The threat of an outbreak of smallpox anywhere in the world is indeed a frightening prospect. It’s quite obvious that even a very small terrorist organisation could easily spread the disease globally without technically advanced vectors – provided it had access to the pathogenic virus. Furthermore, smallpox belongs to the category of biological weapons of mass destruction. It is extremely contagious and will easily spread outside the area of conflict. Thus completely “innocent” or only peripherally affected people can be stricken with disease.
This is a severe, global threat against one and all!
As a Swedish citizen one must ask: can we handle an attack even if we are affected only in the second-hand? Have those who have been delegated the power created a realistic preparedness against what may happen?
In 1980 smallpox was officially declared eradicated following an internationally successful vaccination campaign. Simultaneously the former – sometimes compulsory – inoculation against smallpox was terminated all over the world.
The smallpox virus, variola, was internationally saved in two qualified high risk laboratories: the Center for Disease Control and Prevention in Atlanta, Georgia and the Russian State Centre for Research on Virology and Biotechnology, Koltsovo, in the Novosibirsk region.
There are rumours that smallpox virus – intentionally or unintentionally – has been released from one of the two and that Iraq, for example, has had access to it.
In the present-day situation, it’s fairly obvious that the American preparations for war on Iraq are close to a point of no return and that the risk of war must be judged as very great.
The only clearly stated motive to begin a war against Iraq are to prevent weapons of mass destruction from getting into the wrong hands and perhaps be used on an unprotected civilian populations, particularly in the USA.
The American way of acting is characterised by a very strong resolution to use unreserved force – war.
It’s also very clear that the USA is taking the threat from biological weapons of mass destruction, especially smallpox, in earnest and, in parallel with the war preparations, is planning protective measures against this particular disease. This planning is extensive and includes plans for the vaccination of key personnel and military troops all within five days after a smallpox outbreak. Detailed plans for all regions of the nation have been submitted and quarantine measures have been taken. Using old stores of vaccine, new purchases of 400 million doses, and research to minimise the untoward inoculation side effects, have secured vaccine assets. In addition, research has been initiated towards a cure of the actual disease, a cure that is today non-existent .
It’s obvious that in the USA, many important decision-makers find the risk of a global smallpox epidemic impending and one of the main reason for finding Iraq such a threat. It’s possible that striking first and rendering the weapons harmless will solve the problem. Naturally, failure isn’t part of this plan. Neither does it seem to have been taken into consideration that an act of war may provoke a counterattack using terror weapons against a third party.
Another solution could be to abstain from open acts of war, at least until a global defence system against the actual weapon systems is in operation. There should be a preparedness that will reasonably guarantee the survival of the world population.
The fact is that if all nations were effectively protected against smallpox, the motive to use this particular weapon will be non-existent, as will the motive to make war to destroy it.
If a despotic leader is convinced that his country will be attacked in order to kill him, then certainly there will be a risk that he’ll use his weapons of mass destruction before his opponent is ready to start the war.
There is also a risk that he’ll chose to strike the first blow against the opponent’s sympathisers and allies, which will probably be easier to hit and more severely hurt than the main enemy with an effective defence already in operation.
In plain language: a war in Iraq could involve the risk of an attack on, for example, European countries.
What weapons could then be used?
Nuclear weapons are difficult to hide and can only be used with technically complicated weapon carriers to reach far-away countries. Iraq probably does not have access to such weapons today.
Likewise chemical weapons must have carriers and technically complicated dispersing systems. To obtain an adequately high concentration of e.g. a nerve gas to kill more than a very limited number of people, it takes well equipped military units or administration in semi-closed places like department stores, underground railways etc. It is difficult but not impossible to unveil preparations for such operations. The probability, however, for that type of terror attack is judged to be relatively small.
The use of biological weapons for the transmission of infectious diseases remains the biggest risk. From the terrorist’s point of view only smallpox, by being highly contagious and having a relatively high mortality, is an effective weapon of mass destruction. Consequently, the risk is high that not only the main enemy, but loyal allies as well, will be struck with disease.
Human beings all have experiences with being ill, but still find it difficult to understand what a smallpox epidemic would really involve.
The cessation of general vaccination against smallpox has made all young people vulnerable when exposed to the virus.
The virus – when released – will spread by itself without any help by sophisticated technical equipment. The mortality is high – every third patient will die – and the strain on the medical care organisation will be enormous. No effective treatment, like antibiotics for bacterial infections, exists.
Many experts judge the risk of a global spread with mass cases and casualties to be very high. The experiences from earlier epidemics make others claim that the harmful effects can be limited, particularly if strong quarantine measures and immediate mass vaccinations are applied.
The smallpox virus can survive only in body fluids and human secretions. It is transferred between people by droplets of saliva and mucus from infected airways. That makes it the perfect weapon for a suicidal agent. The only thing required is someone prepared to sacrifice oneself. Loaded with the virus, the agent then begins globetrotting to come in contact with as many people as possible. During the final seven days of the incubation period he or she still has no or only slight symptoms but is extremely contagious. Such an agent in an aircraft could, with a high probability, infect the other passengers by the air-conditioning system. They will then spread the disease further on. If the agent is able to withdraw before the disease becomes too severe, the world won’t understand what has happened until the huge epidemic is a fact.
Within the medical world, tthere is still knowledge about the disease, but very few doctors have personal experience.
The defence against smallpox has mainly been vaccination, stimulating the immune system of the body to produce antibodies. Vaccination was compulsory in many countries until 1976, but from then on all newborns of the world were unprotected. It is common knowledge that having smallpox and recovering or being vaccinated will render the individual immune for a very long time. It is now understood that this immunity is not lifelong but will begin to deteriorate after about 20 years.
In humans it’s possible to watch the virus develop by symptoms that can be chronologically predicted with a high level of accuracy. Mathematical models have been constructed that can predict the development of an outbreak with reasonable precision and also act as a foundation for planning vaccine requirements and the isolation and quarantine of cases of smallpox.
The fact that the disease can, and must, be prevented gives the people the right to demand not only that realistic and well-planned protective measures are undertaken in ample time, but also to demand instructions about individual actions and decisions to be taken in case of an epidemic.
What can be done to increase instant preparedness? Global mass vaccination with very short notice will probably be very difficult or impossible. Firstly, because time will not allow for more than inoculation of certain key groups of personnel and secondly, because there will not be enough vaccine available.
Almost all the vaccine doses available on the world market have been bought by USA and UK except for small amounts for national vaccine production programmes. Extensive scientific research is trying to find an effective antiviral medicine, but so far no preparations are available.
Without effective treatment, old techniques of medical care must be used. If the patient and those near to him can be quickly isolated, the risk of further spread is limited.
Therefore observations from a professional medical staff will be vital to prevent the spread. High fever, initial rash progressing to maculae and vesicles that finally become encrusted are unmistakable signs. To gain time everyone must know what actions to take. Unfortunately, that applies not only to the medical staff but also to borders and customs officers, security officers, and the airline staff at the check-in desks. They all must be aware what to do if a passenger who shows signs of disease wants to get onboard.
The key words in case of an outbreak must be isolation of the patient and quarantine for those who may have been infected. It may sound simple, but is in fact very complicated. It takes knowledge and careful planning of what decisions to make and which coercive measures to use. Another problem is the gigantic resources necessary for medical care and induced quarantine measures.
Central authorities have probably planned all this in detail. However, it is time to disperse ample parts not only to the personnel groups in question, but also to the general public.
-What are the quantities of vaccine available?
– If the supply is limited, who are the first to be vaccinated?
– If the supply is adequate, how will a mass vaccination be carried out?
– How shall quarantine be arranged?
– How long will the incarceration last?
– What preparations have been made?
– If you are placed in quarantine on the suspicion of being infected, won’t incarceration virtually guarantee that you will contract the disease?
– How will the public be informed of the first case of smallpox?
– What will happen to the economy when all travel stops?
– How will our grandchildren get the vaccine and be protected?
The authors are of the definite opinion that all this will be impossible to carry out when the first case is a fact – in Sweden or elsewhere.
The well-intentioned strategy – to avoid panic by saying nothing – is perhaps not too well thought-out. In any case, the authors are not reassured.
Some references:
Henderson, Donald A., T.V. Inglesby, J.G. Bartlett, M.S. Ascher, E. Eitzen, P.B. Jahrling, J. Hauer, M. Layton, J. McDade, M.T. Osterholm, T. O’Toole, G. Parker, T. Perl, P.K. Russell, and K. Tonat, for the Working Group on Civilian Biodefense. “Smallpox as a Biological Weapon: Medical and Public Health Management,” Journal of the American Medical Association 281, No. 22 (June 9, 1999): 2127-2137.
Smallpox as a biological weapon
Donald A. Henderson, MD, MPH; Thomas V. Inglesby, MD; John G. Bartlett, MD; Michael S. Ascher, MD; Edward Eitzen, MD, MPH; Peter B. Jahrling, PhD; Jerome Hauer, MPH; Marcelle Layton, MD; Joseph McDade, PhD; Michael T. Osterholm, PhD, MPH; Tara O’Toole, MD, MPH; Gerald Parker, PhD, DVM; Trish Perl, MD, MSc; Philip K. Russell, MD; Kevin Tonat, PhD; for the Working Group on Civilian Biodefense
Alibek K., Biohazard. New York, NY: Random House Inc; 1999
Emerging Infectious Diseases Journal
National Center for Infectious Diseases
Centers for Disease Control and Prevention
http://www.bt.cdc.gov/agent/smallpox/index.asp
http://www.cdc.gov/ncidod/EID/vol5no4/henderson.htm
A ProMED-mail post
http://www.promedmail.org
where you can see:
SMALLPOX VACCINATION STRATEGIES – USA (04)
SMALLPOX VACCINATION STRATEGIES – USA (05)
SMALLPOX VACCINATION STRATEGIES – USA (07)
SMALLPOX VIRUS, RETENTION OF STOCKS (02)
Birger Schantz
Born 10 June 1932 in Stockholm. 1962 VMD, 1974 Ph. 1979 Full Professor of Surgery at the Faculty of Veterinary Medicine, Swedish University of Agricultural Sciences, SLU, Uppsala. 1986 Director and Head of the Division of Human Sciences, National Defence Research Establishment, FOA, Stockholm.1993 Elected Member of the Royal Swedish Academy of War Sciences. “Kungl. Krigsvetenskapsakademien”. 1994 Appointed Member of the FOA Directorate as Research and Quality Director particularly responsible for scientific quality. 1997 Retired from FOA on 31 May. Emeritus Professor of Surgery, SLU. Henceforth engaged by Bo Rybeck Research AB, Stockholm.
© TFF & the authors 2002
