Click cover for interactive viewer

The Pre-Event Vaccination Question
By Sean Cann-Sheppard
Aug 31, 2017

For First Responders

The ever increasing threat of bio-terrorism has led to modernizing the way we prepare for a potential outbreak.

Topping the World Health Organization’s list of the most dangerous threats to global health security is smallpox. Although considered eradicated in 1979 by the WHO, smallpox could return in the future; either through the discovery of a new, infectious strain or through a biological weapon.

Bearing out the predictions that a lab could potentially recreate a virus such as smallpox, the WHO announced in November of 2016 that, in only six months, a team using publicly available information on the internet recreated the horse pox variation of the smallpox virus.

Tim Dear, who is a Senior-Associate for Centre-Arch Inc, a company involved with government procurement and major acquisition programs, has been one of the leading voices for the push of new strategies to combat the bio-terror threat.

He advised FrontLine of a concern that first responders and first receivers in Canada are ill-prepared to respond to the kind of threat bio-terrorism brings.

“[They] really don’t know anything about bio-terrorist threats that are going on in the world right now,” he said. But that’s not to say Canada itself is ill-prepared; as Dear puts it, the Public Health Agency of Canada (PHAC) and the Department of National Defence (DND) has outperformed many countries around the world in terms of bio-terror security. However, he asserts that there is still much to improve upon.

For smallpox, PHAC is stockpiling the new Imvamune vaccine, which was developed by Bavarian Nordic. While they don’t plan on buying enough of the new vaccine for everyone, Dear explains that the new vaccine wasn’t meant to replace the old smallpox vaccine, but to bolster the current stockpile.

“They cannot do 100% protection for the health effects of every flu, flood, fire or Fentanyl crisis in Canada. They do cost-benefit analysis to try to have something ready for every emergency situation – and work with other nations to share and use best practices,” he said.

The old smallpox vaccine worked by scarring a recipient and placing a live pox strain on that scar. Since it is a live (replicating) virus, the vaccine can lead to serious side effects (including death) for anyone with a pre-existing skin condition.

The new vaccine uses a non-replicating version of the smallpox virus, and can cover those who are contraindicated by the first generation of smallpox vaccines. Dear says he hopes to help expand coverage to fill in the gaps for the contraindicated population for whom the live-virus vaccine would be a health risk.

The plan, he says, is to use the newer vaccine to provide a pre- and post-event vaccination of both military personnel and first responders, as well as give those not covered by the traditional vaccine a chance to immunize themselves. It is a big step. 

Considering that it can take up to three weeks to fully immunize an individual, the benefits of a pre-event vaccination are obvious. First, responder personnel are “ready to go” in the event of an outbreak; and second, contra-indicated individuals would also have time to be assessed and receive their vaccination.

Health Canada, the departmental lead for PHAC, currently doesn’t have a plan for pre-event vaccination, and this is something Dear hopes to change.

Dear and several others hosted a panel at the 2016 Canadian Immunization Conference in Ottawa. His goal was to give background on the importance of pre-event vaccination. “Along with Dr Jim Anderson from DND, Jean-François Duperre from PHAC, Commander Robert Davidson from the Ottawa Paramedic Services, and Jesper Elsgaard from Bavarian Nordic, [the panel] was designed to educate the Canadian immunization practitioners and get them to start thinking about pre-event vaccination.” Dear says that a pre-event deployment of vaccines by both DND and Health Canada could happen quickly once the decision is made.

“Canada, through the efforts of DND and the Public Health Agency of Canada is considered a true leader in this field,” he says. “Several times a year we’re approached by military attachés or other representatives from different countries to get the names and contacts from key Canadian personnel” working on this file.

However, Dear notes will take time before any specific changes to occur. Strategies would need to be reviewed and changed, including Canada’s current policy of ring decontamination.

Ring decontamination is an event protocol that has health officials looking for ‘patient zero’ in the event of an outbreak, and then tracing where that person has been in order to treat everyone ‘patient zero’ has been in contact with.

Dear explained that the policy was put into place at a time when the number of global travellers was not as high. Now that travelling has become more and more intertwined in society, finding where patient zero has been to and who he/she has been in contact with becomes next to impossible in major urban cities.

However, ring decontamination was used successfully in the Ebola outbreak in Africa and, as Dear puts it, the strategy still works well in situations where travel isn’t much of an issue.

“It’s still the methodology used for breakouts of various diseases,” he said “It’s still the best plan out there,”

Just how much does the new, safe vaccine cost compared to the traditional, live-virus version? A study published by the WHO explained the numerous factors comparing the Imvamune with other smallpox vaccines. In taking into account the distribution of the vaccine, the training needed for doctors, population, etc, the report noted that fixed costs would vary from country to country. Dear says the initial cost may appear higher than traditional smallpox vaccines, mainly because some countries already own the old, replicating vaccine. Canada currently has a different indication from the combined 31 countries in European Economic Union, and although the product is basically the same, regulations restrict the use the European product in Canada and vice versa.

This is part of the reason why Health Canada didn’t purchase enough vaccines to cover the entire population, but Dear says there’s no magic number to determine who gets the new vaccine, and every country is different. “The USA has a target of non-replicating vaccine for nominal 20% of the population. It will take them years to get there. The Netherlands is considering 100% based on the ethical decision of choosing between who deserves it and who doesn’t, but Israel is recommending 4.5%,” he says. As for Canada, the “Public Health Agency of Canada is implementing a multi-year plan to purchase a certain base percentage and are reviewing the open literature on the subject.”

Dear explains that much of the related data dates back to the 1950s and 60s. Comparative reviews on how many immuno-compromised people were around then and now are underway. Some of the immuno compromised conditions have increased significantly over the past 50 years. 

Although the projected costs are well within the range of other pay-to purchase vaccines, he doubts that PHAC will openly offer individual Canadians the chance to choose which smallpox vaccine (live-virus or non-replicating) they want, certainly not within the next five years. “It will take time to educate all levels of decision makers,” he notes. 

Sean Cann-Sheppard is a journalism intern based in Ontario.