Smallpox Bioterrorism: Being Prepared for the Worst

Beth Cason
Santa Clara University

Introduction
Introduction
Smallpox was successfully eradicated in
1979 by the World Health Organization
campaign. This was a tremendous success
for the human race because Smallpox has
been one of the deadliest epidemics
throughout history, taking millions of lives.
However, the virus still remains in the
laboratory, and the threat of using Smallpox
as a bioterrorist weapon is a reality. Since
routine vaccination of the virus is no longer
administered, every person is susceptible. If
Smallpox were to be unleashed into urban
cities, the government would need a quick
and efficient method for vaccination.
Currently, there are two methods taken into
consideration. The first, called targeted
vaccination, isolates the symptomatic
individual and vaccinations are administered
to the individual’s contacts. The second,
called mass vaccination, simply administers
vaccinations to everyone after an attack is
recognized. While the former method is the
strategy currently adopted by The Centers
for Disease Control and Prevention, the
latter method is being reconsidered.
Questions
Questions
What is the most effective strategy of
vaccination if a bioterrorist attack of Smallpox
were to occur?
What should the government do with those
people exposed?
Methods
Methods
A Markov chain model was constructed to
describe the spread of smallpox through a
susceptible population. (See figure 1). For each
day after release of the disease, the model
calculates the number of new cases and the
cumulative total. The duration in days of a given
disease stage was then controlled by a
probability function (See figure 2). This
probability was integrated into a disease
transmission model of a Smallpox attack in a
large urban area. This transmission model
incorporates four stages of infection: (1)
asymptomatic, noninfectious and vaccine-
sensitive; (2) asymptomatic, noninfectious, and
vaccine-insensitive; (3) asymptomatic and
infectious; and (4) symptomatic and isolated.
Using the assumption that disease transmission
derives from free mixing of the susceptible
population with the symptomatic infectious
population, a population dynamic of the spread of
infection was constructed. (See figure 3). The
time it would take to reach and vaccinate all
those infected was compared between target
vaccination and mass vaccination.
Results
Results
The daily probability of remaining in the
incubating stage of the smallpox disease greatly
decreases after 8 days. One remains in the
prodromal stage for the shortest amount of time,
only 1 or 2 days. It is almost certain that an
infected individual will remain in the overtly
symptomatic stage for about 9 days.
Transmission will only occur during the prodromal
and overtly symptomatic stages. If the targeted
vaccination strategy were to be used, the number
of individuals waiting in queue for vaccination,
and therefore the number of infected individuals,
would prolong across many more days than if
mass vaccination were to be used.
Figure 2. It is probable an infected individual will be in the
incubating stage for 8 days and the prodromal and overtly
symptomatic stage for a combined total of 10 days. The
probability functions describe the probability on any day of a
patient remaining in a disease stage during the next day. On
any given day, the probability of moving from one stage to the
next is 1 minus the probability of remaining in the stage.
Conclusions
Conclusions
 The tracing vaccination method would not be
adequate if a bioterrorist attack of smallpox were
to occur in a large urban city.
 With the tracing vaccination method, there
would eventually be a backup in quarantine. It
would be impossible to quarantine individuals at a
quick enough rate to halt the spread of the
disease.
 Since vaccination is only effective either before
the individual is effected or during the incubating
stage, individuals would have to be vaccinated no
later than 8 days from infection.
 The backup in quarantine would decrease the
effectiveness of vaccination because most people
would be past the vaccine-sensitive stage one of
the disease.
 Mass vaccination would be the most efficient
method for controlling a smallpox outbreak,
reducing the number of individuals waiting to be
vaccinated.
 It is important to note the limitations of this
model, as it is only hypothetical data.
Data can be compared with the recent 2008
outbreak of measles in San Diego, CA where an
unvaccinated boy transmitted the disease to
unvaccinated family and schoolmates. The
targeted vaccination and quarantine approach
was implemented, but ultimately the fact that the
majority of the population was vaccinated halted
transmission of the disease, demonstrating the
importance of mass vaccination.
References
References
Henderson, D. A. (2009). Smallpox: the death of a
disease : the inside story of eradicating a
worldwide killer. Amherst, N.Y.: Prometheus
Books.
Kaplan, E., Craft, D., Wein, L. (2002). Emergency
response to a smallpox attack: The case for mass
vaccination. PNAS, 99. Retrieved from
http://www.pnas.org/content/99/16/10935.full.

Meltzer, M., Damon, I., LeDuc, J., Millar, J.

(2001). Modeling Potential Responses to
Smallpox as a Bioterrorist Weapon. Emerging
Infectious Diseases, 7. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC263
1899/pdf/11747722.pdf.

Figure 1: Transmission of smallpox only occurs in the

prodromal and overtly symptomatic phases. Schematic of the
Markov-chain model was used to model the movement of a person
infected with smallpox through the four stages of disease. Each
stage is represented as the probability of remaining in that stage.
The probabilities are determined by a daily probability (Figure 2).
Patients who have reached the fourth and final stage (no longer
infectious) effectively drop out of the model.
Figure 3: With the mass vaccination policy, the number of
individuals waiting to be vaccinated declines with a quicker
rate than with the targeted vaccination policy. The number of
infected people, regardless of disease stage, and the number of
people, whether susceptible or asymptomatically infected, waiting
in the vaccination queue during the aftermath of a smallpox attack.
The (A) TV policy and the (B) MV policy are both initiated 5 days
after an initial attack size of 1,000 in a population of 10⁷.