Posted on 10/29/2001 12:44:48 PM PST by tallhappy
A REPORTER AT LARGE
How smallpox, a disease of officially eradicated twenty years ago,
became the biggest bioterrorist threat we now face.
_______________
BY RICHARD PRESTON
THE smallpox virus first became entangled with the human species somewhere between three thousand and twelve thousand years ago -- possibly in Egypt at the time of the Pharaohs. Somewhere on earth at roughly that time, the virus jumped out of an unknown animal into its first human victim, and began to spread. Viruses are parasites that multiply inside the cells of their hosts, and they are the smallest life forms. Smallpox developed a deep affinity for human beings. It is thought to have killed more people than any other infectious disease, including the Black Death of the Middle Ages. It was declared eradicated from the human species in 1979, after a twelve-year effort by a team of doctors and health workers from the World Health Organization. Smallpox now exists only in laboratories.
Smallpox is explosively contagious, and it travels through the air. Virus particles in the mouth become airborne when the host talks. If you inhale a single particle of smallpox, you can come down with the disease. After you've been infected, there is a typical incubation period of ten days. During that time, you feel normal. Then the illness hits with a spike of fever, a backache, and vomiting, and a bit later tiny red spots appear all over the body. The spots turn into blisters, called pustules, and the pustules enlarge, filling with pressurized opalescent pus. The eruption of pustules is sometimes called the splitting of the dermis. The skin doesn't break, but splits horizontally, tearing away from its underlayers. The pustules become hard, bloated sacs the size of peas, encasing the body with pus, and the skin resembles a cobbled stone street.
The pain of the splitting is extraordinary. People lose the ability to speak, and their eyes can squeeze shut with pustules, but they remain alert. Death comes with a breathing arrest or a heart attack or shock or an immune-system storm, though exactly how smallpox kills a person is not known. There are many mysteries about the smallpox virus. Since the seventeenth century, doctors have understood that if the pustules merge into sheets across the body the victim will usually die: the virus has split the whole skin. If the victim survives, the pustules turn into scabs and fall off, leaving scars. This is known as ordinary smallpox.
Some people develop extreme smallpox, which is loosely called black pox. Doctors separate black pox into two forms -- flat smallpox and hemorrhagic smallpox. In a case of flat smallpox, the skin remains smooth and doesn't pustulate, but it darkens until it looks charred, and it can slip off the body in sheets. In hemorrhagic smallpox, black, unclotted blood oozes or runs from the mouth and other body orifices. Black pox is close to a hundred per cent fatal. If any sign of it appears in the body, the victim will almost certainly die. In the bloody cases, the virus destroys the linings of the throat, the stomach, the intestines, the rectum, and the vagina, and these membranes disintegrate. Fatal smallpox can destroy the body's entire skin -- both the exterior skin and the interior skin that lines the passages of the body.
Smallpox virus's scientific name is variola. It means "spotted" in Latin, and it was given to the disease by a medieval bishop. The virus, as a life form, comes in two subspecies: Variola minor and Variola major. Minor is a weak mutant, and was first described in 1863 by doctors in Jamaica. People usually survive it. Classic major kills one out of three people if they haven't been vaccinated or if they've lost their immunity. The death rate with major can go higher -- how much higher no one knows. Variola major killed half of its victims in an outbreak in Canada in 1924, and presumably many of them developed black pox. Smallpox is less contagious than measles but more contagious than mumps. It tends to go around until it has infected nearly everyone.
Most people today have no immunity to smallpox. The vaccine begins to wear off in many people after ten years. Mass vaccination for smallpox came to a worldwide halt around twenty-five years ago. There is now very little smallpox vaccine on hand in the United States or anywhere else in the world. The World Health Organization once had ten million doses of the vaccine in storage in Geneva, Switzerland, but in 1990 an advisory committee recommended that most of it be destroyed, feeling that smallpox was longer a threat. Nine and a half million doses are assumed to have been cooked in an oven, leaving the W.H.O. with a total supply of half a million doses -- one dose of smallpox vaccine for every twelve thousand people on earth. A recent survey by the W.H.O. revealed that there is only one factory in the world that has recently made even a small quantity of the vaccine, and there may be no factory capable of making sizable amounts. The vaccine was discovered in the age of Thomas Jefferson, and making a lot of it would seem simple, but so far the United States government has been unable to get any made at all. Variola virus is now classified as a Biosafety Level 4 hot agent -- the most dangerous kind of virus -- because it is lethal, airborne, and highly contagious, and is now exotic to the human species, and there is not enough vaccine to stop an outbreak. Experts feel that the appearance of a single case of smallpox anywhere on earth would be a global medical emergency.
At the present time, smallpox lives officially in only two repositories on the planet. One repository is in the United States, in a freezer at the headquarters of the federal Centers for Disease Control and Prevention, in Atlanta -- the C.D.C. The other official smallpox repository is in a freezer at a Russian virology institute called Vector, also known as the State Research Institute of Virology and Biotechnology, which is situated outside the city of Novosibirsk, in Siberia. Vector is a huge, financially troubled former virus-weapons-development facility -- a kind of decayed Los Alamos of viruses -- which is trying to convert to peaceful enterprises.
There is a growing suspicion among experts that the smallpox virus may also live unofficially in clandestine biowarfare laboratories in a number of countries around the world, including labs on military bases in Russia that are closed to outside observers. The Central Intelligence Agency has become deeply alarmed about smallpox. Since 1995, a number of leading American biologists and public-health doctors have been given classified national-security briefings on smallpox. They have been shown classified evidence that as recently as 1992 Russia had the apparent capability of launching strategic-weapons-grade smallpox in special biological warheads on giant SS-18 intercontinental missiles that were targeted on the major cities of the United States. In the summer of last year, North Korea fired a ballistic missile over Japan in a test, and the missile fell into the sea. Some knowledgeable observers thought that the missile could have been designed to carry a biologic warhead. If it had carried smallpox and landed in Japan, it could have devastated Japan's population: Japan has almost no smallpox vaccine on hand and its government seems to have no ability to deal with a biological attack. The United States government keeps a list of nations and groups that it suspects either have clandestine stocks of smallpox or seem to be trying to buy or steal the virus. The list is classified, but it is said to include Russia, China, India, Pakistan, Israel, North Korea, Iraq, Iran, Cuba, and Serbia. The list may also include the terrorist organization of Osama bin Laden and, possibly, the Aum Shinrikyo sect of Japan -- a quasi-religious group that had Ph.D. biologists as members and a belief that an apocalyptic war will bring them worldwide power. Aum members released nerve gas in the Tokyo subway in 1995, and, as the year 2000 approaches, the group is still active in Japan and in Russia. In any case, the idea that smallpox lives in only two freezers was never anything more than a comfortable fiction. No one knows exactly who has smallpox today, or where they keep the virus, or what they intend to do with it.
THE man who is most widely credited with the eradication of smallpox from the human species is a doctor named Donald Ainslie Henderson. Everyone calls him D. A. Henderson. He was the director of the World Health Organization's Smallpox Eradication Unit from its inception, in 1966, to 1977, just before the last case occurred. "I'm one of many in the eradication," Henderson said to me once. "There's Frank Fenner, there's Isao Arita, Bill Foege, Nicole Grasset, Zdenek Jezek, Jock Copland, John Wickett -- I could come up with fifty names. Let alone the tens of thousands who worked in the infected countries." Nevertheless, Henderson ran it. Smallpox killed at least three hundred million people in the twentieth century. During that time, humanity was largely immune to smallpox, which is not the case today. When D. A. Henderson arrived on the scene in 1966, two million people a year were dying of smallpox. In the years since the eradication effort began, Henderson and his team have effectively saved more than fifty million lives. This could be the most impressive achievement in the history of medicine. Henderson and his colleagues, however, have never received the Nobel Prize for their work.
D. A. Henderson is now a professor at the Johns Hopkins School of Public Health. He is the founder and the director of the Johns Hopkins Center for Civilian Biodefense Studies, a think tank that considers what might be done to protect the American population during a biological event. The term "biological event" hardly existed two years ago, but it is now used by emergency planners and by the F.B.I. to mean a terrorist attack with a bioweapon -- an unnatural event, caused by human intent.
Henderson lives with his wife in a large brick house in Baltimore. I arrived there on a cold, drizzly Saturday, and he ambled to the door. Henderson is an imposing man, six feet two inches tall. He is seventy years old. He has broad shoulders and a broad, seamed, angular face, pointed ears that stick out at angles from his head, a brush of gray hair, metal-framed eyeglasses, sharp blue eyes, and an easygoing voice that can flash with calculation. He was wearing a red checked shirt, with suspenders that held up Saturday slacks.
"In the last ten days, we've had fourteen different anthrax scares," he remarked in an offhand way as we stood in the front hallway of his house and he loomed over me. He has a top-secret-level national-security clearance, and he hears about little bioterror events that don't get noticed by the media. He went on to say, "Everybody and his brother is threatening to use anthrax. This week, it happened in Atlanta, in Washington, D.C., in Michigan, and in California. It's largely hoaxes. Of course, a real bioterror event is going to happen one of these days."
We settled into easy chairs in the family room. The walls and shelves of the room were crowded with African and Asian sculptures and wooden Ethiopian crosses, which he had picked up in his global hunt for smallpox. A Japanese garden was visible through sliding-glass doors.
We ate ham and roast-beef sandwiches, and drank Molson Ice beers. Henderson bit into a sandwich and chewed thoughtfully. Then he said, "Often, you get a worried look on your face, with the first signs of rash. We speak of the 'worried face' of smallpox. That face is a diagnostic sign. The rash comes up all at once. It's more dense on the face and the extremities. That's how you can tell smallpox from chicken pox. With chicken pox, the rash crops up over a period of days, and it's more dense on the chest and trunk of the body. Smallpox pustules have a dimple, a dent in the center. Doctors say that the pustules have a 'shotty' feel, like shotgun pellets. You can roll them between your fingertips under the skin."
"How many doctors could recognize smallpox today?" I asked.
"Virtually none. Smallpox takes forms that even I can't diagnose. And I wrote the textbook." He is a co-author of "Smallpox and Its Eradication," a large book in red covers, which experts call the Big Red Book of Smallpox. It was supposed to be the final word on smallpox-the tombstone of the virus.
ON February 15,1972, a thirty-eight-year-old Muslim clergyman returned to his home town of Damnjane, in Kosovo, Yugoslavia, after he'd been on a pilgrimage to Mecca, stopping at holy sites in Iraq. I will call him the Pilgrim. A photograph of the Pilgrim shows a man who looks well educated, has an intelligent face, and is wearing a clipped mustache and a beret. He had travelled by bus for his entire journey. The morning after his return home, he woke up feeling achy. At first, he thought he was tired from the long bus ride, but then he realized that he had caught a bug. He shivered for a day or two, and developed a red rash brought on by his fever, but quickly recovered. He had been vaccinated for smallpox two months earlier. Indeed, the Yugoslav medical authorities had been vaccinating the population of Yugoslavia relentlessly for more than fifty years, and the country was considered to be thoroughly immunized. The last case of smallpox in Yugoslavia had occurred in 1930.
The Pilgrim's family members and friends came to visit him. They wanted to hear about his trip, and he enjoyed telling them about it. Meanwhile, variola particles were leaking out of raw spots in the back of his throat and mixing with his saliva. When he spoke, tiny droplets of saliva, too small to be seen, drifted around him in a droplet cloud. If the person is throwing off a lethal virus, the cloud becomes a hot zone that can extend ten feet in all directions. Although the raw spots in the Pilgrim's throat amounted to a tiny surface of virus emission, smaller than a postage stamp, in a biological sense it was as hot as the surface of the sun, and it put enough smallpox into the air to paralyze Yugoslavia.
Variola particles are built to survive in the air. They are rounded-off rectangles that have a knobby, patterned surface-a gnarly hand-grenade look. Some experts call the particles bricks. The whole brick is made of a hundred different proteins, assembled and interlocked in a three-dimensional puzzle, which nobody has ever figured out. Virus experts feel that the structure of a smallpox particle is almost breathtakingly beautiful and deeply mathematical-one of the unexplored wonders of the viral universe. The structure protects the virus's genetic material: a long strand of DNA coiled in the center of the brick.
Pox bricks are the largest viruses. If a smallpox brick were the size of a real brick then a cold-virus particle would be a blueberry sitting on the brick. But smallpox particles are still extremely small; about three million smallpox bricks laid down in rows would pave the period at the end of this sentence. A smallpox victim emits several bricks in each invisible droplet of saliva that spews into the air when the person speaks or coughs. When an airborne smallpox particle lands on a mucus membrane in someone's throat or lung, it sticks. It enters a cell and begins to make copies of itself. For one to three weeks, the virus spreads from cell to cell, amplifying silently in the body. No one has discovered exactly where the virus z hides during its incubation phase. Probably it gets into the lymph cells, confusing the immune system, and victims are said to experience terrible dreams.
On February 21st, when the Pilgrim had been feeling achy for almost a week, a thirty-year-old man, a schoolteacher, who is known to experts as Ljatif M., arrived in Djakovica, a few miles from the Pilgrim's town, to enroll in the Higher Institute of Education. Doctors who later investigated the schoolteacher's case never found out how he had come in contact with the Pilgrim. One of them must have ended up in the other's town. Possibly they stood next to each other in a shop-something like that.
On March 3rd, Ljatif developed a fever. Two days later, he went to a local medical center, where doctors gave him penicillin for his fever. Antibiotics have no effect on a virus. Then his skin broke with dark spots, and he may have developed a worried face. He felt worse, and a few days later his brother took him by bus to a hospital in the town of Cacak, about a hundred miles away. The dark spots were by this time merging into blackened, mottled splashes, which the doctors in Cacak didn't recognize. Ljatif became sicker. Finally, he was transferred by ambulance to Belgrade, where he was admitted to the Dermatology and Venereal Diseases Department of the city's main hospital. By then, his skin may have turned almost black in patches. We don't have access to his clinical reports, so I am describing a generalized extreme smallpox of the kind Ljatif had.
Inside the cells of the host, smallpox bricks pile up as if they were coming off a production line. Some of the particles develop tails. The tails are pieces of the cell's protein, which the virus steals from the cell for its own use. The tailed smallpox particles look like comets or spermatozoa. They begin to twist and wriggle, and they corkscrew through the cell, propelled by their tails toward the cell's outer membrane. You can see them with a microscope, thrashing with the same furious drive as sperm. They bump up against the inside of the cell membrane, and their heads make lumps, and the cell horripilates. Then something wonderful happens. Finger tubes begin to extend from the cell. The tubes grow longer. The cell turns into a Koosh ball. Inside each finger tube is a smallpox comet. The fingers lengthen until they touch and join nearby cells, and the smallpox comets squirm through the finger tubes into the next cell. The comets are protected from attack by the immune system, because they stay inside the finger tubes, where antibodies and killer white blood cells can't reach them. Then the Koosh ball explodes. Out pour heaps of bricks that don't have tails. These smallpox particles are wrapped in a special armor, like hand grenades. They float away, still protected by their armor, and they stick to other cells and go inside them, and those cells turn into Koosh balls. Each infected cell releases up to a hundred thousand virus particles, and they are added to the quadrillions of particles replicating in the universe of the ruined host.
Ljatif's skin had become blackened, mottled, and silky to the touch, and sheets of small blood blisters may have peppered his face. In a case of black pox, variola shocks the immune system so that it can't produce pus. Small blood vessels were leaking and breaking in his skin, and blood was seeping under the surface. His skin had developed large areas of continuous bruises.
On March 9th, the Belgrade doctors showed Ljatif to students and staff as a case that demonstrated an unusual reaction to penicillin. (In fact, a very bad reaction to penicillin can look like this.) Ljatif's eyes may have turned dark red. In hemorrhagic smallpox, one or two large hemorrhages appear in each eye, in the white encircling the iris, making the eyes look as if they could sag or leak blood. The eyes never do leak, but the blood in the eyes darkens, until the whites can sometimes seem almost black.
During the day of March 10th, Ljatif suffered catastrophic hemorrhages into the intestines. His intestines filled up with blood, and he expelled quarts of it, staining the sheets black, and he developed grave anemia from blood loss. For some unknown reason, black-pox patients remain conscious, in a kind of paralyzed shock, and they seem acutely aware of what is happening nearly up to the point of death -- "a peculiar state of apprehension and mental alertness that were said to be unlike the manifestations of any other infectious disease," in the words of the Big Red Book of Smallpox. We can imagine that Ljatif was extremely frightened and witnessed his hemorrhages with a sense that his insides were coming apart. During the final phase of a smallpox intestinal bleedout, the lining of the intestines or the rectum can slip off. The lining is expelled through the anus, coming out in pieces or in lengths of tube. This bloody tissue is known as a tubular cast. When a smallpox patient throws a tubular cast, death is imminent. Al1 we know about Ljatif is that his bleeds were unstoppable, that he was rushed to the Surgical Clinic of the Belgrade hospital, and that he died in the evening. The duty physician listed the cause of death as a bad reaction to penicillin.
"These hemorrhagic smallpox cases put an incredible amount of virus into the air," D. A. Henderson said. Some of the doctors and nurses who treated Ljatif were doomed. Indeed, Ljatif had seeded smallpox across Yugoslavia. Investigators later found that while he was in the hospital in Cacak he infected eight other patients and a nurse. The nurse died. One of the patients was a schoolboy, and he was sent home, where he broke with smallpox and infected his mother, and she died. In the Belgrade hospital, Ljatif infected twenty-seven more people, including seven nurses and doctors. Those victims infected five more people. Ljatif directly infected a total of thirty-eight people. They caught the virus by breathing the air near him. Eight of them died.
Meanwhile, the Pilgrim's smallpox travelled in waves through Yugoslavia. A rising tide of smallpox typically comes in fourteen-day waves -- a wave of cases, a lull down to zero, and then a much bigger wave, another lull down to zero, then a huge and terrifying wave. The waves reflect the incubation periods, or generations, of the virus. Each wave or generation is anywhere from ten to twenty times as large as the last, so the virus grows exponentially and explosively, gathering strength like some kind of biological tsunami. This is because each infected person infects an average of ten to twenty more people. By the end of March, 1972, more than a hundred and fifty cases had occurred.
The Pilgrim had long since recovered. He didn't even know that he had started the outbreak. By then, however, Yugoslav doctors knew that they were dealing with smallpox, and they sent an urgent cable to the World Health Organization, asking for help.
Luckily, Yugoslavia had an authoritarian Communist government, under Josip Broz Tito, and he exercised full emergency powers. His government mobilized the Army and imposed strong measures to stop people from travelling and spreading the virus. Villages were closed by the Army, roadblocks were thrown up, public meetings were prohibited, and hotels and apartment buildings were made into quarantine wards to hold people who had had contact with smallpox cases. Ten thousand people were locked up in these buildings by the Yugoslav military. The daily life of the country came to a shocked halt. At the same time, all the countries surrounding Yugoslavia closed their borders with it, to prevent any travellers from coming out. Yugoslavia was cut off from the world. There were twenty-five foci of smallpox in the country. The virus had leapfrogged from town to town, even though the population had been heavily vaccinated. The Yugoslav authorities, helped by the W.H.O., began a massive campaign to revaccinate every person in Yugoslavia against smallpox; the population was twenty-one million. "They gave eighteen million doses in ten days," D. A. Henderson said. A person's immunity begins to grow immediately after the vaccination; it takes full effect within a week.
At the beginning of April, Henderson flew to Belgrade, where he found government officials in a state of deep alarm. The officials expected to see thousands of blistered, dying, contagious people streaming into hospitals any day. Henderson sat down with the Minister of Health and examined the statistics. He plotted the cases on a time line, and now he could see the generations of smallpox -- one, two, three waves, each far larger than the previous one. Henderson had seen such waves appear many times before as smallpox rippled and amplified through human populations. Reading the viral surf with a practiced eye, he could see the start of the fourth wave. It was not climbing as steeply as he had expected. This meant that the waves had peaked. The outbreak was declining. Because of the military roadblocks, people weren't travelling, and the government was vaccinating everyone as fast as possible. "The outbreak is near an end," he declared to the Minister of Health. "I don't think you'll have more than ten additional cases." There were about a dozen: Henderson was right -- the fourth wave never really materialized. The outbreak had been started by one man with the shivers. It was ended by a military crackdown and vaccination for every citizen.
AT the present time, the United States' national stockpile of smallpox vaccine is a collection of four cardboard boxes that sit on a single pallet behind a chain-link fence inside a walk-in freezer in a warehouse in Lancaster County, Pennsylvania, near the Susquehanna River, at a facility owned by Wyeth-Ayerst Laboratories. The vaccine is slowly deteriorating. The Food and Drug Administration has put a hold on the smallpox vaccine, and right now no one can use it -- not even emergency personnel or key government leaders.
The vaccine is owned by the federal government and is managed by Wyeth-Ayerst, which is the company that made it, twenty-five to thirty years ago. It is stored in glass vials. The vials contain freeze-dried nuggets of live vaccinia virus. Vaccinia is a mild virus. When you are infected with it by vaccination, it causes a pustule to appear, and afterward you are immune to smallpox for some years. People who have been vaccinated have a circular scar the size of a nickel on their upper arm, left by the vaccinia-virus pustule they had in childhood after vaccination. Some adults can remember how much the pustule hurt.
People from Wyeth periodically open the boxes and send some of the vials out for testing, to see how the vaccine is doing. The vials once held fifteen million good doses, but now moisture has invaded some of them. The nuggets are normally dry and white in color, but when moisture invades they turn brown and look sticky, and the vaccine may be weakened. The vaccine was made by a traditional method: the manufacturer had a farm where calves were raised. The calves' bellies were scratched with vaccinia virus, and their bellies developed pustules. Then the calves were killed and hung up on hooks, the blood was drained out of them, and the pustules were scraped with a knife. The resulting pus was freeze-dried. The vaccine is dried calf pus. According to one virologist who examined it under a microscope, "It looks like nose snot. It's all hair and wads of crap." It was a good vaccine for its time, but the F.D.A. would never clear it for general use today except in a national emergency. Furthermore, some people have bad or fatal reactions to the vaccine. There is an antidote, but the supplies of it have turned strangely pink, and the F.D.A. has put a hold on the use of these supplies, too.
D. A. Henderson believes that in practice doctors could obtain about seven million doses of vaccine from the vials. Unaccountably, most of the vaccine has not recently been tested for potency, so it has not been absolutely proved to work. The experts believe that it would work, but there still isn't enough.
Henderson explained the problem this way: "If there's a bioterror event, and someone releases enough smallpox to create a hundred cases -- let's say in the Baltimore area -- it would be a national emergency. The demand for vaccine would be beyond all belief." In Yugoslavia in 1972, the outbreak was started by one man, and eighteen million doses of vaccine were needed -- one for almost every person in the country.
Does anyone have smallpox?
With Anthrax, at least it is a common disease. - In agricultural areas we get about 100 cases per year, usually on the skin, but also a few respiratory cases from cattle trucks on the freeway, or rail cars.
But smallpox has not even been proven to be a legitimate hypothetical threat. - This is fear mongering.
It's not worth fear mongering, though, because it is easy to avpid it, to stave off any potential use of it and that is to do what we used to do to everyone. Simply vaccinate.
There is no evidence that there is any smallpox thread; it's all wild conjecture by agitators.
In the U.S. in the the 20th century, more people died from complications of vaccinations than from contagion. - That's a FACT.
So? That is to be expected. If the vaccination is 95 percent effective preventing full scale infection among the general population, the only cases you will see are in the failed five percent. That doesn't mean the vaccination is more deadly than the disease. Quite the opposite.
I am not sure how to respond because your comment is so off the wall.
Perhaps what you say is factual (I doubt it) but if so it is because vaccination was already commonplace before the 20th century.
I think you have deeper issues with questions of reality.
Haven't seen too many anti-vaccination threads recently, have we? Although DaRocksMom tried to start one with a story about a soldier having a reaction to the Anthrax vaccine, but there were few takers.
Oh sweet serendipity.
I'm sure you know this, aruanan, and I'm not sure the article covered this, but I try to post this on every smallpox thread I see. The incubation period for smallpox is between 7-17 days (usually 12). After that you have a fever spike with intense and debilitating muscle pain. At this point the patient is usually bedridden, as it is hard to move. Only then, about 2-3 days later does the rash start to appear. And it is only at that time that the person becomes contagious.
This information makes the idea of containment a little easier to understand.
Just adding this topic to the catalog, not sending a ping.
Please FREEPMAIL me if you want on, off, or alter the "Gods, Graves, Glyphs" PING list --
Archaeology/Anthropology/Ancient Cultures/Artifacts/Antiquities, etc.
The GGG Digest -- Gods, Graves, Glyphs (alpha order)
How did you do this? They won't let me post New Yorker articles?
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