Smallpox

Variola - major and minor; Variola Last reviewed: June 23, 2011. Smallpox is a serious and contagious disease due to a virus.

Causes, incidence, and risk factors

Smallpox was once found throughout the world, causing illness and death wherever it occurred. It mainly affected children and young adults. Family members often infected each other. Smallpox spreads easily from one person to another from saliva droplets. It may also be spread from bed sheets and clothing. It is most contagious during the first week of the infection. It may continue to be contagious until the scabs from the rash fall off. Researchers believe that the smallpox infection might be able to stay alive (under the right conditions) for as long as 24 hours. In unfavorable conditions, the virus may only remain alive for 6 hours. People were once vaccinated against this disease. However, the United States stopped giving the smallpox vaccine in 1972. In 1980, the World Health Organization (WHO) recommended that all countries stop vaccinating for smallpox. There are two forms of smallpox:

Variola major is a serious illness that can be life threatening in people who have not been vaccinated Variola minor is a milder infection that rarely causes death

A massive program by the World Health Organization (WHO) wiped out all known smallpox viruses from the world in the 1970s, except for a few samples saved for government research. Researchers continue to debate whether or not to kill the last remaining samples of the virus, or to preserve it in case there may be some future reason to study it. You are more likely to develop smallpox if you:

Are a laboratory worker who handles the virus (rare) Are in a location where the virus was released as a biological weapon

It is unknown how long past vaccinations stay effective. People who received the vaccine many years ago may no longer be fully protected against the virus. THE RISK OF TERRORISM

There is a concern that the smallpox virus could be intentionally spread through a terrorism attack. The virus could be deliberately spread in spray (aerosal) form.

Symptoms
Symptoms usually occur about 12 - 14 days after you have been infected with the virus. They may include:

Backache Delirium Diarrhea Excessive bleeding Fatigue High fever Malaise Raised pink rash -- turns into sores that become crusty on day 8 or 9 Severe headache Vomiting

Signs and tests

Tests include:

DIC panel Platelet count White blood cell count

Special laboratory tests can be used to identify the virus.

Treatment
If athe smallpox vaccine is given within 1-4 days after a person is exposed to the disease, it may prevent illness or make the illness less severe. Once symptoms have started, treatment is limited. There is no drug specifically for treating smallpox. Sometimes antibiotics are given for infections that may occur in people who have smallpox. Taking antibodies against a disease similar to smallpox (vaccinia immune globulin) may help shorten the duration of the disease. People who have been diagnosed with smallpox and everyone they have come into close contact with need to be isolated immediately. They need to receive the vaccine and be monitored. Emergency measures would need to be taken immediately to protect the general population. Health officials would follow the recommended guidelines from the CDC and other federal and local health agencies.

Expectations (prognosis)
In the past, this was a major illness with the risk of death as high as 30%.

Complications

Arthritis and bone infections Brain swelling (encephalitis) Death Eye infections Pneumonia Scarring Severe bleeding Skin infections (from the sores)

Calling your health care provider

If you think you may have been exposed to smallpox, contact your health care provider immediately. Because smallpox has been wiped out this would be very unlikely, unless you have worked with the virus in a laboratory or there has been an act of bioterrorism.

Prevention
Many people were vaccinated against smallpox in the past. The vaccine is no longer given to the general public because the virus has been wiped out. The possible complications and costs of the vaccine outweigh the benefits of taking it. If the vaccine needs to be given to control an outbreak, it can have a small risk of complications. Some complications are mild, such as rashes. Others are more serious. Only military personnel, health care workers, and emergency responders may receive the vaccine today. Smallpox vaccination policies and practices are currently being reviewed.

References
1. Damon, Inger. Orthopoxviruses: vaccinia (smallpox vaccine), variola (smallpox), monkeypox, and cowpox. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, Pa: Churchill Livingstone Elsevier;2005:chap 129. 2. Frequently asked questions about smallpox vaccine. CDC Emergency preparedness and response. Accessed February 7, 2007. Review Date: 6/23/2011.

Reviewed by: Jatin M. Vyas, MD, PhD, Assistant Professor in Medicine, Harvard Medical School; Assistant in Medicine, Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

The control and eradication of smallpox in South Asia

Rural vaccinator in United Provinces, British India, c.1930, private collection of Dr. Sanjoy Bhattacharya

Smallpox was a devastating scourge. It was a highly contagious viral disease that killed up to half of those infected and seriously maimed survivors, through severe scarring of the skin with deep pock marks, blindness and infertility. However, those who did survive enjoyed protective immunity from further infection for the rest of their lives. The smallpox virus, or variola its scientific name exist in more than one form, some producing more severe illness than others. Historical and epidemiological evidence suggests that South Asia was home to the more virulent strain of the disease variola major, which sometimes mutated into the deadly haemorrhagic form of smallpox. On the other hand, the less virulent variola minor also known as alastrim was commonest in Europe and North Africa, where mortality levels were lower and haemorrhagic cases extremely rare. The tools of modern science have yet to explain the relation between the different forms of variola, why some strains were more virulent than others or how some individual human

physiologies were better able to respond to infection than others. However, there is broad agreement in scientific, medical and public health circles about one point, namely, that variola major could inflict a heavy loss of life amongst non-immunised populations, killing between 25 to 50 per cent of those infected, whereas the case-fatality rate for variola minor could be as low as 1 per cent. The other striking aspect of variola major was its well defined features: high fever, deep rashes, oozing pustules and a putrid smell were the norm, and a large percentage of the victims tended to die from bleeding, cardiovascular collapse and secondary infections. Haemorrhagic smallpox caused death rapidly from dramatic internal and external bleeding.

Efforts at control

Poster advertising the benefits of vaccination and the dangers of smallpox, c.1970, Maharashtra, India, private collection of Dr. Sanjoy Bhattacharya

Historical evidence suggests that smallpox outbreaks were relatively regular occurrences in the continents of Asia, Europe and Africa. A range of sources also indicate that such events stoked widespread fear amongst members of the ruling elites, medical profession, social commentators and civil society, not least as it was recognised that smallpox did not respect political, geographical, racial and class boundaries. In fact, it was not uncommon for a mere handful of variola cases to foster great official and civilian nervousness, which meant that

epidemic emergencies were promptly announced, almost as soon as a few specific cases were confirmed. That said, smallpox epidemics could involve scores, hundreds or thousands of cases the highly contagious nature of variola and its gruesome possibilities made number crunching relatively unimportant. Indeed, in colonial South Asia the discovery of a few cases was often considered to represent a prelude to the unravelling of a crisis that would inevitably result in further infections and innumerable deaths; while large-scale mortality was usually considered to be an affirmation of the dangers expected of variola, a less dramatic toll on human life was generally celebrated as an instance of good fortune. The destructive nature of smallpox and the frequent reappearance of outbreaks of the disease ensured that a variety of medical, political, religious and social players kept searching for effective means of controlling its spread. Continuing disagreements about the best means of countering the threat posed by variola meant that a plethora of approaches coexisted side by side; a feature visible across ages and geographical locations, as those stricken or threatened by smallpox picked and chose from preventives and remedies. Sometimes involving the use of the isolation of those stricken with the disease, smallpox control measures could also range from religious ceremonies (the worship of the goddess Sitala was widespread in South Asia) to the inoculation of humans with live variola virus (variolation) or more benign animal pox-based viruses (vaccination).

The push for eradication

Smallpox recognition card, c.1973, courtesy Dr. Damodar Bhonsule, Panjim, Goa, India.

Official policy documents from Asia and Africa, dating from the nineteenth and early

twentieth centuries, sometimes refer to the goal of certain administrators to eradicate smallpox in such cases, the term eradication was generally used to describe their relatively limited aim of banishing variola from the geographical confines of specific political units. The term eradication was used in a far more wholesome and ambitious sense in the decade following the Second World War, when the formation of the United Nations fostered the development of wide-ranging plans to tackle the global incidence of certain diseases. Although the first concerted international assault led by the Geneva-based World Health Organization was directed at malaria, Soviet delegates drew attention to the possibility of expunging variola globally in the latter stages of the 1950s. The lobbying paid off, not least as there were fears within Europe and North America that smallpox could be reintroduced to those regions from countries where the disease was endemic, and the WHO Health Assembly made a concerted call for global smallpox eradication in 1958. This caused several national governments in Asia, Latin America and Africa to draw up blueprints for national smallpox eradication programmes, based on the plan to introduce 100 per cent vaccinal coverage within three to five years; the WHOs stated goal was to provide technical assistance and inter-regional coordination, as and when it was required. However, some national governments proved to be more committed to goal of smallpox eradication than others, which meant that the expansion of the global campaign was anything but uniform. Problems in this regard were compounded by the fact that the WHOs early commitments to field activities remain unspectacular, which allowed countries like India, which had expected its programme to be bankrolled with UN money, to develop its programme extremely slowly and unevenly. Therefore, while progress was reported and confirmed in Latin America by the late 1960s, smallpox remained firmly entrenched in Asia.

Annual number of smallpox cases by continent, 1959-1966** Continent 1959 Africa Asia Europe North America South America Oceania Total 1960 1961 1962 1963 1964 1965 1966 1967* 16,307 16,823 26,060 24,329 16,863 12,506 16,784 14,127 9,554 71,309 39,843 53,957 63,616 98,784 43,537 39,145 50,494 50,958 26 -47 -24 -136 -129 ---1 -71 -3 --

5,490 7,931 9,026 9,718 7,151 -1 ----

3,398 3,515 3,092 426 -----

93,132 64,645 89,067 97,800 122,927 54,441 59,445 67,784 60,941

**Consolidated data compiled by WHO from various sources *Until 15th July 1967 Source: Smallpox Eradication Report of a WHO Scientific Group: World Health Organization Technical Report Series, No. 393 (Geneva: WHO, 1968), 7, Official

Publications Room, Cambridge University Library, UK. Some parts of Asia were, of course, far more badly affected by smallpox than others. South Asia, composed of India, Bangladesh (East Pakistan before 1971), Pakistan, Sri Lanka, Nepal, Bhutan and Afghanistan was a major focus of endemic variola, causing the WHO to scrutinise the situation in this region carefully. India, because of its size, its geographical, political and social diversity, and its regular smallpox outbreaks was identified as a particularly challenging field of operations. This characterisation was not misplaced, as the country began to throw up innumerable problems, ranging from political and administrative apathy to civilian hostility. Persistently visible right through the 1960s, these difficulties delayed the Indian national smallpox eradication programme (NSEP) and ultimately caused it to face complete collapse by the end of the decade. Smallpox cases in India and the world, 1950-1977 Year 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 India 157,487 253,332 74,836 37,311 46,619 41,887 45,109 78,666 168,216 47,109 31,091 45,380 55,595 83,423 41,160 33,402 32,616 83,943 30,925 19,139 12,341 16,166 20,407 88,109 188,003 1,436 World 332,224 485,942 155,609 90,768 97,731 87,743 92,164 156,404 278,922 94,603 65,737 88,730 98,700 133,003 75,910 112,703 92,620 131,418 80,213 52,204 33,663 52,794 65,153 135,851 218,364 19,278 India/World Percentage 47.4 52.1 48.1 41.1 47.7 47.7 48.9 50.3 60.3 50.4 47.3 51.3 56.3 62.7 54.2 29.8 35.2 63.9 37.8 35.3 36.7 30.6 31.3 64.9 86.1 7.5

1976 1977

Zero Zero

953 3,234

---

Source: R.N. Basu, Z. Jezek and N.A. Ward, The Eradication of Smallpox from India (WHO/SEARO: New Delhi, 1979), 36. The Indian NSEP was rescued from complete breakdown by the detailed negotiations carried out by WHO representatives like Donald Henderson (then Chief of the Smallpox Eradication Unit in the WHO Headquarters in Geneva), who realised that its termination would spell the end for the global programme for smallpox eradication. For this reason, Henderson and his colleagues went out of their way to meet senior Indian politicians, promise heightened levels of financial and technical aid, and, not least, assure reforms within the WHO regional office; these efforts at winning over Indian political support for the smallpox eradication goal received backing from the highest levels of WHO administration, as it was accepted that the failure of such a high profile public health campaign would adversely affect the organisations international standing.

Variola (smallpox) virus, J Cavallini/Wellcome Photo Library. The WHOs negotiations with the Indian authorities, and its ability to mobilise significant funds for the NSEPs needs from the Swedish International Development Agency, allowed the programme to be expanded gradually, with the active assistance of some Indian officials and politicians based in New Delhi. Indeed, Indias bilateral agreements with the Soviet Union for the supply of millions of doses of freeze-dried smallpox vaccine as aid proved crucial to the extension of NSEP and its ability to reach an intensified level of activity in 1973. Administrative and political hiccups were never completely banished, but were dealt with by WHO and Indian federal officials with a combination of diplomacy, aggressive negotiation, hard work and doses of good fortune. Subsequent NSEP work based on intensive searches for variola, the laboratory testing specimens collected from rash and fever cases, the isolation of smallpox cases and the vaccination of all their contacts allowed India to achieve the so-called Smallpox Zero status in 1975. This initially caused as much disbelief as relief amongst senior WHO and Indian government personnel, who had not expected to reach this stage so quickly. There was, in fact, much nervousness amongst WHO officials about the Indian authorities decision to advertise and celebrate the achievement, as they continued to worry about the prospect of

finding a hidden pocket of variola in what was a vast country; these concerns ensured the retention of regular and comprehensive searches over the course of several months, which revealed, to the great relief of all concerned, that the country had remained variola free for two years. These findings were carefully examined by an independent committee, which certified India to be free of smallpox in March 1977. It is widely acknowledged that success in India was crucial to the achievement of the global eradication of naturally occurring smallpox in 1980, which was ultimately achieved after the last few cases of the disease were tracked down in the Horn of Africa (the last case of smallpox, which was the result of a variola minor infection, was tracked down, isolated and cured by WHO-led teams in Somalia in 1977). At the same time, it is useful to recognise that the success of other South Asian national smallpox eradication programmes were important as well, not least as the territories of East Pakistan/Bangladesh had been badly affected by civil strife and environmental disasters through the course of the 1960s and 1970s. While the last case of smallpox in Pakistan was found in 1974, the eradication of variola in Bangladesh could only certified in the second half of 1977, due mainly to all the political and social upheavals faced by the new nation (the country reported the last cases of smallpox in Asia in October 1975).

Historical research: How and why

Mr. John Wickett, of the World Health Organization, with the last person to have contracted and survived naturally occurring smallpox in Somalia (1977), courtesy Mr. John Wickett. The global eradication of smallpox is arguably the greatest achievement of twentieth century medicine. Historical research into the developments that made this feat possible is important both from an academic point of view as well as an international public health perspective there are many lessons to be learnt from a detailed historical examination of the unfolding of a multi-faceted campaign, based on the involvement of a range of international and national aid donors, in a diversity of political, social, economic and cultural contexts. Indeed, as the international polio eradication programme continues to suffer from serious structural difficulties, and as worried discussions about how best to cope with the possible outbreak and spread of a human variant of bird flu gather momentum, it seems that the lessons provided by

the smallpox eradication could be extremely pertinent for governments and civilians alike. For instance, the smallpox story warns us that public health policies cannot be imposed with any confidence from the top. If anything, the smallpox eradication programme reveals the central importance of mobilising local bureaucratic, political and civilian support for public health programmes reliant on large-scale immunisation and isolation; it also reveals the significance of adapting public health activity and messages to a plethora local cultural mores and concerns, even though this policy is expensive. Effective public health delivery, as WHO and Indian federal government officials realised during their tours of duty in the sub-continent during the 1960s and 1970s, involved much more than the clinical provision of a medical technology that promised to protect from a grievous disease. Instead their experience in the field revealed that such work required intricate negotiations with those being targeted, as assurances had to be provided by vaccinal efficacy and safety, explanations provided about why someone had to be isolated and her/his contacts immunised, and, why young babies and children needed to endure painful post-vaccinal symptoms. Indeed, many field officials found that forcible vaccination proved counter-productive in the long term, especially when such regimes were followed by serious post-vaccinal complications and/or death. Resistance to future investigative tours could be violent, or be marked by peoples refusal to co-operate or, even, based on them fleeing their places of abode en masse (or hiding others); each of these tactics badly weakened the effectiveness of emergency measures, which prolonged campaigns and caused administrative problems for international and national agencies working with finite financial and personnel resources. The studies on which this website is based have been made possible by generous financial support provided by the Wellcome Trust, UK. This website is the result of two Wellcome Trust-funded projects, one of which was started in October 2005 at the Wellcome Trust Centre for the History of Medicine at UCL. Dealing with the case study of smallpox control and eradication East Pakistan/Bangladesh, it builds on a previous project that dealt with historical developments in India and resulted in several publications. This website has several goals, namely:

It seeks to advertise the research findings of the Wellcome Trust-funded projects dealing with the global eradication of smallpox, with special reference to the South Asian region, to the widest possible audience we seek to reach and interact with academics as well as members of the public, in the hope that we can help develop an active interest in international health history. We seek to reach and contact people who were involved in any capacity with smallpox control and eradication work in South Asia or elsewhere: those took part in field operations, in financial and personnel management at international-, federal- and local-government level, in vaccine research and deployment, in publicity work, in immunisation camps etc.

Please feel free to contact us!

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The Suez Crisis erupts on July 26, 1956 when Egyptian President Abdul Nasser nationalises the Suez Canal Company which had been run by the French with the British government as the largest single shareholder. Dubbed the lifeline of Empire, the Canal was an absolutely vital conduit for oil. If Nasser blocked the precious flow, he could cripple the British economy. Just as critical, Nassers dramatic gesture comes during the midst of the Cold War while Britain and France are struggling to maintain their influence in the Middle East and North Africa as well as their own sense of relevance.

For British Prime Minister, Anthony Eden, the whole issue is an echo of his own struggle during the 1930s an d 1940s to confront Hitler and Mussolini. The British cabinet concedes in private that Nassers action is technically legal especially as he claims he will reimburse the shareholders. But London and Paris both feel they cannot afford to suffer this insult to their pride and prestige. They immediately begin making plans for a military strike. This will take months to plan and conduct. In the meantime, Nasser runs the Canal like a business giving London and

Paris no excuse to invade.

As Canal traffic flows smoothly under Egyptian ownership, the initial public outrage fades and the widespread support for a military strike begins to evaporate. Eden decides he needs a pre-text to invade. Here the former diplomat and foreign secretary is trapped by his reputation as a man of peace and United Nations man.

France is fighting a desperate guerrilla war in Algeria and sees Nasser as the dangerous embodiment of pan-Arab nationalism. The French government is keen to provide the British with their much sought after pre-text to invade Egypt and hopefully topple Nasser. So in October 1956, French officials arrange a piece of theatre with the newly created State of Israel, already an ally in the war against Nasser.

Worried by the recent arms acquisitions in Egypt, seeking to build up credit with the Great Powers, Israel agrees to launch a major strike against Egypt. This will allow France and Britain to express their grave concern for peace and then land their own troops as peacekeepers to separate the Israeli and Egyptian armies.

U.S. President Dwight Eisenhower is horrified by the steady

lurch to war and repeatedly urges Eden to avoid force. But Eden refuses to back down. The Suez Crisis is arguably the worst break in U.S./U.K. relations in the 20th century.

On the other side of the Atlantic Ocean, with no military, economic or geo-strategic interest in the Canal, Canada and therefore Lester Pearson is in a perfect position to carve out a middle ground between two extreme positions.

But throughout the summer and fall of 1956, all his diplomatic efforts fail to change the course of British and French policy or halt the growing divide between Washington and London.

Once Israel invades Egypt, Britain and France take on their guise as peacekeepers and begin bombing Egyptian positions. France and Britain are condemned at the United Nations. The Commonwealth splits along racial lines. The Western alliance is ripped apart.

As the situation deteriorates, Pearson decided to propose the first UN peace-keeping force. Grasping at straws, his initial idea is to convert the invading French and British forces into real peacekeepers with a mandate from the UN. But the fury in the General Assembly and the rage from Washington will

not allow this. Pearson abandons this stance and proposes a real UN force with no British or French forces.

While the crisis is debated in the Security Council where Canada lacks a permanent seat, Pearson can play no direct role. Only when the debate is forcibly moved against the wishes of London and Paris to the General Assembly can the master diplomat play a front line role. Arriving at the Assembly on the evening of November 1st, Pearson and his delegation begin building a consensus for his proposal. Working closely with all parties across all divisions, Pearson puts together a coalition of support over 4 hectic sleepless days and nights. In the early hours of November 4th 1956, the General Assembly overwhelming supports Pearsons proposal for the worlds first peacekeeping forces.

Within two weeks, advance units arrive in Egypt. Bowing to international pressure and the arrival of UNEF, British and French forces complete their withdrawal from Egypt by the end of 1956. Israeli forces withdraw in the spring of 1957. UNEF will remain in Egypt until President Nasser expels it in

1967 on the eve of the 6 Day War with Israel.

Praised at the UN for his brilliant efforts, Pearson is condemned by some at home for betraying the Mother Land. He tries to defend his record as one that actually tried to help Great Britain. Discontent with the Liberal government in power for 22 years leads to Prime Minister Louis St. Laurent losing the 1957 election. Removed from the world stage, Pearson now becomes a backbencher in Her Majestys Loyal Opposition. But in October 1957, on the opening of Parliament, he receives news that he has won the Nobel Peace Prize.

In January of 1958, Pearson is chosen leader of the Liberal Party of Canada and eventually becomes Prime Minister in 1963 but that is another story.