If smallpox got out, how bad would it be in modern times

An article about covid mentioned how there was a leaked vial of smallpox during physical transportation of some biological specimens, but luckily it didn’t infect anyone.

I don’t know tons about smallpox, but I know we already have a vaccine. I also get the impression that its not contagious until you have symptoms.

So would things like that make it far easier to control than covid if it broke out of a lab? Would it be like SARS (the original SARS) where people only spread it after they were contagious, which made quarantines easier? Would face masks do much stop the spread of smallpox?

Also I assume there’d be a massive vaccine rollout if the spread couldn’t be controlled with quarantines, and it wouldn’t take a year to create the vaccines, since we already know how to make them. But in the US at least, even when its a national priority our rate of vaccination seems to top out at about 3 million a day, which means 1% of people vaccinated a day. That seems to be about the fastest we can roll vaccines out, at least for covid.

If smallpox got out, the WORLD would go on lockdown. I hope we never find out what that is like.

When a smallpox outbreak occurred in New York in 1947, they vaccinated 600,000 people the first week. These days I wouldn’t be shocked if a substantial number of people would refuse to get the vaccine.

…until their friends and relatives started to die, or become horribly disfigured…

Here’s a thought: If that started to happen (what @nearwildheaven wrote just above), what would others’ reactions be? Would the rest of the worlds anti-vaxxers mostly get the message and get the vax? Would the worlds pro-vaxxers chortle with schadenfreude? Would medical insurance companies refuse to cover treatment for people who refused the vax?

I don’t think we would see a significant number of anti-vaxxers if there were a smallpox outbreak. First being that it’s a historical and well-known disease that strikes fear in people, and also is far deadlier than Covid. Second being that it’s also a disease that leaves people terribly disfigured on the outside, as nearwildheaven mentioned, which leaves a much more vivid impression (and fear of being disfigured).

If anything, we’d have the opposite problem: Demand for the vaccine would be so high and intense that people would be wiling to fight or even kill each other for it. All sorts of ugly accusations of bias (racial preference, privilege preference, wealth privilege, etc.) would crop up when it came to determining which people would get vaccinated first.

Not even then. You are seriously understimating the ability of humans to make stupid decisions. Plenty of idiots would refuse to get the vaccine, blame the usual suspects of their favorite whacked out nut job conspiracy nonsense, and protest legitimate government action. It’s not like they haven’t had any practice for that over the last, what, 14 months or so.

I think the opposite. How many anti-vaxxers remember smallpox? They’d be all, “it’s no worse than chicken pox, what’s the big deal?”

Smallpox is very contagious. Although often spread by contact with surfaces/fluids/scabs the particles can be airborne (launched by a cough or sneeze), can travel through ventilation ducts, and have a long hang time. They can render surfaces and items contagious for long periods of time until carefully cleaned. The initial rash can occur inside the mouth and nose, at which point the person becomes contagious even though the rash can’t be seen at that point.

We do know from past experiences that quarantines are useful and effective. We also know from past experiences that these quarantines have to be solid, with no exceptions.

At present, our supply of smallpox vaccine is small, there’s no huge stockpiles anywhere. More would have to be made. Most is made by culturing the vaccinia virus - smallpox vaccine is a live virus vaccine, where you gain immunity to smallpox by getting an infection with vaccinia, which is (usually) a much more mild disease. However, it also has - for a vaccine - a high rate of complications and can kill people with eczema, dermatitis, and weakened immune systems. There is a difference vaccine for people with those disorders, but it has never faced an actual outbreak of smallpox in humans so while it should work just fine we don’t have actual real-world experience with it. It would be months, at best, before the world could be immunized.

^ This.

Any lingering immunity in people vaccinated previously (such as myself) disappeared years ago, outside of a few armed services personnel. As far as smallpox is concerned, the world is largely virgin territory at this point.

In the bad old days there were people who refused the vaccine even during actual outbreaks with 1/3 or more of the infected dying horribly and the survivors suffering pretty badly, too, emerging scarred at best and at times blind or otherwise maimed.

There will always be people who refuse vaccines. That needs to be taken into account when dealing with public health.

Yep, you’d have that, too. You’d have people willing to kill for the vaccine and others refusing it entirely. Again, based on history.

If smallpox got out, how bad would it be in modern times

As bad as it gets.

Global casualties would, at least rival a limited nuclear war, and very likely much, much worse.

It depends on what we mean by “get out”. Do we realize that there’s been a containment failure immediately? Then we can lock down the immediate vicinity, give everyone in that vicinity the vaccine (if they don’t already have it-- I’m sure that the folks who work in these labs are among the few who still get vaccinated for smallpox these days), and not lift the lockdown until the vaccines have had a chance to take hold. The net result would be a bad scare, and maybe a handful of people seriously affected.

On the other hand, if we only realize there’s a problem a week after the people immediately exposed have flown to and come back from five different international conferences, then the problem becomes much harder.

Their concerns would be somewhat more legitimate, or at least a lot more legitimate than with COVID-19. One of the major reasons we were able to eliminate smallpox is because it doesn’t hang around in animals. If it gets out, it’ll be either due to a really bad mistake on someone’s part or due to a purposeful release. It’s one thing to try to convince people that it’s almost certain something like COVID-19 or the various ebola outbreaks started from someone eating a contaminated bat or pangolin or some other bush meat. Most reasonable people will buy that explanation, because there’s evidence to support the hypothesis. With smallpox, however, we won’t be dealing with the word of trusted virologists. It won’t be a scientific question. It would be a criminal investigation, and we’d be left having to depend on the word of police and intelligence agencies rather than medical doctors and virologists. That’s a whole different ballgame, and the conspiracy theories would likely have more evidence to help them spread, or at the very least have extremely little evidence to disprove them.

The existing smallpox vaccine is not very safe relative to more recent standards. Probably the only reason it was ever approved at all is because smallpox is such a terrible disease.

There would be a roaring debate over whether to produce the current vaccine (which would take time) or to start from scratch using more recent medical knowledge, and try to produce a safer vaccine (which would take even longer).

This is true of the original smallpox vaccine, vaccinia, which is a live vaccine. But there are safer alternatives out there already, like MVA, which have already been in clinical trials.

But, yeah, vaccinia is a weird one. For starters, nobody even knows where the hell it came from.

I remember that. I was in fifth grade and the lined us up in the school yard and vaccinated us all. It was not an injection; just a scratch on the upper arm.

The problem is that I don’t think there are any stores of smallpox vaccines. Moreover, I have read that the old vaccine has never received the kind of regulatory study that would be required today before approval. You’d think that billions of successful doses would suffice, but you know those bureaucrats.

As for the anti-vaxxers, well just think of it as evolution in action.

While I do agree with this assessment, once we’ve reach that point we’re talking about a full blown healthcare crisis. I strongly suspect one of the reasons anti-vaxxers are such a threat these days is because vaccines have been so successful we’ve collectively forgotten just how horrible some of those diseases could be. While there have always been and always will be anti-vaxxers, I suspect we’ll continue to have significant number of them until we’re ravaged by a disease and the bodies start to pile up.

I wish I could. But because of the way herd immunity works they’re actually putting those of us who get our vaccinations in danger. And let’s face it, their children shouldn’t be held responsible for the idiocy of their parents.

By way of illustration, let’s crunch some numbers:

There are two major subdivisions of smallpox: variola major, and variola minor. Let’s look at v. minor first, sometimes called “alastrim” to distinguish it from its big sibling. This one doesn’t kick your ass quite as bad as the other, so it actually spreads better since people sick with it can still be ambulatory. Death rates are around 1% with this one. Assuming a global pandemic that could potentially be as high as 78 million dead, but likely wouldn’t be because of quarantines, vaccinations, etc. This is actually about where covid is, with around a 1% fatality rate, although with our current pandemic we have had “only” about 2,270,000 deaths globally so far (remember, it ain’t over yet). So… probably between what we’ve seen with covid to a somewhat higher number. That would be the best case for a large smallpox outbreak.

If it was variola major that got loose, well, things get stickier. A whole lot depends on the particular variant. V. major variants range from 30% fatal to up to ninety percent. Allegedly, at least one nation’s military attempted to culture the more lethal variant as part of their bioweapons program.

30% of the current global population is 2,340,000,000 people
50% is 3,900,000,000
90% is 7,020,000,000 people - that would leave about 780 million people left in the world. Well, I guess the good new is that there would be a lot of resources to go around at that point… if you can keep from starving because that would almost certainly collapse civilization as we know it.

However, as we’ve seen with covid-19, just because 1% of people with the infection die doesn’t mean everyone will get the infection or that we’ll see 1% of the world population die off from it. Let’s assume any counter-measures we take will be as effective as those we’ve taken for our current viral problem:

Alastrim (v. minor): 3 million (yes, I rounded off to make the math easier. Also, we we will almost certainly reach that before covid is over).
Variola major - typical 30% fatality rate: 90 million dead.
Variola major - apocalypse grade 90% fatal: 270 million dead. Just over 1/4 billion people dead.

Don’t forget - smallpox leaves survivors scarred, and sometimes maimed. Survivors will have to deal with millions, even tens of millions, of people newly blinded, as an example.

Other people should feel free to check my math, as it’s not my strongest subject, but I’m probably in the ballpark.

It was also the first vaccine, In face, the word “vaccine” is derived from the name of the virus: vaccinia. Use of vaccinia for inoculation may have started as early as the 1500’s in China and by the 1700’s it had been introduced to Europe. It was in the 1790’s that the “modern” form and technique of vaccination against smallpox was developed.

Considering the people who came up with this had no germ theory of disease, no clue what a virus was, and not even a microscope they actually did a very good job. It’s just that vaccines developed later on were made with more knowledge and precision.

There has been some work done on making a safer smallpox vaccine, but since the disease is supposed to be extinct there’s not a lot of funding for that project.

There are some stocks of the vaccine. Vaccinia is related to cowpox, a disease of cows, and cattle can get vaccinia, too, so in the past you sacrificed some calves to the cause to make more. Looks like recent genetic sequencing actually marks vaccinia as most closely related to horsepox, so presumably they could be used as well except we have so damn many cattle anyway. As I mentioned, there has been some work on improving the vaccine over the rather crude methods of the past. None of which have been tested against an actual outbreak but they probably should work.

The past vaccine as used in the 20th Century had a severe complication rate of 1-2% and everyone was left with a round scar from the vaccine. Death was rare but not unknown and could be pretty gruesome, as every once in awhile the live virus would spread and destroy the skin. It could also cause blindness. Inoculated people were actually infectious themselves for awhile, it being a live virus, and could inadvertently spread it to someone not vaccinated who maybe shouldn’t get the vaccine due to medical issues. Here is a case of smallpox vaccination getting out of control from 2007. Fortunately, with modern medicine such complications are fatal less often.

As for the “regulatory studies” - not a lot of those back in the 1500’s or 1700’s when this was first developed.

The other possibility is that melting permafrost could allow smallpox in dead corpses to thaw out and transmit again.

I know people that after having covid and a close friend dying of it still refused to wear mask because it’s not really a thing.