Russia and the United States: The Pandemic on Ice
"In the past, smallpox was relatively easy to recognize. Today, health care professionals have to be educated about the characteristics of smallpox, which can easily be confused clinically with monkeypox, or even chickenpox" (Meyer, Ehmann & Smith, 2020)
Birmingham Medical School
Photo taken in 2008 by Dr. Graham Beards of Birmingham Medical School, location of the world's last smallpox outbreak
When scientists say smallpox has been "eradicated", they do not mean that the virus has gone extinct, expunged from the world forevermore. While widespread vaccination programs led to the global eradication of smallpox in 1980, the variable variola virus (VARV), the causative agent of smallpox, was kept in several maximum-security laboratories for continued research. In fact, the last fatal case of smallpox was a result of an outbreak at a laboratory. In 1978, just before smallpox was officially declared eradicated, a British medical photographer working at the University of Birmingham Medical School named Janet Parker was infected with the disease. How exactly Parker became infected remains undetermined, but it is believed she had some contact with contaminated material, likely from the lab of Prof. Henry Bedson, who was left so distraught by his possible role in the outbreak that he committed suicide five days before Parker succumbed to the virus. For fear of another smallpox outbreak, laboratory stocks of the virus were either destroyed or transferred until by 1984 only two laboratories had possession of VARV: the State Research Center of Virology and Biotechnology VECTOR in Koltsovo, Russia and the Centers for Disease Control and Prevention in Atlanta, United States.
According to Ken Alibek, a former deputy director of the former Soviet Union's bioweapons program, the former Soviet Union expanded its bioweapons research program during the 1980s. This eventually led to the development of a weaponized version of smallpox. However, very little information is available about the extent and outcome of the project. This brings forth concern that somewhere, somehow, VARV might be kept illegitimately in clandestine stocks. Biosecurity experts also fret about the potential for an accident to unintentionally release smallpox from one of its two containment facilities. In 2019, an explosion at VECTOR in Russia caused a brief panic, but it was revealed that the fire at the facility did not compromise any biohazardous materials.
The impact of an accidental or intentional release of VARV would result in a public health emergency of global concern for many reasons. Largest among them, smallpox vaccination programs were stopped decades ago, and due to this, an increasing proportion of the world's population has no immunity because they have never been exposed to smallpox or other orthopoxviruses (e.g., monkeypox) in any capacity. Other concerns include the fact that the percentage of immunocompromised individuals has increased, and intercontinental air travel allows for rapid viral spread around the world. With smallpox, shedding the virus from rashes in the mouth, throat, and on the skin, before a diagnosis is made is a real concern, even in countries with highly developed healthcare systems.
Despite these fears, it is extremely unlikely that widespread vaccination programs will be re-introduced. Ultimately, success in controlling any future outbreak of smallpox will depend on supplies of medical countermeasures as well as on the classical methods used in the past: early detection, isolation of smallpox patients, quarantine of contacts, and ring vaccination (i.e., vaccination of close contacts, and contacts of close contacts, to a confirmed smallpox patient) ("Ring Vaccination", CDC).