Smallpox virus, used as a weapon against an unimmunized population, has the potential to infect tens of thousands of individuals, kill 30% or more of those infected, and trigger the vaccination of many times that number.1 The neurologist will be faced with recognizing and treating the neurologic complications of both the disease and the vaccine.1,2 As the most serious untoward reaction to the vaccine is fatal encephalitis, the neurologist will be central to the debate over whether the government should consider a national campaign to reimmunize the population or wait until there is a terrorist attack involving this agent as a single entity or in combination with another virus, bacteria, and/or chemical or nuclear agents.2,3 This review discusses the recent history, virology, epidemiology, pathogenesis, clinical manifestations of smallpox and smallpox vaccine (vaccinia virus), and preventive strategies with special emphasis on the role of preexposure prophylaxis for the general population.
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