- I have two articles for you on this topic. Nothing else
needs to be said. I have no idea what to do about this one. It may well
be that we are all going to see the whole world regress to a very basic
state due to the folly of health officials who thought they were gods.
They destroyed the vast bulk of the surplus smallpox vaccine, so there
is no hope. If you think this could be bad on your heart or blood pressure,
I suggest you back out of this page and forget it.
-
-
- WASHINGTON 7-23-01 (AFP)
- A chilling scenario of possible national collapse was presented Monday
to US lawmakers by a group of prominent security experts, who warned that
a biological terrorist attack on US soil could bring the country to the
brink of disintegration.
-
- The panel, which included former deputy secretary of
defense John Hamre, Oklahoma governor Frank Keating and former senator
Sam Nunn, presented their conclusions after holding a two-day exercise
code-named "Dark Winter," which featured a computer-simulated
bioterrorist attack on three US states.
-
- Members of the House Subcommittee on National Security
closely listened as participants painted a picture of the world's most
powerful nation descending into chaos in a matter of several weeks.
-
- The game starts with a brief television report that about
two dozen people checked into an Oklahoma City hospital with an unidentified
illness. Doctors soon find the patients have smallpox, a highly contagious
and deadly disease unseen in the United States since 1949.
-
- Similar smallpox cases are reported in Pennsylvania and
Georgia. By day six, 300 Americans are dead and 2,000 others are infected.
Cases of smallpox are reported in Mexico, Canada and Britain, according
to the scenario.
-
- Meanwhile the US heath system is overwhelmed, the 12
million doses of smallpox vaccine quickly disappear, schools nationwide
are forced to close, and public gatherings are limited due to fear of contagion.
-
- Droves of Oklahomans anxious to flee stream toward Texas
-- but the Texas governor, eager to protect his own residents, closes the
border and deploys the state National Guard. Shots are fired.
-
- As the standoff between Texans and Oklahomans deepens,
a rift opens between federal and local authorities. Members of the US National
Security Council suggest "nationalizing" the national guard,
while state governors insist on keeping the local troops under their control.
-
- On day 12 of the scenario, when the death toll reaches
1,000, interstate commerce grinds to a halt and stock trading is suspended.
Demonstrations demanding more smallpox vaccines turn into riots. The United
Nations moves its headquarters from New York to Geneva, Switzerland.
-
- Less than two months after the outbreak, when the number
of dead reach one million and three million more are infected, the president,
played in the exercise by Nunn, gathers his top aide to considers imposing
marshal law.
-
- Dead silence reigned in the hearing room as Hamre and
Nunn presented their findings with the help of colorful "emergency
newscasts" prepared by the nation's leading television broadcasters,
who also took part in the exercise, which took place at Andrews Air Force
Base outside Washington, D.C. in June.
-
- "I think we felt it would cripple the United States
if it occurred," Hamre said.
-
- "We though we were really gathering together to
talk about the mechanics of government," Hamre said. "What we
ended up doing is thinking how we save democracy in America."
-
- To Republican Congressman Benjamin Gilman, scenarios
like this no longer belong to the realm of science fiction.
-
- "Sadly, events of the last few years, with bombings
... in New York, Oklahoma City, have transformed the bioterrorism debate
from the question of 'if' to the seeming inevitability of 'when,"
he said.
-
- Nunn, who had sat on the Senate Armed Services Committee
for more than two decades, said the exercise raised more questions than
answers.
-
- If there is only one dose of smallpox vaccine for every
23 Americans, whom do you vaccinate? he asked.
-
- "Do you seize hotels and convert them to hospitals?
Do you close borders and block all travel? What level of force do you use
to keep someone sick with smallpox in isolation?" he asked.
-
- No clear answer was offered by those present. ___
-
-
- Smallpox - Diseases Associated With Biological Warfare
-
- By Robert Trupin, BS
-
- Introduction
-
- The willingness of terrorist groups to employ weapons
against the United States was alarmingly demonstrated by the World Trade
Center bombing, in which the stated goal of the terrorists was to maximize
civilian casualties. But the use of conventional weapons to terrorize a
civilian population is not the only cause for concern. Health professionals
should be acquainted with diseases that lend themselves to bioterrorism.
The possibility of a biological attack against one or more American cities
is a major concern. Should such an attack occur, medical professionals
are the nation's first line of defense. The quickness with which they diagnose
and respond to a bioterrorist outbreak could decide whether or not the
U.S. suffers a calamity.
-
- The two most threatening diseases associated with bioterrorism
are smallpox and anthrax. Despite widespread assurances that smallpox is
not longer a threat, there is overwhelming evidence that contaband samples
of the virus remain stored in several laboratories throughout the world.
That so little attention has been devoted to the possible emergence of
a deliberately induced smallpox epidemic is evidence of poor planning as
well as governmental irresponsibility.
-
- History of Smallpox
-
- The smallpox virus probably existed since the infancy
of the human species, but required the population density that can be supported
by agriculture to spread quickly. The first historical record of smallpox
infection occurred about 3000 years ago in Egypt. Since then massive smallpox
epidemics have swept across Asia and Europe killing and disfiguring hundreds
of millions. Its contagiousness and explosive infection rate allows the
virus to spread rapidly . Smallpox is unique to humans and is believed
to have killed more people than any other disease in recorded history.
(1)
-
- Egypt. The oldest known case of smallpox was that of
Pharaoh Ramses V of Egypt who died in the twelfth century BC. His mummy
reveals that the young king's face and torso were covered with blisters
characteristic of smallpox. (2)
-
- Rome. In 165 A.D. the Roman empire was devastated by
a smallpox epidemic that raged for fifteen years and killed tens of millions.
Romans were completely vulnerable to smallpox, the disease having suddenly
emerged from the Asian continent. The decline in population reduced the
Roman army which replaced its losses with barbarians who had no particular
loyalty to Rome. Rome was never able to recover its former military prowess,
and was eventually over-run by barbarian armies. (3)
-
- Europe and Asia. The middle-ages saw devastating outbreaks
of smallpox that killed untold millions throughout Europe and Asia leaving
many of the survivors immune. It was not uncommon for victims of smallpox
or some other plague to be catapulted over the walls of a city under siege
in an attempt to start an epidemic within it.
-
- Mexico. Cortez and his conquistadors invaded Mexico in
1518. The Aztecs had no immunity to a host of European diseases, the worst
being smallpox. By the time Cortez and a few hundred of his exhausted warriors
attacked Mexico City with its huge population, the defenders had been decimated
and demoralized by smallpox. The city fell, and Aztec civilization fell
with it. (4)
-
- North America. It is estimated that smallpox, along with
a number of lesser diseases, killed 56 million native Americans during
the Spanish conquest of Mexico. The death toll mounted as smallpox spread
to other Indian nations, none of which had any resistance to infection.
Infected blankets from smallpox victims were presented to native Americans
as gifts during the westward expansion of the United States.
-
-
- Smallpox eradication campaign. In 1952, after the disease
had killed about 300 million people in the twentieth century (5), a campaign
to eradicate smallpox was initiated by the World Health Organization. The
Smallpox Eradication Unit was led by Dr. Donald A. Henderson, a particularly
capable epidemiologist. The disease existed in thirty-three countries and
was killing more than two-million people per year. A program of mass inoculation
was instituted over a twenty year period. Eighty percent of the population
was inoculated in regions harboring the disease, and the number of new
smallpox cases approached zero.
-
- Yugoslavia. Yugoslavia had one of the last serious epidemics
in 1972. A Muslim pilgrim returned from Mecca to his home in Kosovo carrying
the deadly virus. No case had occurred in Yugoslavia since 1930, and the
entire population of Yugoslavia had been routinely vaccinated for the past
50 years. The pilgrim himself was inoculated just two months earlier. Yugoslavia
had, at the time, eighteen million doses of vaccine available to serve
21 million people. The World Health Organization of the United Nations
had millions more. Yugoslavia had an authoritarian government under Tito
which was capable of acting swiftly, and if need be, ruthlessly.
-
- The pilgrim felt achy with flu-like symptoms shortly
after his return from Mecca. For over a week he had been exposing his family
to infection. His first serious symptom was hemorrhaging in the whites
of his eyes, which darkened until they were almost black. The development
of lesions on his body did not immediately alert anyone to the possibility
of smallpox, since no case had occurred in Yugoslavia for over forty years.
-
- After the onset of severe hemorrhaging, the pilgrim was
rushed to a local hospital where he infected a nurse and eight other patients.
From the local hospital he was rushed to a hospital in Belgrade where he
infected twenty-eight more people including eight doctors and nurses. They
in turn in infected 150 more. The disease was moving rapidly throughout
Yugoslavia.
-
- The army was mobilized and martial law was declared.
The borders were sealed and unauthorized travel was forbidden. Hotels and
apartment houses were requisitioned and used to quarantine over ten thousand
people. Within two weeks everyone in Yugoslavia had been revaccinated.
The number of newly infected individuals dropped with each wave soon reaching
zero.(6)
-
- Bangladesh. In early 1975 smallpox broke out in Bangladesh
and swept through more than five-hundred villages. Dr. Henderson and his
team vaccinated people in rings around each new outbreak, and tracked down
everyone who had contact with infected individuals. By the end of the year
there were no new cases.(7)
-
- The last known case in the world occurred in Somalia
in 1977.(8)
-
- Epidemiology of Smallpox
-
- Smallpox is among the least pleasant diseases known to
man.
-
- It is an explosively contagious viral infection that
is unique to humans. It is classified as a hot agent in Biosafety Level
4 category, which means that a single case, anywhere in the world, would
be considered a global medical emergency.(1) If smallpox infection is suspected,
the Centers for Disease Control (CDC) Emergency Response Office should
be immediately notified.
-
- The Bioterrorism Emergency Number is (770) 488-7100.
-
- Outbreak. In the event of an outbreak of even a single
case of smallpox, emergency powers are immediatelt assumed by local, state,
and federal authorities according to a chain of command and division of
responsibilities. CDC personnel will rush to the scene with protective
gear, vaccine, and whatever equipment is needed to collect samples. Specimen
packaging and transporting includes a documented chain of possession coordinated
by the FBI. Biosafety Level 4 disease specimens are rushed to CDC or several
select Department of Defense (DOD) laboratories.(9) Travel may be restricted
and quarantines imposed. Civil liberties and constitutional rights tend
to fare badly during national emergencies of this gravity.
-
- Epidemic outbreak. Smallpox epidemics develop in waves,
with peaks and troughs separated by two-week intervals that correspond
to the average incubation period of the virus. The virulence of the epidemic
is a function of non-immune population density. Immunized people stifle
the epidemic by lowering the average number of transmissions per infected
individual. In an unvaccinated population, one infected person can infect
all non-immune people with whom he comes in contact. Immunized people in
an epidemic are analogous to control rods in nuclear reactors - they slow
down and stifle chain-reactions.
-
- Precautions.
-
- The U.S. Navy's Bioterrorism Task force specifies the
use of masks, gowns, gloves, with thorough washing after each exposure,
and the isolation of smallpox patients, preferably in negative pressure
rooms. Face masks must be worn when entering the patient,s room. Airborne
precautions should be followed. Smallpox is transmitted by particles of
five microns or less. They can remain suspended near the patient, or move
considerable distances in air currents.
-
- Contact precautions include use of clean gloves on entry
into a patient's room, removing gown before leaving room, washing hands
and exposed surfaces with antimicrobial soap, and air exchange every 6
to 12 hours through monitored high-efficiency filters.(10)
-
- For prophylactic and post-exposure immunization, smallpox
vaccine should be administered to everyone in contact with infected individuals.
If more than three days have elapsed since exposure, smallpox vaccine should
be administered in conjunction with vaccinia-immune globulin (VIG) ) (0.6l/kg
1M).(11) (this, of course, assumes that such supplies exist).
-
- Exposed individuals should be on the alert for flue-like
symptoms and rashes for 7 to 17 days after exposure. Isolating smallpox
patients, individually when possible or in groups when not possible, is
essential.
-
- The Smallpox Virus (Variola)
-
- Variola, the causative agent in smallpox, is a large
virus with a complex structure that belongs to a class of pox viruses called
Chordopoxviridae. It has a somewhat brick-like shape with rounded corners
and a knobby surface looking much like the surface of a hand-grenade. (Figure
1) By dry weight variola contains 90% protein, 5% lipid, and 3.2% DNA.
Its double-stranded DNA consists of over 190,000 nucleotide base pairs
built from over 100 proteins. Its dimensions are about 250 x 250 x 200
nm, large enough to be seen with an optical microscope.(12)gure I: The
variola virus
-
- Replication.
-
- Variola replicates in the cytoplasm of the host cell
independent of the host cell enzymes. The virus rapidly multiplies until
the cell bursts, releasing tens of thousands of variolas capable of attacking
other host cells. The replication cycle is repeated every few hours and
by the time the victim shows symptoms, he is awash in quadrillions of variolas.
-
- Identification. Confirmation of the presence of the variola
virus is carried out by examination of fluid from an active lesion. Active
skin lesions are characterized by altered epidermal cells containing eosinophilic
intracytoplasmic bodies (Guarneri bodies). Further confirmation is carried
out using immunofluorescence and microscopy. The distinctive shape and
size of variola (it is the largest known virus) should make a diagnosis
definitive.
-
- Mechanism of Infection
-
- Droplet infection. To sustain itself, the smallpox virus
is passed from person to person in a continuing and expanding chain of
infection. It is spread primarily by the inhalation of airborne droplets,
and secondarily by physical contact. A single invisible droplet of exhalant
travels in still air about ten feet from its human source, and contains
far more viruses than is needed to infect a single individual.(13) Variola
major. There are two variants of the smallpox virus: variola major which
is the more lethal variant, and variola minor which is a weak mutant. We
will only deal wih variola major. There is enough variation in the disease
progression that smallpox may not be recognized even by doctors familiar
with the disease of whom there are virtually none. Onset. During a typical
incubation period of ten to fifteen days the infected person will feel
normal, but is already contagious. The first signs of the onset of the
disease are severe flu-like symptoms, headache and fever. In another three
or four days, tiny red dots appear over the entire body. The spots develop,
in order of progression, from macules to papules to vesicles to pustules.
An identifying characteristic of smallpox is its foul and distinctive odor
arising from the victim's pustules, which once smelled is never forgotten.
-
- Pustules. If the pustules merge to form a cont inuous
surface encasing the entire body, the disease is said to have split
the skin, and the person will usually die. The pustules can be so close
together that the skin resembles a cobblestone street. If the person survives,
the blisters will turn into highly contagious scabs which fall off the
body, leaving the victim permanently scarred and in some cases blind.
The mortality rate is usually between twenty-five and fifty percent.
An epidemic in Canada in 1924 killed 50% of those stricken.<#3.(14)<#14
-
- There are two particularly deadly forms of smallpox -
flat black pox and hemorrhagic black pox:
-
- Flat black pox. In flat black pox the skin remains
relatively smooth, but blackens in large areas. The victim's immune
system, having been paralyzed, produces no pus. The blackened areas merge
as hemorrhaging under the skin advances. The skin sometimes detaches
from the body and falls off in large sheets.
-
- Hemorrhagic black pox. In the presence of hemorrhagic
black pox, highly contagious black, unclotted blood seeps from the victim's
orifices. The virus will sometimes break down the internal membranes
which line the body's organs. Pieces of membrane can be expelled through
the victim's orifices accompanied by a profusion of blood. The victim
almost never survives this development.
-
- Chicken pox. The disease most commonly confused with
smallpox is chicken pox. During the first two or three days after the
rash has appeared, it may be difficult to tell them apart. Chicken pox
lesions are more superficial and variated than the smallpox pustules which
are dense and almost identical. Smallpox pustules tend to be more numerous
than chicken pox on the face and limbs. Chicken pox lesions, unlike smallpox
lesions, are very rarely found on the palms and soles<#3..(15)
-
- The Smallpox Vaccine
-
- Because many of the proteins present in other pox viruses
are similar to those found in smallpox, it is possible to develop effective
vaccines based on non-human pox viruses (cow pox for instance). Other pox
viruses that might grant immunity to humans are monkey pox, orf in sheep,
and molluscum contagiosum, a relatively mild sexually transmitted disease
in humans. Smallpox vaccine is effective for approximately ten years, after
which it begins to lose potency. No one has been vaccinated in the United
States for the past twenty-five years. We are almost as virgin a population
as were the Aztecs when the conquistadors descended upon them.
-
- The Centers for Disease Control owns a small supply of
smallpox vaccine that is stored in four cardboard boxes in the walk-in
freezer of a pharmaceutical company in Pennsylvania. The company, Wyet-Ayerst
Laboratories, manufactured fifteen million doses of smallpox vaccine
over a period of five years some twenty-five to thirty years ago.<#1.(16)
The CDC owns six to seven million doses of this production, a ridiculously
insufficient amount to protect a population the size of the US. But
even this may be an inflated figure and it has been reported that the
vaccine has seriously deteriorated. Some people on whom it was tested
have had serious and even fatal reactions. The antidote to these reactions
has also deteriorated.(17) Such is our state of readiness.
-
- When the World Health Organization declared total victory
over smallpox in 1979 it had ten-million doses of smallpox vaccine in
storage in Geneva, Switzerland. The CDC then proceeded to deliberately
destroy nine and one-half million of these doses.(18) The people making
this decision had total confidence in the highly unlikely proposition that
variola was completely and permanently eradicated from the face of the
earth. (Why, in that case, did they not destroy all ten million doses
of vaccine?) This leaves one-half million doses to deal with a global crisis,
or one dose for every 12,000 people.
-
- Smallpox vaccine is not difficult to produce. In the
late eighteenth century it was noticed by an English country doctor
named Edward Jenner that dairy maids who had contracted a mild disease
called cowpox were never stricken with smallpox. Using a drop of liquid
from a cowpox blister, Dr. Jenner scratched it into the arm of a young
boy. Several months later he introduced deadly smallpox pus into the
boy's arm. The boy did not come down with the disease.<#3.(19)
-
- Smallpox vaccine is almost 100% effective. Only three
in one-million doses produce adverse side-effects. The most frequent
of these side-effects is a condition called progressive vaccinia which
affects immune-compromised people. This condition, in which vaccinia
grows at the vaccination cite, can be cured with vaccinia immune globulin.(20)
-
- The United States does not manufacture smallpox vaccine
in even limited quantities. This nation, which managed to manufacture
and distribute smallpox vaccine during the administration of Thomas
Jefferson, seems incapable of doing so today. Compared to other defense
and/or health systems, the cost of inoculating our entire population
would be trivial. If the U.S. began a crash program to manufacture the
vaccine and inoculate every person in the nation, it is estimated that
it would take about 36 months to complete the task.<#3.(21)
-
- Government Readiness
-
- If we compare our readiness with that of Yugoslavia in
1972 we might as well be a stone-age civilization. Official indifference
to the threat of smallpox could be rationalized if the virus was known
to be extinct. Unfortunately, the opposite is known to be the case.
Anti-terrorist experts are certain that the virus, though outlawed by
the United Nations, exists in a number of clandestine biowarfare laboratories
located in several countries.<#3.(22) These include Russia, China, North
Korea, Pakistan, Iraq and Iran. The United States keeps several vials
of live virus at the Centers for Disease Control in Atlanta, hopefully
under foolproof security. The viruses are used to experiment with drugs
that might be effective against smallpox. So far none have been found.<#3.(23)
-
- In 1995 the CIA gave a classified briefing to a number
of public health officials and biologists during which the list of possible
variola sources was extended to include Osama bin Ladden's Islamic terrorist
organization, and Japan's Aum Shinrikyo sect that was responsible for
attacking subway commuters in Tokyo with nerve gas.(24) Unlike nuclear
weapons, the virus could be surreptitiously introduced into a population
without revealing that a deliberate attack had occurred, or who had
launched the attack.
-
- In 1992 the leading Russian bioweapons expert and the
inventor of the world's most powerful anthrax virus, Dr. K. Alibekov,
defected to the U.S. He revealed that the Russian military has secretly
stored at least twenty tons of the live smallpox virus on various military
bases throughout Russia. The intelligence community has corroborated
this information.<#3.(25)
-
- The leading Russian institute of virology, known as Vector,
is situated outside Novosibersk in Siberia. It is also a viral weapons
development facility that contains living variolas in a freezer.<#3.(26)
Vector is underfunded and is considered by the intelligence community to
be a viral Chernobyl - an accident waiting to happen. Since the fall
of the Soviet Union, unpaid weaponry scientists have been leaving rotting
Soviet military facilities in droves, carrying their expertise with
them to unknown paymasters. There is no reason to believe that some
Vector scientists are not numbered among them. Nor do we have any assurance
that living variolas were not stolen amidst post-Soviet chaos.
-
- Our principle biodefence laboratory is the United States
Army Medical Institute of Infectious Diseases in Fort Detrick, Maryland.
The head of the laboratory, Dr. Peter Jahring, recently said the following:
"I don't think there is any higher biological threat to this nation
than smallpox... . If we have a bioterror emergency with smallpox, there
will be no time to start stroking our beards. We'd better have vaccine
pre-positioned on pallets and ready to go." <#3.(27)
-
- In 1995 the National Security Council declared defense
against smallpox bioterrorism to be a top priority. The Department of
Health and Human Services (HHS), headed by Donna Shalala, was given
responsibility for building a stockpile of smallpox vaccine large enough
to protect the United States. A controversial study estimated the cost
of producing 300,00 doses at seventy-five dollars per dose and a delivery
date in the year 2006.<#3.(28) It was decided that the cost was
prohibitive. (For several generations a much poorer U.S. managed to
inoculate everyone in the nation). The project was put on a back-burner,
from where it has apparently fallen off the stove.
-
- Retired General P. K. Russell MD, who headed the biohazard
team that stopped an ebola epidemic in 1989, blames our vulnerability
to smallpox on "a lack of effective leadership on the part of the
government." D. A. Henderson said "The effort at HHS still
isn't organized."<#3.(29) The Department of Health and Human
Services is highly politicized even by Washington D.C. standards, and has
no history of assuming responsibility for any portion of national defense.
This makes the failure to build a smallpox vaccine stockpile even more
incomprehensible, since it does not entail the risk of handling live
variolas.
-
- Conclusion
-
- Our lack of preparedness is not limited to smallpox.
We cannot hope to be completely protected from every possible mode of
attack. There is always a period of vulnerability between the introduction
of a new attack weapon, and a defense against it. However in the case
of smallpox, vaccination predated the bioterrorist threat by more than
two centuries. There is no reason why we should remain vulnerable to
this terrible disease.
-
- Addendum
-
- In August 1999 the new director of CDC in Atlanta, Jeffrey
Koplan, decided to end the bureaucratic stalemate concerning the production
of smallpox vaccine. He called a meeting of high officials in the relevant
agencies (the Pentagon, the White House, the National Institutes of
Health, and the Department of Health and Human Services) and announced
that no one was allowed to leave the room untill a feasable plan for
manufacturing an adequate supply of vaccine in the shortest possible
time was instituted.
-
- Dr. Koplan is one of the few doctors in the world with
experience in fighting smallpox. He had served on the medical team that
successfully stopped the world's last epidemic in Bangladesh in 1973.
The CDC was given the responsibility of creating the stockpile of smallpox
vaccine with a target date set for 2002.
-
- Copyright © 2000-2001 Robert Trupin. Reprinted with
permission.
-
- References
-
- 1. Henderson D. Smallpox: Clinical and Epidemiological
Features CDC Vol.5, 08/99
-
- 2. Garret L. The Coming Plague Farrar, Straus, &
Giroux; 1994.
-
- 3. Preston, Richard The New Yorker 7/12/99. Conde
Nash Pubications
-
- 4. O'Tool T. Smallpox: An Attack J. Hopkins School of
Public Health Vol 5, 1999
-
- 5. Bardi J. Aftermath of a Hypothetical Smallpox Disaster
J. Hopkins University; CDC:7/99.
-
- 6. Henderson D. Bioterrorism as a Public Threat. Emerging
Infectious Diseases CDC Vol 5 No.4. 1999.
-
- 7. McCade J. Addressing the Potential Threat of Bioterrorism
Emerging Infectious Diseases; CDC: Vol5 No.4. 1999.
-
- 8. English J, et al. Bioterrorism Readiness Plan:
A Template for Healthcare Facilities. Department of Navy: 4/13/99.
-
- 9. Preston R. The New Yorker. 1/10/00. ___
-
-
- Special Issue - Aftermath of a Hypothetical Smallpox
Disaster
-
- By Jason Bardi Johns Hopkins University Baltimore, Maryland,
USA From the Center of Disease Control Web Site http://www.cdc.gov/ncidod/EID/vol5no4/bardi.htm
-
-
- The second day of the symposium featured a discussion
of a scenario in which a medium-sized American city is attacked with smallpox.
Four panels represented various time milestones after the attack, from
a few weeks to several months. Panelists discussed what they and their
colleagues might be doing at each of these milestones. The goal of the
responses was to communicate the complexity of the issues and to explore
the diverse problems that might arise beyond the care and treatment
of patients.
-
- The scenario itself was a step-by-step account of a smallpox
epidemic in the fictional city of Northeast. Tara O'Toole, the scenario's
lead author, read the narrative account before each panel.
-
- The panelists responded to the events as if the epidemic
were real and they were actually trying to identify, contain, communicate,
and otherwise deal with it. Panel members included experts on hospital,
city, state, federal, and media responses. Representing the hospitals
were John Bartlett and Trish Perl, Johns Hopkins Hospital; Julie Gerberding,
Hospital Infections Program, Centers for Disease Control and Prevention;
and Gregory Moran, Emergency Medicine, University of California at Los
Angeles. Jerome Hauer represented New York City's response. Representing
the state were Michael Ascher, California Department of Health Services
Laboratory; Arne Carlson, former governor of Minnesota; Terry O'Brien,
a Minnesota State Assistant Attorney General; and Michael Osterholm,
Minnesota Department of Public Health. The federal representatives on
the panels were Robert Blitzer, former counterterrorism chief with the
Federal Bureau of Investigation; Robert DeMartino, Substance Abuse and
Mental Health Services Administration; Robert Knouss, Office of Emergency
Preparedness, Department of Health and Human Services; and Scott Lillibridge,
Centers for Disease Control and Prevention. Joanne Rodgers, Johns Hopkins
Medical Institutions Public Affairs, spoke to the response of the media.
George Strait, the medical news director for ABC News, acted as moderator
for each of the panels scheduled on day two. D.A. Henderson also helped
to moderate.
-
- Identifying the Agent
-
- At the start of the epidemic, 2 weeks after the bioterrorist
attack, confusion reigns. There is uncertainty as to what the infection
is and reluctance to diagnose smallpox even when it is suspected. It
is unclear who is in charge of investigating and containing the epidemic.
Outside, reporters are knocking on the hospital doors. The question
of what took so long to identify the agent opens the panel. Smallpox,
a nonspecific flulike illness, is hard to diagnose, replies an emergency
medicine physician. The disease is not suspected because it was eradicated
in the late 1970s. Any laboratory work on the first cases would initially
be testing for a battery of other causes, such as other viral infections
(e.g., monkeypox) or reactions to recent vaccinations. A window of 2
weeks before positive identification of smallpox may even be optimistic.
The diagnosis would probably take much longer because of physicians'
lack of familiarity with the disease.
-
- When all the tests for other infections turn up negative
and smallpox is strongly suspected, suggests a state laboratory chief,
a conclusive result from the laboratories at the Centers for Disease
Control and Prevention (CDC) or the U.S. Army Medical Research Institute
of Infectious Diseases (USAMRIID) would still be needed. These are the
only two places in the United States equipped to identify smallpox virus
in tissue samples. This part of the diagnosis is fairly straightforward
but it would take at least 1 day before the definitive results could
be obtained.
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- Responding at the Hospital Level
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- Hospitals would probably isolate the early cases presumptively,
even if smallpox was not suspected, since the symptoms would appear infectious.
This is the opinion of a hospital infections expert. In the city, argues
a state health department professional, several hospitals would each
see one or two of the first few cases. The city health department would
quickly become aware of the similarity of the cases in the various hospitals,
recognize a potential outbreak (probably measles) and mobilize early
to contain it.
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- Once smallpox is identified, the following organizations
within city government would be notified: the police department, the
local emergency management office, the city health commissioner's office,
and, ultimately, the mayor's office. This process may be difficult since
it requires integrating the health department into emergency management
plans, an event with little precedent, notes a city emergency official.
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- Coordinating Response Efforts
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- Who is in charge, agree panelists, is one of the most
important questions yearly in the epidemic, because any large-scale relief
effort would require good management. Complicating the answer, however,
are various levels of government, each with its own responsibilities
and perspective on response, as reflected in panelists' remarks.
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- Acts of domestic terrorism are under the jurisdiction
of the federal government, so several federal agencies become involved,
starting with FBI. FBI is involved from the very beginning since any
cases of smallpox would indicate a deliberate terrorist attack. A criminal
investigation begins immediately. CDC is involved as soon as samples
are sent for laboratory diagnosis.
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- The state government becomes involved at the outset,
since major threats to public health are dealt with on the state level.
The state health department starts its own investigation, and to reassure
the public, the governor may act as a spokesperson for the management
of the epidemic.
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- The city is involved from the outset, explains the city
emergency management official, understanding that "bioterrorism
is a local issue," which escalates very rapidly to state and federal
levels. The local police and emergency management teams, as well as
the city health commissioner, the city health department, and the mayor,
are involved.
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- The problems of the city become state problems immediately,
counters the former governor, because the news media treat any potential
infectious disease outbreak as a regional problem. This forces the governor's
hand. The governor has to move in because there is a need for one person
to be in charge.
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- The most difficult situation is how to deal with the
hospital patients. One danger in the early days is losing control of the
crisis through panic. Once rumors about smallpox start to spread, many
workers within the hospital walk off the job. Understaffing also leads
to increased stress and confusion for patients and providers alike.
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- Even before federal and state command structures are
in place, suggests a hospital infections control expert, hospital epidemiologists
would already be addressing infection control issues. She notes that
hospital infection control specialists would be on the phone to colleagues
in other city hospitals alerting one another. Hospital epidemiologists,
adds a state health official, would have a contact list of state, local,
and federal public-health authorities who also would be notified.
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- Another problem in coordination becomes clear to panelists:
the difficulty in sharing classified risk information among agencies and
various levels of government. Any early warning, which could have contributed
to a more effective response, was missing in the scenario. Even though
the FBI had some early intelligence of the attack, the alerting of health
care workers was nonexistent. The problem lies in the fact, assesses
a state health department official, that health departments have never
been seen as intelligence communities, nor has there ever been a precedent
for passing such information to them.
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- On the federal level, CDC addresses the public health
issues of the epidemic, and FBI addresses the law enforcement issues.
These aims are not necessarily exclusive of one another, and the possibility
of linking efforts is raised. Everyone interviewed as a part of the
epidemiologic investigation may have to be interviewed as part of the
criminal investigation as well. Perhaps the most effective way to accomplish
this is to conduct both interviews simultaneously.
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- Some aspects of the two federal agencies may overlap,
perhaps even conflict, in agendas. Specimens that are sent to CDC for
positive identification of the smallpox virus may be needed by FBI as
evidence for any eventual prosecution. In many ways, it may appear as
if FBI is running the investigation. However, dealing with the sick,
obtaining vaccine, and mobilizing the epidemiologic investigation at
the local, state, and federal levels are outside the scope of FBI. CDC
takes the lead on these public health issues, and together with FBI,
coordinates the management of federal resources.
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- However, who is coordinating activities at the hospitals
is still unclear, and the question of authority on that level is unresolved.
Can outsiders come into a hospital and wield power, and if so, who are
they? Federal responders may have ambiguous authority within a hospital
and may add to the chaos. An FBI offical notes that his agency's role
in the hospitals will simply be to inform the doctors and administrators
of what the hospital needs to do to assist in the criminal investigationkeeping
evidence and coordinating interviews with patients. However, this may
still leave gaps of authority within the hospital.
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- In the scenario under consideration, the state identifies
one hospital as the smallpox hospital, and this also presents a problem
of coordination. The hospital itself has to work out the details of local
quarantine and the distribution of medicine to the patients, and there
is a need to protect the health-care workers and other hospital staff.
Vaccine should be immediately available to these workers, and its distribution
will have to be coordinated with CDC.
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- Outside the hospitals, an epidemiologic investigation
will be taking place that will need to be coordinated with CDC. A CDC official
points out the need for surveillance in the early days of the epidemic.
To assist in collecting data necessary to identify the release source
and people at risk, he recommends that CDC provide additional staff
for much of the epidemiologic work, including mid- and senior-level
investigators. Bringing in these outside experts should not represent
a problem for local officials, he suggests, since CDC already has strong
ties with state epidemiologists.
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