January 2002 (vol. 18, #2)
1601 N Tucson Blvd #9, Tucson AZ 85716
c 2001 Physicians for Civil Defense


Smallpox inoculation was introduced in Boston in the early 1700s. ``The idea had come from a slave belonging to Cotton Mather, an African named Onesimus, who had said the practice was long established in Africa, where those with the courage to use it were made immune, and he had his own scar on his arm to show. The technique ... was to make a small incision, then with a quill scoop the `pus from the ripe pustules' of a smallpox patient into the open cut. A generally mild case of smallpox would result, yet the risk of death was relatively slight. The ordeal of the patient ... could be considerable, ... largely because of various purges that were thought essential.''

Abigail Adams took her children to a relative's house in Boston for a two-month confinement to undergo the procedure. Poor Nabby got a bad case, being so covered with sores that she could neither walk, sit, stand, nor lie down in comfort, and her six-year-old brother had a raging fever and delirium that lasted 48 hours (McCullough, John Adams). Still, the risk of death in the recurrent epidemics that swept early America was such as to warrant the dangerous ordeal.

By 1966, 2 million people a year were still dying of smallpox, though no cases had been seen in the United States since 1949. Smallpox was officially declared to be eradicated worldwide in 1980, and routine vaccination stopped in 1972.

A hideous paradox was pointed out by Richard Preston: ``the eradication [with critical help from Russians] caused the human species to lose its immunity to smallpox, and that was what made it possible for the Soviets to turn smallpox into a weapon rivalling the hydrogen bomb'' (New Yorker 7/12/99,

By 1998, the World Health Organization (WHO) had destroyed all but 500,000 doses of its smallpox vaccine for lack of $25,000 to pay for the electricity to store it properly, and manufacturing facilities had been converted to other use or destroyed. U.S. academics called for the destruction of the ``only two'' remaining virus stocks, to signal that any use of smallpox as a weapon would be the ``most reprehensible of crimes.'' (N Engl J Med 1998;339:556-559).

This was despite the fact that in 1991 U.S. and British inspectors got a whirlwind tour of some of the major bases of the clandestine Soviet biowarfare program Biopreparat. They were stunned when a technician at Vector, the virology center near Novosibirsk, spoke of work with variola major (smallpox). Since all the Soviet stocks were supposed to be in one freezer in Mos-cow, this was a major violation of WHO Rules. Building 6 housed a Model UKZD-25, a bioweapons explosion-test chamber, the most sophisticated ever found by inspectors in any country. Inspectors were not permitted to don space suits and go inside; they were told their vaccines might not protect them. The smallpox bioreactors had a capacity of 630 liters-big enough for a microbrewery. According to Dr. Donald Ainslie Henderson of Johns Hopkins, who led the effort to eradicate smallpox, the Soviets weaponized the virus and manufactured up to 100 tons annually, possibly supplying Iran, Iraq, Libya, and North Korea (Wash Post 11/7/01).

The U.S. stockpile of possibly 7 million usable doses of smallpox vac-cine (6.3 million doses were used in New York City in 1947 to contain an outbreak) was kept in four card-board boxes in a walk-in freezer at a warehouse in Lancaster County, PA, as of 1999. Contracts have now been let to boost the stockpile to 280 million doses (Wall St J 11/30/01). Mean-while, studies are underway to test the efficacy of diluted doses of the old vaccine. Vaccine-resistant strains could make all this irrelevant: According to the Global Public Health Intel-ligence Net-work, Health Canada, Russians have weaponized and tested vaccine-resistant strains on prisoners (ProMED post 8/6/98).

In contrast to anthrax, smallpox gets around the most difficult technical problem of bioweapons: dissemination. After the initial attack, people become the disseminators. By the time the initial diagnosis was made, in about two weeks, the initial victims could be widely dispersed. A mathematical model predicts that each case could lead to an average of 3.5 to 6 secon-dary cases, assuming quarantine and vaccina-tion of traced contacts (Nature 2001;414:748-751). However, epidemiologist Michael Osterholm points out that in previous epidemics there was considerable immunity in the population. Today's American population is like a ``nuclear reactor without control rods,'' a set-up for an ``uncontrolled smallpox chain reaction'' (Preston).

Transmission is generally by airborne spread from close contacts (say within 10 feet). The virus does retain infectivity for long periods outside the host, so transmission from items such as contaminated bedding is possible though probably infrequent. Patients are infectious from the time that the rash appears, about 3 to 6 days after the onset of fever. Although patients are generally too sick to be ambulatory, it is thought that some close contacts may harbor the virus in their throats and transmit it without becoming ill (WHO Bull 1973;48:523-527). The incubation period averages 12 days, and contacts are quarantined for at least 17 days. Contacts should be immediately vaccinated, even if they were vaccinated in the past. In the 1960s, two-thirds of smallpox victims had a previous vaccination scar (McClain, Cpt. 27 in Medical Aspects of Chemical and Biological Warfare, 1997).

The typical smallpox rash begins on the face, hands, then legs, and spreads centrally to the trunk (a ``centrifugal'' distribution). Lesions are more abundant on the face and extremities, and involve the palms and soles. In contrast to varicella (chickenpox), lesions on one part of the body are generally in the same stage of development, progressing from macules (spots) to papules (bumps) to vesicles (blisters) to pustules, which develop umbilications (central depressions), then scabs. The patient is infectious until all the scabs separate.

In flat-type smallpox (2 to 5%), skin lesions are small and soft, accompanied by severe systemic toxicity, with 95% fatalities in unvaccinated patients (vs. 30% in typical smallpox). In hemorrhagic smallpox, the patient usually dies before the skin lesions develop (McClain).

The odor of smallpox is said to be quite distinctive.

Unlike anthrax, smallpox is not treatable with antibiotics. A high index of suspicion, rapid diagnosis, and aggressive public health response to quarantine contacts and vaccinate if possible are the only tools currently available to prevent death on a massive scale.


Routine Vaccination?

Current plans are to stockpile smallpox vaccine, not distribute it, because of vaccine toxicity. Though not nearly as bad as the variolization of John Adams's day-which caused severe smallpox in about 1 in 200 inoculations-about 1 in 1,000 persons suffered some adverse reaction to vaccinia. Inadvertent autoinoculation of another site (or another person) was most frequent; ocular vaccinia, which can cause corneal scarring, was the most troublesome. In children under the age of 5, as many as 6 per 1,000 suffered an encephalitis, followed by serious neurological impairment or death. Progressive vaccinia primarily occurs in persons with immunodeficiency and is 75% fatal. In persons with eczema, eczema vaccinatum could be severe or even fatal. Primary vaccination of pregnant women has caused fetal vaccinia, with fetal or early postnatal death.

Among those disagreeing with this government policy is Amherst biologist Paul W. Ewald. ``If you wait until a crisis is at hand, you lose a chance to have careful analysis on a patient-by-patient basis of the risks posed by vaccinating.'' Moreover, people vary greatly in their tolerance for risk as well as their tolerance for vaccines. The decision involves weighing imponderables, and individuals are best qualified to make this decision for themselves (Rauch, Atlantic Monthly 12/01).

An Associated Press poll showed that 60% of American adults would choose to get vaccinated if they could (Deroy Murdock, National Review Online, 11/26/01).

A prepared population is a less attractive target. ``Enough vaccine to protect the entire American population could be stored in a building smaller than a garage, and the vaccine would last for decades before it had to be replaced,'' writes Richard Preston. ``That would pretty much remove smallpox from the arsenal of a terrorist. It would also take smallpox away from Saddam Hussein far more effectively (and cheaply) than bombing his laboratories'' (NY Times 4/-21/98).


The FDA Road Block

Sixty years ago, U.S. industry, using untrained workers, could build a ship in less than 5 days. Novavax, a small biotech firm in Maryland says it could make 16 million doses of smallpox doses in two weeks-except for one thing: the FDA.

The previous vaccine was made of dried calf pus. Drug companies have switched to advanced cell culture techniques to make vaccines. If the FDA treats smallpox vaccine thus made as a new drug, it could take 6 years to run the regulatory maze.

A ``wartime FDA'' is needed-but is unlikely to happen without intense public pressure (Wall St J 11/15/01).


Are You Immune?

Although a public web site states that smallpox vaccination only lasts 3 to 5 years, some researchers believe that those born before 1970, who were vaccinated in infancy, may have significant residual protection. In a 1902-1903 outbreak in England, 93% of persons age 50 and older, who had received vaccine once in infancy, escaped severe disease or death, whereas 6 of 12 unvaccinated persons in that age bracket got a serious case and died.

Many uncertainties remain. James Leduc, leading smallpox authority at the CDC, states: ``We have a disease and a scientific database that really stopped progressing 20 years ago'' (Science 2001;294:985). Except possibly in Russia.


Do Biological Weapons Work?

One consequence of the end of the U.S. offensive bioweap-ons program in 1969, as a result of the Biological and Toxin Weapons Convention, was the loss of technical understanding of these weapons. Many scientists believe that such weapons don't work: they are uncontrollable, liable to infect their users, or impractical. A handful of influential scientists also held pas-sionately to the view that the Soviet Union was not violating the Conven-tion-despite intelligence reports that Biopreparat was set up in 1973, the year after the USSR signed the agreement.

Ken Alibek, deputy chief of research and production for Biopreparat before his defection, responded to this view about bioweapons: ``You test them to find out. You learn how to make them work,'' he told Richard Preston. ``I had a meeting yesterday at a defense agency. They knew absolutely nothing about biological weapons. They want to develop protection against them, but all their expertise is in nuclear weapons. I can say I don't believe in nuclear weapons work. Nuclear weapons destroy everything. Biological weapons are more .. beneficial... They don't destroy buildings, they only destroy vital activity.... People'' (New Yorker 3/9/98). The ultimate capitalist weapon?

From the first defector from Biopreparat, Vladimir Pasech-nik, Western intelligence learned that the U.S. was a ``deep target''-far enough away so that the Soviet Union wouldn't be contaminated. Inspectors found the same problem there as in Iraq: denials, evasions, large rooms stripped of equipment. ``These people just sat there and lied to us, and lied, and lied.''

William Patrick, one of a handful of living American scientists with a hands-on understanding of bioweapons, had doubts about whether bioweapons work-until the summer of 1968. At that time, a long series of open-air tests was conducted downwind from Johnston Atoll, as elaborate as the first tests of the hydrogen bomb, involving enough ships to constitute the world's fifth largest navy. The method: a line-source laydown. A Marine Phantom jet flew low, releasing dust from a single pod under its wing.

U.N. inspectors found a videotape of an Iraqi Phantom jet doing a line-source laydown over the desert.

Though the agent used was susceptible to antibiotics, Dr. Patrick pointed out that to treat 30,000 infections in, say, Frederick, MD, would require more than 2 tons of antibiotics, delivered overnight. ``There isn't that much antibiotic stored anywhere in the United States'' (Preston, ibid.).

Then there's the problem of bioengineered smallpox or other agents, also discussed in Preston's article (available at http://


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