Smallpox and Bio-terrorism

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What is small pox?

Smallpox (from the Latin words "varius" meaning "stained" or "varus" meaning "mark on the skin" or "raised bumps") is a very contagious, sometimes fatal, viral infection, that has claimed millions and millions of lives in the various pandemics around the globe since around 10,000 BC, when it first appeared in agricultural settlements in northeastern Africa. Smallpox has been one of mankind's greatest scourges ever. Even the plague, cholera, and yellow fever have not had such a universal and persistent impact on various societies. The first documented smallpox epidemic happened in 1350 BC during the Egyptian-Hittite war. The disease annihilated at least three empires. Generations watched helplessly as people fell victims to the deadly disease or were disfigured or blinded by it. Smallpox has greatly affected the western civilization. The initial stages of the decline of the Roman Empire, around AD 180, coincided with a large-scale epidemic: the plague of Antonine, which wiped out between 3.5 and 7 million people. Smallpox was instrumental in the fall of the empires of the Aztecs and the Incas. When the Spanish arrived in Mexico in 1518, it had about 25 million inhabitants; by 1620, smallpox had reduced it to 1.6 million. A similar decrease occurred on the eastern coast of what became the United States, where the advent of smallpox had disastrous consequences for the native population.

What was its impact of Smallpox on the people psyche?

This passage from the literature eloquently described the sad effect of the dreaded epidemic on everyone: "Smallpox was always present, filling the churchyard with corpses, tormenting with constant fear all whom it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to the lover."

Why was smallpox known as the killer of kingdoms?

Researching the history of smallpox gave us the answer as to why this devastating illness was tagged the killer of kingdoms and empires. Here, we quote an excerpt: "Smallpox made no distinctions. It affected all ages and socioeconomic classes. It killed Marcus Aurelius in AD 180; the first Abbasid caliph, Abbul al-Abbas al-Saffah ("the blood shedder"), in 754; King Thadominbya of Burma in 1368; the Aztec emperor Ciutláhuac in 1520; King Boramaraja IV of Siam in 1534; the King and Queen of Ceylon and all of their sons in 1582; Prince Baltasar Carlos, heir to the Spanish throne, in 1646; William II of Orange and his wife, Henrietta, in 1650; Emperor Ferdinand IV of Austria in 1654; Emperor Gokomyo of Japan in 1654; Emperor Fu-lin of China in 1661; Queen Mary II of England in 1694; King Nagassi of Ethiopia in 1700; Emperor Higashiyama of Japan in 1709; Emperor Joseph I of Austria in 1711; King Louis I of Spain in 1724; Tsar Peter II of Russia in 1730; Ulrika Eleanora, Queen of Sweden, in 1741; and King Louis XV of France in 1774. During the 18th century, four reigning European monarchs died of the disease, and the Habsburg line of succession to the throne changed four times in four generations because of the deaths of heirs. Citizens were equally at the mercy of the illness. In the late 18th century in Europe, 400 000 people died of smallpox each year and one third of the survivors went blind."

What was the cause of Smallpox?

Smallpox was caused by the Variola virus that suddenly appeared in human populations thousands of years ago, as related above, just like the SARS coronavirus of today. The Variola virus has been eliminated around the globe except for some laboratory stockpiles. In view of terrorism around the globe, there is today a heightened concern that the Variola virus might be used as an agent of bioterrorism. Hence, the U.S. government is maintaining its vigilance and is taking precautionary measures for dealing with a potential smallpox outbreak.

What is the incubation period?

After exposure to the virus, the person may not have symptoms and may feel well, until the incubation period, which averages about 13 days, but ranges from 7 to 17 days. During this period, the patient is still not contagious until the prodrome sets in. The symptoms listed above then show up after the incubation period. Mortality rate of smallpox: about 30%.

How is smallpox transmitted?

The mode of transmission is by direct and prolonged face to face contact with an infected patient. Smallpox could also be spread by contact with infected bodily fluids or contaminated items such as clothing, beddings, tabletops, utensils, pens, etc., much like the SARS virus. It was most rare for smallpox to have been spread by air in an enclosed setting like in an airplane, building, bus or train. No vector (insects, animals) transmission was reported, and humans were the only natural host of the Variola virus.

What are the signs and symptoms of smallpox?

The first groups of symptoms of smallpox is called the prodrome phase which may last for 2 to 4 days. This includes fever, head and body aches, malaise, and sometimes vomiting. The fever is usually high, in the range of 101 to 104 degrees Fahrenheit. The patient is sometimes contagious during the prodrome stage but becomes most contagious 7-10 days after the appearance of skin rash, and remains contagious until the last smallpox scab falls off.

Where does the first rash appear on?

The first rash appears as small red spots on the tongue and in the mouth. They develop into sores that break open and spread huge quantity of virus into the mouth and throat, which makes the patient most contagious. When the sores in the mouth break open, a rash emerges on the skin, initially on the face and spreading to the arms and legs, then to the hands and feet. Within 24 hours, the rash is all over the entire body. At this time, the patient will start to feel better. The rash is transformed into raised bumps by the third day. The following day, the bumps fill with a thick opaque fluid, and develop umbilication (crater depression at the center) like a bellybutton. This is the major and typical characteristic skin lesion of smallpox. The fever will elevate at this time and stay high until the scabs form over the bumps. The patient is still very contagious at this stage. The bumps become pustules (filled with pus), then begin to develop a crust and about the end of the 14th day, most sores are covered by scabs. The patient remains contagious. The scabs will start to fall off, leaving marks on the skin that look like pitted scars. By the end of the third week, all of the scabs will have fallen off. After the last scab falls off, the patient is no longer contagious.

When was the last recorded case?

Smallpox outbreaks have been known for thousands of years, but in the United States, the last case of smallpox on record was in 1949. The last naturally occurring case in the world was in Somalia in 1977. Routine public vaccination against smallpox has totally eradicated the disease from the world, hence this was discontinued in the United States in 1972.

Who pioneered in vaccination against smallpox?

The world will forever be indebted to Edward Jenner (1749 to 1823), who led the pioneering work that led to the discovery of the smallpox vaccination. He was originally ostracized and severely criticized by his peers for his medical postulates and ideas on cowpox and smallpox. He persisted in his experiments and was later vindicated and held as a hero in medicine. In January 1996, the 97th session of the WHO's executive board that met in Geneva and recommended to the 49th World Health Assembly that the last stocks of smallpox virus be destroyed. There have also been proposals to retain 500,000 doses of smallpox vaccine and to keep the Lister Elstree strain of vaccinia virus as seed virus stock of the smallpox vaccine. The destruction would affect all stocks of smallpox virus, including variola minor, clinical specimens, and other material containing infectious smallpox virus or viral genomic DNA. "Genomic DNA of the smallpox virus should be destroyed in all laboratories holding such material. The deadline for variola virus was 31 June 1999. This represented the first deliberate elimination of a biological species from this planet but also the extinction of an old enemy that humankind will not miss."

Smallpox as a bioterrorist weapon?

There are concerns that the smallpox virus could be used for bioterrorism as a weapon of mass destruction, one of the reasons why the United States declared the war on Iraq. As of May 13, 2003, two Iraqi microbiologists, known as "Dr Germ and Mrs. Anthrax," the ones in-charge of the germ warfare laboratory in Iraq, have surrendered to the Allied Forces. In the meantime, officials across the USA conducted "a $16-Million, 5-day drill, using an imaginary dirty bomb in Seattle and the fake threat of a biological agent in Chicago - both part of the most extensive bioterrorism drill in the nation's history to test the ability of local, state and federal authorities to handle terrorist attacks." The US has developed a national strategy, response plan and guidelines to deal with any eventuality of smallpox biological warfare. Currently, the US has a big enough stockpile (expected availability of 286 million doses by the end of 2002) of smallpox vaccine for everyone who might need protection in the event of an emergency.

Who should not get the Smallpox Vaccine?

The vaccine is not recommended for everyone since there are health risks. The following should not receive the vaccine, UNLESS at risk of exposure to, or actually exposed to, the smallpox virus: pregnant women, breastfeeding mothers, people with immune systems problems (due to diseases like AIDS or treatments like chemotherapy), people with certain skin conditions (eczema, atopic dermatitis, etc.), and people under 18 years old or living with someone less than a year old. According to CDC, "careful monitoring of smallpox vaccinations given over recent months has suggested that the vaccine may cause heart inflammation (myocarditis), inflammation of the membrane covering the heart (pericarditis), and/or a combination of these two problems (myopericarditis). Experts are exploring this more in depth".

If one is exposed to smallpox, is it too late to get a vaccination?

No. If given within 3 days of exposure, the vaccine will still completely prevent or significantly modify smallpox in the vast majority of persons, and vaccination 4 to 7 days after exposure will still provide some protection from disease or may modify the severity of disease. The first dose of the vaccine offers protection for 3 to 5 years, with decreasing immunity thereafter. People vaccinated 10 or 20 or more years ago have enough immunity to lessen their chance of death if infected, but these persons still require another dose of smallpox vaccine to restore their full protection. New studies have shown that diluted smallpox vaccine is just as effective in providing immunity as full-strength vaccine.

Can one get smallpox from the vaccination?

No. The smallpox vaccine does not contain smallpox virus and cannot spread or cause smallpox.

How safe is the smallpox vaccine?

CDC reports that there is nothing better today than smallpox vaccine to protect a person exposed to the smallpox virus. Side reactions, such as sore arm, fever, headache, body ache, and fatigue are usually mild. These may peak 8 to 12 days after vaccination. The report also states that in the past, about 1,000 people for every 1,000,000 (1 million) vaccinated people experienced reactions that were serious, but not life-threatening. Most involved spread of virus elsewhere on the body. Between 14 and 52 people out of 1,000,000 vaccinated for the first time experienced potentially life-threatening reactions. These reactions included serious skin reactions and inflammation of the brain (encephalitis). From past experience, one or two people in 1 million who receive smallpox vaccine may die as a result. Those with increased risk should not receive the vaccine.

What is the treatment for smallpox?

There is no treatment for smallpox. Studies on new antiviral drugs (cidofovir, etc) are ongoing. Smallpox vaccine can prevent the disease. Patients with smallpox are given supportive treatment as IV fluids, medicatiosn for pain and fever, and antibiotics to prevent secondary bacterial infections.

©2003Raoul R. Diez, M.A.O.D.