Dear President Bush:

Thank you for considering our proposal released earlier this week to make smallpox vaccine available to anyone who wants it in advance of an attack or outbreak. We respectfully urge you to implement this immediately, as any delay could cost thousands of lives in the event of an outbreak.

The plan announced by the CDC to withhold smallpox vaccine until after an outbreak is fatally flawed, and would most likely lead to chaos and thousands of preventable deaths.

They claim the vaccine is too dangerous for the general public. But children are routinely required to take vaccines against diseases much less serious than smallpox despite comparable side effects. For example, statistical projections estimate the number of deaths associated with administration of 300 million does of the smallpox vaccine would be 350 deaths. And yet there were 440 deaths associated with only 20 million doses of hepatitis b vaccine in the VAERS data base as of 1998.

The CDC plan is overly optimistic. Their ring immunization plan is outdated in an age of bio-terrorism. In the days when this was effectively used, an outbreak consisted of a few cases in a population that had a high degree of immunity to begin with. Today, the entire U.S. population is susceptible. And an attack could cause thousands of simultaneous cases in many different areas.

Prudent medicine as well as public policy tells us the logical alternative is to make immunizations available, with full disclosure and informed consent, to those who want them. This will allow much more effective screening of those who are at a high risk of complications from the vaccine, and allow people who are more likely to be exposed to voluntarily be inoculated. Medical workers, frequent travelers, or people who work in crowded areas or high-rise buildings are among those at risk of early exposure.

Please consider the following points:

TIME LAG IN DELIVERY OF VACCINE POST-ATTACK
According to the CDC fact sheet on "Smallpox vaccination Clinic Guide," dated 9/23/02, smallpox vaccine will be distributed from national stockpiles to state field sites within 5 - 7 days. � but only after a confirmed outbreak. Since the initial smallpox symptoms are similar for those for the flu, it could take days to confirm an outbreak.

Add to that the 10 days the CDC says will be necessary to administer 1 million doses , if all goes well. Massive outbreaks in several population centers could mean a delay of up to a month to receive the vaccine, well after the window of opportunity to use the vaccine as a palliative.

PROTECTION NEEDED FOLLOWING VACCINATION
The vaccine is a live virus called vaccinia, which can, in vulnerable people, cause an extensive rash, blindness, swelling of the brain, and even death. This virus can be transmitted by persons who have just been vaccinated. Thus, precautions are needed for about two weeks.

TRANSMISSION BY NEWLY IMMUNIZED MEDICAL PERSONNEL
Medical personnel are being vaccinated in Israel. They cannot all be vaccinated at once because they cannot come in contact with patients, especially immunodeficient patients, while they are contagious.

The CDC estimates that at least 1.3 million volunteers will be needed to administer the vaccine, and yet news reports suggest that you are considering making only 500,000 advance doses available for first response and emergency personnel.

IMMUNIZED VOLUNTEERS NEEDED TO PRODUCE MEDICINES FOR OTHERS
For patients who can�t be actively immunized, either because they are already sick or because their immune system is damaged, passive or borrowed immunity can be life-saving. Vaccinia immune globulin or VIG is the treatment for severe vaccine reactions and could help in smallpox also. This is in very short supply. To make more, we need blood donors who have developed immunity. This is another reason for immunizing volunteers before an outbreak. Israel is doing this already.

Mr. President, AAPS has been very vocal in its opposition to mandatory vaccines, and we don�t make these recommendations lightly. But we fear the alternative will be forced immunizations in the face of mass exposure. The potential loss of life is unimaginable. Please allow voluntarily screening and vaccination now.

Respectfully submitted,

JANE M. ORIENT, M.D.
Executive Director
Association of American Physicians and Surgeons