Don't Panic. We Can Fight Smallpox.

As frightening as the threat of anthrax has been, the nightmare scenario for biological warfare calls for another pathogen—one which, unlike anthrax, can be transmitted from person to person.

Smallpox fits this description well. It is spread through face-to-face contact, by means of infected saliva or respiratory droplets, usually in a closed setting. It can also be spread by infected linens or clothes: It was probably first used as a biological weapon during the French and Indian Wars by British soldiers who deliberately gave blankets that had been used by smallpox patients to American Indians.

Smallpox is fatal in approximately 30% of cases. As a virus, it is not treatable by antibiotics. No American civilian has been vaccinated since 1972, and it is likely that those who were before that have little, if any, immunity left.

Is this cause for panic or resignation, born of a grim reality that there is nothing we can do to protect ourselves? No, not at all. A review of medical and historical realities should give us confidence that if the unthinkable occurs, we could mount an effective campaign against the biological terrorism of smallpox.

First, smallpox no longer exists in nature. The last naturally occurring case was seen in 1977, in Somalia. At present, smallpox, at least officially, is stored in only two repositories: in freezers at the headquarters of the Centers of Disease Control and Prevention in Atlanta, and at a Russian virology installation known as Vector, in Siberia. While there is speculation about rogue nations possessing smallpox as a biological weapon, there is no hard evidence to confirm this.

Second, smallpox is not immediately contagious. A person infected with smallpox does not become contagious until he or she is too sick to be walking around. If you are wondering if the guy next to you on the subway has smallpox and decide to hold your breath between stops just in case, you are worrying needlessly. In the first 12 days or so after infection, the patient feels fine and is not contagious. On or about the 12th day, there is a spike in fever, and then, after a couple of days, the appearance of a rash—the highly visible "pox"—which is the signature of smallpox.

The beginning of the onset of the rash signals communicability. By this time, the patient is bedridden, or in a medical facility, which is why most secondary infections occur at home or in a hospital, not in schools or other public places. For this and other reasons, smallpox transmission throughout the population is generally slower than for such diseases as measles or chickenpox. Of course, should a terrorist attempt to spread the virus by means of an aerosol release, this limitation on venues for infection would not be relevant. But such means of transmission is at this point only theoretical.

Third, it would be difficult to acquire and disseminate the virus—much more so than anthrax. Even if there were an illicit source of smallpox, a terrorist would have to overcome sophisticated scientific and technological obstacles to cultivate it (one would need to grow the virus in eggs or animal cells) and disseminate it (putting it in the form of inhalable particles). Theoretically, it would be possible to have an individual "suicide vector" walk around once contagious, but one might question whether even the most devoted terrorist would be physically capable of effectively spreading the disease given the severity of the illness once it becomes communicable.

Fourth, we have medical means of treating infected persons. While there is no Cipro equivalent to treat smallpox, there is evidence that vaccination within three or four days after infection can prevent or significantly ameliorate subsequent illness. There are some 15 million units of smallpox vaccine available now, and there is an urgent effort underway to try to stretch that supply to cover as many as 150 million people. Hundreds of millions more doses are on order.

The vaccine offers some immunity immediately, and is in full effect after a week. In addition to the use of vaccine after infection, there may be an effective antiviral drug, Cidofovir (made by Gilead Sciences of Foster City, Calif.), sold under the brand name Vistide. This drug won FDA approval in June 1996 for the treatment of cytomegalovirus retinitis, a sight-threatening viral infection in AIDS patients. In March 1998, researchers at the U.S. Army Medical Research Institute of Infectious Disease reported that Cidofovir prevented death and disease associated with a pox disease in primates—monkeypox—similar to smallpox in humans.

Fifth, we have standard protocol in place for dealing with infectious disease. Right now, physicians (nearly all of whom have never seen a case of smallpox) are being educated to be on high alert for the symptoms of smallpox, particularly the high fever and unique rash which appears on the face and extremities. Should a case be diagnosed—and make no mistake, one case would be considered an epidemic and a world-wide catastrophe—the patient would be isolated, all exposed medical personnel would be vaccinated, as would emergency personnel. Case contact tracing to identify recent close contacts of "Patient Zero" would begin, and they would be immunized and/or isolated.

We have something of a model protocol for this emergency activity: In New York City in late March 1947, a man arrived from Mexico, sick with smallpox. He was hospitalized, but the disease was not recognized until two other cases in the hospital were identified. These individuals were isolated, medical personnel inoculated, and a decision made to inoculate all New Yorkers who had not been vaccinated recently. In just over a month, more than 6 million residents were immunized. In the end, that smallpox epidemic resulted in only 12 cases—demonstrating the effectiveness of preparedness and a systematic, scientifically sound response.

The better technology and medical knowledge we have today should offer even more assurance.

Tom, I don't know what you are arguing anymore.

I am arguing that this statement of yours is incorrect:

The point is, not to scare anyone, but to realize that people who have no idea they have small pox could easily unknowingly transmit it.

The one sentence in the Henderson book notwithstanding, the consensus as it exists now is that there is NO asymptomatic carrier. As I have said, all diseases have anomalies, but they are so rare as to not be considered, as evidenced by the current writings of Dr. Henderson.

The asymptomatic vectors who never get the disease would have "a rash" as a sore throat of some sort, perhaps some sin rashing as well.

First of all, where did this "asymptomatic vectors that never get the disease" come from? The Henderson book only mentions "10% of household contacts", but does not state in any way that they are "vectors".

Also, if someone is "asymptomatic", they won't have a sore throat or rash, as those are "symptoms".

I understood this to be a basis for miscommunication and tried to address it, but you never seemed to understand.

The following statement was the LAST thing you had to say about this ridiculous rash/pox/lesion nonsense:

I think you'll say that the pox refers to the "rash" confined to the oral cavity. That's fine, but the point is that is not how most people think of it. Most people think pox refers to visible pox on the skin, not a red throat.

Since you seem to be the only one around who has the problem determining the difference, I referenced the article for clarification.

Tom, I don't know what you are arguing anymore.

How about Free Vulcan's previous post?

1. There is a 7-17 day incubation period, with no apparent symptoms and no contagiousness.

2. The first syptoms of smallpox mimic the flu, however the person is still not contagious at this point.

3. Smallpox first becomes contagious when lesions/pox appear, AFTER the flu-like symptoms have existed for a day or two.

4. However, those lesions/pox generally first appear in the throat, and not on the skin, and therefore may not be immediately detectable.

5. After they appear in the throat, they then appear on the body at the face and extremities, and at that point confirm that the person has smallpox.

From that data, it would seem that:

1. An infected person, once lesions occur in their throat, may not immediately see them, or may think they are something else such as strep, and may not take immediate steps to quarantine themselves.

2. Meaning that in the period, that any lesions are in their throat ONLY, there is a window of time where they may be spreading the disease and unaware of it, even though that window is probably only a day or two.

3. Meaning that the zero patient may infect others during that window, but as soon as doctors realized there was smallpox in the area, would be on alert to quarantine people as soon as they came down with flu-like sypmtoms, but before they had lesions in their throat. This may mean a local or regional outbreak, but it would burn out quickly.

4. Meaning that the smallpox threat is moderate, not terribly high or low.

Would that be a correct analysis?

Look, Tom, you have lost it totally.

Read this:

The point is, not to scare anyone, but to realize that people who have no idea they have small pox could easily unknowingly transmit it.

Free Vulcan and myself are both saying the exact same thing.

I say, "unknowingly transmit it" he says, "may be spreading the disease and unaware of it".

And you agree. I don't understand what it is you want to talk about anymore.

You are being disingenuous. In your original statement in the first thread you say:

The point is, not to scare anyone, but to realize that people who have no idea they have small pox could easily unknowingly transmit it.

And then you say:

I say, "unknowingly transmit it" he says, "may be spreading the disease and unaware of it".

Seems you omitted the word "easily", which makes all the difference in the world. FV made it clear that transmitting the disease without knowing you have an oro-pahrangeal rash is not common. Rereading Dr Henderson's JAMA article, it is clear that in the vast majority of cases, the initial symptoms of smallpox are extreme and painful. Therefore in the vast majority of cases it wouldn't be easy to "easily unknowingly transmit" it.

We've jumped through hoops for you on these thread to get your Clintonian parsing of words down. Is it a pox or a rash? Is the oral mucosa considered the skin?

The fact of the matter is that the statement I started out with in post #153 is the one I end with (with alterations to make the nit-pickers happy):

Incubation period is 7-17 days, followed by a fever spike and incapacitating muscle aches, after 2-3 days the rash starts to form (usually forming in the mouth, in rare cases the person may not notice it). ONLY THEN is smallpox contagious (but in rare cases people may unknowingly transmit the disease prior to recognizing symptoms).

Alright, I lied. Just ONE MORE POST

In post #121, Dixie Mom writes:

The incubation period of smallpox is usually 12-14 days (range 7-17) during which there is no evidence of viral shedding. During this period, the person looks and feels healthy and cannot infect others

And then, you write:

Yes, I have read this. It's just not accurate.

Do you still maintain that this is true?

I`m not trying to help any bad guys, but before we dismiss the threat posed by smallpox lets realize you don`t need "rocket scientists" to do this.

What if they had say 12 or so guys willing to die, arranged in cells of three around the country, then they isolated and infected 1 individual from each group in some safe house, with smallpox, and waited for them to get sick. The other 2 guys of the cells could then use their human guinea pigs as an infection source and spread the virus laden pus over a wide area, hell, if they use one carrier/guinea pig from each group (keeping the other fresh and unexposed) then when the first gets sick replace him with a fresh (and formerly uninfected) carrier/guinea pig, the only limitation to its spread (aside from vaccine, or getting caught) would be enough idiots/"martyrs", and the quarenteening of an area.

If you had enough of these *ssholes spread around the country, do you think it would work?

The issue between you two definitely seems to revolve around 'easily transmit.' JAMA's information gives the impression that the flu mimicing symptoms are pretty incapacitating. I know however the flu doesn't stop motivated people who really don't want to take the day in bed. I guess it would differ from person to person and their threshhold of pain and the occasional person outside the bell curve may not get severe enough symptoms to incapacitate them. Probably a random luck of the draw in that respect as to if patient zero is incapacitated before they become contagious or able to keep upright and spread the disease.

Of course there is the issue of someone deliberately spreading it too, small as that window would be. Such a case might mean more individuals get it intially, however if the doctors and LEO's do their jobs, it should burn out just as quickly, unless like was suggested above there was a willing pool of people trying to keep it going. And being that the only way smallpox would get here would be as a terrorist event, that scenario isn't out of the realm of possibility.

Still, that leaves the risk level around moderate in my mind, say above anthrax but below some left over cold war genetically engineered bioweapon., unless there is something we all have have missed.

The issue between you two definitely seems to revolve around 'easily transmit.'

I agree. While there isn't any doubt that a terrorist could walk around a few days while symptomatic, we have both taken pains to point out that the index patient will infect people. But once the diagnosis of smallpox goes out, the spread can be stopped with proper isolation procedures.

I was mainly fighting the impression that there is a significant asymptomaic transmission of the disease. There isn't. As a matter of fact it is so insignificant that D.A. Henderson, author of the JAMA study, does not even see fit to mention it.

If you had enough of these *ssholes spread around the country, do you think it would work?

Yea, I have no doubt. But the epidemology of the disease is such that there would have to be a lot of close contact with a large amount of people. And while hijacking a jetliner and crashing it into a building has a kind of terrible sexiness to it, slowly dying of a painfully disfiguring disease mighthave its problems finding volunteers.

The more likely route of infection is delivering the virus itself from some sort of device in a closed area frequented by many people (the example of an exploding light bulb in a subway was used).

Re 46, I addressed that and said I was mistaken and sloppy in saying that.

But, the latter is misleading, which I was addressing. A person can be infectious yet look perfectly healthy (unless you want to look down the person next to you's throat). And by feeling healthy I mean simply have the symptoms of a cold or flu -- not advanced small pox.

We could examine the first sentence:

The incubation period of smallpox is usually 12-14 days (range 7-17) during which there is no evidence of viral shedding.

This is nonsense because the virus has obviously shed from the cells it has infected, but we know they meant shed from an erupted lesion in the throat.

You might play those games, but I see no reason to.

I agree with your comments in 48. I think the rarer possibilities for transmission are of more concern now for two reasons. One is it would be an attack where a large number of people would be infected, not a single or handful of people in a rural third world nation, as have been almost all the study cases of the last few decades.

Second is we are urban and suburban. In cases studied there is no equivalent to malls, subways, sporting events and similar everyday occurances where people come in to close proximity.

We have something of a model protocol for this emergency activity: In New York City in late March 1947, a man arrived from Mexico, sick with smallpox. He was hospitalized, but the disease was not recognized until two other cases in the hospital were identified. These individuals were isolated, medical personnel inoculated, and a decision made to inoculate all New Yorkers who had not been vaccinated recently. In just over a month, more than 6 million residents were immunized. In the end, that smallpox epidemic resulted in only 12 cases—demonstrating the effectiveness of preparedness and a systematic, scientifically sound response.

For what it's worth, the author neglects to mention that in 1947 most New Yorkers had been vaccinated for smallpox. As a born and bred New Yorker, I know that children were required to have vaccinations before attending school and we even got booster vaccinations in high school.

Almost no one has been vaccinated in the past thirty years. I think the above mentioned scenario would be quite different today.

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