Last Updated

02 Dec 2002

Source: Rocky Mountain News, March 18, 2002.

A demon in a bottle

Alive only in labs since 1977, the specter of smallpox as a weapon sparks terror in scientists

By Bill Scanlon, News Staff Writer

Colorado had its first recorded smallpox case in 1829, its last in 1948.

The state's infectious disease experts are holding their breaths, hoping that 1948 truly was the last. They fear otherwise.

Smallpox has been silent worldwide since 1977, but it still scares the daylights out of experts, fearful that rogue nations such as North Korea, Iran or Iraq may have obtained weaponized versions of the virus from the Russians.

"Smallpox is the one that we're really worried about" of all the weapons of bioterrorism, said state chief medical officer Dr. Ned Calonge, overseer of Colorado's bioterrorism response plans.

Smallpox is a major reason that Colorado hospitals are on a stepped-up effort to prepare for the worst since last Sept. 11's terrorist attacks, including such grim precautions as "access to 25,000 body bags" in their plans.

No one in Colorado has been vaccinated for smallpox since the 1970s. In any event, the vaccine can start losing effectiveness after about 10 years, which means that virtually no one here -- or elsewhere in the United States -- can presume immunity to the disease.

In the 18th century, smallpox-infected British colonial army blankets laid waste to the Algonquin Indians.

In the 21st, the mode of delivery could be a rogue nation's airliner flown above a crowded city, according to one disaster planning scenario. Vials are uncorked, the aerosolized virus unleashed and 30 percent of the non-immunized populace is likely to succumb to the deadly red papules and pustules.

The fear isn't that Russians would arm terrorists, but that Russia's underpaid scientists would succumb to lucrative offers from terrorist states and smuggle some smallpox to them.

Experts agree that an individual or two couldn't carry off a mass smallpox infestation, but that a rogue state that supports terrorists might be able to manage it.

Dr. Steven Mostow, a professor of infectious diseases at the University of Colorado School of Medicine and a world authority on infectious disease, will feel better in two years when the United States builds a stock of 280 million doses of smallpox vaccine.

"I don't think any of us can predict how likely it is" that smallpox will be unleashed as a weapon, Mostow said. But, he said, several countries are believed to have come into possession of weaponized smallpox, "so it's definitely possible."

Right now, the nation has just 15 million doses of vaccine on hand, said Dr. Harold Margolis, senior adviser for smallpox preparedness for the Centers for Disease Control in Atlanta. By the end of this year, it could have 130 million and by the end of next year 280 million, at the cost of some $500 million.

The CDC has no plans for a national vaccine program. "The adverse events from this vaccine would far outweigh any benefit," said Margolis, noting that of every 1 million vaccinated, one to five would die and 10,000 would get sick.

Instead, if terrorists released smallpox in a major city and people began getting sick, the agency would send teams in and immunize everyone within a five- or 10--mile radius.

Administering a vaccine within 48 to 72 hours of an attack could sharply reduce fatalities.

Mostow prefers the preventive approach. "I'd like to see a more controlled approach, rather than a panic."

But Dr. Frank Judson, director of the Denver Public Health Department, and a veteran smallpox hand, says "having a vaccine for every man, woman and child in the United States is just overkill."

To him, the need for the government's order of 200 million "is such an improbable scenario."

Margolis says it's unlikely CDC will ever need to vaccinate everyone, "but if an outbreak occurred, we don't want the public to feel panicked that they couldn't get the vaccine if they needed it."

Pox traced to Egyptian tombs

The earliest evidence of smallpox is in the telltale pox on the face of a mummified Egyptian who died some 3,200 years ago.

It wiped out entire towns in medieval Europe, decimating populations from Portugal to Bulgaria. The infected Europeans who survived had some genetic immunity, which they passed to their descendants.

The farmers, hunters, gatherers and fisherman of the Americas, not living in the crowded conditions that spark smallpox outbreaks, had no such immunity.

Smallpox reached the Americas about 15 years after Columbus' first voyage, ultimately taking the lives of 3 million indigenous people in Central and South America.

Hope rose in 1798 when British Dr. Edward Jenner discovered that milk maids exposed to the mild cowpox developed immunity to deadly smallpox. He developed a vaccine from the mild disease.

Smallpox first hit Colorado in 1829 when Mexicans helping to build Fort Bent near modern-day La Junta contracted the virus, according to Dr. Robert H. Shikes in Rocky Mountain Medicine, a history of medicine in Colorado.

William Bent and Kit Carson were among those who also contracted the disease there. Unlike the British soldiers who deliberately gave Indians contaminated blankets 60 years earlier, the officers in Colorado issued an empathetic edict: Keep the Indians away from the fort.

A quarter century later, the Arapahoe Indians in eastern Colorado were so decimated by smallpox that they canceled their annual buffalo hunt, resorting to stealing cattle. This time, the Army officers weren't sympathetic, canceling the cavalry's annual payments to the tribe.

Three years later in 1858, smallpox wiped out hundreds of Indians at Bent's Fort.

A year after Denver was founded, in 1860, a smallpox outbreak prompted the Rocky Mountain News to write: "Dr. Feld has just received from the coast a lot of fresh and pure vaccine matter. He can be found in his office on 5th Street."

In 1862, a smallpox outbreak hit the Cheyennes near Fort Wise, according to the News, which cautioned: "Those who have not been vaccinated should be at once."

Twenty years later, the Sisters of Mercy built an eight-bed hospital in Durango, but an epidemic decimated the nuns. The hospital, now Mercy Hospital, had to close down for five months.

In the 1880s, Silverheels, a beautiful saloon dancer at Buckskin Joe mining camp near Fairplay, ignored her own safety and nursed dozens of sick miners. She came down with the disease herself, her face was covered with the pox and she disappeared from the town. But for decades, people reported seeing glimpses of a mysterious, heavily veiled woman.

By the turn of the century, most Hispanics in southern Colorado had accepted vaccination, dropping the view that "infection will afford them a better chance of salvation," according to Trinidad doctor T.J. Forhan.

Towns and cities erected "pesthouses" to quarantine those with smallpox. Denver built its pesthouse seven miles up Sand Creek, which, according to accounts, had "all the allure of the Black Hole of Calcutta."

Some Coloradans opposed vaccination, citing religion, individual liberty or the fear of a government conspiracy.

"I do not want my daughter vaccinated," one mother wrote the Denver School Board. "It is pure and simple a medical fake and delusion."

While the last recorded case in Colorado was 1948, the disease continued to kill hundreds of thousands annually around the world and sicken millions.

In the late 1950s, Dr. C. Henry Kempe, chief of pediatrics at the University of Colorado Medical Center, developed a life-saving smallpox serum that became the standard of care around the world.

For years, frantic parents from around the United States would fly their sick children to Denver. In 1959, the serum saved a Rhode Island infant with eczema, who had caught a smallpox infection from his older sister who had just been vaccinated. The Denver chapter of the American Red Cross distributed the serum for free.

In 1964, 16 years after the last Colorado smallpox case, Jefferson County schools canceled the smallpox vaccine due to budget cuts.

By 1965, about half of Denver's low-income children were immunized, while seven out of eight upper-income children were.

Even Kempe said it was time to re-evaluate routine smallpox vaccines, saying it kills more people than it saves. He had gone to Madras, India, to show that his serum is effective after an outbreak.

He gave his methisazone treatment to 2,297 Indians who had been exposed to people with smallpox. Six developed the disease and two died. Among a similar-sized group that didn't get Kempe's serum, 114 got the disease and 20 died.

In the late 1960s, experts cautiously talked about wiping out smallpox worldwide within a decade.

But in 1974, a last huge epidemic killed 30,000 in India.

Smallpox was in its last gasp in 1975 when News editorial writer H. Peter Metzger derided as "crazy" the idea of some disease experts to treat the virus as an endangered species. Don't destroy the last remnants, they said. Instead, keep it in a lab so future scientists can learn from it.

"This crazy idea really takes the cake," Metzger wrote. "It makes the combined dangers from all atomic radiation seem small by comparison. There is nothing to prevent any overconfident visionary from squirreling away some virus."

Virus is deadly, but unstable

Smallpox was declared wiped out worldwide in 1978, but Metzger's column proved fateful.

That same year, the World Health Organization, seeking to reduce the number of labs with remnants of the virus, asked the United States, the Soviet Union, Japan and Great Britain each to have one secure storage place for it.

Today, there are just two official repositories of the smallpox virus in the world. One is in the CDC laboratories in Atlanta and the other is at Vector, the State Research Institute of Virology and Biotechnology, outside Novosibirsk in Siberian Russia. WHO scheduled but then called off the destruction of the virus at the two centers -- doctors wanted it destroyed, scientists wanted it preserved.

Ken Alibek, a former Soviet scientist, said in his 1999 book Biohazard that he supervised the production of 20 tons of smallpox for Biopreparat, the Soviet Union's biological weapons complex. He said the Soviet Union had plans to deliver the virus on SS-18 missiles if it was engaged in a total war with the United States.

By 1992, the Russians were making thousands of tons of the virus each year.

"Hopefully, that's all been destroyed, but they don't know where it all is," said Dr. Stephen Cantrill, an emergency medicine specialist at Denver Health Medical Center. "I am very concerned about the risk of smallpox."

Releasing smallpox as a weapon of mass destruction can boomerang on the terrorist, but some of today's terrorists "don't care who they harm including themselves," Cantrill said.

The CDC finally is taking steps to increase the number of smallpox vaccines, Cantrill noted. "But where have they been since 1992?"

Judson, who participated in an effective vaccine-upon-outbreak program in India in 1976, says the smallpox virus can't stay contagious under conditions idealized by terrorists.

"The smallpox virus is extremely unstable," said Judson, noting that ultraviolet light and humidity can kill it. "When we were getting a million cases a year, virtually all of them were when people were standing a few feet from an infected person."

Further, he said, smallpox doesn't reach its infectious state until a person is very sick. "It's hard to imagine" that a very sick suicidal terrorist would have the strength to infect more than a few people.

Isolating those infected, and then vaccinating those within concentric rings of the sick can be virtually 100 percent effective if done within three or four days, he said.

In Denver last May, several hospitals participated in a disaster drill in which it was assumed that 4,000 people had contracted smallpox.

"We found it was a scenario that would just severely stress the hospitals," Cantrill said.

What are the risks of weaponized smallpox being released?

"Some say they are vanishingly small," Cantrill said. "I'm not quite as enthusiastic.

"It's small, without question. But if you read some stuff on biohazards, it can still scare the bejesus out of you."