Can a State/Nonstate Actor Become a Suicide Vector and Infect Him or Herself and then Infect Others?

One of the favorite storyline in several books and movies has been the use of terrorists who infect themselves with a contagious BW and then proceeds to visit populated areas to infect others. They usually pick smallpox since it is contagious (F/X network's movie Smallpox and the May 2002 ER finale). To create a gripping and interesting storyline requires the producers hurry the pace of an outbreak and to increase the possible causalities. The following is a list of misconceptions a viewer of these sorts of shows might be left with after viewing such a program (58, The following contains six misconceptions come from the CDC website (58) are commonly given to viewers of these outbreak storylines.

Misconception 1: The incubation period of Smallpox virus infection is usually shortened significantly. Shortly following exposure (1-2 days) to the suicide terrorist people begin showing symptoms of smallpox.

Reality: The incubation period for smallpox is usually about 12-14 days. During that time people do not feel ill and will go about their normal daily task and they are NOT infectious.

Misconception 2: The suicide terrorist is highly contagious infecting many people following brief interactions. Those infected by the terrorist then infect others before they become ill. Within a very short period of time almost everyone is infected.

Reality: Smallpox is a contagious disease, but it is not highly contagious like the measles or influenza. Usually the only one infected following exposure to someone with smallpox is a susceptible (unvaccinated) person with close, intimate or household contact. Many experts estimate that each infectious person could infect 5-6 others and that if, 1 person infected approximately 5 others, and so on, by the fifth generation, 3,125 people would be infected. This relatively slow infection rate many believe would give public health officials time to institute measures to slow the spread of the infection. The long incubation period in this case is also helpful. After the first case is identified as having smallpox there is a lot of time to identify close contacts, vaccinate them if possible and monitor them for any signs of infection.

Using ring vaccination would also limit the number of those that become ill. This method was used worldwide in 1967 to help eradicate smallpox disease. Ring vaccination involves finding people who were exposed to a person with smallpox. The smallpox vaccine is then given to those people who had been, or could have been, exposed to an infected person. This approach creates a "ring" of vaccinated people around the smallpox victims and stops the spread of smallpox.

 Misconception 3: The ability of the smallpox virus to spread from person-to-person is exaggerated.
Some fictional accounts depict people getting smallpox after walking into a room that a contagious person occupied 2-3 hours earlier. Smallpox victims are shown infecting other people by bumping into them or touching them briefly.

Reality: To be infected with the smallpox virus usually requires direct (within 6-7 feet) and prolonged (about 3 hours) face-to-face contact. Only close, intimate, or household contacts of symptomatic (with rash) smallpox patients are likely to become infected. 

Misconception 4: The timing of smallpox vaccination following exposure is not always clear. How long a person can wait to get the vaccine following exposure is sometimes abbreviated and uncertain.

Reality: Vaccination within 3 days postexposure will completely prevent or significantly modify smallpox disease in most people. Vaccination 4 to 7 days postexposure is likely to afford some protection from disease or may lower the severity of disease. 

Misconception 5: An apparently healthy person is walking around infecting people with smallpox.
The terrorist can infect him or herself and before the rash occurs give the virus to others following chance and brief encounters.

Reality: People with smallpox are most contagious after the rash appears. When the rash appears they are very ill, their face and hands will have many unsightly lesions on them and they are usually unable to walk around appearing normal to passersby. Some virus can be found in saliva after the onset of fever and before the rash onset, so it is possible that a person with smallpox could be contagious before a rash appears, but the person would be then be very ill. They would have a high fever (104-105o F) and would feel like they had a severe case of the flu. Even before the onset of rash, most people, once they start developing symptoms, are too sick to walk, or even stand. It would be highly unlikely that a terrorist or other contagious person would be able to move around let alone appear normal enough that people would not avoid contact with them. 

Misconception 6: There is never enough vaccine and panic over shortage of the vaccine causes riots and disarray.

Facts about Vaccine Supply: By 2004 the U.S. government (2005) had stockpiled enough smallpox vaccine to vaccinate every person in the U.S. in the case of a smallpox outbreak. The Centers for Disease Control (CDC) has a detailed plan to keep the smallpox vaccine stockpile current and to protect people against the use of smallpox as a BW. 

The following is the plan CDC anticipates using in the event of a smallpox epidemic. They will use:  “special teams of health care and public health workers. If a smallpox case is found, these teams will take steps immediately to control the spread of the disease. Smallpox was wiped out through specific public health actions, including vaccination, and these actions will be used again.

•  If a smallpox outbreak occurs, public health officials will use television, radio, newspapers, the Internet and other channels to inform members of the public about what to do to protect themselves and their families.

•  Officials will tell people where to go for care if they think they have smallpox.

•  Smallpox patients will be isolated and will receive the best medical care possible. Isolation prevents the virus from spreading to others.

•  Anyone who has had contact with a smallpox patient will be offered smallpox vaccination as soon as possible. Then, the people who have had contact with those individuals will also be vaccinated. Following vaccination, these people will need to watch for any signs of smallpox. People who have been exposed to smallpox may be asked to take their temperatures regularly and report the results to their health department.

•  The smallpox vaccine may also be offered to those who have not been exposed, but would like to be vaccinated. At local clinics, the risks and benefits of the vaccine will be explained and professionals will be available to answer questions.

•  No one will be forced to be vaccinated, even if they have been exposed to smallpox.

•  To prevent smallpox from spreading, anyone who has been in contact with a person with smallpox but who decides not to get the vaccine may need to be isolated for at least 18 days. During this time, they will be checked for symptoms of smallpox.

•  People placed in isolation will not be able to go to work. Steps will be taken to care for their everyday needs (e.g., food and other needs)” (


© 2005 Neal Chamberlain. All rights reserved. 
Site Last Revised 5/13/05
Neal Chamberlain, Ph.D. A. T. Still University of Health Sciences/Kirksville College of Osteopathic Medicine.

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