Smallpox, Bioterrorism Smallpox, Bioterrorism and WHOand WHOThomson PrenticeThomson Prentice

Global Health HistoriesGlobal Health HistoriesJuly 2006July 2006

IntroductionIntroduction

This paper:This paper:summarizes the historical background of summarizes the historical background of

the smallpox and bioterrorism debate;the smallpox and bioterrorism debate;traces relevant events, statements and traces relevant events, statements and

publications since eradication in 1980;publications since eradication in 1980;gives examples of public health protection gives examples of public health protection

measures;measures;explains the current role of WHO in global explains the current role of WHO in global

preparedness.preparedness.

WHO's Greatest Moment?WHO's Greatest Moment?

Halfdan Mahler, Director-General, WHO

1973-1988.

““The end of smallpox The end of smallpox –– but for WHO it is but for WHO it is only the end of the beginningonly the end of the beginning…… victory victory over smallpox has implications that go far over smallpox has implications that go far beyond the individuals directly beyond the individuals directly concernedconcerned…… It reasserts our It reasserts our ability to change the world ability to change the world around us for the better." around us for the better."

19801980

Donald Ainslie Henderson, Chief, Smallpox Eradication,

WHO 1966-1977.

““For centuries, For centuries, variolavariola virus stalked the virus stalked the world with impunity, causing unmeasured world with impunity, causing unmeasured suffering, death and blindness. Today it is suffering, death and blindness. Today it is confined to glass vials kept under high confined to glass vials kept under high security in six laboratoriessecurity in six laboratories…… smallpox is a smallpox is a disease which can be confined disease which can be confined to history to history –– the first disease the first disease ever eradicated by man.ever eradicated by man.””

19881988

April 1999April 1999

"While we fervently hope smallpox would "While we fervently hope smallpox would never be used as a weapon, we have a never be used as a weapon, we have a responsibility to develop the drug and responsibility to develop the drug and vaccine tools to deal with any future vaccine tools to deal with any future contingency contingency –– a research and a research and development process that development process that would necessarily require would necessarily require smallpox virus.smallpox virus.””

US President Bill Clinton

May 1999May 1999

During the World Health Assembly, the USA During the World Health Assembly, the USA successfully argues against calls for the successfully argues against calls for the destruction of smallpox stocks held in the destruction of smallpox stocks held in the USA and Russia, recommending instead USA and Russia, recommending instead that stocksthat stocksshould be kept for should be kept for therapeutic research therapeutic research purposes purposes

June 9, 1999June 9, 1999

"If used as a biological weapon, smallpox "If used as a biological weapon, smallpox represents a serious threat to civilian represents a serious threat to civilian populations because of its casepopulations because of its case--fatality fatality rate of 30% or more... Although smallpox rate of 30% or more... Although smallpox has long been feared as the most has long been feared as the most devastating of all infectious diseases its devastating of all infectious diseases its potential for devastation today is far potential for devastation today is far greater than at any previous time."greater than at any previous time."

Henderson et al.JAMA 1999;281:2127-2137

June 13, 1999June 13, 1999

The The New York TimesNew York Times cites a US government cites a US government intelligence analysis which concludes that intelligence analysis which concludes that North Korea, Iraq and Russia are probably North Korea, Iraq and Russia are probably keeping secret stocks keeping secret stocks of smallpox virus of smallpox virus intended for military use.intended for military use. Did this analysis Did this analysis prompt Clinton's statement in April and the prompt Clinton's statement in April and the US position at the WHA in May?US position at the WHA in May?

June 22June 22--23,200123,2001

Dark WinterDark Winter

A US government smallpox terrorism A US government smallpox terrorism exerciseexercise

After September 11, 2001After September 11, 200120022002: US government orders 200 million doses of : US government orders 200 million doses of

smallpox vaccine, costing $428 million. The UK smallpox vaccine, costing $428 million. The UK government orders 20 million doses, costing government orders 20 million doses, costing ££32 32 millionmillion

20032003: UK government sets up Health Protection : UK government sets up Health Protection Agency to help prevent terrorist attacks and limit Agency to help prevent terrorist attacks and limit their impacttheir impact

20032003: WHO, US, UK, European Commission and : WHO, US, UK, European Commission and 6 other countries stage "Global Mercury " 6 other countries stage "Global Mercury " smallpox alert exercise smallpox alert exercise

September 2003: Global Mercury September 2003: Global Mercury

In this scenario, two travelers collapse at Vancouver In this scenario, two travelers collapse at Vancouver airport with a suspicious rash. They confess they are airport with a suspicious rash. They confess they are members of a terrorist group who have infected members of a terrorist group who have infected themselves with smallpox and dispersed to 14 countries themselves with smallpox and dispersed to 14 countries just as their infectivity is peaking.just as their infectivity is peaking.Quarantine officers issue an international alert. Frantic Quarantine officers issue an international alert. Frantic communications ensue among the affected countries. communications ensue among the affected countries. Problems include crossProblems include cross--border coordination, language border coordination, language difficulties and equipment failures.difficulties and equipment failures.Afterwards, the exercise was described as a well Afterwards, the exercise was described as a well coordinated, realistic and valuable test of international coordinated, realistic and valuable test of international communications. "Participants believe that similar communications. "Participants believe that similar exercises should be scheduled regularly, possibly exercises should be scheduled regularly, possibly annually."annually."

Exercise Global MercuryExercise Global Mercury

WHO's Greatest Fear?WHO's Greatest Fear?

2004:2004: "The greatest fear is that in the "The greatest fear is that in the absence of global capacity to contain an absence of global capacity to contain an outbreak rapidly, smallpox might reoutbreak rapidly, smallpox might re--establish endemicity, undoing one of establish endemicity, undoing one of public health's greatest achievements."public health's greatest achievements."

WHO report, WHO report, Global smallpox vaccine reserve,Global smallpox vaccine reserve,

December 2004December 2004

20052005

"We are not saying there might not be "We are not saying there might not be fatalities, but we could prevent any fatalities, but we could prevent any widespread disaster.widespread disaster.””

Gordon MacDonald, Head of Emergency Strategic Planning,

UK Health Protection Agency The Times August 24, 2005

20052005

"We shouldn"We shouldn’’t be complacent but it is t be complacent but it is important for the public to realise that important for the public to realise that while there would be deaths, as there while there would be deaths, as there would be in a conventional attack using would be in a conventional attack using explosives, there wouldn't be the kind of explosives, there wouldn't be the kind of widespread catastrophe they might widespread catastrophe they might imagine.imagine.””

Dr Nigel Lightfoot, director of Emergency Response Capability,

UK Health Protection Agency .

20062006: WHO Global Outbreak Network : WHO Global Outbreak Network

WHO Web Sites WHO Web Sites

The following WHO web sites are related to The following WHO web sites are related to deliberate epidemics, and deliberate epidemics, and WHO'sWHO's global global outbreak and alert response networks:outbreak and alert response networks:

http://www.who.int/csr/delibepidemics/en/http://www.who.int/csr/delibepidemics/en/http://www.who.int/csr/outbreaknetwork/en/http://www.who.int/csr/outbreaknetwork/en/http://www.who.int/csr/alertresponse/en/http://www.who.int/csr/alertresponse/en/

ConclusionsConclusions

The risk of a terrorist smallpox attack is The risk of a terrorist smallpox attack is currently low but is being taken very currently low but is being taken very seriouslyseriouslyMany countries are staging prevention and Many countries are staging prevention and control exercisescontrol exercisesMultimillion doses of vaccine are being Multimillion doses of vaccine are being held in readinessheld in readinessWHO is urging countries to develop and WHO is urging countries to develop and strengthen preparedness plansstrengthen preparedness plans

AcknowledgementsAcknowledgementsI gratefully acknowledge the valuable technical assistance provI gratefully acknowledge the valuable technical assistance provided by the ided by the

Department of Department of Epidemic and Pandemic Alert and Response, WHO HQ, Epidemic and Pandemic Alert and Response, WHO HQ, Geneva, in particular:Geneva, in particular:

Dr Mike RyanDr Mike RyanDr Cathy RothDr Cathy Roth

Dr Daniel Dr Daniel LavanchyLavanchy

I also gratefully acknowledge the editing and presentation asI also gratefully acknowledge the editing and presentation assistance sistance provided byprovided by

Gael KernenGael KernenLeo VitaLeo Vita--FinziFinzi

World Health Report and Global Health Histories, WHO HQ, GenevWorld Health Report and Global Health Histories, WHO HQ, GenevaaThis presentation is available on: This presentation is available on:

http://www.who.int/kms/initiatives/ghhistories/en/http://www.who.int/kms/initiatives/ghhistories/en/