Physicians may understand smallpox risk, but the public hasn’t a clue
A series of articles written for the Jan. 30, 2003, New England Journal of Medicine demonstrate the need for a massive public and professional education program about the threat of a smallpox release by terrorists and the nation’s vaccination program.
Two physicians from Mount Auburn Hospital in Cambridge, MA, wrote that while the federal government’s vaccination planning is based on mathematical modeling of smallpox attack scenarios, no statistical model can predict the thoughts of a terrorist and no analysis can tell how individuals or countries will act in a time of crisis.
"The public health question has changed from, Are we at risk from a smallpox attack?’ to, Whom should we be vaccinating?’ wrote Terry L. Schraeder and Edward W. Campion.
"Although physicians may be familiar with risk, the public is not. A risk of disease and death from a vaccine, no matter now small, may be unacceptable. The public needs to understand the risks associated with vaccination, including possible transmission to others. . . . The more people we vaccinate, the more likely we are to see serious complications. Media coverage and public outcry will most likely follow the first severe reactions to the vaccine. The information and perspective that physicians provide will affect how the public responds. Some may demand immediate access to the vaccine, and others may refuse it altogether. . . . The best decisions are made when all the facts are known. Many health care workers and much of the public still appear to be ill-informed about smallpox and the smallpox vaccine," they wrote.
A survey conducted by researchers from Harvard School of Public Health in Cambridge indicates just how difficult the educational process will be.
Lead researcher Robert Blendon said the Harvard team wanted to learn Americans’ views on a number of key questions — whether frontline health workers should be vaccinated now, whether it is appropriate to make smallpox vaccination available to the general public, and whether states should be given additional emergency powers to respond to bioterrorist attacks. While there has been considerable discussion of these issues in the news media and professional journals, Blendon wrote, it hasn’t been known how the general public views them. And prior research has shown that public opinion can strongly influence policy decisions.
A 61-question survey was given to 1,006 U.S. adults through telephone interviews, with a response rate of 65% and a sampling error of 3.1%. Blendon said the results revealed "substantial misinformation among Americans about smallpox and smallpox vaccination. Our data show that the majority of the public would agree to vaccination and other measures to control smallpox, but that they would not agree to be vaccinated if physicians declined vaccination."
Physician response is key
The findings, he said, have important implications for physicians and public health professionals since they highlight the central role that physicians will play in providing advice and care related to smallpox vaccination and treatment. If physicians are reluctant to be vaccinated, the researchers say, large numbers of Americans will be unwilling to do it voluntarily. And if there are deaths from side effects of the vaccine, the public will be less willing to be vaccinated and will look to their physicians for advice.
Blendon said the results also suggest the need for public education about smallpox, since many Americans have beliefs about the disease that are incorrect according to scientific views.
Interestingly, a third key survey finding is that while the current opinion of many public health leaders is that there is no need at this point for a mass vaccination of the general public, that view is at odds with the public’s desire for access to the vaccine. "Health officials need to clarify to the public the basis for their judgment to limit access to the vaccine," Blendon wrote.
The researchers conclude that the Bush administration’s decision to begin vaccinating military personnel and state response teams may make the issue more salient to the general public.
"As adverse reactions to the vaccine occur, members of the public may look to their physicians for guidance in weighing the risks of vaccination against the risk of a bioterrorist attack involving smallpox," they said.
Here are the survey results:
• Concern about a smallpox attack. 64% of respondents said they believe that an attack by terrorists using smallpox is likely if the United States takes military action against Iraq.
• Knowledge about smallpox. 89% of respondents knew that smallpox is a contagious disease, but 30% believed there had been a case of smallpox in the United States in the past five years, and 63% thought there had been a case someplace in the world in the past five years. Some 78% believe there is a medical treatment for smallpox that would prevent death or serious effects after symptoms of the disease develop.
• Beliefs about smallpox. A majority of respondents said they believed it was likely they would survive if they contracted smallpox. 67% thought it was likely they would contract smallpox if they came within a few feet of someone who had the disease. Respondents were split on the aftereffects of smallpox, with 48% reporting that most people who contracted the disease and survived would have a full recovery, and 46% saying they would have permanent, serious aftereffects such as disfigurement and blindness.
• Smallpox vaccine. 66% of those interviewed believed they had previously been vaccinated against smallpox and 46% of those who reported a prior vaccination believed it would protect them from becoming seriously ill if there were a smallpox outbreak. 93% believed that the smallpox vaccine would be effective in preventing a person from contracting smallpox if the person received the vaccine before being exposed to the virus, but only 42% believed that vaccination within a few days of exposure could prevent a person from contracting the disease.
• Vaccination policy. A strong majority (81%) of respondents favored voluntary vaccination of doctors and nurses in preparation for a bioterrorist attack, and 65% favored offering the vaccine to the general public in preparation for such an attack. Many respondents believed they would not be able to get vaccinated quickly if cases of smallpox were detected in their community, and that there would not be enough vaccine for everyone in this country. Nearly three-fourths said that if it were not possible to vaccinate everyone, wealthy and influential people would get the vaccine first. 43% said they believed that distribution of vaccine would discriminate against the elderly, and 22% believed it would discriminate against blacks.
• Vaccination decision. 61% of respondents said they would choose vaccination (or revaccination) if it were offered as a precaution against a bioterrorist threat, while 36% said they would not take it. If there were a smallpox attack, 75% of respondents would choose to be vaccinated. If there were cases of smallpox in their community, the proportion of respondents who would be willing to be vaccinated increased to 88%. Actions of physicians influence the vaccination decision, with 73% of respondents saying they would be vaccinated if their own physician and most other physicians were vaccinated. Only 21% would be vaccinated if their own physician and many other physicians refused vaccination. Further, only 33% of respondents would choose to be vaccinated if they heard that "some people" had died from the smallpox vaccine; only 44% would be willing to be vaccinated if they had to stay out of work for two weeks.
• Reactions to a smallpox attack. Approximately half of the respondents said they would go to their own physician first for diagnosis and care if they thought they had smallpox, while 40% would go to a hospital emergency department, and 7% would go to their local health department. Most respondents expressed confidence that their personal physician would recognize the symptoms of smallpox. 95% of respondents said they would agree to be quarantined for two to three weeks if they were exposed to smallpox but did not have symptoms of the disease. 77% said that if they were told they had smallpox and had to be isolated in a special health facility with other smallpox patients for three to four weeks, they would agree to go.
• State emergency powers. The respondents offered a high level of support (87%) for legislation requiring hospitals and clinics to provide services to people who might have smallpox and requiring people with smallpox to be isolated in a special health facility (73%). Two-thirds believed that state governors should be able to use National Guard troops to prevent people from leaving areas with reported cases of smallpox. A smaller majority (57%) favored quarantining people suspected of having smallpox, and respondents were divided on the question of whether a person should be required to undergo a medical examination or test to diagnose smallpox.
The researchers say that those responsible for public education about smallpox need to consider the degree and type of misinformation that was revealed in the survey. Although the last case of smallpox was reported in the United States in 1949 and in the world in 1977, a substantial proportion of respondents thought there had been cases in the past five years.
There is no specific treatment for smallpox, but a majority of respondents thought the disease could be effectively treated.
In many people, it is believed, immunity from a previous vaccination is likely to be negligible after 20 years and the U.S. vaccination program ended in 1972. But almost half of the respondents who had been vaccinated believed they were protected from the disease.
A majority of respondents did not know that vaccination within two to three days after exposure to smallpox can provide protection against the virus, and although serious adverse reactions to the smallpox vaccine are expected to be relatively rare in patients without contraindications to the vaccine, a substantial proportion of respondents thought that serious complications, including death, would be likely.
Government sources say there are enough doses of vaccine for everyone, but a majority of respondents said they did not believe that to be the case.
(The articles are available on-line at www.nejm.org.)
A series of articles written for the Jan. 30, 2003, New England Journal of Medicine demonstrate the need for a massive public and professional education program about the threat of a smallpox release by terrorists and the nations vaccination program.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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