Smallpox without doubt holds a special place in the history of infectious diseases of mankind. Records of the disease date back almost 6 millennia, during which time smallpox has not only severely decimated the world population but has also had significant influence on the political history of the world through its toll on monarchs and common people alike. Smallpox also provided Edward Jenner with the necessary ingredients to develop the first vaccine in medical history, a development that subsequently led to the whole field of vaccinology. That smallpox was probably the first disease to be used in active biological warfare belongs to the darker part of our history and one that we would often prefer to forget. Smallpox, however, also provided what may rightly be termed one of the greatest successes in the history of the control of infectious diseases when, in 1980, the World Health Organisation of the United Nations, 13 years after the inauguration of the Global Intensified Smallpox Eradication Programme declared the world free of this terrifying scourge.
Following the events of September 11, 2001, when terrorists hijacked and flew passenger planes into the two towers of the World Trade Center and the Pentagon in the US, the issue of bioterrorism suddenly took on a new sense of reality and urgency. Today the major issue is no longer one of biological warfare, where a number of superpowers largely attempt to ensure that the balance of power will favor the non-use of high-tech, armorised biological weapons, but of biological terrorism and biosecurity. Today the issue is centered on individuals who are prepared to infect themselves with deadly diseases and pay with their own lives in pursuit of what they believe to be righteous causes. This is no longer high-tech and controllable; it is low no-tech, difficult to control and the perspectives are frightening. And smallpox is perveived as being the most immediate risk.
Few practicing physicians and general practitioners have had any personal experience of smallpox during the past 40 or more years, and many would have difficulties recognizing and diagnosing this disease. If indeed smallpox should ever be used by bioterrorists, immediate diagnosis and containment will be of the utmost importance. In today's world of extensive international and national travel there will be little time for individual learning experiences. These Pages have been compiled in an attempt to contribute towards the elimination of this knowledge gap both with regard to the disease itself and to issues that must be considered when contemplating medical measures against this threat.
The only effective protection against smallpox was and still is vaccination. However, the only potentially available vaccines today are unlicensed. This applies both to the older, first-generation vaccines that are un-licensable according to current guidelines on Good Manufacturing Practices, as well as the second-generation vaccines that have only recently entered into clinical trials. Thus, while these pages are intended also to present the extensive experience gained in the past vaccination against smallpox, it must not be construed or interpreted as giving any recommendation whatsoever on the use of unlicensed products.
We dedicate these pages to the sincere hope that smallpox will never again become a scourge of mankind.