Instruct: Given a question, retrieve relevant documents that answer the question.
Query: When was the last case of smallpox in the US?
Smallpox was an infectious disease caused by one of two virus variants, variola major and variola minor.[7] The last naturally occurring case was diagnosed in October 1977 and the World Health Organization (WHO) certified the global eradication of the disease in 1980.[10] The risk of death following contracting the disease was about 30%, with higher rates among babies.[6][11] Often those who survived had extensive scarring of their skin and some were left blind.[6]
There are no credible descriptions of smallpox-like disease in the Americas before the westward exploration by Europeans in the 15th century CE.[30] Smallpox was introduced into the Caribbean island of Hispaniola in 1509, and into the mainland in 1520, when Spanish settlers from Hispaniola arrived in Mexico bringing smallpox with them. Smallpox devastated the native Amerindian population and was an important factor in the conquest of the Aztecs and the Incas by the Spaniards.[27] Settlement of the east coast of North America in 1633 in Plymouth, Massachusetts was also accompanied by devastating outbreaks of smallpox among Native American populations,[66] and subsequently among the native-born colonists.[67] Case fatality rates during outbreaks in Native American populations were as high as 80–90%.[68] Smallpox was introduced into Australia in 1789 and again in 1829.[27] Although the disease was never endemic on the continent,[27] it was the principal cause of death in Aboriginal populations between 1780 and 1870.[69]
The USAID initiative provided an important impetus to a World Health Organization (WHO) program to eradicate smallpox throughout the world within a 10-year period. In 1966, Henderson moved to Geneva to become director of the campaign. At that time, smallpox was occurring widely throughout Brazil and in 30 countries in Africa and South Asia. More than 10 million cases and 2 million deaths were occurring annually. Vaccination brought some control, but the key strategy was "surveillance-containment". This technique entailed rapid reporting of cases from all health units and prompt vaccination of household members and close contacts of confirmed cases. WHO staff and advisors from some 73 countries worked closely with national staff. The last case occurred in Somalia on October 26, 1977, only 10 years after the program began. Three years later, the World Health Assembly recommended that smallpox vaccination could cease. Smallpox is the first human disease ever to be eradicated. This success gave impetus to WHO’s global Expanded Program on Immunization, which targeted other vaccine-preventable diseases, including poliomyelitis, measles, tetanus, diphtheria, and whooping cough. Now targeted for eradication are poliomyelitis and Guinea Worm disease; after 25 years, this objective is close to being achieved.
The practice of variolation (also known as inoculation) first came out of East Asia. First writings documenting variolation in China appear around 1500. Scabs from smallpox victims who had the disease in its mild form would be selected, and the powder was kept close to body temperature by means of keeping it close to the chest, killing the majority of the virus and resulting in a more mild case of smallpox. Scabs were generally used when a month old, but could be used more quickly in hot weather (15–20 days), and slower in winter (50 days). The process was carried out by taking eight smallpox scabs and crushing them in a mortar with two grains of "Uvularia grandiflora" in a mortar. The powder was administered nasally through a silver tube that was curved at its point, through the right nostril for boys and the left nostril for girls. A week after the procedure, those variolated would start to produce symptoms of smallpox, and recovery was guaranteed. In India, where the European colonizers came across variolation in the 17th century, a large, sharp needle was dipped into the pus collected from mature smallpox sores. Several punctures with this needle were made either below the deltoid muscle or in the forehead, and then were covered with a paste made from boiled rice. Variolation spread farther from India to other countries in south west Asia, and then to the Balkans.
From the earliest years of colonialism, conquistadores like Vasco Núñez de Balboa would brazenly advocate genocide against the native population. In the 1700s, British militia like William Trent and Simeon Ecuyer gave smallpox-exposed blankets to Native American emissaries as gifts at Fort Pitt, "to Convey the Smallpox to the Indians", in one of the most famously documented cases of germ warfare. While it is uncertain how successful such attempts were against the target population, historians have noted that, "history records numerous instances of the French, the Spanish, the British, and later on the American, using smallpox as an ignoble means to an end. For smallpox was more feared by the Indian than the bullet: he could be exterminated and subjugated more easily and quickly by the death-bringing virus than by the weapons of the white man." The British High Commander Jeffery Amherst authorized the intentional use of disease as a biological weapon against indigenous populations during the Pontiac's Rebellion, saying, "You will Do well to try to Innoculate the Indians by means of Blanketts, as well as to try Every other method that can serve to Extirpate this Execrable Race", and instructing his subordinates, "I need only Add, I Wish to Hear of no prisoners should any of the villains be met with arms." When smallpox swept the northern plains of the US in 1837, Secretary of War Lewis Cass ordered that the Mandan (along with the Arikara, the Cree, and the Blackfeet) not be given smallpox vaccinations, which had been provided to other tribes in other areas.
Monkeypox was first reported by Preben von Magnus in 1958 in laboratory Cynomolgus monkeys, when two outbreaks of a smallpox-like disease occurred in colonies of monkeys kept for research. The first report of Monkeypox in humans was discovered more than a decade later, in a person with a suspected smallpox infection in the Democratic Republic of Congo during efforts to eradicate smallpox. It was subsequently reported in humans in other central and western African countries. Almost 50 cases were reported between 1970 and 1979, with more than two thirds of these being from Zaire. The other cases originated from Liberia, Nigeria, Ivory Coast and Sierra Leone.
Todd was elected to the Los Angeles City Council in 1898, representing the 8th Ward; he served until 1904. On the council, he sponsored a measure that would have established a hospital in the city to treat smallpox cases. "It is an injustice to quarantine a whole boarding or lodging house because a case of smallpox has been discovered.. . . . The city has spent enough money in guard hire in the last year to more than pay for the erection of a detention hospital."
The last major smallpox epidemic in the United States occurred in Boston, Massachusetts throughout a three-year period, between 1901-1903. During this three-year period, 1596 cases of the disease occurred throughout the city. Of those cases, nearly 300 people died. As a whole, the epidemic had a 17% fatality rate.
Smallpox was eradicated by a massive international search for outbreaks, backed up with a vaccination program, starting in 1967. It was organised and co-ordinated by a World Health Organization (WHO) unit, set up and headed by Donald Henderson. The last case in the Americas occurred in 1971 (Brazil), south-east Asia (Indonesia) in 1972, and on the Indian subcontinent in 1975 (Bangladesh). After two years of intensive searches, what proved to be the last endemic case anywhere in the world occurred in Somalia, in October 1977. A Global Commission for the Certification of Smallpox Eradication chaired by Frank Fenner examined the evidence from, and visited where necessary, all countries where smallpox had been endemic. In December 1979 they concluded that smallpox had been eradicated; a conclusion endorsed by the WHO General Assembly in May 1980. However, even as the disease was being eradicated there still remained stocks of smallpox virus in many laboratories. Accelerated by two cases of smallpox in 1978, one fatal (Janet Parker), caused by an accidental and unexplained containment breach at a laboratory at the University of Birmingham Medical School, the WHO ensured that known stocks of smallpox virus were either destroyed or moved to safer laboratories. By 1979 only four laboratories were known to have smallpox virus. All English stocks held at St Mary's Hospital, London were transferred to more secure facilities at Porton Down and then to the US at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia in 1982, and all South African stocks were destroyed in 1983. By 1984 the only known stocks were kept at the CDC in the US and the State Research Center of Virology and Biotechnology (VECTOR) in Koltsovo, Russia. These states report that their repositories are for possible anti-bioweaponry research and insurance if some obscure reservoir of natural smallpox is discovered in the future.
In malignant-type smallpox (also called flat smallpox) the lesions remained almost flush with the skin at the time when raised vesicles would have formed in the ordinary type. It is unknown why some people developed this type. Historically, it accounted for 5–10 percent of cases, and the majority (72 percent) were children.[27] Malignant smallpox was accompanied by a severe prodromal phase that lasted 3–4 days, prolonged high fever, and severe symptoms of toxemia. The rash on the tongue and palate was extensive. Skin lesions matured slowly and by the seventh or eighth day they were flat and appeared to be buried in the skin. Unlike ordinary-type smallpox, the vesicles contained little fluid, were soft and velvety to the touch, and may have contained hemorrhages. Malignant smallpox was nearly always fatal.[22]
The clinical definition of smallpox is an illness with acute onset of fever equal to or greater than 38.3°C (101°F) followed by a rash characterized by firm, deep seated vesicles or pustules in the same stage of development without other apparent cause.[22] When a clinical case was observed, smallpox was confirmed using laboratory tests.
Diseases caused by pox viruses, especially smallpox, have been known about for centuries. One of the earliest suspected cases is that of Egyptian pharaoh Ramses V who is thought to have died from smallpox circa 1150 years BCE. Smallpox was thought to have been transferred to Europe around the early 8th century and then to the Americas in the early 16th century. It is widely accepted that the main defeat of the Aztecs was due to a smallpox epidemic and within two years over 3.2 million Aztecs died. This death toll can be attributed to the American population's complete lack of exposure to the virus over millennia. A century after Edward Jenner showed that the less potent cow pox could be used to effectively vaccinate against the more deadly smallpox, a worldwide effort to vaccinate everyone against smallpox began with the ultimate goal to rid the world of the plague-like epidemic. The last case of endemic smallpox occurred in Somalia in 1977. Extensive searches over two years detected no further cases, and in 1979 the World Health Organization (WHO) declared the disease officially eradicated. In 1986, all virus samples were destroyed or transferred to two approved WHO reference labs: at the headquarters of the federal Centers for Disease Control and Prevention (the C.D.C.) in Atlanta, Georgia (the United States) and at the Institute of Virus Preparations in Moscow. Post September 11, 2001 the American and UK governments have had increased concern over the use of smallpox, or a smallpox like disease, in bio-terrorism.
In the early 1950s an estimated 50 million cases of smallpox occurred in the world each year.[10] To eradicate smallpox, each outbreak had to be stopped from spreading, by isolation of cases and vaccination of everyone who lived close by. This process is known as "ring vaccination". The key to this strategy was the monitoring of cases in a community (known as surveillance) and containment. The initial problem the WHO team faced was inadequate reporting of smallpox cases, as many cases did not come to the attention of the authorities. The fact that humans are the only reservoir for smallpox infection, and that carriers did not exist, played a significant role in the eradication of smallpox. The WHO established a network of consultants who assisted countries in setting up surveillance and containment activities. Early on, donations of vaccine were provided primarily by the Soviet Union and the United States, but by 1973, more than 80 percent of all vaccine was produced in developing countries.[83]
By 1972, vaccination for smallpox had long been widely available and the disease was considered to be eradicated in Europe. The population of Yugoslavia had been regularly vaccinated against smallpox for 50 years, and the last case was reported in 1930. This was the major cause for the initial slow reaction by doctors, who did not promptly recognize the symptoms of the disease.
The containment efforts proved effective and, on 17 April 1978, WHO's Nairobi office sent a telegram stating: "Search complete. No cases discovered. Ali Maow Maalin is the world's last known smallpox case." Although there was one further smallpox outbreak in 1978 acquired from a laboratory in Birmingham, UK, Maalin remains the last case of naturally acquired smallpox in the world. On 26 October 1979, two years after the day when Maalin's rash appeared, WHO declared that smallpox had been eradicated globally.
In 1888 the foundation stone of West Heath Hospital was laid and the following year it was opened as The Kings Norton Infectious Diseases Hospital with the last case of smallpox being treated there in 1906, subsequent cases being treated at Rubery. When the first Medical Superintendent was appointed in 1910 the hospital began to admit cases of pulmonary tuberculosis. The City of Birmingham took over responsibility for the hospital in 1911 and by 1919 the hospital was known as West Heath Sanatorium with the last cases of other infectious diseases being treated there in 1920.
In 1977, the last case of smallpox was in reported in Somalia. The smallpox eradication campaign had come to a successful conclusion
Through his study, he incorrectly deduced that smallpox and cowpox were all the same disease, simply manifesting themselves differently in different animals, eventually setting back his research and making it difficult to publish his findings. Though Jenner had seen cases of people becoming immune to smallpox after having cowpox, too many exceptions of people still contracting smallpox after having had cowpox were arising. Jenner was missing crucial information which he later discovered in 1796. Jenner hypothesized that in order to become immune to smallpox using cowpox, the matter from the cowpox pustules must be administered at maximum potency; else it was too weak to be effective in creating immunity to smallpox. He deduced that cowpox was most likely to transfer immunity from smallpox if administered at the eighth day of the disease.
The last cases of smallpox in the world occurred in an outbreak of two cases (one of which was fatal) in Birmingham, United Kingdom, in 1978.[94] A medical photographer, Janet Parker, contracted the disease at the University of Birmingham Medical School and died on 11 September 1978. Professor Henry Bedson, the scientist responsible for smallpox research at the university, killed himself.[94][95] All known stocks of smallpox were subsequently destroyed or transferred to two WHO-designated reference laboratories with BSL-4 facilities– the United States' Centers for Disease Control and Prevention and Russia's State Research Center of Virology and Biotechnology VECTOR.[96]
Over 15,000 people contracted and died from smallpox between January and May 1974. Most of the deaths occurred in the Indian states of Bihar, Orissa and West Bengal. There were thousands who survived but were disfigured or blinded. India reported 61,482 cases of smallpox to World Health Organization (WHO) in these five months. India had over 86% of the world's smallpox cases in 1974, primarily due to this epidemic. By January 1975, an operation was started aimed at containing the last cases of smallpox, called "Target Zero", with the identification of the last smallpox patient in India occurring on May 24, 1975. By 1980, smallpox was certified as being eradicated from the world.
Alastrim, also known as variola minor, was the milder strain of the variola virus that caused smallpox. The last known case of variola minor was in Somalia, Africa in 1977. Smallpox was formally declared eradicated in May 1980. 
The Manchus feared smallpox more than any other disease because they had no immunity to it and almost always died when they contracted it. By 1622 at the latest, they had already established an agency to investigate smallpox cases and isolate sufferers to avoid contagion. During outbreaks, royal family members were routinely sent to "smallpox avoidance centers" ("bidousuo" 避痘所) to protect themselves from infection. The Shunzhi Emperor was particularly fearful of the disease, because he was young and lived in a large city, near sources of contagion. Indeed, during his reign at least nine outbreaks of smallpox were recorded in Beijing, each time forcing the emperor to move to a protected area such as the "Southern Park" (Nanyuan 南苑), a hunting ground south of Beijing where Dorgon had built a "smallpox avoidance center" in the 1640s. Despite this and other precautions—such as rules forcing Chinese residents to move out of the city when they contracted smallpox—the young monarch still succumbed to that illness.
Following mass vaccinations, disease detection and containment were central to the eradication campaign. As soon as cases were detected, the victims were isolated as were their close contacts, who were vaccinated. Successes came quickly; by 1970 smallpox was no longer endemic in western Africa, nor, by 1971, in Brazil. By 1973, smallpox remained endemic only in the Indian sub-continent, Botswana and Ethiopia. Finally, after 13 years of coordinated disease surveillance and vaccination campaigns throughout the world, the World Health Organization declared smallpox eradicated in 1979. Although the main weapon used was vaccinia virus, which was used as the vaccine, no one seems to know exactly where vaccinia virus came from; it is not the strain of cowpox that Edward Jenner used, and it is not a weakened form of smallpox.
The terminology used to describe the prevention of smallpox can cause confusion. In 18th-century medical terminology, "inoculation" refers to "smallpox inoculation". Confusion is caused by writers who interchange "variolation" and "vaccination" through either mistranslation or misinterpretation. The term "variolation" refers solely to inoculation with smallpox virus and is not interchangeable with "vaccination". The latter term was first used in 1800 soon after Edward Jenner introduced smallpox vaccine derived from cowpox, an animal disease distinct from smallpox. The term "variolation" was then used from the 19th century to avoid confusion with vaccination. Most modern writers tend to refer to smallpox inoculation as variolation throughout without regard for chronology, as is used here. Further confusion was caused when, in 1891, Louis Pasteur honoured Jenner by widening the terms "vaccine/vaccination" to refer to the artificial induction of immunity against any infectious disease. "Inoculation" is used synonymously with "injection" in connection with the use of vaccines or other biopharmaceuticals, but has other meanings in e.g. laboratory work.
Like smallpox, alastrim has now been totally eradicated from the globe thanks to the 1960s Global Smallpox Eradication campaign. The last case of indigenous variola minor was reported in a Somali cook, Ali Maow Maalin, in October 1977, and smallpox was officially declared eradicated worldwide in May 1980.