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Smallpox as a Biological Weapon
Medical and Public Health Management
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
Objective To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of smallpox as a biological weapon against a civilian population.
Participants The working group included 21 representatives from staff of major medical centers and research, government, military, public health, and emergency management institutions and agencies.
Evidence The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox as well as this article. The literature identified was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group.
Consensus Process The first draft of the consensus statement was a synthesis of information obtained in the evidence-gathering process. Members of the working group provided formal written comments that were incorporated into the second draft of the statement. The working group reviewed the second draft on October 30, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.
Conclusions Specific recommendations are made regarding smallpox vaccination, therapy, postexposure isolation and infection control, hospital epidemiology and infection control, home care, decontamination of the environment, and additional research needs. In the event of an actual release of smallpox and subsequent epidemic, early detection, isolation of infected individuals, surveillance of contacts, and a focused selective vaccination program will be the essential items of an effective control program.
JAMA. 1999;281:2127-2137
This is the second article in a series entitled Medical and Public Health Management Following the Use of a Biological Weapon: Consensus Statements of the Working Group on Civilian Biodefense.1 The working group has identified a limited number of widely known organisms that could cause disease and deaths in sufficient numbers to cripple a city or region. Smallpox is one of the most serious of these diseases.
If used as a biological weapon, smallpox represents a serious threat to civilian populations because of its case-fatality rate of 30% or more among unvaccinated persons and the absence of specific therapy. Although smallpox has long been feared as the most devastating of all infectious diseases,2 its potential for devastation today is far greater than at any previous time. Routine vaccination throughout the United States ceased more than 25 years ago. In a now highly susceptible, mobile population, smallpox would be able to spread widely and rapidly throughout this country and the world.
CONSENSUS METHODS
Members of the working group were selected by the chairman in consultation with principal agency heads in the Department of Health and Human Services (DHHS) and the US Army Medical Research Institute of Infectious Diseases (USAMRIID).
The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox2 as well as this article. The literature was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group.
The first draft of the working group's consensus statement was the result of synthesis of information obtained in the evidence-gathering process. Members of the working group were asked to make written comments on the first draft of the document in September 1998. Suggested revisions were incorporated into the second draft of the statement. The working group was convened to review the second draft of the statement on October 30, 1998. Consensus recommendations were made and no significant disagreements existed at the conclusion of this meeting. The third draft incorporated changes suggested at the conference and working group members had an additional opportunity to suggest final revisions. The final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.
This article is intended to provide the scientific foundation and initial framework for the detailed planning that would follow a bioterrorist attack with smallpox. This planning must encompass coordinated systems approaches to bioterrorism, including public policies and consequence management by local and regional public and private institutions. The assessment and recommendations provided herein represent the best professional judgment of the working group at this time based on data and expertise currently available. The conclusions and recommendations need to be regularly reassessed as new information becomes available.
HISTORY AND POTENTIAL AS A BIOWEAPON
Smallpox probably was first used as a biological weapon during the French and Indian Wars (1754-1767) by British forces in North America.3 Soldiers distributed blankets that had been used by smallpox patients with the intent of initiating outbreaks among American Indians. Epidemics occurred, killing more than 50% of many affected tribes. With Edward Jenner's demonstration in 1796 that an infection caused by cowpox protected against smallpox and the rapid diffusion worldwide of the practice of cowpox inoculation (ie, vaccination),4 the potential threat of smallpox as a bioweapon was greatly diminished.
A global campaign, begun in 1967 under the aegis of the World Health Organization (WHO), succeeded in eradicating smallpox in 1977.1 In 1980, the World Health Assembly recommended that all countries cease vaccination.5 A WHO expert committee recommended that all laboratories destroy their stocks of variola virus or transfer them to 1 of 2 WHO reference laboratoriesthe Institute of Virus Preparations in Moscow, Russia, or the Centers for Disease Control and Prevention (CDC) in Atlanta, Ga. All countries reported compliance. The WHO committee later recommended that all virus stocks be destroyed in June 1999, and the 1996 World Health Assembly concurred.6 In 1998, possible research uses for variola virus were reviewed by a committee of the Institute of Medicine (IOM).7 The IOM committee concluded, as did the preceding WHO committee, that there were research questions that might be addressed if the virus were to be retained. However, the IOM committee did not explore the costs or relative priority to be assigned to such an effort, and that committee was not asked to weigh the possible benefits resulting from such research activities contrasted with the possible benefits resulting from an international decision to destroy all virus stocks. These considerations will be weighed and decided by the 1999 World Health Assembly.
Recent allegations from Ken Alibek, a former deputy director of the Soviet Union's civilian bioweapons program, have heightened concern that smallpox might be used as a bioweapon. Alibek8 reported that beginning in 1980, the Soviet government embarked on a successful program to produce the smallpox virus in large quantities and adapt it for use in bombs and intercontinental ballistic missiles; the program had an industrial capacity capable of producing many tons of smallpox virus annually. Furthermore, Alibek reports that Russia even now has a research program that seeks to produce more virulent and contagious recombinant strains. Because financial support for laboratories in Russia has sharply declined in recent years, there are increasing concerns that existing expertise and equipment might fall into non-Russian hands.
The deliberate reintroduction of smallpox as an epidemic disease would be an international crime of unprecedented proportions, but it is now regarded as a possibility. An aerosol release of variola virus would disseminate widely, given the considerable stability of the orthopoxviruses in aerosol form9 and the likelihood that the infectious dose is very small.10 Moreover, during the 1960s and 1970s in Europe, when smallpox was imported during the December to April period of high transmission, as many as 10 to 20 second-generation cases were often infected from a single case. Widespread concern and, sometimes, panic occurred, even with outbreaks of fewer than 100 cases, resulting in extensive emergency control measures.2
Smallpox as a Biological Weapon
Medical and Public Health Management
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
Objective To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of smallpox as a biological weapon against a civilian population.
Participants The working group included 21 representatives from staff of major medical centers and research, government, military, public health, and emergency management institutions and agencies.
Evidence The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox as well as this article. The literature identified was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group.
Consensus Process The first draft of the consensus statement was a synthesis of information obtained in the evidence-gathering process. Members of the working group provided formal written comments that were incorporated into the second draft of the statement. The working group reviewed the second draft on October 30, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.
Conclusions Specific recommendations are made regarding smallpox vaccination, therapy, postexposure isolation and infection control, hospital epidemiology and infection control, home care, decontamination of the environment, and additional research needs. In the event of an actual release of smallpox and subsequent epidemic, early detection, isolation of infected individuals, surveillance of contacts, and a focused selective vaccination program will be the essential items of an effective control program.
JAMA. 1999;281:2127-2137
This is the second article in a series entitled Medical and Public Health Management Following the Use of a Biological Weapon: Consensus Statements of the Working Group on Civilian Biodefense.1 The working group has identified a limited number of widely known organisms that could cause disease and deaths in sufficient numbers to cripple a city or region. Smallpox is one of the most serious of these diseases.
If used as a biological weapon, smallpox represents a serious threat to civilian populations because of its case-fatality rate of 30% or more among unvaccinated persons and the absence of specific therapy. Although smallpox has long been feared as the most devastating of all infectious diseases,2 its potential for devastation today is far greater than at any previous time. Routine vaccination throughout the United States ceased more than 25 years ago. In a now highly susceptible, mobile population, smallpox would be able to spread widely and rapidly throughout this country and the world.
CONSENSUS METHODS
Members of the working group were selected by the chairman in consultation with principal agency heads in the Department of Health and Human Services (DHHS) and the US Army Medical Research Institute of Infectious Diseases (USAMRIID).
The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox2 as well as this article. The literature was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group.
The first draft of the working group's consensus statement was the result of synthesis of information obtained in the evidence-gathering process. Members of the working group were asked to make written comments on the first draft of the document in September 1998. Suggested revisions were incorporated into the second draft of the statement. The working group was convened to review the second draft of the statement on October 30, 1998. Consensus recommendations were made and no significant disagreements existed at the conclusion of this meeting. The third draft incorporated changes suggested at the conference and working group members had an additional opportunity to suggest final revisions. The final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.
This article is intended to provide the scientific foundation and initial framework for the detailed planning that would follow a bioterrorist attack with smallpox. This planning must encompass coordinated systems approaches to bioterrorism, including public policies and consequence management by local and regional public and private institutions. The assessment and recommendations provided herein represent the best professional judgment of the working group at this time based on data and expertise currently available. The conclusions and recommendations need to be regularly reassessed as new information becomes available.
HISTORY AND POTENTIAL AS A BIOWEAPON
Smallpox probably was first used as a biological weapon during the French and Indian Wars (1754-1767) by British forces in North America.3 Soldiers distributed blankets that had been used by smallpox patients with the intent of initiating outbreaks among American Indians. Epidemics occurred, killing more than 50% of many affected tribes. With Edward Jenner's demonstration in 1796 that an infection caused by cowpox protected against smallpox and the rapid diffusion worldwide of the practice of cowpox inoculation (ie, vaccination),4 the potential threat of smallpox as a bioweapon was greatly diminished.
A global campaign, begun in 1967 under the aegis of the World Health Organization (WHO), succeeded in eradicating smallpox in 1977.1 In 1980, the World Health Assembly recommended that all countries cease vaccination.5 A WHO expert committee recommended that all laboratories destroy their stocks of variola virus or transfer them to 1 of 2 WHO reference laboratoriesthe Institute of Virus Preparations in Moscow, Russia, or the Centers for Disease Control and Prevention (CDC) in Atlanta, Ga. All countries reported compliance. The WHO committee later recommended that all virus stocks be destroyed in June 1999, and the 1996 World Health Assembly concurred.6 In 1998, possible research uses for variola virus were reviewed by a committee of the Institute of Medicine (IOM).7 The IOM committee concluded, as did the preceding WHO committee, that there were research questions that might be addressed if the virus were to be retained. However, the IOM committee did not explore the costs or relative priority to be assigned to such an effort, and that committee was not asked to weigh the possible benefits resulting from such research activities contrasted with the possible benefits resulting from an international decision to destroy all virus stocks. These considerations will be weighed and decided by the 1999 World Health Assembly.
Recent allegations from Ken Alibek, a former deputy director of the Soviet Union's civilian bioweapons program, have heightened concern that smallpox might be used as a bioweapon. Alibek8 reported that beginning in 1980, the Soviet government embarked on a successful program to produce the smallpox virus in large quantities and adapt it for use in bombs and intercontinental ballistic missiles; the program had an industrial capacity capable of producing many tons of smallpox virus annually. Furthermore, Alibek reports that Russia even now has a research program that seeks to produce more virulent and contagious recombinant strains. Because financial support for laboratories in Russia has sharply declined in recent years, there are increasing concerns that existing expertise and equipment might fall into non-Russian hands.
The deliberate reintroduction of smallpox as an epidemic disease would be an international crime of unprecedented proportions, but it is now regarded as a possibility. An aerosol release of variola virus would disseminate widely, given the considerable stability of the orthopoxviruses in aerosol form9 and the likelihood that the infectious dose is very small.10 Moreover, during the 1960s and 1970s in Europe, when smallpox was imported during the December to April period of high transmission, as many as 10 to 20 second-generation cases were often infected from a single case. Widespread concern and, sometimes, panic occurred, even with outbreaks of fewer than 100 cases, resulting in extensive emergency control measures.2
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