Interim smallpox guidelines for the United Kingdom

Department of Health interim guidelines for management of deliberate release of smallpox virus are deeply flawed (www.doh.gov.uk/smallpoxguidelines)1. The guidelines assume a one- dimensional picture of a clinical emergency. It will prove to be anything but.

Governmental control of a national emergency is legitimate. The Department of Health, however, is not set up to deal with a civil emergency, as severe disruption of the community life, panic, likely violation of human rights and the sheer logistics of managing even a single smallpox case makes it an issue of civil defence to be managed at the highest possible government level

Besides riding roughshod over local government’s legal authority to manage a notifiable disease bypasses tried operational procedures entrenched in the community using local resources. Meltdown of the proposed arrangements will be inevitable at the mere whisper of an occurrence of an incident.

Little consideration is given too to personal freedom issues except to note that unimmunised patients will be soon too ill to resist compliance. They may of course spread the infection freely until they become moribund.

The accidental Birmingham laboratory release of small poxvirus in August 1978 during the countdown of world smallpox eradication resulted in the population of a major urban city systematically searched for first line contacts and isolated from the rest of the community for the first time in modern public health history.

A massive surveillance-containment organisation was set up to offer social, clinical, diagnostic and pathological support to the population at risk and rest of the community for unexplained fevers especially those accompanying a rash. 2. Considering an annual Birmingham birth rate of over 15,000 babies (a child population of 75,000 under 5 years of age), the number of daily cases of chicken pox in the city alone required roving medical teams, working round the clock, to deal with chickenpox reported in their hundreds weekly.

60 doctors, 40 nurses, 85 environmental health officers, 6 disinfecting operators and 90 administrative, clerical and support staff took part in the control - operated twenty-four hours a day - for 6 weeks and then for another six weeks of winding down of the outbreak management. 3. The city was divided into four operational units and 30 telephone lines were installed at a time when communication needs were considerably less sophisticated than today.

Smallpox vaccination was not an issue as the source of the infection was soon located and shut down. It would have added considerably to the resource requirements if immunisation clinics had to be set up. Besides, the emphasis was on surveillance containment. A policy based on immunisation unaccompanied with vigorous isolation of contacts would probably have resulted in a confused picture of persons at risk mixing freely with the non-contact population.

Three hundred and twenty-eight (5000 person-days) of 414 general Categories contacts were placed under quarantine. Of these 75 contacts were considered close category A contacts. Category A contacts were put under medical surveillance, while category B and other contacts were under nursing supervision.

And that was for just one smallpox case!

This was the nightmare picture in the summer of 1978 in Birmingham. Mitigating circumstances were that most of the adult population was reasonably immune to small pox because of previous vaccination.

Further a relatively stable population, familiar with smallpox infection and more compliant in its time than now were other supportive factors. The incident was brought to a conclusion to the satisfaction of WHO without delaying the world smallpox eradication timetable.

I predict personal freedom objections from the community and Health care workers against vaccination 4. Not only can smallpox vaccination leaves an ugly scar, it is not clear if the benefits of smallpox vaccination outweigh the risks to vaccinees, their families and patients. We already know of the reluctance of NHS staff to accept influenza vaccination for occupational reasons. There will also be the bar to Department of Health to use public health infection control legislation to ensure compliance as that is the remit of the local authority excluded from control management.

Managing deliberate release of smallpox virus is a civil defence matter of the utmost national importance requiring emergency action at the highest government level. Nothing less will do. The confusion in the handling of the anthrax scare is an abject lesson in planning inappropriately at local levels. Deliberate launch of smallpox virus will be an unparalleled escalation of act of bioterrorism. We underestimate its impact at our peril.

Yours truly

Surinder Bakhshi Consultant in communicable Disease control (Retired)

References

1.Interim smallpox guidelines for the United Kingdom

Harling R, Morgan D,Edmunds WJ and Campbell H.

BMJ 2002; 325: 1371-1372

2.Department of Health. Memorandum of the outbreaks of smallpox. London: DoH 1977

3. Nicol W, Bakhshi SS. Exotic infectious diseases -smallpox. Royal Society of Health Journal April 1980

4 Moynihan R. Health professional challenge US smallpox vaccination plan (News). BMJ 2003: 326, 179.

Competing interests:   None declared