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You return to your office from lunch to find your office staff around the TV. A nurse states that CNN is reporting a confirmed case of smallpox in the Chechnyen Republic. You realize immediately that your office will be flooded with calls from anxious patients worried about smallpox, concerned about rashes they’ve just noticed, and demanding immediate vaccination. You go to the CDC website and confirm indeed that the first case of Variola major in over thirty years has been diagnosed and that a worldwide public health emergency looms. From the CDC website you download their fever rash algorithm and plan to meet with your staff to review the protocol. Within two hours you receive calls from your local health department and the hospital where you have admitting privileges asking you to report immediately for a planning meeting for a townwide mass vaccination clinic.

Variola major is a double-stranded DNA virus of the Orthopox family. There are two recognized forms of smallpox: Variola major and Variola minor. Variola major is the more virulent strain with mortality rates 30% or higher in vaccine-naïve populations. Variola major has historically been more prevalent. Variola minor is considered rather mild with mortality rates less than 1%. Like its close relative, chickenpox, smallpox historically followed seasonal patterns of outbreaks, peaking in the late winter and early spring. Such a pattern is likely secondary to the sensitivity of the aerosol droplets to higher temperatures and humidity. It is not known what sensitivities (or lack thereof) weaponized forms might have. All Category A, B, and C biological weapons occur sporadically in nature with the exception of smallpox. Therefore, barring an extraordinary occupational history (i.e., laboratorian working in a Biosafety Level-4 (BSL-4) facility, diagnosing smallpox equates with diagnosing bioterrorism and constitutes an international medical emergency of the first order.

In what is one of the finest public health achievements of the 20th century, the virus that had killed more people than any other pathogen in the history of humanity was declared eradicated in 1980 thanks to a global vaccination program spearheaded by the WHO (Fig. 12–1). At that time, it was held that nations need not continue vaccination programs. It was not entirely accurate to claim the virus was eradicated as the WHO approved two sites to maintain smallpox: the CDC in Atlanta and the Institute for Viral Preparations in Moscow. Archives unearthed following the collapse of the U.S.S.R. demonstrated that the Soviets engaged in more than simple storage: they were actively developing large quantities and possibly vaccine-resistant strains of the virus that could be fitted to intercontinental ballistic missiles and bombs. The WHO called for both nations to destroy all stored viruses in 1999 and again in 2002; both declined. Reportedly, Russia continues to maintain smallpox research and active development of strains with greater resistance to standard vaccines amid reports of woefully lax security at these labs.

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