The strategic use of novel smallpox vaccines in the post-eradication world

We still face a threat of orthopoxviruses in the form of biological weapons and emerging zoonoses. Therefore, there is a need to maintain a comprehensive defense strategy to counter the low-probability, high-impact threat of smallpox, as well as the ongoing threat of naturally occurring orthopoxvirus disease. The currently licensed live-virus smallpox vaccine ACAM2000 is effective, but associated with serious and even life-threatening adverse events. The health threat posed by this vaccine, and other previously licensed vaccines, has prevented many first responders, and even many in the military, from receiving a vaccine against smallpox. At the same time, global immunity produced during the smallpox eradication campaign is waning. Here, we review novel subunit/component vaccines and how they might play roles in unconventional strategies to defend against emerging orthopoxvirus diseases throughout the world and against smallpox used as a weapon of mass destruction.