Doctors play out bioterrorism scenario

About bioterrorism

By LAURAN NEERGAARD

WASHINGTON (February 21, 1999 11:50 a.m. EST
http://www.nandotimes.com) - Terrorists contaminate an
auditorium with silent, odorless smallpox just before a
political rally. Soon, emergency rooms see mysterious
illnesses. By the time doctors diagnose smallpox,
coughing patients are spreading the lethal virus
around the globe.

This time it was a test-run.

Doctors, hospital workers and U.S. health leaders
used that fictional scenario, set in Baltimore, to test
how they would control disease if bioterrorists ever
attack - debating step by step how to quarantine, shut
down airports, control panic when vaccine runs out.

How did the trial run go?

"We blew it," said a grim Michael Ascher, California's
viral disease chief.

If an attack really had happened, it would have taken
just three months for 15,000 Americans to catch
smallpox, 4,500 to die and 14 countries to be
re-infected with a disease thought wiped out decades
ago.

"We would be irresponsible if we left this room and
didn't remedy this," said Jerome Hauer, New York
City's emergency management director.

How can doctors prepare? The test-run offers clues.

The fictional scenario begins:

     April 1. The FBI gets a tip terrorists might
     release smallpox during the vice president's
     speech at a Baltimore college. The tip is too
     vague to warn health officials. Smallpox
     incubates for two weeks so no one has yet
     become sick.
     April 12. A college student and electrician come
     to the emergency room with fever and other
     flu-like symptoms. Doctors suspect mild illness,
     maybe flu, and send them home.
     April 13, 10 a.m. Both patients are back, sicker
     and covered in a rash. Doctors now suspect
     adult chickenpox. The two are hospitalized.
     6 p.m. An infectious disease specialist is
     puzzled. That rash doesn't really look like
     chickenpox, and it's popping up in places
     chickenpox normally doesn't afflict, like the soles
     of the feet. More testing suggests it might be
     smallpox.
     8 p.m. Because smallpox is spread through the
     air, officials seal the hospital, telling visitors and
     staff they can't leave but not why. Frightened
     hospital visitors alert TV news crews, who report
     rumors of the dreaded Ebola virus.
     3 a.m. The Centers for Disease Control and
     Prevention confirms it's smallpox, and ships
     some of the nation's 6 million doses of smallpox
     vaccine to Baltimore. The mayor will announce
     the bad news at noon.

Is this scenario realistic? It's optimistic, said Gregory
Moran of the University of California, Los Angeles. A
typical hospital would take at least another full day to
even suspect smallpox. Labs would test for other
diseases first, and many don't have the equipment to
hazard a smallpox guess.

"Half of the health care workers would try to leave the
hospital out of panic," added Minnesota state
epidemiologist Michael Osterholm.

Who's in charge? The governor should go on TV and
tell the public the truth fast - what are the symptoms,
who's at risk, how are doctors fighting back - to limit
panic, advised former Minnesota Gov. Arne Carlson.

But a smallpox outbreak can only be terrorism, so
watch Washington seize control, others say. After all,
the FBI has to hunt the terrorists.

Sealing the hospital actually fuels fear, Osterholm
contends. Getting vaccinated a few days after
breathing smallpox is soon enough to stay healthy and
not spread infection, so let visitors and staff go home
until the vaccine arrives.

No, get everybody vaccinated: "That's total damage
control," Ascher argued.

Could anyone quarantine the city? If this happened in
Minnesota, thousands would flee to Canada, Carlson
said, but the governor couldn't seal the state's
borders. Canada might.

The scenario continues:

     April 16, 7 a.m. FBI, CDC, White House and
     hospital workers are debating via conference
     call. Do they vaccinate everyone? No, just
     people who came into contact with sick patients.

     Hospitals report other cases of mysterious
     fevers and rashes. By day's end, CDC counts
     48 smallpox cases - 10 in nearby states, so it's
     spreading.

     Noon. The president addresses the nation,
     saying the attack may have occurred April 1. It's
     too late for vaccine to help anyone exposed that
     day.

No wonder the fictional epidemic is spreading - notice
that nobody closed the airport. John Bartlett of Johns
Hopkins University can't believe that other cities would
accept travelers from a region experiencing smallpox.

You're seriously underestimating public panic,
Osterholm adds. He recalled watching a simple, tiny
meningitis outbreak paralyze a Minnesota town, as
traffic snarled while people demanded vaccine.

"Doctors need to know what to do," added Moran:
Hospitalize everyone with mild fevers, or send them
home?

Hospitalization would require rooms with special
ventilation systems to keep the virus from spreading
through the building. Such rooms are rare, 450 in all of
Minnesota, for example.

Back to the pretend scenario:

     April 18. The first victim, the college student,
     dies.
     April 29. Two hundred are ill in eight states.
     Canada discovers two victims, Britain another.
     People with mild fevers jam hospitals. Doctors
     tell them to stay home so they don't breathe on
     others - there are no hospital beds left.
     Unvaccinated health workers walk off the job.
     CDC announces there's not enough vaccine for
     the millions demanding it. Governors ration the
     shots. Public anger is fueled at press reports
     that the president, Congress and military were
     quietly vaccinated.
     April 30. A well-known college basketball player
     dies of hemorrhagic smallpox, massive bleeding
     instead of the more typical rash. TV stations get
     confused and report he died of hemorrhagic
     fever like Ebola. Doctors scramble for a
     correction.

This daylong role-playing is doctors' first chance to
learn how complex fighting bioterrorism could be, said
Hopkins' Tara O'Toole, who wrote the test case. Cities
and states are used to dealing with earthquakes or
plane crashes, but a spreading infection is totally
different.

Who's in charge? How do you physically vaccinate
100,000 people in a day? How do you ration scarce
vaccine so only the at-risk get it, not the hysterical
healthy or the pushy politicians?

"If there's even a possibility this could happen, health
departments have to prepare. ... But they've never
looked at the big picture," O'Toole said. "You're
hearing everybody confess they need to do a lot."

In the fictional scenario, a month has passed:

     May 15. All U.S. vaccine is gone. The president
     declares the worst-hit states are disaster areas.
     Thousands more become sick before the
     epidemic finally slows in June.

The real-life doctors absorb the grim ending with brief
silence. Then come calls for state health workers to
plan how they would better fight bioterrorism in case it
really happened.

"I don't want the audience walking away thinking,
'Damn, there's nothing we can do,'" Osterholm said. "If
this meeting does nothing else, it should ensure we
get an adequate supply of smallpox vaccine (stored)
as soon as possible."