CONSULT November 2018

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FDA-approved smallpox treatment gives rise to resurrection concerns

Published on Thursday, November 8, 2018

By: Gary Pettus

In spite of what your Uncle Billy might have told you, that mysterious, cratered pockmark on his upper left arm is probably not from the war, especially if he’s past his mid-40s.

Still, it’s a good bet he was shot – with a vaccine-pumping needle wielded in a worldwide war against a cruel enemy: smallpox.

Discontinued in the United States 46 years ago, the vaccination and its calling card gave rise to the “Round Scar Generation,” marking, like tree rings, its membership’s age range and testifying to the pain (however brief) it endured to help eradicate a contagion that has not been a threat for decades.

Still, this past summer, the Food and Drug Administration approved the first-ever treatment for smallpox. Which begs the question: How dead is this deadly disease?

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“There is always a concern it will never go away,” said Dr. Bhagyashri Navalkele, assistant professor of medicine in the Division of Infectious Diseases at the University of Mississippi Medical Center. “There are concerns that there could be an accidental release of the virus, which is stored in laboratories in the United States and Russia [for research]. Or that it could be used as a bioterrorist weapon. In either case, a pandemic could follow.

“Also, because smallpox was originally transmitted from animals to humans, there is the concern that it could happen again.”

Adding to those worries was the publication of a paper in January by a team of researchers in Canada who resurrected another exterminated virus, horsepox. If horsepox can return in this way, then why not its not-so-distant relative, smallpox?

“It is a complex process to recreate smallpox, but someone with the mind to do it could do it,” Navalkele said.

To measure the likelihood of a smallpox plague, it may be useful to review the history of the variola virus, once known as the “Fearful Dragon” and the “Spotted Death.”

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Historians believe animals – probably camels or other tamed creatures – first spread the disease to humans some 3,000 years ago. In China, healers ground up scabs from victims’ lesions to treat those at-risk, compelling them to snort this inoculating dust, said Dr. Donna Sullivan, UMMC professor emeritus of medicine in infectious diseases.

But the 16th century Caribbean slave trade incited far-flung human contact that not only revived the virus, but also turned it into a mass murderer. The mortality rate was as high as 90 percent. Sufferers’ faces and bodies pulsed with rashes and sores. Survivors were disfigured for life; some became blind.

During the early 1700s, Europeans and American colonists discovered the secrets of inoculation from West African and Ottoman pioneers. Near that century’s end, England’s Dr. Edward Jenner developed a breakthrough called a “vaccine.” Most historical accounts say Jenner’s vaccine deployed cowpox, a related virus.

“Vaccine” derives from the Latin “vacca,” meaning “cow.” Waggish illustrators of the day imagined bovines popping out of recipients’ body parts. (The vaccine’s modern version is less colorful and risky, consisting of extremely watered-down forms of smallpox.)

After Jenner’s discovery, the vaccination train got rolling in this country. In 1846, a smallpox vaccine “depot” appeared in Jackson. Fifty years later, smallpox vaccinations were mandatory in this state, according to a timeline on the Mississippi State Department of Health’s website.

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Not since 1972 has Mississippi and other states routinely provided the vaccine, said Dr. Paul Byers, state epidemiologist with the MSDH. That was 23 years after the last natural outbreak of smallpox in this country, or when Harry S. Truman was still U.S. president and the movie “It’s a Wonderful Life” was just a toddler.

Elsewhere, the last case to spread naturally happened in 1977, in Somalia. The following year, it spread, unnaturally, to a medical photographer at a university lab in England; She is believed to be the last person it killed.

In 1980, the World Health Organization wrote smallpox’s obituary. The disease’s death toll stood at “many millions.”

“Because smallpox is so contagious and produces such a severe illness, this eradication was one of the biggest public health successes ever,” Byers said.

Still, experts don’t agree on how long a vaccinated person is protected. Immunity could endure for decades, three to five years, or 10 to 15.

“No one really knows how long,” Navalkele said. “If you have had the vaccine, you would still need a booster. Unless you’re older than 40, there is no chance you have even some immunity, and even then it’s a low chance.”

In the U.S., the Centers for Disease Control and Prevention in Atlanta store stocks of the vaccine, “but they are not enough to vaccinate everybody, and no new vaccine stocks are being developed,” Navalkele said.

Diligence has been up, though, since the anthrax scare that followed the 9-11 attacks in 2001.

“It increased awareness of potential bioterrorist threats,” Byers said.

In Mississippi, the MSDH has set up vaccination dispensing areas and keeps an eye out for possible signs of a smallpox outbreak.

“The hope is that we won’t ever come to this kind of thing,” Byers said. “It’s concerning, but only theoretical at this point.”

Even so, having a smallpox treatment, called tecovirimat, is welcome news, Navalkele said.

“While its development is a precautionary measure, it’s good for the public to know that the CDC and WHO are working so that smallpox doesn’t become a global threat,” she said. “This new treatment can be stockpiled as a measure to contain a future public health risk – even if there’s only a small chance of one.”

Sullivan, for one, believes that, compared to a mass vaccination effort, “it would probably be easier to have stockpiles of the antiviral drug.”

Like Navalkele and Byers, she does not believe smallpox is likely to return. Even if it did, the fearful “Dragon’s Breath” shouldn’t be nearly as hot.

“You never say ‘never,’ but it would take a good bit of work to reach the explosive levels of days gone by,” Sullivan said.

If people really need a disease to fret about, she said, then one is handy: It killed an estimated, and record-breaking, 80,000 people in the U.S. during the 2017-18 season. It’s called the flu.

“That’s where I would put my attention,” she said.