Bioterrorism Smallpox Vaccination: Experience and Considerations

smallpox, which is believed to have originated more than 3,000 years ago in India or Egypt, is one of the most devastating diseases known to humanity. For centuries, repeated smallpox epidemics swept across continents, decimating populations in their wake. The disease, for which no effective treatment was ever developed, killed as many as 30% of those infected. Between 65% and 80% of survivors were marked with deep-pitted pockmarks, most prominently on the face. Blindness was another complication. In 18th century Europe, a third of all reported cases of blindness were because of smallpox. As late as the 18th century, smallpox killed every 10th child born in Sweden and France. During the same century, every 7th child born in Russia died from smallpox. It wasn’t until 1798, when Edward Jenner demonstrated that inoculation with pus from cowpox lesions could protect against smallpox, that there was hope that the disease could be contained through medical means. In the early 1950s—150 years after the introduction of vaccination— an estimated 50 million cases of smallpox occurred in the world each year, a figure which fell to around 10 to 15 million by 1967 because of vaccination. Based on these encouraging statistics, the World Health Organization (who) launched an intensified plan in 1967 to eradicate smallpox— the “ancient scourge” that threatened 60% of the world’s population. Through the success of the global eradication campaign, smallpox was finally pushed back to the horn of Africa and then to a single last natural case, which occurred in Somalia in 1977 (the last case in the United States occurred in 1949 in Texas). There has been only one smallpox-related fatality since: a laboratory-acquired case that occurred in the United Kingdom in 1978. In 1979, who certified the global eradication of smallpox—one of the greatest achievements in the history of public health. With the end of smallpox, the virus went on to survive only in laboratories in the United States and in Koltsovo, Siberia. After the Soviet Union collapsed, reports surfaced alleging that the Soviets had produced variola in large quantities and were attempting to weaponize the virus in the 1970s, 80s, and 90s. Bioterrorism experts began to worry that the Russians might have let the virus slip into the wrong hands, with recent media reports suggesting that at least four countries have hidden stocks of variola. Still, most experts have long discounted the use of variola as a biological weapon, given numerous safety and “effectiveness” considerations. However, after the terrorist attacks on the World Trade Center and the Pentagon on September 11, 2001, many of the nay-sayers did an about-face and recognized that, in the hands of the wrong people, a lethal and socially destabilizing attack using variola was possible, if not likely. Because of the lingering threat of a terrorist attack involving variola—an attack anywhere in the world could easily result in widespread dissemination before the first case of smallpox is officially diagnosed—a number of health agencies throughout the world have begun the process