The smallpox threat: a time to reconsider global policy.

In May of this year, the 67th World Health Assembly will again debate the question of when the remaining specimens of smallpox virus should be destroyed. Over the past 18 years, this has been on the agenda of 5 previous Assemblies, the last being in 2011. At that time, the delegates ‘‘affirmed strongly the decisions of previous Health Assemblies that the remaining stocks of variola virus should be destroyed.’’ They asked that the date be decided by the 2014 Assembly. Inordinate amounts of time, effort, and resources have been spent in endeavoring to reach consensus on this one component of a smallpox threat strategy: whether to destroy or not destroy smallpox virus strains now being retained in the 2 World Health Organization (WHO) Collaborating Laboratories (in the United States and Russia). In both, the virus is being held under secure conditions. This year, a WHO-appointed group of international scientists concurred that there is no justification for retaining live smallpox virus. In any case, as others have pointed out, advances in genomic biology would now permit strains of virus to be replicated should someone wish to do so. Logic dictates an early date for destruction of the last laboratory strains. Meanwhile, countries and committees have substantially ignored the far more important initiatives that the global community and individual nations should take in order to be prepared to deal with smallpox outbreaks should they occur. Few have stockpiles of vaccine; not more than 8 to 10 countries have sufficient vaccine to cope with an outbreak. A WHO global emergency reserve, recommended 10 years ago, is steadily shrinking. Strategic plans for outbreak containment have been little discussed. At the same time, 2 initiatives have received special attention and resources: one to develop a vaccine that would protect without adverse reactions, and one to perfect antiviral drugs to treat cases should they occur. Both have failed to meet expectations. In writing this commentary, we have jointly drawn on our own half-century of experience with smallpox to offer a brief historic context for a better comprehension of current efforts and to critique the contemporary status of preparedness and response in coping with the unlikely return of smallpox, which has played such a dominant role throughout mankind’s history.