Rejected by the New England Journal of Medicine in 2003.

To the Editor:

Mack (1) describes “average” smallpox characteristics in naturally occurring outbreaks. This represents a best-case scenario. The next outbreak will not be natural, and it may not be average.

The Soviets, for example, weaponized a highly virulent variola strain (2) and treated their variola “with plastics and resins to increase its potency and longevity in the air” (3). Responsible policy cannot, therefore, assume that attacks will use an average strain and natural delivery of variola.

Mack’s suggestion that “the media should provide more information about the dangers of vaccination” is exactly opposite the true need. In the same issue, Blendon et al (4) report that 25% of Americans believe death is a “likely” outcome of smallpox vaccination. The Journal should have caught the contradiction, and should have used its bully pulpit with lay readers and journalists to provide reminders of the safety of vaccination in appropriate populations.

(1) Mack T. A different view of smallpox and vaccination. N Engl J Med 2003;348:460-3.

(2) Alibek K. Biohazard. New York: Dell Publishing, 1999. Page 112

(3) Statement for the Record by Richard Preston Before The Senate Judiciary Subcommittee on Technology, Terrorism & Government Information and the Senate Select Committee on Intelligence. Chemical and Biological Weapons Threats to America: Are We Prepared? April 22, 1998. Available at: [Link is dead in 2014]

(4) Blendon RJ, DesRoches CM, Benson JM, Herrmann MJ, Taylor-Clark K, Weldon KJ. The public and the smallpox threat. N Engl J Med 2003;348:426-32.

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Published on January 29, 2018