Stage one was expected to complete the vaccination goal of 450,000 hospital healthcare workers in four weeks. However, there has been widespread refusal by hospitals and individuals to participate. Do the remaining 433,000 healthcare workers who have chosen not to participate know something that the experts do not know? At this rate of 5000 vaccinated per week it could take up to 86 weeks, or 1.7 years, just to complete stage one.

America has been told that there are sufficient doses (300 million) of an effective vaccine to render all of the U.S. population protected from a smallpox attack. With this stockpile of available vaccine in place and stage one of the protection program floundering, it has been suggested that moving on to stage two, the vaccination of first responders (police, firefighters and emergency management personnel) might in some way compensate for the shortfall. Participation estimates for this target group is also expected to be disappointingly low.

Additionally, stage two vaccinations will not produce the smallpox-protected teams of healthcare workers necessary for vaccinating the general public as planned for in stage three. The remaining 289 million Americans are slated for vaccination within four days of a confirmed smallpox outbreak.

Is this possible, and at what price? Such a feat has never been previously attempted. Will mass panic be the result? Can such an approach allow for the proper, methodical screening of the general population for potential contraindications (reasons why the vaccine should not be given) so that life-threatening complications are reduced, not increased?

Smallpox is one of the most dangerous biological weapons of mass-destruction available to terrorists. It is a contagious viral disease with no known treatment once an individual is infected. Thirty percent of those who become infected with smallpox (3 out of every 10) will die. The United States population is unprotected.

Smallpox killed hundreds of millions of people around the world before being declared eradicated in 1980. Early smallpox symptoms are flu-like in nature. Those who are not protected against smallpox and become infected during a bio-terror attack using smallpox, pose a clear and present danger to their families, their communities, and the nation. The commitment must be prevention as the key to survival for the welfare of the American people and in support of winning the war on terrorism.

However, there are life-threatening complications and deaths related to the vaccine, which includes a live virus that can infect the body. This represents a risk that equates to approximately 300 to 600 deaths (l in 500,000) included in up to 10,500 complications possible for the total population of 300 million.

The universal vaccination of the U.S. population would be a prevention strategy, rendering the use of smallpox as a bio-terrorism weapon essentially meaningless. Vaccination properly performed will protect individuals from infection. Protection can result from a systematic, methodical, and progressive program of universal (everyone who can be vaccinated safely) smallpox vaccination of Americans. This is one of the very few opportunities available to remove a bio-terror agent from being used by America's enemies.

Universal vaccination has been resisted based on concerns relating to potential complications of the vaccine. A major stumbling block has also been doubts about the certainty as to whether the threat of a bio-terrorism attack using smallpox as the agent, justifies the risk. Many hospitals have rejected participation due to concerns about vaccinated workers accidentally spreading the live virus in the vaccine to patients susceptible to complications.

Compensation for those injured by vaccination has been an issue raised by medical and healthcare workers when they refused participation in the vaccination program.

A compensation proposal of $262,100 for each person who dies or is permanently and totally disabled by the vaccine has been proposed. Another factor has been virtually non-existent education programs for the public in general, ineffective education programs for medical professionals, healthcare workers, and first responders, and contradictory information that has been released by government officials on all levels.

Many opponents, especially physicians and other healthcare professionals, of a universal program for smallpox vaccination starting as soon as possible for all Americans without contraindications, are now rethinking this position.

In the editorial by Dr. John Clough in the February 2003 issue of the Cleveland Clinic Journal of Medicine he agonizes through the alternatives and comes to the conclusion, "The choices are not pretty or easy. And perhaps it comes down to the nasty conclusion that we really don't have any choice. We may have to provide whatever protection we can for the population."

A recently related concern has been the outbreak of a respiratory illness with associated pneumonia now having resulted in deaths, which seems to have begun in China as early as January 2003. As it spreads it is becoming a serious world public health problem. It is not considered to be terrorist related.

The illness called SARS (severe acute respiratory syndrome) begins with flu-like symptoms. For the first three weeks of March 2003 the World Health Organization (WHO) working with the other major public health organizations and laboratories has been trying to identify the cause.

This demonstrates that even in the hands of the best available public health organizations and laboratories identification has at best been difficult and delays can and do occur. Such a delay in responding to a bio-terror agent changes the response assumptions and the preparedness to react.

In applying this scenario, flaws in expert thinking process used in the design of the smallpox vaccine protection program become apparent, especially in relation to stage three.

The use of smallpox virus by terrorists is a consideration since the virus is contagious, has no treatment, has a high death rate, is easily transported, and can be readily disseminated to an unprotected population.

Just as in the anthrax experience in 2001 where finely milled spores with a high potential for causing death were used, the smallpox virus could be genetically altered. Changes are possible in the incubation period for the disease (the length of time before the disease symptoms appear) and changes in the duration of the early flu-like symptoms therefore, making it more difficult to diagnose infection.

Elements that make identification more difficult cause the assumed time frames such as a four day window in which to vaccinate the American population to be unrealistic.

America is not presently prepared for a bio-terrorism attack, especially not for the use of smallpox as the bio-terror agent. There is a better way than the program presently in place.

A universal smallpox vaccination program instituted now and progressively implemented with enough time to adequately screen out those with contraindications will protect the vast majority of the American population and simultaneously minimize the complications and deaths due to the vaccine. Using a universal protection program, prevention is established against a terrorism attack using smallpox as the bio-terror agent.

Dr. Saul B. Wilen is President and CEO of International Horizons Unlimited (IHU), a national consulting and resources consortium based in San Antonio, Texas that applies "educational foundations and processes that support prevention strategies to solve problems." Dr. Wilen is a recognized authority in prevention strategies and problem solving, systems dynamics, and informatics. He directs IHU terrorism prevention and strategies development initiatives. Dr. Wilen serves on the U.S. Secret Service Task Force on Electronic Crimes and Terrorism, the U.S. Department of Commerce Critical Infrastructure Working Group on Community Structure for Crisis Management and Preparedness, and as a consultant to the Best Practices Institute of the National Governors' Association.

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