New smallpox vaccine safe for eczema patients

A Danish company will be supplying the US government with 20 million doses of a smallpox vaccine that is safe for eczema patients--unlike the existing vaccine, which can cause rampant and life-threatening infection in rare cases. I blog briefly about it on the National Eczema Association website.

Eczema under the guns

Today, depending where you are in the non-German Western world, is Remembrance Day (British Commonwealth), Veteran's Day (US), or Armistice Day (France & Belgium).

My father's father, Titus, served in the 48th Nova Scotia Highlanders in WWI. I've seen a map of his regimental movements and although there were a number of famous place names on the path, I remember only one: Passchendaele. I think Ypres might have been there too. Old Titie, as my dad calls him, apparently used to freak out whenever someone burned the toast at home, because the smell reminded him of poison gas.

Titus was the one grandparent of mine who had eczema. His itch was legendary. "Old Titie was always scratching," my dad says. (I don't remember Titus; he died when I was five.) I don't know whether the stress of being under bombardment would exacerbate eczema, or distract the mind from itch, and with any luck I'll never find out. Eczema must have made life in the trenches even worse. Titus, we can't imagine what you went through. Thank you.

These days, eczema is a condition that disqualifies you from service in the US military. The reason: in 2007, a soldier vaccinated against smallpox gave his two-year-old son the often lethal condition eczema vaccinatum. An all-out medical effort saved the kid. Now, one can understand why eczema disqualifies you from active service: it would make sense that all service members have to be vaccinated against smallpox, a major biological weapon; and the military would face a major problem if soldiers, etc., refused to be vaccinated because they or their families might die from eczema vaccinatum.

The military therefore is only ruling out about 3-5% of recruits, is my guess. The crucial question is whether you've been diagnosed with eczema after the age of 9. I'm not sure what the precise number is, but about 20% of infants get eczema, and only 2% of adults continue to suffer from it.

I do think that we can look at the bright side of the smallpox/eczema question. It's a point of leverage for us. The US government spends a lot of money on the military, and probably wouldn't mind spending a few hundred million more. The Atopic Dermatitis Research Network was given $31 million to study MRSA and other infections in patients with eczema-- but the initial request-for-proposals was actually aimed at studying eczema vaccinatum. It wouldn't hurt to make our concerns about smallpox vaccination widely known; we could attract major funding. Eczema infection researchers might discover powerful new antibiotics, or other ways for us to protect ourselves from infections such as MRSA.

Eczema sufferers thank you, Dr. Anthrax

Voov and I are in a good stretch-- neither of us has any eczematous patches right now. Of course, that can change overnight. But when eczema isn't bothering you, you tend not to think about it-- you get to pretend everything's normal, and wear clothing that nobody but an eczema patient would find daring-- t-shirts, collarless "shirtly sweaters" (you know, those thin pullovers that were a fad a few years ago). Maybe go swimming.

Not to go on about this Atopic Dermatitis Research Network too much, but I had a thought. Why is this grant so big? One clue, maybe, is the story I mentioned yesterday (NYTimes version) about the 2-year-old son of a US soldier who developed eczema vaccinatum after his father was inoculated with vaccinia virus, the live smallpox vaccine.

The episode must have opened a lot of eyes to the danger this vaccine poses to eczema patients. But the NIH was aware of the problem beforehand. ADRN is the sequel to the ADVN, which was established as early as 2004 and perhaps before. Almost certainly the whole ADVN/ADRN focus on vaccines and eczema is a direct consequence of the 2001 anthrax attacks.

So, eczema sufferers, we can thank Bruce Ivins if, in a few years' time, drugs or other therapies start filtering down the pipeline to protect us against MRSA. Bioterror is big money. I don't know exactly how the NIH receives its funding, but the US civilian biodefense budget for financial year 2011 is about $6.5 billion. $32 million is peanuts. We should angle for more!

For me, although MRSA or staphylococcus in general is a continual concern, I feel that it would be a shame if a huge expenditure of research dollars removed the danger of eczema infection but left us all itching and scratching without relief. Let's not forget that.

A postscript: I asked a mathematical epidemiologist, Jamie Lloyd-Smith, an assistant professor at  UCLA, what fraction of the US population would have to be vaccinated against smallpox to shut down an epidemic. His answer, which he stresses is a back-of-the envelope calculation (I leave out the math):

"You can prevent an epidemic--or eliminate an endemic disease--by vaccinating a high enough proportion of people that Reff<1. This gives herd immunity...you'd need to vaccinate 70-83% of people to eliminate smallpox."

Since, including children, about 20% of the US population has experienced eczema in some form--and, say, there are three people in the average family, and even if you don't have eczema, you can't expose your child to viral danger-- it is clear that the government cannot vaccinate 70% of the population in the event of a smallpox attack without putting a small fraction at real risk of developing eczema vaccinatum. Given the loud objections of the anti-vaccination fringe to protecting their kids against measles and whooping cough--with vaccines for which the benefit overwhelmingly outweighs any imagined risk--you can imagine the trouble the government would run into if it tried to jab us all with smallpox vaccine.

Say no to smallpox vaccine

In March 2007 a two-year-old boy in Chicago contracted the smallpox virus from his father, a soldier who had recently been vaccinated prior to a tour of duty in Iraq. Only an all-out response from a Who's Who of U.S. infectious disease experts saved the boy, who had become a victim, it appears, because of an immune defect associated with eczema.

Why does this matter to you? Or to me? I read this article in Science (sorry about the paywall) at the time and the story just leaped off the page at me. It's scary. If you have eczema, you basically shouldn't get vaccinated for smallpox because the risk of dying is too high. And the effects aren't pretty.

(You may notice that I never post images of this stuff. That's my policy. I have eczema, and it grosses me out enough on my own body that I don't need to see it on anyone else's. I eat dinner after writing these posts.)

In the year following that nasty discovery, the NIH founded a research group called the Atopic Dermatitis and Vaccinia Network (ADVN) to look into why vaccinia virus can cause such an extreme reaction. Vaccinia is closely related to variola, the agent of smallpox, and used as the vaccine. In most people, it's benign. An ADVN group at the La Jolla Institute for Allergy and Immunology found that levels of "natural killer" cells, a class of white blood cells, are low in a strain of mice used as models for atopic dermatitis, and which develop "eczema vaccinatum," the same condition the Chicago boy nearly died from. In normal people, the theory is,  natural killer cells somehow keep the virus in check.

Science is complicated-- this is one paper, and it's a mouse model, but you can imagine that these results might point the way to studies that could find similar results in humans, and possibly therapies to boost natural killer cells to prevent deadly reactions to vaccine. (The ADVN must have published reams of papers, and right now I have no idea what their most significant findings were. Will have to find out.)

The ADVN has now morphed into the ADRN, the Atopic Dermatitis Research Network, the group that in July received $31.5 million from the NIH to conduct extensive research over five years into why patients with eczema are susceptible to deadly microbial infections. In the NIH's original request for proposals for this funding, they define four research areas; the first two are eczema vaccinatum and staph infections. The second two are vaccine reactions and infections from other organisms. The constraint was that applicants had to pick one of the first two areas, plus one to three of the remaining three. The successful consortium, led by Donald Leung at National Jewish Health in Denver, appears to have picked staph infections as their primary focus, according to their press release.

I wrote to Leung and he informed me that the group has not yet determined a protocol for its experiments, but will have done so by the end of the year. I can't wait to find out the details. It is an undertaking of huge scope-- ten academic centers involved. Staphylococcus, and MRSA, is surely a worthy enemy to vanquish. Imagine bringing up a child with eczema knowing that because of what they discovered on this project, you didn't have to worry about runaway staph infections. Life might not be all smooth sailing, but the fear factor would be a lot lower.

Initially, I called the NIH media department, asking whether they made the details of grant applications public. They do not, and the officer directed me to contact the scientists directly. "I'm an eczema sufferer myself," he told me. "I understand why you want to know."