The Law and Politics of Smallpox Edward P. Richards

Modeling Infectious Diseases What makes a disease a plague? Which plagues make good bioterrorism agents? You can predict this from a core set of variables You manage a natural epidemic or bioterrorism event by modifying these variables

Key Variables

I = Infectivity How easy is it to catch the disease? The flu is easy Respiratory spread (you rub stuff in your eyes) Causes coughing which sheds virus Same as smallpox HIV versus Gonorrhea Anthrax – can be pneumonic, but not often Bioengineering to increase infectivity

S = Severity of illness The usual flu is a massive world wide epidemic each year but it is not severe so we do not care In flu was deadly That is why SARS scared the epidemiologists so much Severity includes treatablity Treatability only matters if you can do it Creates terrible justice issues if limited

T = Susceptible population How many people can catch the disease? Vaccinations attack disease by reducing the number of susceptible persons Direct protection Herd Immunity Jacobson v. MA People need to fear the disease Tort law has undermined faith in vaccination The CDC and many states have lost the will to say vaccination will be mandatory

P = Persistence Does the disease persist in the environment? Anthrax spores stick around Probably not nearly as dangerous as people think We have created such fear that cleanup will be difficult Smallpox can linger on personal effects but not in the general environment Cholera, typhoid, plague, SARS, and many diseases have non-human hosts which makes eradication impossible

D = Duration of infective Stage How long can you spread the disease? Makes a huge difference in the ability to restrict individuals Tuberculosis can be months or more SARS was 10 days Smallpox is about 2 weeks on the outside The longer the period The more demand for due process The higher the cost of providing for people

M = Mixing coefficient How many people can you infect? Depends on the number of people you contact in a way that can spread the disease HIV – took the bathhouses in the US Smallpox in NYC is much more dangerous than in a small town in Maine Key issue in quarantine and restrictions

TF = Terror Factor The product of the other factors These can be manipulated to change perceptions Smallpox 2002 – seen as terrible threat 2003 – CDC pushes models that reduce I and M so smallpox does not spread quickly Why?

What does this mean for Emergency Response? Which variables can you affect? Anthrax Pre-exposure antibiotics Limit exposure by limiting movement Smallpox Vaccinate Quarantine

Smallpox demands massive restrictions and mandatory vaccination in a hurry CDC now downplays the time factor Official policy says no mandatory vaccinations No realistic plans for mass immunization Feds completely ignore the problem of immunosuppressed communities because of AIDS politics

No serious discussion of whether smallpox is a real threat Why are suddenly worried? If it is real, should we do routine immunizations? How would we change these decisions if the vaccine was safer?

Making the hard choices What did TOPOFF ignore? How do we enforce quarantine when people resist? How do we force people to be vaccinated? How do we keep people out of health care facilities? How do we defend vaccine centers from people who do not want to wait? How do we keep core services working when people do not go to work?