Date: February 21, 1999
Abstract: 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.
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, andmany 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.
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 demandingit. 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." (SFSU, 1999).