are They known as
Class A agents:
anthrax, smallpox,
plague, tularemia, viral
hemorrhagic fevers
and botulinum toxin.
Weapons of mass
destruction (WMD).
They are known as
Class A Agents.
Anthrax, smallpox,
plague, tularemia, viral
hemorrhagic fevers,
And botulinum toxin.
Bioweapons.
Weapons of Mass
Destruction (WMD).
(USAMRIID, 4th Ed.,
US Army Medical Research Institute of Infectious
Diseases, Ft. Detrick, MD)
Pathogens that cause
Death and disease on a large scale.
That cause mass disruption.
That are transmissible person-to-person.
That lack effective or available vaccine or
treatment or antidote.
Are infective as aerosols.
Are able to be manufactured and delivered
relatively easily.
While none of these agents have all of these
features, most have most of them.
Community preparation is based on the work
of this group which has identified the
pathogens that, if used against civilians, will
cause death, illness and disruption on a large
scale.
The Groups Goal: to gather, distill and
disseminate information on bioweapons to
aid medical and public health professionals
to protect the public.
Smallpox, says D.A. Henderson, is
the real gorilla.
The basis for the consensus recommendations on key
medical and public health issues derives from the
military and civilian arena:
* Anthrax can be treated, although a weaponized
version presents difficulties.
* Tularemia can be treated.
* Plague can be treated.
* Botulism cannot be treated.
* Viral Hemorrhagic Fevers (VHF) cannot be treated.
* Smallpox cannot be treated.
1.
2.
3.
4.
5.
All are difficult to handle, and delivery systems are
difficult to develop.
Tularemia and anthrax are treatable. Vaccines
exist.
VHF are extremely difficult to handle and deliver.
Vaccines are in development.
Botulism is very concerning, but is not propagated
person-to-person (non-contagious). Vaccine is
available. (Morefield; J. Immune Based Therapies and Vaccines; Sept 2008)
Of all the Class A bioweapons, it is the availability of
the knowledge, the technology, and the supplies of
smallpox that makes it the most fearsome offender
of these felons.
Four people intentionally contract smallpox and wander the Mall of
America, OHare Airport in Chicago, Kennedy Airport in NY, and
the NY Subway system. It is December.
About 10-14 days later, an estimated 500+ severe, flu-like illnesses
would be seen in doctor offices, schools, and hospitals. The
illness hits with a spike of fever, muscle aches, maybe headache,
maybe vomiting. The rash comes later.
In successive two-week epidemic waves, conservative estimates
place the number of dead at around 50,000,000 by June (in six
months).
In military terms, smallpox is a force multiplier. These four initiating
cases are the equivalent of two medium hydrogen bombs over,
say, NY and Washington.
12th Century: Romans, Greeks and Persians pollute drinking
water with corpses and dead cattle as strategy during
besieging cities.
1340- Northern France: attackers catapult dead cattle at the
besieged castle of Thun LEveque
1346- Crimea: Tartars send infected bodies (plague) in the
siege of Caffa (Ukraine)
1422- Bohemia: Catapulting decaying cadavers in siege
against Karlstein
1532- Columbia and Peru: Inca Empire collapses after
inadvertent introduction of Smallpox by Conquistador
reduces population from 25,000,000 to 2,500,000 (15191589). Virgin turf epidemic, nearly 90% of natives die.
1616-1619- North America: near total extermination of
the Massachusett, a people of the Algonquin
Nation, decimated prior to arrival of the Pilgrims in
1620. Seventy percent of the native population
dies in the virgin turf epidemic, many suicide as the
disease advances. The natives, they are near all
dead of the smallpox, wrote Pilgrim leader John
Winthrop, so as the Lord hath cleared our title to
what we possess.
1763- Colonial America (Fort Pitt): General J. Amherst
describes fomite transfer to Delaware Indians via
blankets and bandages.
1775- Revolutionary America (Boston and Quebec):
The British variolate prostitutes and civilians to
spread contagion (successfully) amongst the
rebels. G. Washington enters the city after it is
captured with 1000 troops known to have survived
smallpox.
Smallpox killed an estimated
450,000,000 people during the
20th century alone when the
world was still largely immune
(via vaccination). In the course
of human history, smallpox has
claimed more lives than plague,
the Black Death of the Middle
Ages, and all the wars of the
20th century combined.
The WHO global eradication
campaign, proposed by Viktor
Zdhanov in 1958, was
entrusted to D. A. Henderson in
the 1960s and declared
successful in 1978.
Variola Major and Minor have a fatal weakness:
as a virus it can infect only man. We are its only
host animals.
Hendersons strategy for Global Eradication thus
was global vaccination plus isolationcontainment. Identify all outbreaks, quarantine
the victim, vaccinate all the contacts to encircle
and contain the outbreak.
The Global Campaign task force was multinational and multi-cultural. The Campaign
lasted twelve years.
First Phase: Intensified
Universal Vaccination
and vigorous
promotional efforts to
achieve it.
Second Phase: Isolate
and Contain any and all
outbreaks.
Promoting
Universal
Vaccination
PROMOTE AND
PURSUADE
Stamps
Ali Maow Maalin, the last
naturally occurring case of
smallpox. Ethiopia, Oct. 1977
Proof Set of Silver Coins presented by
WHO Director General to each nation that
participated in the Eradication Campaign.
Issued 31 March 1978, originally. 2nd set,
May 1980
Worldwide vaccination ceased with confirmation of eradication. 40+ years
later, none of us retains immunity: we are a virgin turf except for
military populations (Russia, China, America, Britain, Germany, Israel,
Pakistan, Iran, Cuba, N. Korea, Serbia, etc.).
Zhdanov established Biopreparat Fermenty in 1973 and engaged in the
weaponization of Class A agents, including smallpox and several hybrid
strains. The Soviets were extremely successful. They produced a
freeze-dried, highly lethal strain of the virus in metric tonnage amounts.
A workforce in excess of 60,000 was engaged in this endeavor. Since
the dissolution of the Soviet Union, the whereabouts of this workforce
and frozen virus has not been completely established.
The amount of lyophilized virus capable of killing worlds the population is
3.5 grams the amount that would sit comfortably on an average
human thumbnail.
When D.A.Henderson learned and then verified this horror, he was
speechless. He first remark: Its a great letdown. I never would have
suspected.
Prodromal rash,
vaccinated
subjects: lesions of
oropharynx plus
enanthema.
The next ten pictures, illustrate the evolution and
clinical picture in an unvaccinated 9 month old
Pakistani child.
The photographer working for the WHO and
expressly for purposes of capturing this
progression of the disease. Goal: to publicize
for the Eradication Campaign. Exposure had
occurred 10-14 days before.
This child is prodromal, febrile, uncomfortable, but
with very little by way of outward signs, as is
characteristic of smallpox.
Remember these
pictures: they are used
as exemplars of
smallpox in all the
medical literature and
educational materials.
The case can now be
diagnosed as
DISCRETE,
ORDINARY-TYPE
Smallpox. Confluent
type would have
blended over face and
arms. This is classic
centrifugal distribution.
Variola Major such as
this carried 25-40%
lethality, depending on
strain variant.
Scabbing, scarification and resolution. The crusted
scabs are highly contagious.
WHO pocket recognition card,
as used during the Campaign.
Pregnant 18 year old,
lethal in 5 days.
This was India type
1967, and was the
strain weaponized
as per K. Alibek,
who defected from
the Soviet Bioweapons Program
in 1991.
Usually fatal in 6-9
days.
Unvaccinated
male and female.
Unvaccinated 60
y/o, died on 4th day
of illness. These
pictures have been
misidentified as a
reaction to
smallpox vaccine.
20 y/o vaccinated
patient. Vaccine was
not a guarantee
against the disease
as much as a means
to survive, attenuate
and reduce personto-person
transmission.
it now becomes too manifest to admit of
controversy, that the annihilation of the Small
Pox, the most dreadful scourge of the human
species, must be the final result of this
practice. E. Jenner, June 21, 1798
Chinese develop variolation, the use of dried
smallpox scabs, insufflated into nose, in the
16th century.
In the 1820s, armto-arm transfer
allowed vaccine to
be propagated
even to the New
World in the
days prior to
refrigeration.
Orphans were
frequently used as
a living vaccine
transport
mechanism.
Arm-to-arm, Orphanage, Nice,
France
Vaccine was
always
controversial,
resisted and
met with
skepticism.
French cartoon, 1801
English cartoon, circa 1800
Recognition poster from
French-speaking and
English-speaking Africa. The
reward poster reads
(Indonesia) 5000 rupees to
the first person who
discovers a real case of
smallpox. Report to the local
health inspector and ask
about terms.
Commonly held beliefs
and customs, such as
Shaman variolation or
tribal belief made
universal vaccination
difficult.
A technique developed in many cultures
(Africa, China, Japan, others) that infected
with detritus (scabs), creating, hopefully, a
mild case of smallpox. Popularized by and
for English Royalty, variolation resulted in
immunity but also in contagion. One in every
100 cases would become full blown
smallpox. Pox houses were the result.
Hereditary variolators practiced throughout Africa, Afghanistan, and the
Pacific Rim.
Shaman kit for variolation.
Vaccinomodification: Smallpox occurs in
vaccinated subjects based on viral strain as
well as length of time since vaccination took
place. Usually, the smallpox attenuated and
the patient survived. The problem, however,
was that the patient was just as contagious,
and thus represented a threat to all those
with whom contact with the virus occurred.
Vaccination reduces
spread by increasing
host defenses and
attenuating the
infection. Airborne
spread of the virus
from this 20 y/o
vaccinated electrician
returning to Germany
from Pakistan in 1970
infected 17 other
patients without once
ever having direct
contact with any of
them.
Jennerian Calf-lymph (live vaccinia virus, or
cowpox) vaccine carries a risk and
complication rate of 0.09%. Up to 1 per
million primary vaccinees could die.
Newer vaccines (genomic, cell culture,
recombinant and inhalational) have proven
very effective and much safer (military
experience).
Common reactions:
1. fever plus redness and soreness at the vaccine
site.
2. Non-life threatening inadvertent inoculation,
erythematous or urticarial rashes, erythema
multiforme, and generalized vaccinia.
3. The most serious, potentially life-threatening,
adverse events are eczema vaccinatum,
progressive vaccinia, and post-vaccinial
encephalitis.
A.Eczema
Vaccinatum
B.DiGeorges-type
immunodeficiency:
lethal progressive
vaccinia
C. Generalized
Vaccinia
D.Inadvertent
innoculation
Careful screening can eliminate most
complications. A VACCINE HIGH-RISK
GROUP has been defined:
1. Immunocompromised patients: solid-organ
transplant, HIV+, cancer patients
2. Atopic dermatitis: eczema
3. Pregnancy; very young, very old.
Contraindications are NOT absolute and must be
balanced by epidemiological context. Treatment
of an adverse vaccine event exists: VIG
(Vaccine Immune Globulin).
Inadvertent
Inoculation
Eczema
Vaccinatum
Vaccine attenuates
smallpox, usually
to confluent-type,
modified
smallpox, or to
Alastrim, the
mildest form of
smallpox.
Alastrim: vaccinomodulated, or due to
Variola minor.
Techniques:
1. Universal vaccination to create maximum
herd immunity.
2. Isolation and Containment and Ring
Vaccination: effective quarantining plus postexposure re-vaccination.
3. Vaccinate all the populace within 72 hours of
an identified outbreak.
A typical village.
Typical setting and geography: isolation simplified by
the setting.
The CDCs Smallpox Response plan
incorporates many of the concepts
that eradicated smallpox 40+ years
ago, when the world was still largely
immune to naturally occurring
smallpox.
Can we really distribute medication
and successfully vaccinate a
population of 3,000,000 (medium
city) in 72 hours? Can we isolate
and contain the city? Do we have
the vaccinated workforce that can
deliver vaccine and supplies?
There is much more than
smallpox epidemiology at
play in preparing for a
bioterror attack. one
cannot overestimate the
consequences of the terrorist
imagination or
desperation.
Edward H. Kaplan, Prof. of Public Health,
Yale School of Management.
Epidemiology, Vol 15, No3, 5/2004, p 260.