Round Up the Unusual Suspects

A New Health-Emergency Law Raises Concerns for the Immune Compromised

After a businessman sick with smallpox arrived in New York in 1947, infecting four people before dying himself, officials sprang into action. The city vaccinated 6 million people in a month. That contained the epidemic, but at a cost: Between four and eight people died from reactions to the vaccine. In fact, with only three people succumbing in the initial outbreak, the vaccine was ultimately more deadly than the disease itself.

"It raises the classic public-health dilemma," says David Rosner, professor of public health and history at Columbia University. "Is a solution going to harm more people than it helps?"

In the wake of September 11, that dilemma is back with a few new twists. Two weeks ago, the federal government released a revised version of legislation the Bush administration hopes every state will pass, which would solidify government authority to enforce vaccination and isolate people exposed to infectious diseases. Though the law does not distinguish among contagious diseases that could set off the emergency powers, it seems designed to counter smallpox—the deadly virus that bioweapons experts fear may have fallen into terrorist hands.

But while the bill lays out an emergency strategy, in which those exposed to a contagious disease are either inoculated or quarantined, the smallpox vaccine now being stockpiled by the government can endanger—and even kill—people with suppressed immune systems. Under the proposed law, it's unclear how these people—including an estimated 900,000 Americans infected with HIV and more than 200,000 living with transplants, as well as cancer patients and people with chronic diseases—will be treated in the event of a true health emergency.

The Model State Emergency Health Powers Act, drafted by the Centers for Disease Control and Georgetown health policy professor Larry Gostin, would allow for forced isolation in the event of a public health emergency. Health officials would also have the power to seize hospitals and property (including cell phones, if they're jamming circuits), identify infected individuals, ration medication, and mandate testing, treatment, and vaccination. The act even allows health officials to call in the militia if they see the need.

But beyond specifying that authorities are not allowed to compel people to be vaccinated if it is "reasonably likely to lead to serious harm," the law doesn't outline protections for the growing number of immune-suppressed people who may be harmed by the vaccine. Because of advances in treating people with cancer, AIDS, and other serious diseases, "the number of [these people] is much greater than at any other time," says Joel Kuritsky, director of the National Immunization Program and Early Smallpox Response and Planning at the CDC.

Some emergency planners have focused on immune-suppressed people as threats to the general public during a possible outbreak, both because they are more vulnerable to infection and more likely to pass it on, since they emit more viral particles in their breath. Peter Jahrling, senior scientist at the U.S. Army Medical Research Insitute of Infectious Disease in Fort Detrick, Maryland, has said that "having a lot of immune-compromised people during a smallpox outbreak will be like pouring kerosene on the fire."

The situation can be even more frightening from vulnerable people's perspective. In the event of a smallpox outbreak, Kuritsky says, they and their doctors would have to decide "whether the risk [posed by the vaccine] outweighed the benefit." A June 22 issue of the CDC publication Morbidity and Mortality Weekly Reportdetails some of these risks, citing the deaths of two HIV-infected people who participated in smallpox vaccine trials, as well as an HIV-positive military recruit who developed severe vaccinia, a life-threatening condition in which sores spread all over the body.

Because of the seriousness of these problems and their frequency (roughly 5.2 in 1000 people vaccinated report side effects ranging from rashes to encephalitis), health authorities say that even in the event of a serious outbreak they would likely inoculate only a few thousand people—those directly exposed to the virus and their contacts. But what might happen if some of those exposed were immune suppressed to begin with?

According to Gostin, who has also written extensively about quarantine, isolation would be a "rare but necessary" last resort. "If people were a risk to others, then they would be subject to isolation," he says. If such people were unable to be vaccinated, "we would provide care and treatment and a safe place. If they were exposed, we would place them in isolation but make sure they were given due process, food, and clothing."

But according to AIDS activists, this resurrection of quarantine—a public-health relic that has fallen out of use with the taming of infectious diseases like measles, scarlet fever, and smallpox—raises serious concerns about civil liberties.

Many point to the past misuses of quarantine, which has not been used on a wide scale in the U.S. for more than 80 years. Before that, forced isolation was often applied unevenly. When a cholera outbreak was reported on a ship in New York Harbor in 1892, the Port Authority sequestered only poor immigrant passengers in unsanitary conditions below deck—58 of whom died—while moneyed travelers were allowed to go free. In San Francisco, the quarantine set off by a bubonic-plague epidemic in 1900 applied only to Chinese businesses and homes.

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