With the World Trade Center and Pentagon attacks and public angst subsequent to anthrax dissemination, fears of terrorist attacks have escalated dramatically in the United States. A cabinet-level Office of Homeland Security was created, and a system of identifying the level of terrorist threat from rogue states and terrorist groups was developed. Prompted by bioterrorism fears, in spring 2002 the Bush administration engaged in planning to offer smallpox vaccinations to the entire population of the United States, a decision that produced widespread criticism from public health experts. Subsequently, this plan was reduced to 10 million, and after the Iraq war, calls for widespread vaccination abated, at least temporarily.
This article addresses the need for sound policy and rational actions in the face of bioterrorist threats. Characteristics of smallpox, anthrax, botulism, and plague are presented. Then, given the national and international attention smallpox has received as a likely means of attack, the article presents a thorough discussion of the disease, the historical and current risks of smallpox and smallpox vaccination, and the significance of effective prevention and treatment strategies. The importance of bioterrorism policies and practices that best protect the public's health is emphasized. Of particular importance is the need for social workers to obtain accurate information, to educate clients, and to advocate for sound anti-bioterrorism policies and practices.
At least four deadly but vaccine-preventable microorganisms have been identified by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) (English et al., 1999) as having significant bioterrorism potential; three--botulism, anthrax, and plague--are bacterial and can be treated with antibiotics, whereas smallpox is viral and unresponsive to antibiotics. (Characteristics of the four are described in Table 1.)
Potential dissemination of smallpox has produced the greatest fears of widespread catastrophe because of its nonresponsiveness to antibiotics, its history of devastation, and the present worldwide absence of immunity. Therefore, the remainder of this article is devoted to smallpox and smallpox vaccination.
HISTORY OF SMALLPOX VARIOLA
Smallpox variola major has infected people for thousands of years. As early as 1157 BC, Ramses V of Egypt is believed to have contracted smallpox, as evidenced by his scarred mummified remains. Smallpox kills up to one-third of the people it infects, leaves survivors permanently scarred, and has decimated populations. When introduced into populations with no previous exposure--thus no population or "herd" immunity--smallpox has produced even higher mortality rates. Nowhere is this more apparent than in early European contacts in the western hemisphere. Smallpox contributed to the eradication of the entire indigenous population of Hispaniola, today's Haiti and Dominican Republic, when natives were infected by Europeans. The Spanish conquistadors inadvertently decimated, then subsequently conquered the Aztecs and Incas by unintentionally exposing them to smallpox. In the 18th century, the British intentionally distributed blankets infected with smallpox to American Indians, with devastating effects (Barreto & Rutty, 2002; Flight, 2002).
Until recently, smallpox epidemics regularly infected populations with devastating effects worldwide. In the 20th century alone, smallpox killed an estimated 300 million people. However, the last case of smallpox reported in the United States occurred in 1949, and the last case worldwide was in 1977 in Somalia. In 1980 the World Health Organization (WHO) declared smallpox eradicated from the natural environment. The only smallpox viruses remaining on earth were contained in WHO-sanctioned laboratories in the United States and the Soviet Union, and …