A Dec. 24 article about smallpox vaccination incorrectly identified Michael Richardson. He is the senior deputy director for medical affairs in the District of Columbia's Department of Health. (Published 1/1/03)

The Bush administration's plan to vaccinate as many as 10.5 million medical personnel and emergency responders against smallpox will cost between $600 million and $1 billion and is likely to siphon money from other bioterrorism and public health efforts, local and state officials warn.

With most of the 50 states already buckling under budget deficits, the widespread immunization campaign due to begin in late January amounts to "the ultimate unfunded federal mandate," said George Hardy, executive director of the Association of State and Territorial Health Officials. "We can't afford to do this at the expense of all other preparedness."

For months, city and state leaders have been preparing to inoculate about 450,000 medical professionals who would serve on smallpox response teams in the event of an outbreak. But few expected President Bush to adopt a much broader proposal, known as Phase 2, to encourage every remaining health care worker, police officer, firefighter and emergency medical technician to be immunized.

"States and localities already are diverting significant resources to smallpox vaccination and there is no end in sight," said Patrick Libbey, executive director of the National Association of County and City Health Officials. "We urge that the program be kept at minimal levels and grow only as rapidly as threat assessments demand, so as not to disrupt other basic community health protections or cause unnecessary harm."

The decision to revive a vaccine known for its dangerous side effects is a reflection of the changing times, Bush said in announcing the plan. In anticipation of a likely war with Iraq, he ordered mandatory inoculation for 500,000 members of the armed forces and is recruiting volunteers among medical workers and emergency responders to serve as a sort of domestic front line against biological attack. Other Americans will be able to receive the vaccine, even though it has not yet gone through the Food and Drug Administration's licensing and approval process, but the government is recommending against universal vaccination for the general public.

The cost of biodefense is rising steadily. Already, the federal government has spent more than $862 million to buy the smallpox vaccine. Last spring, the Bush administration distributed $918 million to state health departments for homeland security, money it says could defray smallpox vaccination costs.

"We're absolutely committed to working with the states to make this work efficiently and safely, said Tom Skinner, spokesman for the Centers for Disease Control and Prevention. "There are a lot of dollar figures out there, some of which I believe do not take into account the infrastructure that's been put in place."

But that infusion of cash came with extensive demands, said Michael Richardson, acting health director for the District of Columbia. To qualify for the money, states and large cities such as the District submitted detailed plans for improving computer systems, training medical workers and adding emergency hospital beds.

"The word smallpox wasn't even mentioned," he said. The $10 million given to the city was spent stockpiling medications, hiring epidemiologists and other bioterrorism experts and upgrading the public health laboratory. Richardson said he does not know where the District will find the $3.6 million needed to inoculate 10,000 to 20,000 emergency personnel over and above the first group of 3,000 health care workers.

Bill Pierce, spokesman for the Department of Health and Human Services, said he expects Congress to approve an additional $940 million for states "to conduct disease surveillance, upgrade labs and improve public health infrastructure."

The impact of leaping from 450,000 to as many as 10 million inoculations next spring is far greater than the numbers suggest, state officials said. Mounting a smallpox vaccination program 30 years after routine immunizations were stopped in the United States will require extensive education and training, careful medical screening for people at risk of complications, near-daily checking of inoculation sites and vast data collection, health officials say.

Because Phase 1 focuses on medical workers, states plan to rely heavily on hospitals to administer the vaccine and monitor employees for side effects. But hospitals cannot be expected to oversee the second phase, which will entail not only logistical challenges, but also many more medical complications. Historical data suggest that for every 1 million immunized, about one-third will miss at least a day of work because of adverse reactions and 15 to 42 people will suffer life-threatening complications.

To vaccinate Alabama's first group of 12,000 health care workers, state health Commissioner Donald E. Williamson plans to take public health teams into each participating hospital. "If I have to jump to 150,000, it's no longer practical for me to send a team into every volunteer fire department and police station," he said.

Nearly 80 percent of Alabama's initial biodefense grant of $16 million has been spent, Williamson said. The CDC's estimate of $84 per person vaccinated, a figure he said is "in the ballpark," means Alabama will need $8 million to $12 million to run the next phase. Without another large federal grant, he fears the smallpox vaccination program "will fundamentally harm basic public health needs."

The CDC has begun suggesting states funnel money from other anti-terrorism activities to the smallpox vaccination program, said Nancy Ridley, an assistant commissioner in the Massachusetts Department of Public Health. She is considering postponing some bioterrorism training and technological improvements to help cover the cost of immunizing 150,000 to 200,000 emergency workers.

For many in public health, the new challenge of coping with bioterrorism is "exciting," as Ridley put it. But they caution that moving too fast could be costly.

"A lot is riding on the success of Phase 1," Ridley said, joining a chorus of local and state leaders who would prefer a long pause before moving to the broader group.

Libbey of the National Association of County and City Health Officials warned that the time, staff and money needed to conduct smallpox inoculations not only undermine the routine work of health departments, such as flu vaccinations and prenatal care, but also threaten other anti-terrorism projects.

"We may be doing it at a cost of leaving our country more vulnerable to attack," he said.

Warner W. Carr administers the smallpox vaccine at the Walter Reed Army Medical Center in Washington.