We reviewed historical data from 2 smallpox out-breaks in Liverpool and Edinburgh during the early andmiddle years of the 20th century to assess their contribu-tion to developing modern strategies for response to adeliberate release of smallpox virus. Reports contempora-neous to these outbreaks provide detail on the effective-ness of public health interventions. In both outbreaks,extensive contact tracing, quarantine, and staged vaccina-tion campaigns were initiated, and the outbreaks werecontrolled within 15 months and 3 months, respectively. InEdinburgh, the number of fatalities associated with vacci-nation exceeded the number of deaths from the disease.In Liverpool, ambulatory, vaccine-modified cases and mis-diagnosis as chickenpox resulted in problems with out-break control. The relatively slow spread of smallpox, asexemplified by the report from Liverpool, allowed for effec-tive implementation of targeted intervention methods.Targeted surveillance and containment interventions havebeen successful in the past and should be explored asalternatives to mass vaccination
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