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1350 BCE: First Smallpox Epidemic (Korinna)

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1350 BCE: First Smallpox Epidemic (Korinna)

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The first recorded smallpox epidemic occurred during the Egyptian-Hittite War. The disease affected soldiers and commoners. It was passed to the Hittites from the Egyptians, and likely caused the civilization to fall.

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Smallpox- The Triumph over the most Terrible of the Ministers of Death.pdf

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During this outbreak, immunity to smallpox was seemed to have been discovered. Those who got the disease once did not get sick again.

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Smallpox- The Triumph over the most Terrible of the Ministers of Death.pdf

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3rd century BCE: Possible Origin of Smallpox?(Korinna/Kara)

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3rd century BCE: Possible Origin of Smallpox?(Korinna/Kara)

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According to the CDC, smallpox could have originated all the way back in ancient Egypt. There were rashes found on mummies that appear to have been similar to smallpox rashes. One specific example of this is that there were smallpox pustules found on the head of a 3000 year-old mummy (Pharaoh Ramses V) that seem to be the earliest evidence of smallpox.

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Origin of Smallpox

The origin of smallpox is unknown. The finding of smallpox-like rashes on Egyptian mummies suggests that smallpox has existed for at least 3,000 years. The earliest written description of a disease like smallpox appeared in China in the 4 th century CE (Common Era). Early written descriptions also appeared in India in the 7 th century and in Asia Minor in the 10 th century.

Spread of Smallpox

Historians trace the global spread of smallpox to the growth of civilizations and exploration. Expanding trade routes over the centuries also led to the spread of the disease.

Highlights from History:

6th Century-Increased trade with China and Korea brings smallpox to Japan.

7th Century-Arab expansion spreads smallpox into northern Africa, Spain, and Portugal.

11th Century-Crusades further spread smallpox in Europe.

15th Century-Portugal occupies part of western Africa, bringing smallpox.

16th Century-European settlers and the African slave trade import smallpox into:

The Caribbean

Central and South America

17th Century-European settlers bring smallpox to North America.

18th Century-Explorers from Great Britain bring smallpox to Australia.

Early Control Efforts

Smallpox was a terrible disease. On average, 3 out of every 10 people who got it died. People who survived usually had scars, which were sometimes severe.

One of the first methods for controlling smallpox was variolation, a process named after the virus that causes smallpox (variola virus). During variolation, people who had never had smallpox were exposed to material from smallpox sores (pustules) by scratching the material into their arm or inhaling it through the nose. After variolation, people usually developed the symptoms associated with smallpox, such as fever and a rash. However, fewer people died from variolation than if they had acquired smallpox naturally.

The basis for vaccination began in 1796 when the English doctor Edward Jenner noticed that milkmaids who had gotten cowpox were protected from smallpox. Jenner also knew about variolation and guessed that exposure to cowpox could be used to protect against smallpox. To test his theory, Dr. Jenner took material from a cowpox sore on milkmaid Sarah Nelmes' hand and inoculated it into the arm of James Phipps, the 9-year-old son of Jenner's gardener. Months later, Jenner exposed Phipps several times to variola virus, but Phipps never developed smallpox. More experiments followed, and, in 1801, Jenner published his treatise "On the Origin of the Vaccine Inoculation." In this work, he summarized his discoveries and expressed hope that "the annihilation of the smallpox, the most dreadful scourge of the human species, must be the final result of this practice."

Vaccination became widely accepted and gradually replaced the practice of variolation. At some point in the 1800s, the virus used to make the smallpox vaccine changed from cowpox to vaccinia virus.

Global Smallpox Eradication Program

In 1959, the World Health Organization (WHO) started a plan to rid the world of smallpox. Unfortunately, this global eradication campaign suffered from a lack of funds, personnel, and commitment from countries, and a shortage of vaccine donations. Despite their best efforts, smallpox was still widespread in 1966, causing regular outbreaks across South America, Africa, and Asia.

The Intensified Eradication Program began in 1967 with a promise of renewed efforts. Laboratories in many countries where smallpox occurred regularly were able to produce more, higher-quality freeze-dried vaccine. Other factors that played an important role in the success of the intensified efforts included the development of the bifurcated needle, the establishment of a case surveillance system, and mass vaccination campaigns.

By the time the Intensified Eradication Program began in 1967, smallpox was already eliminated in North America (1952) and Europe (1953). Cases were still occurring in South America, Asia, and Africa (smallpox was never widespread in Australia). The Program made steady progress toward ridding the world of this disease, and by 1971 smallpox was eradicated from South America, followed by Asia (1975), and finally Africa (1977).

Last Cases of Smallpox

In late 1975, three-year-old Rahima Banu from Bangladesh was the last person in the world to have naturally acquired variola major. She was also the last person in Asia to have active smallpox. She was isolated at home with house guards posted 24 hours a day until she was no longer infectious. A house-to-house vaccination campaign within a 1.5-mile radius of her home began immediately. A member of the Smallpox Eradication Program team visited every house, public meeting area, school, and healer within 5 miles to ensure the illness did not spread. They also offered a reward to anyone who reported a smallpox case.

Ali Maow Maalin was the last person to have naturally acquired smallpox caused by variola minor. Maalin was a hospital cook in Merca, Somalia. On October 12, 1977, he rode with two smallpox patients in a vehicle from the hospital to the local smallpox office. On October 22, he developed a fever. At first healthcare workers diagnosed him with malaria, and then chickenpox. The smallpox eradication staff then correctly diagnosed him with smallpox on October 30. Maalin was isolated and made a full recovery. Maalin died of malaria on July 22, 2013, while working in the polio eradication campaign.

Janet Parker was the last person to die of smallpox. In 1978, Parker was a medical photographer at England's Birmingham University Medical School. She worked one floor above the Medical Microbiology Department where staff and students conducted smallpox research. She became ill on August 11 and developed a rash on August 15 but was not diagnosed with smallpox until 9 days later. She died on September 11, 1978. Her mother, who was providing care for her, developed smallpox on September 7, despite having been vaccinated two weeks earlier. An investigation suggested that Janet Parker had been infected either via an airborne route through the medical school building's duct system or by direct contact while visiting the microbiology corridor.

World Free of Smallpox

Almost two centuries after Jenner hoped that vaccination could annihilate smallpox, the 33 rd World Health Assembly declared the world free of this disease on May 8, 1980. Many people consider smallpox eradication to be the biggest achievement in international public health.

Stocks of Variola Virus

Following the eradication of smallpox, scientists and public health officials determined there was still a need to perform research using the variola virus. They agreed to reduce the number of laboratories holding stocks of variola virus to only four locations. In 1981, the four countries that either served as a WHO collaborating center or were actively working with variola virus were the United States, England, Russia, and South Africa. By 1984, England and South Africa had either destroyed their stocks or transferred them to other approved labs. There are now only two locations that officially store and handle variola virus under WHO supervision: the Centers for Disease Control and Prevention in Atlanta, Georgia, and the State Research Center of Virology and Biotechnology (VECTOR Institute) in Koltsovo, Russia.

Page last reviewed:

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smallpox (variola major and variola minor)

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4th Century: Evidence of Smallpox in Early China (Kara)

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4th Century: Evidence of Smallpox in Early China (Kara)

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There is record that people in China of the time tried to find protection from smallpox through appealing to the god, Yo Hoa Long. This is one of the first places that there is evidence that people were dealing with smallpox.

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Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below.

Entrance into Europe

Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

Smallpox moves north

Population expansion and more frequent travel renders smallpox endemic in previously unaffected Central and North Europe, with severe epidemics occurring as far as Iceland.

European colonization and the African slave trade import smallpox into the Caribbean and Central and South America.

Illustration by the Franciscan missionary Bernardino de Sahagun who wrote detailed accounts of the Aztec history during his life there from 1545 until his death in 1590 into 12 books entitled "General History of the Things of New Spain." Introduction of smallpox into Mexico by the Spanish around 1520 was one of the factors that led to the demise of Aztec Empire. Scanned from (2009) Viruses, Plagues, and History: Past, Present and Future, Oxford University Press, USA, p. 60. Public Domain.

Variolation-a process of grinding up dried smallpox scabs from a smallpox patient and inhaling them or scratching them into an arm of an uninfected person-is being used in China (inhalation technique) and India (cutaneous technique) to control smallpox.

A container from Ethiopia used to store the powdery variolation material, which was produced by grinding up dried smallpox scabs taken from a smallpox patient. Source: CDC, photo credit Brian Holloway.

Increased use of variolation

Variolation (cutaneous technique) is a widespread method for preventing smallpox in the Ottoman Empire (former Asia Minor, present-day Turkey) and North Africa.

Smallpox spreads into North America

European colonization imports smallpox into North America.

Variolation is introduced into England by Lady Mary Wortley Montagu, the wife of the British ambassador to Turkey.

Lady Mary Wortley Montagu, the wife of the British ambassador, learned about variolation during their appointment in Turkey. A survivor of smallpox herself, she had both of her children variolated and was the foremost person responsible for the introduction of the technique to England.

In 1796, Edward Jenner, an English doctor, shows the effectiveness of previous cowpox infection in protecting people from smallpox, forming the basis for vaccination.

Edward Jenner (1749-1823). Photo courtesy of the National Library of Medicine.

Smallpox is widespread in Africa, Asia, and South America in the early 1900s, while Europe and North America have smallpox largely under control through the use of mass vaccination.

The map shows the worldwide distribution of smallpox and the countries in which it was endemic in 1945. Source: CDC, photo credit Dr. Michael Schwartz.

After a global eradication campaign that lasted more than 20 years, the 33rd World Health Assembly declares the world free of smallpox in 1980.

WHO poster commemorating the eradication of smallpox in October 1979, which was later officially endorsed by the 33rd World Health Assembly on May 8, 1980. Courtesy of WHO.

Page last reviewed:

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Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below. Entrance into Europe Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

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6th Century: Introduction of Smallpox (Korinna/Kara)

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6th Century: Introduction of Smallpox (Korinna/Kara)

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Increased trade with China and Korea brought smallpox to Japan. As the occurances of smallpox began to increase in Japan, it was believed that smallpox was caused by the demons. Myths began that the color red/red light could cure smallpox, and this idea spread through the population.

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Origin of Smallpox

The origin of smallpox is unknown. The finding of smallpox-like rashes on Egyptian mummies suggests that smallpox has existed for at least 3,000 years. The earliest written description of a disease like smallpox appeared in China in the 4 th century CE (Common Era). Early written descriptions also appeared in India in the 7 th century and in Asia Minor in the 10 th century.

Spread of Smallpox

Historians trace the global spread of smallpox to the growth of civilizations and exploration. Expanding trade routes over the centuries also led to the spread of the disease.

Highlights from History:

6th Century-Increased trade with China and Korea brings smallpox to Japan.

7th Century-Arab expansion spreads smallpox into northern Africa, Spain, and Portugal.

11th Century-Crusades further spread smallpox in Europe.

15th Century-Portugal occupies part of western Africa, bringing smallpox.

16th Century-European settlers and the African slave trade import smallpox into:

The Caribbean

Central and South America

17th Century-European settlers bring smallpox to North America.

18th Century-Explorers from Great Britain bring smallpox to Australia.

Early Control Efforts

Smallpox was a terrible disease. On average, 3 out of every 10 people who got it died. People who survived usually had scars, which were sometimes severe.

One of the first methods for controlling smallpox was variolation, a process named after the virus that causes smallpox (variola virus). During variolation, people who had never had smallpox were exposed to material from smallpox sores (pustules) by scratching the material into their arm or inhaling it through the nose. After variolation, people usually developed the symptoms associated with smallpox, such as fever and a rash. However, fewer people died from variolation than if they had acquired smallpox naturally.

The basis for vaccination began in 1796 when the English doctor Edward Jenner noticed that milkmaids who had gotten cowpox were protected from smallpox. Jenner also knew about variolation and guessed that exposure to cowpox could be used to protect against smallpox. To test his theory, Dr. Jenner took material from a cowpox sore on milkmaid Sarah Nelmes' hand and inoculated it into the arm of James Phipps, the 9-year-old son of Jenner's gardener. Months later, Jenner exposed Phipps several times to variola virus, but Phipps never developed smallpox. More experiments followed, and, in 1801, Jenner published his treatise "On the Origin of the Vaccine Inoculation." In this work, he summarized his discoveries and expressed hope that "the annihilation of the smallpox, the most dreadful scourge of the human species, must be the final result of this practice."

Vaccination became widely accepted and gradually replaced the practice of variolation. At some point in the 1800s, the virus used to make the smallpox vaccine changed from cowpox to vaccinia virus.

Global Smallpox Eradication Program

In 1959, the World Health Organization (WHO) started a plan to rid the world of smallpox. Unfortunately, this global eradication campaign suffered from a lack of funds, personnel, and commitment from countries, and a shortage of vaccine donations. Despite their best efforts, smallpox was still widespread in 1966, causing regular outbreaks across South America, Africa, and Asia.

The Intensified Eradication Program began in 1967 with a promise of renewed efforts. Laboratories in many countries where smallpox occurred regularly were able to produce more, higher-quality freeze-dried vaccine. Other factors that played an important role in the success of the intensified efforts included the development of the bifurcated needle, the establishment of a case surveillance system, and mass vaccination campaigns.

By the time the Intensified Eradication Program began in 1967, smallpox was already eliminated in North America (1952) and Europe (1953). Cases were still occurring in South America, Asia, and Africa (smallpox was never widespread in Australia). The Program made steady progress toward ridding the world of this disease, and by 1971 smallpox was eradicated from South America, followed by Asia (1975), and finally Africa (1977).

Last Cases of Smallpox

In late 1975, three-year-old Rahima Banu from Bangladesh was the last person in the world to have naturally acquired variola major. She was also the last person in Asia to have active smallpox. She was isolated at home with house guards posted 24 hours a day until she was no longer infectious. A house-to-house vaccination campaign within a 1.5-mile radius of her home began immediately. A member of the Smallpox Eradication Program team visited every house, public meeting area, school, and healer within 5 miles to ensure the illness did not spread. They also offered a reward to anyone who reported a smallpox case.

Ali Maow Maalin was the last person to have naturally acquired smallpox caused by variola minor. Maalin was a hospital cook in Merca, Somalia. On October 12, 1977, he rode with two smallpox patients in a vehicle from the hospital to the local smallpox office. On October 22, he developed a fever. At first healthcare workers diagnosed him with malaria, and then chickenpox. The smallpox eradication staff then correctly diagnosed him with smallpox on October 30. Maalin was isolated and made a full recovery. Maalin died of malaria on July 22, 2013, while working in the polio eradication campaign.

Janet Parker was the last person to die of smallpox. In 1978, Parker was a medical photographer at England's Birmingham University Medical School. She worked one floor above the Medical Microbiology Department where staff and students conducted smallpox research. She became ill on August 11 and developed a rash on August 15 but was not diagnosed with smallpox until 9 days later. She died on September 11, 1978. Her mother, who was providing care for her, developed smallpox on September 7, despite having been vaccinated two weeks earlier. An investigation suggested that Janet Parker had been infected either via an airborne route through the medical school building's duct system or by direct contact while visiting the microbiology corridor.

World Free of Smallpox

Almost two centuries after Jenner hoped that vaccination could annihilate smallpox, the 33 rd World Health Assembly declared the world free of this disease on May 8, 1980. Many people consider smallpox eradication to be the biggest achievement in international public health.

Stocks of Variola Virus

Following the eradication of smallpox, scientists and public health officials determined there was still a need to perform research using the variola virus. They agreed to reduce the number of laboratories holding stocks of variola virus to only four locations. In 1981, the four countries that either served as a WHO collaborating center or were actively working with variola virus were the United States, England, Russia, and South Africa. By 1984, England and South Africa had either destroyed their stocks or transferred them to other approved labs. There are now only two locations that officially store and handle variola virus under WHO supervision: the Centers for Disease Control and Prevention in Atlanta, Georgia, and the State Research Center of Virology and Biotechnology (VECTOR Institute) in Koltsovo, Russia.

Page last reviewed:

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smallpox (variola major and variola minor)

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7th Century: Arab Expansion Results in Spread of Smallpox (Kara)

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7th Century: Arab Expansion Results in Spread of Smallpox (Kara)

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At the beginning of the century, smallpox was widespread in India. Throughout the expansion of land and regions that occurred during this century, countries in Europe such as Spain and Portugal (port countries), as well as regions of Africa, had their first exposure to the horrible smallpox disease.

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Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below.

Entrance into Europe

Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

Smallpox moves north

Population expansion and more frequent travel renders smallpox endemic in previously unaffected Central and North Europe, with severe epidemics occurring as far as Iceland.

European colonization and the African slave trade import smallpox into the Caribbean and Central and South America.

Illustration by the Franciscan missionary Bernardino de Sahagun who wrote detailed accounts of the Aztec history during his life there from 1545 until his death in 1590 into 12 books entitled "General History of the Things of New Spain." Introduction of smallpox into Mexico by the Spanish around 1520 was one of the factors that led to the demise of Aztec Empire. Scanned from (2009) Viruses, Plagues, and History: Past, Present and Future, Oxford University Press, USA, p. 60. Public Domain.

Variolation-a process of grinding up dried smallpox scabs from a smallpox patient and inhaling them or scratching them into an arm of an uninfected person-is being used in China (inhalation technique) and India (cutaneous technique) to control smallpox.

A container from Ethiopia used to store the powdery variolation material, which was produced by grinding up dried smallpox scabs taken from a smallpox patient. Source: CDC, photo credit Brian Holloway.

Increased use of variolation

Variolation (cutaneous technique) is a widespread method for preventing smallpox in the Ottoman Empire (former Asia Minor, present-day Turkey) and North Africa.

Smallpox spreads into North America

European colonization imports smallpox into North America.

Variolation is introduced into England by Lady Mary Wortley Montagu, the wife of the British ambassador to Turkey.

Lady Mary Wortley Montagu, the wife of the British ambassador, learned about variolation during their appointment in Turkey. A survivor of smallpox herself, she had both of her children variolated and was the foremost person responsible for the introduction of the technique to England.

In 1796, Edward Jenner, an English doctor, shows the effectiveness of previous cowpox infection in protecting people from smallpox, forming the basis for vaccination.

Edward Jenner (1749-1823). Photo courtesy of the National Library of Medicine.

Smallpox is widespread in Africa, Asia, and South America in the early 1900s, while Europe and North America have smallpox largely under control through the use of mass vaccination.

The map shows the worldwide distribution of smallpox and the countries in which it was endemic in 1945. Source: CDC, photo credit Dr. Michael Schwartz.

After a global eradication campaign that lasted more than 20 years, the 33rd World Health Assembly declares the world free of smallpox in 1980.

WHO poster commemorating the eradication of smallpox in October 1979, which was later officially endorsed by the 33rd World Health Assembly on May 8, 1980. Courtesy of WHO.

Page last reviewed:

# data[].attributes.attachment_link.description
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below. Entrance into Europe Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

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10th Century: Spread of Smallpox to Asia Minor (Kara)

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10th Century: Spread of Smallpox to Asia Minor (Kara)

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Trade routes with Asia brought the incidents of smallpox to locations such as present day Turkey. At this point in history, it was certain that Asia had been dealing with smallpox for centuries. Due to expansion of regions and trade with others, the spread of smallpox is beginning to occur outside of Asia.

# data[].attributes.attachment_link.readable_text
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below.

Entrance into Europe

Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

Smallpox moves north

Population expansion and more frequent travel renders smallpox endemic in previously unaffected Central and North Europe, with severe epidemics occurring as far as Iceland.

European colonization and the African slave trade import smallpox into the Caribbean and Central and South America.

Illustration by the Franciscan missionary Bernardino de Sahagun who wrote detailed accounts of the Aztec history during his life there from 1545 until his death in 1590 into 12 books entitled "General History of the Things of New Spain." Introduction of smallpox into Mexico by the Spanish around 1520 was one of the factors that led to the demise of Aztec Empire. Scanned from (2009) Viruses, Plagues, and History: Past, Present and Future, Oxford University Press, USA, p. 60. Public Domain.

Variolation-a process of grinding up dried smallpox scabs from a smallpox patient and inhaling them or scratching them into an arm of an uninfected person-is being used in China (inhalation technique) and India (cutaneous technique) to control smallpox.

A container from Ethiopia used to store the powdery variolation material, which was produced by grinding up dried smallpox scabs taken from a smallpox patient. Source: CDC, photo credit Brian Holloway.

Increased use of variolation

Variolation (cutaneous technique) is a widespread method for preventing smallpox in the Ottoman Empire (former Asia Minor, present-day Turkey) and North Africa.

Smallpox spreads into North America

European colonization imports smallpox into North America.

Variolation is introduced into England by Lady Mary Wortley Montagu, the wife of the British ambassador to Turkey.

Lady Mary Wortley Montagu, the wife of the British ambassador, learned about variolation during their appointment in Turkey. A survivor of smallpox herself, she had both of her children variolated and was the foremost person responsible for the introduction of the technique to England.

In 1796, Edward Jenner, an English doctor, shows the effectiveness of previous cowpox infection in protecting people from smallpox, forming the basis for vaccination.

Edward Jenner (1749-1823). Photo courtesy of the National Library of Medicine.

Smallpox is widespread in Africa, Asia, and South America in the early 1900s, while Europe and North America have smallpox largely under control through the use of mass vaccination.

The map shows the worldwide distribution of smallpox and the countries in which it was endemic in 1945. Source: CDC, photo credit Dr. Michael Schwartz.

After a global eradication campaign that lasted more than 20 years, the 33rd World Health Assembly declares the world free of smallpox in 1980.

WHO poster commemorating the eradication of smallpox in October 1979, which was later officially endorsed by the 33rd World Health Assembly on May 8, 1980. Courtesy of WHO.

Page last reviewed:

# data[].attributes.attachment_link.description
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below. Entrance into Europe Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

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During the Crusades, smallpox was running rampant through Europe due to wars of the time. As European Christians travelled to the Middle East, they often brought smallpox back with them, increasing the incidence in Europe for the first time overall.

# data[].attributes.attachment_link.readable_text
Origin of Smallpox

The origin of smallpox is unknown. The finding of smallpox-like rashes on Egyptian mummies suggests that smallpox has existed for at least 3,000 years. The earliest written description of a disease like smallpox appeared in China in the 4 th century CE (Common Era). Early written descriptions also appeared in India in the 7 th century and in Asia Minor in the 10 th century.

Spread of Smallpox

Historians trace the global spread of smallpox to the growth of civilizations and exploration. Expanding trade routes over the centuries also led to the spread of the disease.

Highlights from History:

6th Century-Increased trade with China and Korea brings smallpox to Japan.

7th Century-Arab expansion spreads smallpox into northern Africa, Spain, and Portugal.

11th Century-Crusades further spread smallpox in Europe.

15th Century-Portugal occupies part of western Africa, bringing smallpox.

16th Century-European settlers and the African slave trade import smallpox into:

The Caribbean

Central and South America

17th Century-European settlers bring smallpox to North America.

18th Century-Explorers from Great Britain bring smallpox to Australia.

Early Control Efforts

Smallpox was a terrible disease. On average, 3 out of every 10 people who got it died. People who survived usually had scars, which were sometimes severe.

One of the first methods for controlling smallpox was variolation, a process named after the virus that causes smallpox (variola virus). During variolation, people who had never had smallpox were exposed to material from smallpox sores (pustules) by scratching the material into their arm or inhaling it through the nose. After variolation, people usually developed the symptoms associated with smallpox, such as fever and a rash. However, fewer people died from variolation than if they had acquired smallpox naturally.

The basis for vaccination began in 1796 when the English doctor Edward Jenner noticed that milkmaids who had gotten cowpox were protected from smallpox. Jenner also knew about variolation and guessed that exposure to cowpox could be used to protect against smallpox. To test his theory, Dr. Jenner took material from a cowpox sore on milkmaid Sarah Nelmes' hand and inoculated it into the arm of James Phipps, the 9-year-old son of Jenner's gardener. Months later, Jenner exposed Phipps several times to variola virus, but Phipps never developed smallpox. More experiments followed, and, in 1801, Jenner published his treatise "On the Origin of the Vaccine Inoculation." In this work, he summarized his discoveries and expressed hope that "the annihilation of the smallpox, the most dreadful scourge of the human species, must be the final result of this practice."

Vaccination became widely accepted and gradually replaced the practice of variolation. At some point in the 1800s, the virus used to make the smallpox vaccine changed from cowpox to vaccinia virus.

Global Smallpox Eradication Program

In 1959, the World Health Organization (WHO) started a plan to rid the world of smallpox. Unfortunately, this global eradication campaign suffered from a lack of funds, personnel, and commitment from countries, and a shortage of vaccine donations. Despite their best efforts, smallpox was still widespread in 1966, causing regular outbreaks across South America, Africa, and Asia.

The Intensified Eradication Program began in 1967 with a promise of renewed efforts. Laboratories in many countries where smallpox occurred regularly were able to produce more, higher-quality freeze-dried vaccine. Other factors that played an important role in the success of the intensified efforts included the development of the bifurcated needle, the establishment of a case surveillance system, and mass vaccination campaigns.

By the time the Intensified Eradication Program began in 1967, smallpox was already eliminated in North America (1952) and Europe (1953). Cases were still occurring in South America, Asia, and Africa (smallpox was never widespread in Australia). The Program made steady progress toward ridding the world of this disease, and by 1971 smallpox was eradicated from South America, followed by Asia (1975), and finally Africa (1977).

Last Cases of Smallpox

In late 1975, three-year-old Rahima Banu from Bangladesh was the last person in the world to have naturally acquired variola major. She was also the last person in Asia to have active smallpox. She was isolated at home with house guards posted 24 hours a day until she was no longer infectious. A house-to-house vaccination campaign within a 1.5-mile radius of her home began immediately. A member of the Smallpox Eradication Program team visited every house, public meeting area, school, and healer within 5 miles to ensure the illness did not spread. They also offered a reward to anyone who reported a smallpox case.

Ali Maow Maalin was the last person to have naturally acquired smallpox caused by variola minor. Maalin was a hospital cook in Merca, Somalia. On October 12, 1977, he rode with two smallpox patients in a vehicle from the hospital to the local smallpox office. On October 22, he developed a fever. At first healthcare workers diagnosed him with malaria, and then chickenpox. The smallpox eradication staff then correctly diagnosed him with smallpox on October 30. Maalin was isolated and made a full recovery. Maalin died of malaria on July 22, 2013, while working in the polio eradication campaign.

Janet Parker was the last person to die of smallpox. In 1978, Parker was a medical photographer at England's Birmingham University Medical School. She worked one floor above the Medical Microbiology Department where staff and students conducted smallpox research. She became ill on August 11 and developed a rash on August 15 but was not diagnosed with smallpox until 9 days later. She died on September 11, 1978. Her mother, who was providing care for her, developed smallpox on September 7, despite having been vaccinated two weeks earlier. An investigation suggested that Janet Parker had been infected either via an airborne route through the medical school building's duct system or by direct contact while visiting the microbiology corridor.

World Free of Smallpox

Almost two centuries after Jenner hoped that vaccination could annihilate smallpox, the 33 rd World Health Assembly declared the world free of this disease on May 8, 1980. Many people consider smallpox eradication to be the biggest achievement in international public health.

Stocks of Variola Virus

Following the eradication of smallpox, scientists and public health officials determined there was still a need to perform research using the variola virus. They agreed to reduce the number of laboratories holding stocks of variola virus to only four locations. In 1981, the four countries that either served as a WHO collaborating center or were actively working with variola virus were the United States, England, Russia, and South Africa. By 1984, England and South Africa had either destroyed their stocks or transferred them to other approved labs. There are now only two locations that officially store and handle variola virus under WHO supervision: the Centers for Disease Control and Prevention in Atlanta, Georgia, and the State Research Center of Virology and Biotechnology (VECTOR Institute) in Koltsovo, Russia.

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smallpox (variola major and variola minor)

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13th Century: Spread of Smallpox to Northern Europe (Kara)

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13th Century: Spread of Smallpox to Northern Europe (Kara)

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Now that smallpox was prevalent in Europe, it began to move northward, therefore affecting some parts of Africa, most of Asia, and nearly all of Europe. This is likely due to new travel to the northern regions and population expansion.

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Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below.

Entrance into Europe

Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

Smallpox moves north

Population expansion and more frequent travel renders smallpox endemic in previously unaffected Central and North Europe, with severe epidemics occurring as far as Iceland.

European colonization and the African slave trade import smallpox into the Caribbean and Central and South America.

Illustration by the Franciscan missionary Bernardino de Sahagun who wrote detailed accounts of the Aztec history during his life there from 1545 until his death in 1590 into 12 books entitled "General History of the Things of New Spain." Introduction of smallpox into Mexico by the Spanish around 1520 was one of the factors that led to the demise of Aztec Empire. Scanned from (2009) Viruses, Plagues, and History: Past, Present and Future, Oxford University Press, USA, p. 60. Public Domain.

Variolation-a process of grinding up dried smallpox scabs from a smallpox patient and inhaling them or scratching them into an arm of an uninfected person-is being used in China (inhalation technique) and India (cutaneous technique) to control smallpox.

A container from Ethiopia used to store the powdery variolation material, which was produced by grinding up dried smallpox scabs taken from a smallpox patient. Source: CDC, photo credit Brian Holloway.

Increased use of variolation

Variolation (cutaneous technique) is a widespread method for preventing smallpox in the Ottoman Empire (former Asia Minor, present-day Turkey) and North Africa.

Smallpox spreads into North America

European colonization imports smallpox into North America.

Variolation is introduced into England by Lady Mary Wortley Montagu, the wife of the British ambassador to Turkey.

Lady Mary Wortley Montagu, the wife of the British ambassador, learned about variolation during their appointment in Turkey. A survivor of smallpox herself, she had both of her children variolated and was the foremost person responsible for the introduction of the technique to England.

In 1796, Edward Jenner, an English doctor, shows the effectiveness of previous cowpox infection in protecting people from smallpox, forming the basis for vaccination.

Edward Jenner (1749-1823). Photo courtesy of the National Library of Medicine.

Smallpox is widespread in Africa, Asia, and South America in the early 1900s, while Europe and North America have smallpox largely under control through the use of mass vaccination.

The map shows the worldwide distribution of smallpox and the countries in which it was endemic in 1945. Source: CDC, photo credit Dr. Michael Schwartz.

After a global eradication campaign that lasted more than 20 years, the 33rd World Health Assembly declares the world free of smallpox in 1980.

WHO poster commemorating the eradication of smallpox in October 1979, which was later officially endorsed by the 33rd World Health Assembly on May 8, 1980. Courtesy of WHO.

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# data[].attributes.attachment_link.description
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below. Entrance into Europe Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

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15th Century: Spread of Smallpox to West Africa (Kara)

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15th Century: Spread of Smallpox to West Africa (Kara)

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Due to the new Colombian Exchange, trade began between Europe, Africa, and the new world. Although smallpox had not made it to the new world (reportedly) yet, it was only a matter of time, for West Africa began to experience the effects of the smallpox.

# data[].attributes.attachment_link.readable_text
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below.

Entrance into Europe

Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

Smallpox moves north

Population expansion and more frequent travel renders smallpox endemic in previously unaffected Central and North Europe, with severe epidemics occurring as far as Iceland.

European colonization and the African slave trade import smallpox into the Caribbean and Central and South America.

Illustration by the Franciscan missionary Bernardino de Sahagun who wrote detailed accounts of the Aztec history during his life there from 1545 until his death in 1590 into 12 books entitled "General History of the Things of New Spain." Introduction of smallpox into Mexico by the Spanish around 1520 was one of the factors that led to the demise of Aztec Empire. Scanned from (2009) Viruses, Plagues, and History: Past, Present and Future, Oxford University Press, USA, p. 60. Public Domain.

Variolation-a process of grinding up dried smallpox scabs from a smallpox patient and inhaling them or scratching them into an arm of an uninfected person-is being used in China (inhalation technique) and India (cutaneous technique) to control smallpox.

A container from Ethiopia used to store the powdery variolation material, which was produced by grinding up dried smallpox scabs taken from a smallpox patient. Source: CDC, photo credit Brian Holloway.

Increased use of variolation

Variolation (cutaneous technique) is a widespread method for preventing smallpox in the Ottoman Empire (former Asia Minor, present-day Turkey) and North Africa.

Smallpox spreads into North America

European colonization imports smallpox into North America.

Variolation is introduced into England by Lady Mary Wortley Montagu, the wife of the British ambassador to Turkey.

Lady Mary Wortley Montagu, the wife of the British ambassador, learned about variolation during their appointment in Turkey. A survivor of smallpox herself, she had both of her children variolated and was the foremost person responsible for the introduction of the technique to England.

In 1796, Edward Jenner, an English doctor, shows the effectiveness of previous cowpox infection in protecting people from smallpox, forming the basis for vaccination.

Edward Jenner (1749-1823). Photo courtesy of the National Library of Medicine.

Smallpox is widespread in Africa, Asia, and South America in the early 1900s, while Europe and North America have smallpox largely under control through the use of mass vaccination.

The map shows the worldwide distribution of smallpox and the countries in which it was endemic in 1945. Source: CDC, photo credit Dr. Michael Schwartz.

After a global eradication campaign that lasted more than 20 years, the 33rd World Health Assembly declares the world free of smallpox in 1980.

WHO poster commemorating the eradication of smallpox in October 1979, which was later officially endorsed by the 33rd World Health Assembly on May 8, 1980. Courtesy of WHO.

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# data[].attributes.attachment_link.description
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below. Entrance into Europe Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

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16th Century: Spread of Smallpox to the New World (Kara)

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16th Century: Spread of Smallpox to the New World (Kara)

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It was only a matter of time before smallpox began showing up in the new world, which was part of the Colombian Exchange. The first incidents seem to have occurred in the Caribbean and Central to South America.

# data[].attributes.attachment_link.readable_text
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below.

Entrance into Europe

Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

Smallpox moves north

Population expansion and more frequent travel renders smallpox endemic in previously unaffected Central and North Europe, with severe epidemics occurring as far as Iceland.

European colonization and the African slave trade import smallpox into the Caribbean and Central and South America.

Illustration by the Franciscan missionary Bernardino de Sahagun who wrote detailed accounts of the Aztec history during his life there from 1545 until his death in 1590 into 12 books entitled "General History of the Things of New Spain." Introduction of smallpox into Mexico by the Spanish around 1520 was one of the factors that led to the demise of Aztec Empire. Scanned from (2009) Viruses, Plagues, and History: Past, Present and Future, Oxford University Press, USA, p. 60. Public Domain.

Variolation-a process of grinding up dried smallpox scabs from a smallpox patient and inhaling them or scratching them into an arm of an uninfected person-is being used in China (inhalation technique) and India (cutaneous technique) to control smallpox.

A container from Ethiopia used to store the powdery variolation material, which was produced by grinding up dried smallpox scabs taken from a smallpox patient. Source: CDC, photo credit Brian Holloway.

Increased use of variolation

Variolation (cutaneous technique) is a widespread method for preventing smallpox in the Ottoman Empire (former Asia Minor, present-day Turkey) and North Africa.

Smallpox spreads into North America

European colonization imports smallpox into North America.

Variolation is introduced into England by Lady Mary Wortley Montagu, the wife of the British ambassador to Turkey.

Lady Mary Wortley Montagu, the wife of the British ambassador, learned about variolation during their appointment in Turkey. A survivor of smallpox herself, she had both of her children variolated and was the foremost person responsible for the introduction of the technique to England.

In 1796, Edward Jenner, an English doctor, shows the effectiveness of previous cowpox infection in protecting people from smallpox, forming the basis for vaccination.

Edward Jenner (1749-1823). Photo courtesy of the National Library of Medicine.

Smallpox is widespread in Africa, Asia, and South America in the early 1900s, while Europe and North America have smallpox largely under control through the use of mass vaccination.

The map shows the worldwide distribution of smallpox and the countries in which it was endemic in 1945. Source: CDC, photo credit Dr. Michael Schwartz.

After a global eradication campaign that lasted more than 20 years, the 33rd World Health Assembly declares the world free of smallpox in 1980.

WHO poster commemorating the eradication of smallpox in October 1979, which was later officially endorsed by the 33rd World Health Assembly on May 8, 1980. Courtesy of WHO.

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# data[].attributes.attachment_link.description
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below. Entrance into Europe Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

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16th Century: Variolation Begins Being Used in China and India (Kara)

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16th Century: Variolation Begins Being Used in China and India (Kara)

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Variolation describes the action of taking smallpox scabs from an infected individual and grinding them up to inoculate an uninfected person. In China, an inhalation technique was used, in which the ground scabs were breathed in. In India, a different technique was used, which involved scratching them into the arm of an individual who did not have smallpox, in hopes of granting them immunity.

# data[].attributes.attachment_link.readable_text
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below.

Entrance into Europe

Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

Smallpox moves north

Population expansion and more frequent travel renders smallpox endemic in previously unaffected Central and North Europe, with severe epidemics occurring as far as Iceland.

European colonization and the African slave trade import smallpox into the Caribbean and Central and South America.

Illustration by the Franciscan missionary Bernardino de Sahagun who wrote detailed accounts of the Aztec history during his life there from 1545 until his death in 1590 into 12 books entitled "General History of the Things of New Spain." Introduction of smallpox into Mexico by the Spanish around 1520 was one of the factors that led to the demise of Aztec Empire. Scanned from (2009) Viruses, Plagues, and History: Past, Present and Future, Oxford University Press, USA, p. 60. Public Domain.

Variolation-a process of grinding up dried smallpox scabs from a smallpox patient and inhaling them or scratching them into an arm of an uninfected person-is being used in China (inhalation technique) and India (cutaneous technique) to control smallpox.

A container from Ethiopia used to store the powdery variolation material, which was produced by grinding up dried smallpox scabs taken from a smallpox patient. Source: CDC, photo credit Brian Holloway.

Increased use of variolation

Variolation (cutaneous technique) is a widespread method for preventing smallpox in the Ottoman Empire (former Asia Minor, present-day Turkey) and North Africa.

Smallpox spreads into North America

European colonization imports smallpox into North America.

Variolation is introduced into England by Lady Mary Wortley Montagu, the wife of the British ambassador to Turkey.

Lady Mary Wortley Montagu, the wife of the British ambassador, learned about variolation during their appointment in Turkey. A survivor of smallpox herself, she had both of her children variolated and was the foremost person responsible for the introduction of the technique to England.

In 1796, Edward Jenner, an English doctor, shows the effectiveness of previous cowpox infection in protecting people from smallpox, forming the basis for vaccination.

Edward Jenner (1749-1823). Photo courtesy of the National Library of Medicine.

Smallpox is widespread in Africa, Asia, and South America in the early 1900s, while Europe and North America have smallpox largely under control through the use of mass vaccination.

The map shows the worldwide distribution of smallpox and the countries in which it was endemic in 1945. Source: CDC, photo credit Dr. Michael Schwartz.

After a global eradication campaign that lasted more than 20 years, the 33rd World Health Assembly declares the world free of smallpox in 1980.

WHO poster commemorating the eradication of smallpox in October 1979, which was later officially endorsed by the 33rd World Health Assembly on May 8, 1980. Courtesy of WHO.

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# data[].attributes.attachment_link.description
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below. Entrance into Europe Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

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17th Century: Spread of Smallpox to North America (Kara)

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17th Century: Spread of Smallpox to North America (Kara)

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North America begins having incidents of smallpox due to European colonization. As the colonists entered North America and interacted with the natives, they brought smallpox to people who had never experienced the disease before.

# data[].attributes.attachment_link.readable_text
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below.

Entrance into Europe

Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

Smallpox moves north

Population expansion and more frequent travel renders smallpox endemic in previously unaffected Central and North Europe, with severe epidemics occurring as far as Iceland.

European colonization and the African slave trade import smallpox into the Caribbean and Central and South America.

Illustration by the Franciscan missionary Bernardino de Sahagun who wrote detailed accounts of the Aztec history during his life there from 1545 until his death in 1590 into 12 books entitled "General History of the Things of New Spain." Introduction of smallpox into Mexico by the Spanish around 1520 was one of the factors that led to the demise of Aztec Empire. Scanned from (2009) Viruses, Plagues, and History: Past, Present and Future, Oxford University Press, USA, p. 60. Public Domain.

Variolation-a process of grinding up dried smallpox scabs from a smallpox patient and inhaling them or scratching them into an arm of an uninfected person-is being used in China (inhalation technique) and India (cutaneous technique) to control smallpox.

A container from Ethiopia used to store the powdery variolation material, which was produced by grinding up dried smallpox scabs taken from a smallpox patient. Source: CDC, photo credit Brian Holloway.

Increased use of variolation

Variolation (cutaneous technique) is a widespread method for preventing smallpox in the Ottoman Empire (former Asia Minor, present-day Turkey) and North Africa.

Smallpox spreads into North America

European colonization imports smallpox into North America.

Variolation is introduced into England by Lady Mary Wortley Montagu, the wife of the British ambassador to Turkey.

Lady Mary Wortley Montagu, the wife of the British ambassador, learned about variolation during their appointment in Turkey. A survivor of smallpox herself, she had both of her children variolated and was the foremost person responsible for the introduction of the technique to England.

In 1796, Edward Jenner, an English doctor, shows the effectiveness of previous cowpox infection in protecting people from smallpox, forming the basis for vaccination.

Edward Jenner (1749-1823). Photo courtesy of the National Library of Medicine.

Smallpox is widespread in Africa, Asia, and South America in the early 1900s, while Europe and North America have smallpox largely under control through the use of mass vaccination.

The map shows the worldwide distribution of smallpox and the countries in which it was endemic in 1945. Source: CDC, photo credit Dr. Michael Schwartz.

After a global eradication campaign that lasted more than 20 years, the 33rd World Health Assembly declares the world free of smallpox in 1980.

WHO poster commemorating the eradication of smallpox in October 1979, which was later officially endorsed by the 33rd World Health Assembly on May 8, 1980. Courtesy of WHO.

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# data[].attributes.attachment_link.description
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below. Entrance into Europe Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

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17th Century: Increased Use of Variolation (Kara)

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17th Century: Increased Use of Variolation (Kara)

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The method of applying scabs onto the skin as a method of protection from getting the smallpox disease became more popular across the globe. The Ottoman Empire and North America began practicing these techniques.

# data[].attributes.attachment_link.readable_text
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below.

Entrance into Europe

Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

Smallpox moves north

Population expansion and more frequent travel renders smallpox endemic in previously unaffected Central and North Europe, with severe epidemics occurring as far as Iceland.

European colonization and the African slave trade import smallpox into the Caribbean and Central and South America.

Illustration by the Franciscan missionary Bernardino de Sahagun who wrote detailed accounts of the Aztec history during his life there from 1545 until his death in 1590 into 12 books entitled "General History of the Things of New Spain." Introduction of smallpox into Mexico by the Spanish around 1520 was one of the factors that led to the demise of Aztec Empire. Scanned from (2009) Viruses, Plagues, and History: Past, Present and Future, Oxford University Press, USA, p. 60. Public Domain.

Variolation-a process of grinding up dried smallpox scabs from a smallpox patient and inhaling them or scratching them into an arm of an uninfected person-is being used in China (inhalation technique) and India (cutaneous technique) to control smallpox.

A container from Ethiopia used to store the powdery variolation material, which was produced by grinding up dried smallpox scabs taken from a smallpox patient. Source: CDC, photo credit Brian Holloway.

Increased use of variolation

Variolation (cutaneous technique) is a widespread method for preventing smallpox in the Ottoman Empire (former Asia Minor, present-day Turkey) and North Africa.

Smallpox spreads into North America

European colonization imports smallpox into North America.

Variolation is introduced into England by Lady Mary Wortley Montagu, the wife of the British ambassador to Turkey.

Lady Mary Wortley Montagu, the wife of the British ambassador, learned about variolation during their appointment in Turkey. A survivor of smallpox herself, she had both of her children variolated and was the foremost person responsible for the introduction of the technique to England.

In 1796, Edward Jenner, an English doctor, shows the effectiveness of previous cowpox infection in protecting people from smallpox, forming the basis for vaccination.

Edward Jenner (1749-1823). Photo courtesy of the National Library of Medicine.

Smallpox is widespread in Africa, Asia, and South America in the early 1900s, while Europe and North America have smallpox largely under control through the use of mass vaccination.

The map shows the worldwide distribution of smallpox and the countries in which it was endemic in 1945. Source: CDC, photo credit Dr. Michael Schwartz.

After a global eradication campaign that lasted more than 20 years, the 33rd World Health Assembly declares the world free of smallpox in 1980.

WHO poster commemorating the eradication of smallpox in October 1979, which was later officially endorsed by the 33rd World Health Assembly on May 8, 1980. Courtesy of WHO.

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# data[].attributes.attachment_link.description
Smallpox began causing illness and death more than a thousand years ago. Follow its spread and eventual eradication in the timeline below. Entrance into Europe Crusades further contribute to the spread of smallpox in Europe with the European Christians moving to and from the Middle East during the next two centuries.

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1715: Lady Mary Wortley Montagu (Korinna/Kara)

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1715: Lady Mary Wortley Montagu (Korinna/Kara)

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Lady Mary was very well known in the Ottoman Empire for her beauty and smarts. But after she contracted smallpox, she was not seen as beautiful. However, she inoculated her son with her smallpox scabs to "vaccinate" him. She was the first to introduce the variolation technique to England.

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Dr. James Kilpatrick from South Carolina started advertising the act of "vaccination" for smallpox. But partly due to his ineffective actions, smallpox came back strong in the late 18th century.

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Smallpox blankets were used as biological warfare by North American conquerors against the Native Americans. However, studies show that the smallpox-infected blankets may not have even worked.

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North American colonists' warfare against Native Americans often was horrifyingly brutal. But one method they appear to have used-perhaps just once-shocks even more than all the bloody slaughter: The gifting of blankets and linens contaminated with smallpox. The virus causes a disease that can inflict disfiguring scars, blindness and death. The tactic constitutes a crude form of biological warfare-but accounts of the colonists using it are actually scant.

Colonial weaponizing of smallpox against Native Americans was first reported by 19th-century historian Francis Parkman. Parkman came across correspondence in which Sir Jeffery Amherst, commander in chief of the British forces in North America in the early 1760s, discussed its use with Col. Henry Bouquet, a subordinate on the western frontier during the French and Indian War.

For all the outrage the account has stirred over the years, there's only one clearly documented instance of a colonial attempt to spread smallpox during the war, and oddly, Amherst probably didn't have anything to do with it. There's also no clear historical verdict on whether the biological attack even worked.

Smallpox had spread at Fort Pitt.

Early American historian Elizabeth Fenn of the University of Colorado Boulder lays out her theory on what happened in her 2000 article in the Journal of American History. In the late spring of 1763, Delaware, Shawnee and Mingo warriors, inspired by Ottawa war leader Pontiac, laid siege to Fort Pitt, an outpost at the confluence of the Allegheny and Monongahela rivers in present-day downtown Pittsburgh.

The fort's commander, Capt. Simeon Ecuyer, reported in a June 16 message to his superior, Philadelphia-based Col. Henry Bouquet, that the situation was dire, with local traders and colonists taking refuge inside the fort's walls. Ecuyer wasn't just afraid of his Native American adversaries. The fort's hospital had patients with smallpox, and Ecuyer feared the disease might overwhelm the population inside the fort's cramped confines.

Bouquet, in turn, passed along the news about smallpox inside Fort Pitt to his own superior, Amherst, in a June 23 letter. In Amherst's July 7 response, he cold-bloodedly saw an opportunity in the disease outbreak. "Could it not be contrived to Send the Small Pox among those Disaffected Tribes of Indians? We must, on this occasion, Use Every Stratagem in our power to Reduce them."

"We must, on this occasion, Use Every Stratagem in our power to Reduce them."

On July 13, Bouquet, who at that point was traveling across Pennsylvania with British reinforcements for Fort Pitt, responded to Amherst, promising that he would try to spread the disease to the Native Americans via contaminated blankets, "taking care however not to get the disease myself." That tactic seemed to please Amherst, who wrote back in approval on July 16, urging him to spread smallpox "as well as try Every other method that can serve to Extirpate this Execreble [sic] Race."

What Amherst and Bouquet didn't know was that somebody at Fort Pitt had already thought of trying to infect the Native Americans with smallpox-and had attempted to do it.

William Trent, a trader, land speculator and militia captain, wrote in his diary that on June 23, two Delaware emissaries had visited the fort, and asked to hold talks the next day. At that meeting, after the Native American diplomats had tried unsuccessfully to persuade the British to abandon Fort Pitt, they asked for provisions and liquor for their return. The British complied and also gave them gifts-two blankets and a handkerchief which had come from the smallpox ward. "I hope it will have the desired effect," Trent wrote.

Though it's not completely clear who perpetrated the biological warfare attack, documentary evidence points to Trent as the probable culprit. As detailed in Fenn's 2000 article, the trader later submitted an invoice to the British military for purchasing two blankets and a silk handkerchief "to Replace in kind those which were taken from people in the Hospital to Convey the Smallpox to the Indians." Ecuyer certified that the items were used to spread smallpox, which indicates that he may have been in on the attempt as well. British Gen. Thomas Gage, who succeeded Amherst that year as colonial commander, eventually approved the payment.

"That's the one documented case that we have," says Paul Kelton, a historian at Stony Brook University, and author of two books on the role of epidemics in the European takeover of the Americas. It's not known whether Bouquet actually followed up on Amherst's letter and made additional attempts on his own to spread smallpox to the Native Americans, he says.

It's not clear that smallpox-infected blankets even worked.

It's also not clear whether or not the attempt at biological warfare had the intended effect. According to Fenn's article, the Native Americans around Fort Pitt were "struck hard" by smallpox in the spring and summer of 1763. "We can't be sure," Kelton says. Around that time, "we know that smallpox was circulating in the area, but they [Native Americans] could have come down with the disease by other means."

Historian Philip Ranlet of Hunter College and author of a 2000 article on the smallpox blanket incident in Pennsylvania History: A Journal of Mid-Atlantic Studies, also casts doubt. "There is no evidence that the scheme worked," Ranlet says. "The infection on the blankets was apparently old, so no one could catch smallpox from the blankets. Besides, the Indians just had smallpox-the smallpox that reached Fort Pitt had come from Indians-and anyone susceptible to smallpox had already had it."

The most important indication that the scheme was a bust, Ranlet says, "is that Trent would have bragged in his journal if the scheme had worked. He is silent as to what happened."

Even if it didn't work, British officers' willingness to contemplate using smallpox against the Indians was a sign of their callousness. "Even for that time period, it violated civilized notions of war," says Kelton, who notes that disease "kills indiscriminately-it would kill women and children, not just warriors."

But Kelton cautions against focusing too much on the smallpox blanket incident as a documented method of attack against Native Americans. He says the tactic, however callous and brutal, is only a small part of a larger story of brutality in the 1600s and 1700s. During this period British forces tried to drive out Native Americans by cutting down their corn and burning their homes, turning them into refugees. In Kelton's view, that rendered them far more vulnerable to the ravages of disease than a pile of infected blankets.

Fact Check

We strive for accuracy and fairness. But if you see something that doesn't look right, click here to contact us! HISTORY reviews and updates its content regularly to ensure it is complete and accurate.

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Did Colonists Give Infected Blankets to Native Americans as Biological Warfare? | HISTORY

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There's evidence that British colonists in 18th-century America gave Native Americans smallpox-infected blankets at least once-but did it work?

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18th Century: Vaccination versus Variolation (Korinna)

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18th Century: Vaccination versus Variolation (Korinna)

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Vaccination and variolation for smallpox both contain the virus. Vaccination is much safer, as the virus is derived from cows and a milder form of the virus. Variolation used the actual live virus from current smallpox patients (crushed up scabs) that were essentially snorted into the person getting inoculated.

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by Dr. Talya Housman, Threadable Books

In the winter of 1764, smallpox descended on Boston and John Adams went to get inoculated against it. You might have heard that Edward Jenner pioneered the smallpox vaccine in 1796 - so how did Adams get inoculated in 1764?

Adams used an earlier method of inoculation called "variolation," rather than Jenner's "vaccination." Inoculation is the process of introducing a small amount of viral matter into the body in order to teach the body's immune system to fight off the virus, thus making the patient immune to future infection. Variolation used viral matter from smallpox patients, usually pus from a light case of smallpox. Jenner's vaccination, meanwhile, used matter from the milder cowpox virus. As a milder disease carrying the same immunities, cowpox matter was much safer.

Zabdiel Boylston, the uncle of John Adams's mother, Susanna Boylston Adams, is often credited for introducing variolation to the Americas in 1721. In fact, Onesimus, one of Cotton Mather's slaves, told Mather of the practice and Mather convinced his friend Boylston to try inoculation.[1] Around the same time, Lady Mary Wortley Montagu had her daughter inoculated in England after learning about variolation during her husband's diplomatic posting at the Ottoman court in Istanbul. Variolation was used in not only Africa and the Ottoman Empire but also China and India long before the Western world ever discovered this secret.

The impetus for Boylston and Mather's efforts in 1721 was the arrival in Boston of the sixth large outbreak of smallpox.[2] Boylston began inoculating hundreds but controversy erupted over his efforts.[3] Many worried about the intentional spread of disease. Others felt that if anyone died from inoculation, Boylston was guilty of murder. Fierce debate raged in Boston between supporters and opponents of the practice of variolation. The debate did not remain on the page - Boylston was physically assaulted on the street. However, Boylston and Mather collected information on infections and were able to show that inoculation dropped the smallpox mortality rate to 1 or 2% from approximately 15%.[4] By 1749, William Douglass, the fiercest opponent of inoculation, published an essay admitting inoculation's benefits and encouraging society to inoculate.[5]

Though variolation was well accepted by the time of Adams's 1764 inoculation, there remained about "500 Persons, who continue to stand it out, in spight of Experience, [and] the Expostulations of the Clergy." These individuals caused Adams to wonder if man was truly "a rational creature" since he would have seen himself as "a deliberate self Murderer" if he had refused to inoculate himself.[6] In addition, inoculation in 1764 was not an entirely uniform process. Adams wrote that in his recovery from the inoculation, "Each [doctor] has a few Particulars in Point of Diet, in which he differs from the others, and Each has Pills and Powders, different from the others to administer."[7]

As we all wait for scientists to develop a vaccine for the coronavirus, it's important to remember the controversy that followed the 1721 Boston inoculations as well as the gradual normalization of the variolation process that preceded Jenner's discovery. The development, adoption, and improvement of infectious disease response are messy processes - not a single "eureka" event. It is common to have initial disagreements among experts on treatments and often the first workable treatment is later replaced with an improved option.

It's easy to see dates like 1796 as the shining beacons in the lines of smallpox history - but to John Adams and much of Boston in 1764, they were thankful to live after 1721. Adams celebrated "Inoculation for the Small Pox" as evidence of America's "Glory of the Invention."[8] He praised Boylston's 1721 "discovery" and "practice" of smallpox inoculation "which has since proved of such inestimable benefit to Mankind."[9]
Dr. Housman's first book project uses digital tools to explore sexual crime in seventeenth century England. She has written on numerous historical topics including slavery, suffrage, religious freedom, industrialization, charitable giving, and pandemics for various public history organizations.
[1] Stefan Riedel, "Edward Jenner and the History of Smallpox and Vaccination," Baylor University Medical Center Proceedings, 18:1, (2005), 22.

[2] Shawn Buhr, "To Inoculate or Not to Inoculate?: The Debate and the Smallpox Epidemic of Boston in 1721," Constructing the Past, 1:1, (2000), 63.

[3] For more on this controversy, see Christianna Elrene Thomas Hurford, " In His Arm the Scar": Medicine, Race, and the Social Implications of the 1721 Inoculation Controversy on Boston, unpublished doctoral dissertation, (Ohio State University, 2012); Amalie M. Kass, "Boston's Historic Smallpox Epidemic," Massachusetts Historical Review, 14 (2012), 1-51.

[4] Buhr, "To Inoculate or Not to Inoculate," 66.

[5] William Douglass, A Summary, Historical and Political, of the first Planting Progressive Improvements, and present State of the British Settlements in North America, (Boston: Rogers and Fowle, 1749).

[6] John Adams to Abigail Smith, 17 April 1764 in Adams Family Correspondence, Vol. 1. [ link]

[7] John Adams to Abigail Smith, 14 April 1764 in Adams Family Correspondence, Vol. 1. [ link]

[8] John Adams to the President of Congress No. 9, 25 February 1780 in Papers of John Adams, Vol. 8. [ link]

[9] Obituary of Susanna Boylston Adams Hall, 29 April 1797 in Adams Family Correspondence, Vol. 12. [ link]

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Variolation vs. Vaccination: 18th Century Developments in Smallpox Inoculation

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by Dr. Talya Housman, Threadable Books In the winter of 1764, smallpox descended on Boston and John Adams went to get inoculated against it. You might have heard that Edward Jenner pioneered the smallpox vaccine in 1796 - so how did Adams get inoculated in 1764?

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After seeing that milkmaids who had cowpox did not show symptoms of smallpox after variolation, the idea started one of the very first vaccines. Edward Jenner used scabs from milkmaids with cowpox, and inoculated an 8 year-old boy, resulting in the first vaccine recorded in history, which allowed cowpox exposure to prevent smallpox occurrences. Vaccines use a dead or weakened form of a pathogen to induce an immune response in patients.

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Origin of Smallpox

The origin of smallpox is unknown. The finding of smallpox-like rashes on Egyptian mummies suggests that smallpox has existed for at least 3,000 years. The earliest written description of a disease like smallpox appeared in China in the 4 th century CE (Common Era). Early written descriptions also appeared in India in the 7 th century and in Asia Minor in the 10 th century.

Spread of Smallpox

Historians trace the global spread of smallpox to the growth of civilizations and exploration. Expanding trade routes over the centuries also led to the spread of the disease.

Highlights from History:

6th Century-Increased trade with China and Korea brings smallpox to Japan.

7th Century-Arab expansion spreads smallpox into northern Africa, Spain, and Portugal.

11th Century-Crusades further spread smallpox in Europe.

15th Century-Portugal occupies part of western Africa, bringing smallpox.

16th Century-European settlers and the African slave trade import smallpox into:

The Caribbean

Central and South America

17th Century-European settlers bring smallpox to North America.

18th Century-Explorers from Great Britain bring smallpox to Australia.

Early Control Efforts

Smallpox was a terrible disease. On average, 3 out of every 10 people who got it died. People who survived usually had scars, which were sometimes severe.

One of the first methods for controlling smallpox was variolation, a process named after the virus that causes smallpox (variola virus). During variolation, people who had never had smallpox were exposed to material from smallpox sores (pustules) by scratching the material into their arm or inhaling it through the nose. After variolation, people usually developed the symptoms associated with smallpox, such as fever and a rash. However, fewer people died from variolation than if they had acquired smallpox naturally.

The basis for vaccination began in 1796 when the English doctor Edward Jenner noticed that milkmaids who had gotten cowpox were protected from smallpox. Jenner also knew about variolation and guessed that exposure to cowpox could be used to protect against smallpox. To test his theory, Dr. Jenner took material from a cowpox sore on milkmaid Sarah Nelmes' hand and inoculated it into the arm of James Phipps, the 9-year-old son of Jenner's gardener. Months later, Jenner exposed Phipps several times to variola virus, but Phipps never developed smallpox. More experiments followed, and, in 1801, Jenner published his treatise "On the Origin of the Vaccine Inoculation." In this work, he summarized his discoveries and expressed hope that "the annihilation of the smallpox, the most dreadful scourge of the human species, must be the final result of this practice."

Vaccination became widely accepted and gradually replaced the practice of variolation. At some point in the 1800s, the virus used to make the smallpox vaccine changed from cowpox to vaccinia virus.

Global Smallpox Eradication Program

In 1959, the World Health Organization (WHO) started a plan to rid the world of smallpox. Unfortunately, this global eradication campaign suffered from a lack of funds, personnel, and commitment from countries, and a shortage of vaccine donations. Despite their best efforts, smallpox was still widespread in 1966, causing regular outbreaks across South America, Africa, and Asia.

The Intensified Eradication Program began in 1967 with a promise of renewed efforts. Laboratories in many countries where smallpox occurred regularly were able to produce more, higher-quality freeze-dried vaccine. Other factors that played an important role in the success of the intensified efforts included the development of the bifurcated needle, the establishment of a case surveillance system, and mass vaccination campaigns.

By the time the Intensified Eradication Program began in 1967, smallpox was already eliminated in North America (1952) and Europe (1953). Cases were still occurring in South America, Asia, and Africa (smallpox was never widespread in Australia). The Program made steady progress toward ridding the world of this disease, and by 1971 smallpox was eradicated from South America, followed by Asia (1975), and finally Africa (1977).

Last Cases of Smallpox

In late 1975, three-year-old Rahima Banu from Bangladesh was the last person in the world to have naturally acquired variola major. She was also the last person in Asia to have active smallpox. She was isolated at home with house guards posted 24 hours a day until she was no longer infectious. A house-to-house vaccination campaign within a 1.5-mile radius of her home began immediately. A member of the Smallpox Eradication Program team visited every house, public meeting area, school, and healer within 5 miles to ensure the illness did not spread. They also offered a reward to anyone who reported a smallpox case.

Ali Maow Maalin was the last person to have naturally acquired smallpox caused by variola minor. Maalin was a hospital cook in Merca, Somalia. On October 12, 1977, he rode with two smallpox patients in a vehicle from the hospital to the local smallpox office. On October 22, he developed a fever. At first healthcare workers diagnosed him with malaria, and then chickenpox. The smallpox eradication staff then correctly diagnosed him with smallpox on October 30. Maalin was isolated and made a full recovery. Maalin died of malaria on July 22, 2013, while working in the polio eradication campaign.

Janet Parker was the last person to die of smallpox. In 1978, Parker was a medical photographer at England's Birmingham University Medical School. She worked one floor above the Medical Microbiology Department where staff and students conducted smallpox research. She became ill on August 11 and developed a rash on August 15 but was not diagnosed with smallpox until 9 days later. She died on September 11, 1978. Her mother, who was providing care for her, developed smallpox on September 7, despite having been vaccinated two weeks earlier. An investigation suggested that Janet Parker had been infected either via an airborne route through the medical school building's duct system or by direct contact while visiting the microbiology corridor.

World Free of Smallpox

Almost two centuries after Jenner hoped that vaccination could annihilate smallpox, the 33 rd World Health Assembly declared the world free of this disease on May 8, 1980. Many people consider smallpox eradication to be the biggest achievement in international public health.

Stocks of Variola Virus

Following the eradication of smallpox, scientists and public health officials determined there was still a need to perform research using the variola virus. They agreed to reduce the number of laboratories holding stocks of variola virus to only four locations. In 1981, the four countries that either served as a WHO collaborating center or were actively working with variola virus were the United States, England, Russia, and South Africa. By 1984, England and South Africa had either destroyed their stocks or transferred them to other approved labs. There are now only two locations that officially store and handle variola virus under WHO supervision: the Centers for Disease Control and Prevention in Atlanta, Georgia, and the State Research Center of Virology and Biotechnology (VECTOR Institute) in Koltsovo, Russia.

Page last reviewed:

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smallpox (variola major and variola minor)

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In 1799, after Jenner discovered an early version of the vaccine, the concept of protecting people against a virus (vaccination) spread widely and people began getting vaccinated. However, there were people who opposed the idea.

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1802: Massachusetts Becomes the First State to Push For Vaccinations for Smallpox (Kara) 

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1802: Massachusetts Becomes the First State to Push For Vaccinations for Smallpox (Kara) 

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Dr. Waterhouse was able to convince Boston's city board to support publicly using vaccines against smallpox. Waterhouse was a physician in Boston and recognized the importance of vaccinations.

# data[].attributes.attachment_link.readable_text
The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.

Evidence exists that the Chinese employed smallpox inoculation (or variolation, as such use of smallpox material was called) as early as 1000 CE. It was practiced in Africa and Turkey as well, before it spread to Europe and the Americas.

Edward Jenner's innovations, begun with his successful 1796 use of cowpox material to create immunity to smallpox, quickly made the practice widespread. His method underwent medical and technological changes over the next 200 years, and eventually resulted in the eradication of smallpox.

Louis Pasteur's 1885 rabies vaccine was the next to make an impact on human disease. And then, at the dawn of bacteriology, developments rapidly followed. Antitoxins and vaccines against diphtheria, tetanus, anthrax, cholera, plague, typhoid, tuberculosis, and more were developed through the 1930s.

The middle of the 20 th century was an active time for vaccine research and development. Methods for growing viruses in the laboratory led to rapid discoveries and innovations, including the creation of vaccines for polio. Researchers targeted other common childhood diseases such as measles, mumps, and rubella, and vaccines for these diseases reduced the disease burden greatly.

Innovative techniques now drive vaccine research, with recombinant DNA technology and new delivery techniques leading scientists in new directions. Disease targets have expanded, and some vaccine research is beginning to focus on non-infectious conditions such as addiction and allergies.

More than the science behind vaccines, these timelines cover cultural aspects of vaccination as well, from the early harassment of smallpox variolators (see the intimidation of a prominent minister described in the 1721 Boston Smallpox Epidemic entry) to the establishment of vaccination mandates, to the effect of war and social unrest on vaccine-preventable diseases. Edward Jenner, Louis Pasteur, and Maurice Hilleman, pioneers in vaccine development receive particular attention as well.

This timeline category holds nearly all of the entries for the subject-specific timelines. A few of the entries have been left out in order to provide a broad overview.

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The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.

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1813: Establishment of National Vaccine Agency in the United States (Kara)

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1813: Establishment of National Vaccine Agency in the United States (Kara)

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The United States government signed "An Act to Encourage Vaccination," and there were rules set to encourage vaccinations. For instance, the U.S Post Office had to send mail for free if it contained vaccination material (up to a specific weight).

# data[].attributes.attachment_link.readable_text
The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.

Evidence exists that the Chinese employed smallpox inoculation (or variolation, as such use of smallpox material was called) as early as 1000 CE. It was practiced in Africa and Turkey as well, before it spread to Europe and the Americas.

Edward Jenner's innovations, begun with his successful 1796 use of cowpox material to create immunity to smallpox, quickly made the practice widespread. His method underwent medical and technological changes over the next 200 years, and eventually resulted in the eradication of smallpox.

Louis Pasteur's 1885 rabies vaccine was the next to make an impact on human disease. And then, at the dawn of bacteriology, developments rapidly followed. Antitoxins and vaccines against diphtheria, tetanus, anthrax, cholera, plague, typhoid, tuberculosis, and more were developed through the 1930s.

The middle of the 20 th century was an active time for vaccine research and development. Methods for growing viruses in the laboratory led to rapid discoveries and innovations, including the creation of vaccines for polio. Researchers targeted other common childhood diseases such as measles, mumps, and rubella, and vaccines for these diseases reduced the disease burden greatly.

Innovative techniques now drive vaccine research, with recombinant DNA technology and new delivery techniques leading scientists in new directions. Disease targets have expanded, and some vaccine research is beginning to focus on non-infectious conditions such as addiction and allergies.

More than the science behind vaccines, these timelines cover cultural aspects of vaccination as well, from the early harassment of smallpox variolators (see the intimidation of a prominent minister described in the 1721 Boston Smallpox Epidemic entry) to the establishment of vaccination mandates, to the effect of war and social unrest on vaccine-preventable diseases. Edward Jenner, Louis Pasteur, and Maurice Hilleman, pioneers in vaccine development receive particular attention as well.

This timeline category holds nearly all of the entries for the subject-specific timelines. A few of the entries have been left out in order to provide a broad overview.

# data[].attributes.attachment_link.description
The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.

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19th Century: Spread of Vaccination 2 (Korinna)

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19th Century: Spread of Vaccination 2 (Korinna)

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People opposed vaccination because they believed the intentions of the inoculators could have been malicious. People also believed that vaccines could transmit other diseases (which could be true) from person to person.

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1949: Last Outbreak in the U.S (Korinna/Kara)

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1949: Last Outbreak in the U.S (Korinna/Kara)

# data[].attributes.body
According to the CDC, the last naturally occurring outbreak of smallpox in the US happened in 1949. This outbreak occurred in Texas, and it was the last to occur in the U.S, aside from cases that came from outside the country.

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1965: Use of the Bifurcated Needle (Kara)

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1965: Use of the Bifurcated Needle (Kara)

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The bifurcated needle began being used in the United States to replace other forms of the smallpox vaccine, such as the jet injector. This needle had two prongs, and held the vaccine just between the prongs, requiring less vaccine material and being more effective. This saved the country money and was more efficient overall.

# data[].attributes.attachment_link.readable_text
The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.

Evidence exists that the Chinese employed smallpox inoculation (or variolation, as such use of smallpox material was called) as early as 1000 CE. It was practiced in Africa and Turkey as well, before it spread to Europe and the Americas.

Edward Jenner's innovations, begun with his successful 1796 use of cowpox material to create immunity to smallpox, quickly made the practice widespread. His method underwent medical and technological changes over the next 200 years, and eventually resulted in the eradication of smallpox.

Louis Pasteur's 1885 rabies vaccine was the next to make an impact on human disease. And then, at the dawn of bacteriology, developments rapidly followed. Antitoxins and vaccines against diphtheria, tetanus, anthrax, cholera, plague, typhoid, tuberculosis, and more were developed through the 1930s.

The middle of the 20 th century was an active time for vaccine research and development. Methods for growing viruses in the laboratory led to rapid discoveries and innovations, including the creation of vaccines for polio. Researchers targeted other common childhood diseases such as measles, mumps, and rubella, and vaccines for these diseases reduced the disease burden greatly.

Innovative techniques now drive vaccine research, with recombinant DNA technology and new delivery techniques leading scientists in new directions. Disease targets have expanded, and some vaccine research is beginning to focus on non-infectious conditions such as addiction and allergies.

More than the science behind vaccines, these timelines cover cultural aspects of vaccination as well, from the early harassment of smallpox variolators (see the intimidation of a prominent minister described in the 1721 Boston Smallpox Epidemic entry) to the establishment of vaccination mandates, to the effect of war and social unrest on vaccine-preventable diseases. Edward Jenner, Louis Pasteur, and Maurice Hilleman, pioneers in vaccine development receive particular attention as well.

This timeline category holds nearly all of the entries for the subject-specific timelines. A few of the entries have been left out in order to provide a broad overview.

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The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.

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In India, a study was done on unvaccinated people who had contracted smallpox. It was found that there are multiple types of smallpox (Ordinary, modified, malignant, hemorrhagic, and variola sine eruptione (no rash)).

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Johns Hopkins Center for Health Security

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Unless otherwise noted, all information presented in this article is derived from the following 2 sources:

Henderson DA, Borio L, Grabenstein J. Smallpox and monkeypox. In Plotkin S and Orenstein W (eds), Vaccines. Philadelphia: W.B. Saunders Company; 2007.

Henderson DA, Inglesby TV, Bartlett JG, et al., for the Working Group on Civilian Biodefense. Smallpox as a biological weapon: medical and public health management. JAMA. 1999;281(22):2127-2137.

Background

Smallpox is a highly contagious and deadly disease caused by the variola virus. It was estimated to have infected 300 million people in the 20th Century before it became the only human infectious disease ever to be completely eradicated. Following a global vaccination campaign led by the World Health Organization (WHO) (the Intensified Global Eradication Program), the last naturally occurring case of smallpox was in Ethiopia in 1977. The World Health Assembly declared smallpox eradicated in 1980 and recommended that all countries cease routine smallpox vaccination.

After the eradication of smallpox, the WHO recommended that all remaining specimens of variola be destroyed or sent to 1 of 2 designated high containment reference laboratories located in the U.S. and Russia. Today, the only potential source of smallpox infection is an unintentional laboratory release or a biological attack.

Smallpox as a Biological Weapon

Smallpox is considered one of the most serious bioterrorist threats. It was used as a biological weapon during the French and Indian Wars, (1754 to 1767) when British soldiers distributed smallpox-infected blankets to American Indians. In the 1980s, the Soviet Union developed variola as an aerosol biological weapon and produced tons of virus-laden material annually intended for intercontinental ballistic missiles.

Several factors contribute to the concern about the use of smallpox as a biological weapon:

Variola can spread from person to person.

There is no widely available or licensed treatment for the disease.

It has a high fatality rate.

Since routine smallpox immunization ceased in the United States in 1972 and in all other countries by 1983, the global population is extremely vulnerable to the disease. Most of the world's population has never been vaccinated or was vaccinated so long ago that immunity to smallpox has waned.

Variola is relatively stable as an aerosol.

The infectious dose is small.

Because there are no symptoms at the time of exposure, a covert release of variola may not be detected until sick people begin showing up at doctor's offices and hospitals. (See " The History of Bioterrorism: Smallpox," a short video from the CDC.)

Transmission

Smallpox spreads from person to person by respiratory droplets or direct contact with body fluids. Contaminated clothing or bedding may also transmit the virus. Animals and insects are not known to carry or spread the virus to humans. The incubation period for smallpox is 7 to 17 days.

Infection Control Measures

Individuals diagnosed with or suspected of having smallpox should be isolated to prevent the spread of disease. Household and other face-to-face contacts of patients who have, or are suspected of having, smallpox should be vaccinated and placed under surveillance.

For smallpox patients in the hospital, airborne precautions (see CDC Isolation Precautions Guidelines) should be followed, and all hospital personnel should be vaccinated.

Illness

Diagnosis of smallpox is based on clinical presentation of symptoms in the patient and is confirmed by laboratory testing. Symptoms most often begin 12 to 14 days after infection, and include high fever, severe malaise, and exhaustion with headache and backache.

Source: WHO Smallpox slide set as a PDF

A rash of small, pink bumps appears in the mouth, on the face and forearms, and then spreads to the trunk of the body and legs, including the palms and soles. Within 1 to 2 days, the rash becomes first fluid-filled and then pus-filled. Lesions are round, hard and deep; they begin to crust over on day 8 or 9. A person infected with smallpox is thought to be contagious from the time the rash appears to the time it heals (~2 weeks). Survivors are often left disfigured, with permanent scars on the face.

Source: CDC

Complications of smallpox include bacterial superinfections of the skin and organs, pneumonia, sepsis, arthritis, keratitis, and encephalitis. In contrast to smallpox, chickenpox (the disease with which it is most likely to be confused) is associated with a milder prodromal illness and a rash that is more superficial, usually starts on the trunk and spreads centripetally, has lesions in different stages of evolution, and rarely appears on the palms or soles.

Smallpox is caused by 1 of 2 closely related strains: variola major and variola minor. The 2 viruses are indistinguishable except by polymerase chain reaction (PCR) testing. Variola minor infection (known as Alastrim) causes fewer systemic symptoms, a less extensive rash, less scarring, and fewer fatalities.

During the era of naturally occurring smallpox, several variations of variola major disease were recognized. See Table 1.

Table I: WHO classification of smallpox types,
based on a study of 3,544 patients in India, 1972*

Modified
Milder form

Produces fewer, smaller, and more superficial lesions

2% of cases in unvaccinated; 25% of cases in vaccinated persons

Cases of modified smallpox were rarely fatal.

Malignant or flat
Lesions were flatter, evolved more slowly and coalesced

7% of cases in unvaccinated persons

Hemorrhagic
Difficult to diagnose; rash accompanied by bleeding into mucous membranes and skin

Less than 3% of cases

Variola sine eruptione (without rash)
Occurred in previously vaccinated contacts or in infants with maternal antibodies Affected persons were asymptomatic or had a short-lived fever, headache, and influenza-like symptoms

Transmission of clinical smallpox had not been documented for variola sine eruptione

Not available; however, in cases of variola minor, death occurred in <1% of persons.

Derived from Fenner F, Henderson DA, Arita I, Ježek Z, and Ladnyi ID. Smallpox and Its Eradication . Geneva: World Health Organization; 1988. Page 4.

Treatment and Prophylaxis

Post-exposure vaccination within 1 to 3 days after exposure to variola can prevent the clinical manifestations of smallpox. Vaccination within 4 to 7 days post-exposure can reduce the severity of disease.

There is no currently licensed antiviral treatment for smallpox. The protease inhibitor SIGA-246 (SIGA Technologies, Inc.) was awarded orphan drug status by the FDA in December 2006 and is currently undergoing clinical trials.

Antibiotics may help treat secondary bacterial infections, and supportive therapy might also benefit patients.

ACAM2000 (Sanofi) is the licensed vaccine for smallpox, currently in the U.S. Strategic National Stockpile (SNS). This vaccine contains live vaccinia virus, a relative of variola. On rare occasions, immunization with vaccinia vaccines can cause serious and potentially life-threatening reactions. Because of the potential for these reactions, newer vaccines are being pursued.

The SNS contains enough smallpox vaccine to immunize every person in the U.S.

The U.S. government does not currently recommend smallpox vaccination for the general public. In December 2002 the president announced the Smallpox Vaccine Program, to vaccinate voluntarily those persons deemed to be at highest risk should a smallpox outbreak occur, including first responders and healthcare workers serving on "smallpox response teams." In all, some 40,000 civilian employees were immunized in the first few months after the program was announced, but further vaccinations are not currently being promoted. Deployed military personnel continue to be vaccinated as well as laboratory staff engaged in work with vaccinia and related viruses.

Since smallpox no longer occurs naturally, a single confirmed case is considered an emergency and will prompt implementation of federal and state smallpox response plans for surveillance and containment.

See Also

Smallpox web page. Centers for Disease Control and Prevention, Emergency Preparedness and Response. https://www.cdc.gov/smallpox/index.html. Accessed February 26, 2014.

Department of Defense Smallpox Vaccination Program website. https://health.mil/smallpox?type=Policies. Accessed February 26, 2014.

Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007 web page. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html. Accessed February 26, 2014.

Henderson DA, Borio L, Grabenstein J. Smallpox and monkeypox. In Plotkin S and Orenstein W (eds), Vaccines. Philadelphia: W.B. Saunders Company; 2007.

Henderson DA, Inglesby TV, Bartlett JG, et al., for the Working Group on Civilian Biodefense. Smallpox as a biological weapon: medical and public health management. JAMA. 1999;281(22):2127-2137. http://jama.ama-assn.org/cgi/content/full/281/22/2127. Accessed February 26, 2014.

Smallpox fact sheet. National Institute of Allergy and Infectious Disease, National Institutes of Health. https://www.niaid.nih.gov/diseases-conditions/smallpox. Accessed February 26, 2014.

Visual Dx: Smallpox. http://www.logicalimages.com/resourcesBTAgentsSmallpox.htm. Accessed February 26, 2014.

Smallpox web page. World Health Organization. http://www.who.int/topics/smallpox/en. Accessed February 26, 2014.

Last reviewed February 26, 2014

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johns hopkins center for health security

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Unless otherwise noted, all information presented in this article is derived from the following 2 sources: Henderson DA, Borio L, Grabenstein J. Smallpox and monkeypox. In Plotkin S and Orenstein W (eds), Vaccines. Philadelphia: W.B. Saunders Company; 2007. Henderson DA, Inglesby TV, Bartlett JG, et al., for the Working Group on Civilian Biodefense.

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1972: United States Vaccinations For Smallpox Ceases (Kara)

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1972: United States Vaccinations For Smallpox Ceases (Kara)

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Because of the small numbers of cases of smallpox in the United States (there had not been a natural case since 1949), the was decided to stop making smallpox vaccines routine, for the herd immunity was preventing cases from occurring.

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The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.

Evidence exists that the Chinese employed smallpox inoculation (or variolation, as such use of smallpox material was called) as early as 1000 CE. It was practiced in Africa and Turkey as well, before it spread to Europe and the Americas.

Edward Jenner's innovations, begun with his successful 1796 use of cowpox material to create immunity to smallpox, quickly made the practice widespread. His method underwent medical and technological changes over the next 200 years, and eventually resulted in the eradication of smallpox.

Louis Pasteur's 1885 rabies vaccine was the next to make an impact on human disease. And then, at the dawn of bacteriology, developments rapidly followed. Antitoxins and vaccines against diphtheria, tetanus, anthrax, cholera, plague, typhoid, tuberculosis, and more were developed through the 1930s.

The middle of the 20 th century was an active time for vaccine research and development. Methods for growing viruses in the laboratory led to rapid discoveries and innovations, including the creation of vaccines for polio. Researchers targeted other common childhood diseases such as measles, mumps, and rubella, and vaccines for these diseases reduced the disease burden greatly.

Innovative techniques now drive vaccine research, with recombinant DNA technology and new delivery techniques leading scientists in new directions. Disease targets have expanded, and some vaccine research is beginning to focus on non-infectious conditions such as addiction and allergies.

More than the science behind vaccines, these timelines cover cultural aspects of vaccination as well, from the early harassment of smallpox variolators (see the intimidation of a prominent minister described in the 1721 Boston Smallpox Epidemic entry) to the establishment of vaccination mandates, to the effect of war and social unrest on vaccine-preventable diseases. Edward Jenner, Louis Pasteur, and Maurice Hilleman, pioneers in vaccine development receive particular attention as well.

This timeline category holds nearly all of the entries for the subject-specific timelines. A few of the entries have been left out in order to provide a broad overview.

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The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.

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In 1980, the World Health Organization (WHO) officially declared the world free of smallpox after a worldwide vaccination campaign. This campaign lasted over 20 years.

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Smallpox is an acute contagious disease caused by Variola virus, a member of the orthopoxvirus family. It was one of the world's most feared diseases until it was eradicated by a collaborative global vaccination programme led by WHO.

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After the events of 9/11, there was fear that the smallpox disease could be used as a bioweapon. Thus, from 2002-2009, over 1.8 million people in the U.S service were vaccinated for smallpox.

# data[].attributes.attachment_link.readable_text
The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.

Evidence exists that the Chinese employed smallpox inoculation (or variolation, as such use of smallpox material was called) as early as 1000 CE. It was practiced in Africa and Turkey as well, before it spread to Europe and the Americas.

Edward Jenner's innovations, begun with his successful 1796 use of cowpox material to create immunity to smallpox, quickly made the practice widespread. His method underwent medical and technological changes over the next 200 years, and eventually resulted in the eradication of smallpox.

Louis Pasteur's 1885 rabies vaccine was the next to make an impact on human disease. And then, at the dawn of bacteriology, developments rapidly followed. Antitoxins and vaccines against diphtheria, tetanus, anthrax, cholera, plague, typhoid, tuberculosis, and more were developed through the 1930s.

The middle of the 20 th century was an active time for vaccine research and development. Methods for growing viruses in the laboratory led to rapid discoveries and innovations, including the creation of vaccines for polio. Researchers targeted other common childhood diseases such as measles, mumps, and rubella, and vaccines for these diseases reduced the disease burden greatly.

Innovative techniques now drive vaccine research, with recombinant DNA technology and new delivery techniques leading scientists in new directions. Disease targets have expanded, and some vaccine research is beginning to focus on non-infectious conditions such as addiction and allergies.

More than the science behind vaccines, these timelines cover cultural aspects of vaccination as well, from the early harassment of smallpox variolators (see the intimidation of a prominent minister described in the 1721 Boston Smallpox Epidemic entry) to the establishment of vaccination mandates, to the effect of war and social unrest on vaccine-preventable diseases. Edward Jenner, Louis Pasteur, and Maurice Hilleman, pioneers in vaccine development receive particular attention as well.

This timeline category holds nearly all of the entries for the subject-specific timelines. A few of the entries have been left out in order to provide a broad overview.

# data[].attributes.attachment_link.description
The story of vaccines did not begin with the first vaccine-Edward Jenner's use of material from cowpox pustules to provide protection against smallpox. Rather, it begins with the long history of infectious disease in humans, and in particular, with early uses of smallpox material to provide immunity to that disease.