It can start by taking a look at what Israel has done over the past six months. Last July, the country decided to start vaccinating for smallpox in case of a bioterror attack from Iraq. Since then, it has vaccinated nearly 15,000 emergency-care workers and come up with a plan to quickly inoculate Israel's entire population of 6 million if hostilities break out.
"The first decision we had to make was how many people and which ones," says Ido Harari, a spokesman for the Israeli Health Ministry. It considered three alternatives: a mass inoculation of the population, which would take a week but might have brought the country to a standstill; a month-long program that would have done the entire country in stages; and a trial-run vaccination of emergency workers and first responders.
EARLY DETECTION. Israel's health experts chose a combination of the first and third options: They would vaccinate a test group of about 15,000 first responders -- plus the remaining population en masse should there be an attack. Since the smallpox virus requires 10 days to take hold and spread, that would give health officials about a week to vaccinate everyone.
To make sure they spot a virus the instant it's released and thus have maximum time to fight it, officials have also launched an information campaign among health-care workers to help them recognize the signs of infection (most notably a splotchy rash accompanied with flu-like symptoms).
Phase one of the program has gone pretty much as planned, though with a few complications. Probably the most surprising was the reluctance of many health-care workers to get the shots, which pushed back the deadline for the first 15,000 from October to December. "Part of it is a less than satisfactory communications effort. But it's mainly a reluctance to take a chance on getting severe side effects," says Ethan Rubinstein, the head of the infectious diseases unit at Tel HaShomer Hospital in Tel Aviv.
"LET EVERYONE KNOW." Those side effects can include high fever (which can hit 50 out of every million recipients of the vaccine), meningitis (15 per million), and even death (1 per million). The authorities pointed out, however, that most people who are affected in such ways are toddlers, the elderly, or those with weakened immune systems, none of whom would be given the vaccine during the initial inoculation.
So far, only four Israelis have been hospitalized in the course of the inoculation: a spouse and child came down with a mild case of cowpox -- from which a version of the smallpox vaccine is made -- and two people had heavy fevers. All are fine now. "My best advice is information, information, information," says Hadari. "Let everyone know exactly how little risk is involved and do everything you can to battle misconceptions."
According to the Bush plan, 500,000 U.S. first responders and health-care workers will get their shots in the initial round of immunization, which began on Dec. 19. With such a large pool of people, any adverse reaction will be front-page news in the media-intense U.S. -- and make Americans as reluctant as Israelis to try an inoculation. Already, two U.S. hospitals -- Virginia Commonwealth University in Richmond, Va., and Grady Hospital in Atlanta -- have refused to administer the vaccine to workers based on safety concerns. And that's despite a widespread public-relations blitz by the White House and the U.S. Centers for Disease Control & Prevention.
SPECIAL TREATMENTS. In Israel, at least, all resistance to taking the serum would disappear in case of a smallpox attack, Hadari believes. "If people start dying from the disease and a mass inoculation is necessary, public relations about the safety of the vaccine will be the least of our problems," he says.
Another obstacle would be harder to overcome, though, especially in a mass inoculation: While the cowpox version of the smallpox vaccine works fine for most people, many can't tolerate cowpox -- including, again, the very young, the very old, and those with weakened immune systems. They have to be vaccinated with live smallpox antibodies, which must be harvested from the blood of people who have already been inoculated. For health officials to collect the antibodies, those who have already received the needle jab must return to the health clinic a month later and donate plasma.
Israelis were eager to participate in this part of the plan, but the system suffered from a shortage of plasmaphoresis machines, which are used to harvest the antibodies. The only such center is located in Tel HaShomer Hospital, which has about 15 of the $100,000 units. Elat Shinar, the center's director, says within three months nearly enough plasma had been collected to protect all the people in the country who would have to have that version of the serum. "We only needed 2,500 liters, and we're almost at that level," she says.
PROTECTING PALESTINIANS. In Israel, the initial rush led to long lines and frustration among donors. "It would have helped to have more machines located throughout the country," says Hadari. "We've since ordered more." Plasmaphoresis machines are common to most phlebotomy units in American hospitals, which should have enough of them on hand.
One of Israel's biggest potential problems wouldn't show up in the U.S.: The need to protect the Palestinian population. Although the Palestinians live under limited sovereignty, their health care is considered Israel's responsibility, since it has reoccupied some Palestinian lands. However, Hadari says no Israeli doctor would survive the trip to administer the vaccine. "Right now, they're killing any unarmed Jew who goes into their territory," he adds. "Any attempt to inoculate the Palestinian population would be a suicide mission."
For now, such an operation is unnecessary. However, if a smallpox attack comes, the Palestinians would be as endangered as Israelis, thanks to the close proximity of the two. In such an instance, Israel would hand some 2 million doses of the vaccine over to Palestinian hospital authorities -- and hope for the best. "They have an infrastructure, and they have the trained manpower to administer vaccines," says Rosenfeld. "I'm sure they would be able to handle it."
Yet, Palestinian health authorities have done no advance planning, says one hospital official who asks to not be named. Nor has have they set up any coordination with Israeli health authorities. "We have enough problems to deal with right now," says the official. "We'll have to face that problem when and if it occurs." Jaffe specializes in coverage of, among other things, the Middle East