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
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.