and daily
  support
• Complete trust in the Health Officer and system

5
Key Issues in the US

• Uncertain Information
• Inappropriate Expertise
• Unreliable Plans
• Potential Catastrophic Breakout

6
Uncertain Information

• There is no good data on smallpox transmission in
  a naïve population
• There is no good risk data on mass immunizations
  in a naïve population with significant
  immunosuppression
• Community reaction to anthrax, which posed little
  risk, is not reassuring for smallpox

7
Inappropriate Expertise

• Public health directors are chosen for
  administrative and political skills
• Most public health physicians are experts in
  personal medical care, not disease control
• Many departments have lost their most skilled
  professionals
• Very limited trust of health officials

8
Unreliable Plans

• States and local government produced plans to get
  federal funding
• Plans must show community preparedness
• Plans assume that all personnel will show up for
  work and obey all orders
• Employees who question whether plans are workable
  are fired

9
Potential Catastrophic Breakout

• Epidemics in naïve populations can spread
  geometrically
• Underestimating current cases or transmission
  rates leads to dramatic errors in estimates of
  future cases
• If public cooperation with control efforts breaks
  down, it will be very difficult to reestablish
  order

10
Command and Control Issues

• How do you evaluate the reliability of technical
  experts you have to depend on?
• How do you deal with questionable experts and
  strategies?
• How do you deal with unworkable or incomplete
  plans?

11
Examples of Ignored Issues

• Every police officer, health care worker, and EMS
  worker has to be vaccinated within hours of an
  outbreak
• Plans say no mandatory vaccinations
• Compensation for time off work, medical and
  other costs is critical
• Individual eligibility for vaccination should be
  known before an outbreak
• What about illegals and others outside the system?

12
Public Participation and Information

• The general public and the media need to know
  well before an outbreak what each individual can
  expect and will be expected to do
• What they are told must be what you are going to
  do, including the strategy for managing a
  breakout
• This forces a discussion of compensation, health
  care access, and mandatory or mass vaccination

13
Strategic Issues

• How do you anticipate breakout?
• How do you decide when to start mass
  immunization?
• Will you shoot the soccer mom and kids to enforce
  quarantine?
• Is the CDC's mass immunization plan workable, or
  should we use a variant of the 1947 model?
• How do our plans change if there is smallpox
  outside the US?

14
Wrap-Up

• Smallpox bioterrorism is possible because of
  hubris
• Current plans assume there will be no breakdown
  in public services and a compliant public
• There is no fallback if these assumptions are
  wrong
• A fallback plan and decision criteria must be in
  place before an outbreak