And Now, the Good News about Smallpox

And Now, the Good News About Smallpox - In the event of a terrorist attack, we're not all toast. By JonCohen
By JonCohen
Updated Friday, October 26, 2001, at 10:38 PM PT

If you received a smallpox vaccine in infancy, as most everyone did in the United Statesbefore routine immunizations stopped in 1972, your immunity to this disfiguring and often lethal disease certainly has waned. Indeed, authoritative sources would have you believe that you have no immunity whatsoever. But if you dig out original scientific studies about the smallpox vaccine, a much different-and a much more optimistic-picture emerges.
According to U.S. Census Bureau data, about 40 percent of the U.S. population is 29 or younger, and having never received a smallpox immunization, up to 30 percent of that cohort would die if infected with the virus during a bioterrorist attack. But what of the remainder of the population, the 60 percent that got the vaccine at one point or another? What is their vulnerability?

The Centers for Disease Control and Prevention Web site offers this depressing answer in a smallpox FAQ: "Most estimates suggest immunity from vaccination lasts 3 to 5 years." In 1999, leading experts offered similar estimates in a "consensus statement" on smallpox as a biological weapon that they published in the Journal of the American Medical Association. "Because comparatively few persons today have been successfully vaccinated on more than 1 occasion, it must be assumed that the population at large is highly susceptible to infection," they concluded. "Dark Winter," a war game conducted in June at Andrews Air Force Base in which a smallpox "attack" was launched, proposed that 80 percent of the U.S. population is susceptible to the disease.

But data from a 1902-1903 smallpox outbreak in Liverpool, England, strongly suggests otherwise. A study analyzed the impact of the disease on 1,163 Liverpudlians, 943 who received the vaccine during infancy, and 220 who were never vaccinated. The study further separated people by age and by the severity of their disease. In the oldest age group, 50 and above, 93 percent of the vaccinated people escaped severe disease and death. In contrast, 50 percent of the unvaccinated in that age bracket died, and another 25 percent had severe disease. To put it plainly, the vaccine offered remarkable protection after 50 years.

Frank Fenner, a virologist at Australia's John Curtin School of Medicine who co-authored Smallpox and Its Eradication-a 1,400-page book that is the field's bible-says the Liverpool study remains the best evidence that vaccine immunity lasts for decades. The Liverpool study, paradoxically, also helped create the common wisdom that vaccine immunity rapidly wanes. In the Liverpool study, Fenner notes, vaccinated kids who were 14 and younger had zero cases of severe disease or death. So out of "conservatism," he explains, many smallpox experts began to advocate that anyone in an area where smallpox exists should be revaccinated every decade (Australia went one step further and said every five years). An added benefit of this aggressive vaccination policy was that it also slowed the spread of smallpox, because recently vaccinated people were less likely to transmit the virus than those who had received their immunizations decades before.

More recent data supports the Liverpool experience. In a 1996 study published in the Journal of Virology, a group led by Francis Ennis at the University of Massachusetts Medical Center pulled immune cells out of people who had received the smallpox vaccine decades before. When they tickled these cells to see whether they remembered the lesson the vaccine had taught them, they found that "immunity can persist for up to 50 years after immunization against smallpox."

James Leduc, the CDC's resident smallpox authority, concedes that the conventional wisdom posted on the CDC's Web site might not tell the whole story. "The issues that you are raising are absolutely accurate and well founded," he says. "What you see on the Web site is a first attempt to get a consistent message out," he says, explaining that the public health quandaries-such as the need to produce more vaccine-sometimes overshadow the scientific ones.

Fenner, like several other smallpox experts queried, has no idea how much protective immunity exists now in the United States. "Oh, gosh, it is a guess," he says. But as Bernard Moss, a researcher who works with the smallpox vaccine at the National Institute of Allergy and Infectious Diseases, stresses, a vaccine simply gives the immune system a head start in the race against a bug. In the case of smallpox, the bug is fairly slow to cause disease-symptoms typically don't surface for a few weeks-and an infection in a vaccinated person can act like a booster shot, revving up an already primed immune system. "Everyone would agree that if you had a vaccination in your life," says Moss, "you're much better off than if you hadn't."

None of this good news argues against rebuilding the nation's smallpox vaccine stockpile, which has dwindled to a mere 15.4 million doses. (The federal government has committed more than $500 million to produce 300 million doses.) Regardless of our country's precise immune status against smallpox, widespread use of the vaccine during outbreaks repeatedly has worked: New York City dramatically aborted an epidemic in 1947 with a rapid and aggressive vaccination (and, importantly, isolation of victims) campaign that limited the spread to 12 cases and two deaths. And surely we have become more vulnerable to smallpox since routine immunizations stopped.

But the good news inspires the sort of confidence the country needs right now: The entire population isn't at extreme risk in the event of a smallpox attack. As the CDC's Leduc says, "This is not going to be a wildfire that overtakes the world."

That's been my point since the beginning of this talk about smallpox. It is such a virilant disease, it would spread to the third world so fast it would make the terrorists heads spin. The Muslim world would be most at risk because they have huge populations, lack of sanitation, lack of medical facilities etc.

We would recover. Some of us have had vaccinations, we live spread out, cities would be quickly quaranteed, there is enough vaccinations available to treat those exposed. However, the Muslim countries would probably end up losing half their population, and the remaining half would be horribly disfigured. If the terrorists use smallpox, they are condemning their own people and way of life to death.

By the way, I wonder what you and the author of the SLATE article would consider an "acceptable" casualty rate? What if only 10% of Americans died? How about only 5%- would that be OK? At what projected case fatality rate should everyone just relax? (A 1% rate would mean the deaths of almost three MILLION Americans...)

You know, I have NO IDEA what you are taking about. If smallpox appears in the US, it is (another) act of war, and we should retaliate in kind (for weapon of mass destruction). Even if one person dies, it is still an attack, and should be treated as such. But that isn't what we are discussing in this thread. Why do you keep bringing it up?

I'm just tired of all the scare mongering going on around here lately, and I'm just trying to add some balance to the "we're all going to die" crap that some people are tying to spread.

There has been a lot of misinformation around here about smallpox, and it needs to be corrected.

If it makes you feel better to believe that smallpox, the ancient scourge of mankind, really isn't all THAT dangerous, then do so.

You know, garden variety infections were an "ancient scourge" also. That doesn't mean we are afraid of them now.

As far as the disease itself, the most important thing to remember is that it is NOT contagious in its initial stages. Only after the appearance of the telltale rash, usually after 10 or 12 days, does the disease become contagious. However, once the rash does appear, the patient becomes very weak and is likely to be bedridden by that time. This means that containing the disease is much easier that you've been led to believe.

Easier if you are talking about ONE patient who is promptly placed in an isolation ward, and all attending nurses, physicians, etc., follow protocols EXACTLY and without any mistakes.

If you are talking about hundreds or thousands of cases happening simultaneously in one city, however, then keeping all patients completely isolated becomes extremely difficult. We simply don't have the isolation wards, equipment, training, etc. to do it.

I've read that smallpox is contagious during incubation, prior to the manifestation of symptoms. There were also several smallpox threads on the subject last week, with comments from doctors, and none suggested that the virus wasn't contagious prior to the development of pustules.

I'm not an expert, but based on what very little I know, I would guess that there is probably at least a very narrow window of opportunity between the moment when the earliest symptoms develop and the earliest moment when the symptoms would be obvious enough to make smallpox a suspicion. In other words, during those first few hours when you start coming down with something, you usually don't know for sure whether it is just a cold, the flu, or something more serious. It is that time period when a contagious kid could infect dozens at school, maybe more dozens on the school bus, the rest of the family, then dozens more in the waiting room. All within the course of perhaps three or four hours.

Another point, there was an outbreak of smallpox in New York City in 1947, in which a man arrived from Mexico sick with the diesase. The diagnosis of smallpox wasn't even made until two other infections had been identified. But despite the headstart, there were only 12 total cases.

We have the ability to keep a dangerous diesase like smallpox under control.

Sure we have the ability to keep a dangerous disease like smallpox under control -- when the vector consists initially of a single infected individual.

I can very easily imagine a technique by which terrorists could simultaneously infect thousands of children in dozens of cities this halloween. That presents a much more challenging scenario.

I wonder if it would be possible to protect our kids by some type of blood transfusion? I mean, if the antibodies to smallpox is still in our blood and the doctors could safely draw a bit of our blood and inject it into our kid's blood to give them a bit of immunity? It would be using the parents instead of a horse or other animal for the innoculation.

Kind of like when some of the African doctors drew blood from the few who survived the ebola outbreak a few years ago and transfused it to the last 8 who were suffering ebola and most probably going to die from the ebola. Those doctors went against other authorities to inject the blood of the survivors into those still suffering ebola and saved 7 out of the last 8 that had it. Including a beloved nurse at the hospital. She was one of those that lived because of those transfusions.

And I wonder if the antibodies are passed to the children who have been breastfed?

In other words, during those first few hours when you start coming down with something, you usually don't know for sure whether it is just a cold, the flu, or something more serious. It is that time period when a contagious kid could infect dozens at school, maybe more dozens on the school bus, the rest of the family, then dozens more in the waiting room. All within the course of perhaps three or four hours.

I believe (and I'll admit it if I'm found to be wrong) it behaves like chicken pox - incubation is several days to 2 weeks and then the pox show up. Once the pox show up is when one is contagious. That's why my pediatrician hustled me out of the waiting room and out the back door of the office when I brought my son in with this strange rash last year . . . .sure 'nuff - It was chicken pox (a year AFTER his chicken pox vaccination).

If there's an outbreak in my area, she won't leave the house until the CDC has vaccinations on the ground, which will probably be within 48 hours of a confirmed case.
You are absolutely right! The only defense against smallpox, other than vaccination, is isolation. Think: Quarantine.
But, remember, you have to isolate EVERYONE in your household until the vaccinations are made available. The previously vaccinated members of the family could still bring the virus home on their clothing, etc. and infect your daughter. No work, no visitors, no mail, no new supplies (food, water). Nothing comes in from outside the home. No contact with the outside world whatsoever.
It would only be for a few days at most and the only sure way to keep your daughter safe.

I'm a nurse, with an unvaccinated son, and this is exactly what I intend to do if a smallpox outbreak occurs in my area.

Congratulations! You've figured it out. Most people have no idea WHY anyone would want to have a few days of food, water, etc. stored at home. A bunch of kooks, they tell us.

The big problem, however, is this: How are we going to know soon enough that there is a smallpox outbreak so that this can become a reliable strategy? The problem is that the public health authorities are unlikely to know for sure until quite a few people have already become infected, and there will be unidientified contageous people out there continuing to infect others even after they have made a firm diagnosis. There is also no certainty that the government is going to be quick to announce this. They will know that most people will be as underprepared as the government itself, and will be greatly concerned about mass panic. Also, while YOU will want to be hidden away out of infection's range, THEY will want you to be at work, preferably oblivious to the danger, at least until they have gotten their own ducks in a row (and their own and their own kids behinds vaccinated).

I would guess that there is probably at least a very narrow window of opportunity between the moment when the earliest symptoms develop and the earliest moment when the symptoms would be obvious enough to make smallpox a suspicion. In other words, during those first few hours when you start coming down with something, you usually don't know for sure whether it is just a cold, the flu, or something more serious. It is that time period when a contagious kid could infect dozens at school, maybe more dozens on the school bus, the rest of the family, then dozens more in the waiting room. All within the course of perhaps three or four hours.

Actually, that is incorrect. According to the CDC:

Twelve to 14 days after infection, the patient typically becomes febrile and has severe aching pains and prostration. Some 2 to 3 days later, a papular rash develops over the face and spreads to the extremities). The rash soon becomes vesicular and later, pustular . The patient remains febrile throughout the evolution of the rash and customarily experiences considerable pain as the pustules grow and expand.

So there are initial symptoms which are likely to cause the person to become bedridden, BEFORE the rash appears. So there is no "window of opportunity".

Historically, the rapidity of smallpox transmission throughout the population was generally slower than for such diseases as measles or chickenpox. Patients spread smallpox primarily to household members and friends; large outbreaks in schools, for example, were uncommon. This finding was accounted for in part by the fact that transmission of smallpox virus did not occur until onset of rash. By then, many patients had been confined to bed because of the high fever and malaise of the prodromal illness. Secondary cases were thus usually restricted to those who came into contact with patients, usually in the household or hospital.

Confined to bed where? At home.
By who? By Physicians who routinely made house calls.
House call? What's that??????

If there is a smallpox attack, every single victime is going to be taken to a clinic or emergency room. And large numbers of people who are already sick or infirm -- and thus more vulnerable -- will inevitably be infected. Many more than would have been typical in those earlier days.

Aren't you glad our new way of doing medicine is so much more "efficient?"

I agree with you, also, considering the medical advancements with anti-virals, and care, I think alot of people who did have it would be saved. If the rate of death was 30% how many years ago, it might be different now, especially now that we are so aware of the possibility of it happening and intervention.
If these jerks even have it, and do spread it out to a large amount of people, I don't worry as much about the actual disease, but the reaction of panic and fear from people, and the way the media will try to put the whole durn country into freak out mode.
You can bet the minute someone walks into an emergency ward covered in pustules, severe measures will be taken to contain and vaccinate those at risk. (cross my fingers)
It's the third world countries that will suffer the most.

Confined to bed where? At home.

Of course. And the most severe cases can be treated at a quarantine ward of a hospital.

Please explain ow this would happen, since you are sick for 2 or 3 days BEFORE YOU ARE CONTAGIOUS?

You are trying to scare people. Fortunately, you aren't doing a very good job of it.

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