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Smallpox Vaccine Not for Everyone

Bush, but not his family, will get it, and experts say many others shouldn't also

FRIDAY, Dec. 13, 2002 (HealthDayNews) -- Have you ever had a rash in the crease of your elbow or behind your knee? Even if it was decades ago, that could be enough to knock you off the list of Americans eligible to get the smallpox vaccine.

Plenty of other people may find themselves exempt too -- pregnant women, patients undergoing chemotherapy, organ transplant recipients and AIDS patients.

The list goes on and on -- all the way to Americans who live with vulnerable people. They shouldn't get the smallpox vaccine either for fear they'll infect their housemates.

As expected, President Bush announced the nation's smallpox vaccination plan today, saying that the jabs will be mandatory for the military and that health-care workers will be next. For the rest of the country, however, the inoculations will be voluntary because, he said, the threat of a smallpox attack by terrorists isn't imminent and the vaccine carries risks.

At a White House briefing, Bush said he personally would get the vaccination.

"As commander in chief [of the armed forces], I do not believe I can ask others to take this risk unless I do the same," he said.

But the White House will first have to determine whether others living and working there are vulnerable, because Bush also said that neither his family nor his staff will be inoculated.

"Our health and national security experts do not believe a vaccination is necessary for the general public," Bush said.

Experts also say a substantial number of Americans should avoid the vaccine.

"An estimated 20 to 40 percent of the population should not be vaccinated," said Dr. Steve Black, director of the Kaiser Permanente Vaccine Study Center in Oakland, Calif.

But it won't be easy figuring out who must avoid the vaccine.

Perhaps the most unusual vaccine risk factor is a history of the skin disease known as eczema. The infection can strike at any age, causing a rash that usually can't be cured without the use of a prescription cream. The infection commonly strikes creases in the skin, such the inside of the elbow and the back of the knee.

Researchers don't know what causes eczema and a sister disease, atopic dermatitis, which is also a vaccine risk factor. But it is clear that people who have had eczema may be left with skin that's especially susceptible to the virus that is in the vaccine.

"Their skin doesn't operate the way other people's skin does," Black said, "even though there's no visible difference."

People who get the smallpox vaccine become infected with a dime-sized pustule on their upper arms. If all goes well, the pustule -- an infection with a virus similar to smallpox but much less dangerous -- will heal and leave the body primed to fight smallpox.

In people who have had eczema, however, the virus can spread across the skin to other parts of the body, said Dr. Corry Dekker, medical director of a children's hospital at Stanford University.

"Under the current circumstances, when there hasn't been any release of smallpox, those people would be best served by sitting tight and not getting vaccinated now," Dekker added.

The challenge will be to figure out who's had eczema. "As many as 8 percent -- or more -- of children may get an infection. It's a rash that could come and go through childhood and then be quiet for the rest of a person's life," Dekker said.

But even dormant eczema can make the smallpox vaccine more dangerous than usual.

Other vaccine risk factors are harder to miss. The virus in the vaccine could get out of control in anyone with a compromised immune system, so AIDS patients and those taking immunosuppressive drugs -- like organ transplant and lupus patients -- can't take the vaccine. Some asthma patients may be at risk too because of the drugs they take, Black said.

In patients with weakened immune systems, the pustule wouldn't heal, he said. "It would get larger and spread all over their body on the surface and also inside as well. These people get really quite ill."

The virus caused by the vaccine is also contagious, and Black said people who live with members of risk groups shouldn't take it.

These various challenges are unavoidable, he said, especially considering that the smallpox vaccine is not a modern invention.

"It's been purified more and comes in a prettier bottle, but it's the same vaccine used 200 years ago. We're used to medicine with more sophistication, a kinder, gentler approach to prevention," Black added.

What To Do

For more on the smallpox vaccine, go to Stanford University or the Centers for Disease Control and Prevention.

SOURCES: Dec. 13, 2002, announcement by President Bush, White House, Washington, D. C.; Steve Black, M.D., director, Kaiser Permanente Vaccine Study Center, Oakland, Calif.; Corry Dekker, M.D, medical director, Lucille Packard Children's Hospital, Stanford University, Palo Alto, Calif.
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