Finally, the outbreak from Kosovo deserves notice because this region is not as developed or as wealthy as most of the other countries studied. This outbreak was the largest identified for this review (N = 176 for both combined hospital and mixed components). Moreover, the hospital and mixed component of this outbreak had the second highest (R = 38) and highest (R = 11) initial reproductive rate, and the hospital component lasted 9 generations (median number of generations for a hospital outbreak = 2). This suggests that a smallpox outbreak in a less developed country with limited resources for healthcare, disease surveillance, and case isolation could be potentially more devastating than a bioterrorist attack in a Western/industrialized country [44] .