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Volume 7, Number 6—December 2001


Modeling Potential Responses to Smallpox as a Bioterrorist Weapon

Martin I. Meltzer*Comments to Author , Inger K. Damon*, James W. LeDuc*, and J. Donald Millar†
Author affiliations: *Centers for Disease Control and Prevention, Atlanta, Georgia, USA;; †Don Millar & Associates, Inc., Atlanta, Georgia, USA

Main Article

Table 2

Sensitivity analyses: Effect on number of cases of smallpox due to variations in numbers initially infected, numbers infected per infectious person, intervention start days, and quarantine and vaccination effectivenessa

No. initially infectedb No. infected per infectiousc Start dayd Quarantine: % removal per daye Vaccination: % reduction transmissionf Impact: Cumulative total at 365 days Impact: Daily cases at 365 days Increase or decrease (+/–g)
Base:100h 3.0 30 25 33 4,421 3
100 2.0 30 25 Nil 2,455 2
100 2.0 30 10 25 10,512 2
100 2.0 45 25 33 1,548 0
100 5.0 30 25 66 4,116 0
100 5.0 45 25 66 19,821 1
1,000 2.0 30 10 25 105,117 511 +
1,000 2.0 30 10 33 32,125 42

aTable 1, Appendix 2 is an expanded version of this table.
bNumber initially infected refers to those who are exposed during a release such that they become infectious. This excludes those who are exposed but either do not become ill or do not become infectious.
cThe number of persons infected per infectious person is the transmission rate.
dStart day, for both quarantine and vaccination interventions, refers to the day postrelease, with the day of release being day 1.
eQuarantine refers to removal of infectious persons only, starting on the first day of overt symptoms (i.e., rash). At a 25% daily removal rate, a cohort of all those entering the first day of overt symptoms is entirely removed in 17 days (18 to 20 days postincubation) after day 1 of overt symptoms, with 90% removed in 9 days. At a 10% daily removal, a cohort of all those entering the first day of overt symptoms is entirely removed in 44 days (45 to 47 days post incubation) after day 1 of overt symptoms, with 90% removed in 22 days. At a daily removal rate of 80%, a cohort of all those entering their first day of overt symptoms is entirely removed in 3 days (4 to 6 days postincubation) after day 1 of overt symptoms, with 90% removed in 2 days.
fVaccination is assumed to reduce the transmission rate by a given percentage (e.g., 25% reduction results in transmission declining from 2.0 to 1.5 persons infected per infectious person, and 33% reduces transmission from 2.0 to 1.32).
g (+) = an increasing rate of daily cases on day 365, and thus the modeled interventions will not stop the transmission of smallpox. (–) = a decreasing rate of daily cases, such that the interventions modeled will eventually stop the transmission of smallpox.
h See Figure 6 for complete results related to the base case in the initial modeling scenario.

Main Article

1Others have suggested that the terms "preeruptive" or "initial" are more descriptively accurate of this stage (6). However, because "prodromal" is used in many standard textbooks (7,8,17), we will use this term.

2Prodromal rashes have been recorded, but they were considered to be uncommon occurrences, ". . . not more than 1 in 10." (17).

3The United States stopped routine vaccination of the civilian population in 1972 (5). In July 1998 in the United States, there were approximately 109.9 million persons <30 years of age, representing 41% of the total resident population (20). Most of these people have not been vaccinated against smallpox. In addition, the immunologic status of those who were vaccinated >30 years ago must be considered. Historical data indicate that vaccination 20 to 30 years ago may not protect against infection but will often protect against death (8,21). No reports, however, define the probability of such persons' transmitting the disease to susceptible persons. Faced with such uncertainty, we chose the simplest approach of assuming an unlimited supply of susceptible persons.

4At a 50% daily removal rate, a cohort of all those beginning the first day of overt symptoms is entirely removed in 7 days (8 to 10 days postincubation), with 90% removed in 4 days after they enter the overtly symptomatic period. At a 25% daily removal rate, a cohort is entirely removed 17 days after entering the overtly symptomatic period (18 to 20 days postincubation), with 90% removed in 9 days after entering the overtly symptomatic period. The calculated numbers of those quarantined relate only to those who are infectious (i.e., overtly symptomatic). The model does not take into account those who might also be quarantined along with the infectious persons, such as unvaccinated household contacts and other exposed persons.

5The number, severity, and cost of vaccine-induced side effects is the subject for a separate paper.

6Allowing 3 days for laboratory confirmation assumes that virus loads in clinical specimens may be insufficient to allow use of rapid assays and confirmation must await the results of a culture-based assay, which takes approximately 72 hours. Rapid laboratory confirmation, within 24 hours, is possible.

7Even by reducing transmission from 3 to 2 persons per infectious person and quarantining infectious persons at a rate of 25% per day, the number of new cases at day 365 is 3, not zero (i.e., transmission is not quite completely stopped) (Figure 6). For transmission to cease completely, vaccination must either achieve a 38% reduction in transmission to 1.85 cases per infectious person (assuming a daily quarantine rate of 25%), or quarantine must achieve a 29% daily reduction in the number of infectious persons (assuming vaccination reduces transmission by 33%).

8Although there are some historical data regarding how infected persons interacted and infected others, all such data were collected when circumstances differed from those of today's societies, particularly with regard to travel and spread of information. Although air and other modes of mass travel were common before smallpox was eradicated, the numbers of travelers and the total miles traveled have vastly increased in the past 30 years. Similarly, although mass media were well known and used in the 1960s and 1970s, more outlets are available to spread information than ever before. It is unknown how these and other changes could affect the spread of smallpox.