CDC weighs vaccinating now or waiting until first smallpox attack; would you take smallpox vaccine? A pox on both your choices.

If smallpox vaccine were made available by the government, would you bare your arm for that tattoo of skin pricks with the little pitchfork needle, hoping that the live cowpox virus entering your bloodstream would do you more good than harm?

That's what it may come down to individual choice. Because whatever the Centers for Disease Control and Prevention (CDC) recommends about the controversial smallpox vaccine, it certainly will be voluntary (at least for nonmilitary personnel). The CDC recently called together a working group of clinicians and experts in Atlanta to solicit advice and opinion about possibly immunizing people with vaccinia (cowpox) against variola (smallpox), one of the more dreaded potential weapons of bioterrorism. The group will forward its analysis of a set of options--without making a consensus recommendation--to the CDC's Advisory Committee on Immunization Practices. That committee and the CDC will hold a series of meetings in the coming months and decide whether to resurrect voluntary smallpox immunization programs in the United States. (See options, p. 3.)

The disfiguring infectious disease that killed millions worldwide for ages was eradicated case by case decades ago in one of the greatest public health achievements of all time. The last smallpox immunization programs in the United States were disbanded in 1972. The last known stores of smallpox virus in the world are officially in Russia and the United States, but the increasingly broad consensus is that the dreaded pox could be in the hands of rogue nations and/or terrorist groups. It is known that smallpox was developed as a weapon in the sweeping bioweapons program in the former Soviet Union. With a new vaccine under production and dilution studies showing that existing vaccine supplies can be greatly expanded, mass immunizations are a possibility again.

In that regard, some of the consultants at the meeting called for action, urging the CDC to recommend voluntary immunizations for health care workers and the public. Others cautioned about a host of potential side effects and the fact that there are some 300,000 people in the United States who do not know they are HIV-positive. Vaccinating them and other immune-compromised people could lead to one of the worst complications of cowpox: fatal, progressive vaccinia. (See "Vaccine reactions and the use of immune globulin".) In addition, a Food and Drug Administration (FDA) official at the meeting warned the CDC that widespread use of the live virus vaccine could imperil the blood supply because those immunized must wait one year before donating blood.

"Currently in the country, there are about 13 million blood donations donated by 9 million blood…