Preparing for Patient Zero
Posted Nov. 16, 2001
By Timothy W. Maier

Concern is growing privately within the government and among health officials that Osama bin Laden or the terrorist states that support him may have obtained a weaponized version of the smallpox virus. Bin Laden has made no secret of his intention to acquire such a biological weapon for use in his jihad against Christians, Jews and others he regards as infidels. If he has obtained it, the nightmare of terrorism may just be beginning.

Consider this: According to public-health professionals, an outbreak of smallpox in the United States would kill about 1 million people in three months. How big an outbreak? One case of smallpox. And if even one case turns up, make no mistake, it will be no accident and immediately regarded as an act of terrorism. Writing for the Wall Street Journal, Elizabeth Whalen, president of the American Council on Science and Health, says one case would mean "epidemic and worldwide catastrophe." The patient would be isolated and all contacts vaccinated. Instead of ground zero, it would be "patient zero."

Fifty years ago the United States was prepared to handle such an outbreak. While most people then received a smallpox vaccination in childhood, the experience of that time provides hope for the future. The outbreak occurred in New York City in 1947 when a man arrived from Mexico very ill with smallpox. Doctors missed the diagnosis until two other cases were detected. Everyone was isolated and a decision was made by public-health authorities to inoculate 6 million Americans. The result? The epidemic was controlled, with only 12 cases being reported.

Some doctors say better technology and medical knowledge will provide even quicker responses should such an incident recur. But others are not so sure because smallpox easily can be missed or misdiagnosed by doctors who never have seen the disease.

Often confused with chicken pox, smallpox is a contagious viral infection that causes high fever, a blistering and painful rash and disfigurement. It has a 30 percent mortality rate. The disease is spread by breathing into someone's face, by infected saliva or by respiratory droplets. It also can be transmitted on linens or clothes. After being infected with smallpox the patient is not contagious for about 12 days until a high fever sets in and a rash, or pox, becomes apparent. Death then can come within 48 hours.

Although it was not indigenous to the New World, smallpox is no stranger in the United States. Because they had no immunity to the disease, whole tribes of American Indians died of it. Smallpox was even used in germ warfare against the Ottawa under Chief Pontiac in the summer of 1763 by Lord Jeffrey Amherst, commander of British forces in North America during the French and Indian War (1754-1763). Historical records show that Amherst approved the sending of smallpox-infected blankets and handkerchiefs to the tribe as it besieged Fort Pitt, now Pittsburgh, in the wilds of Pennsylvania. In his own hand he authorized use of any means "to extirpate this execrable race"; within two weeks a smallpox epidemic began wiping out Chief Pontiac's tribe.

Worldwide use of vaccination eventually brought the disease under control. The last documented case of smallpox was in 1977 in Somalia; two years later the World Health Organization declared it eradicated. The United States stopped its vaccination program in 1972 because there was almost no risk of contracting the disease here and many people had experienced severe side effects from the shots.

In recent years there have been just 15 million doses of the vaccine, and those were stockpiled for U.S. troops. But last year the military restored its vaccine development for smallpox after U.S. intelligence learned that Iraq and North Korea had produced smallpox virus for germ warfare. The U.S. Centers for Disease Control and Prevention (CDC) in Atlanta, and a Russian virology installation in Siberia called "Vector," reportedly are holding smallpox virus in freezer repositories.

Acambis PLC, which manufacturers a new smallpox vaccine, has contracted to deliver 40 million doses to the federal government by next year. Meanwhile, the Food and Drug Administration (FDA) is studying ways to dilute the stockpiled 15 million doses to allow more people to receive the vaccine should an emergency arise.

Most Americans younger than age 40 have not been vaccinated for smallpox, and many of those who have been are no longer protected 10 years after receiving the shot. But some doctors suggest those with outdated vaccinations who come in contact with smallpox infection are not likely to get as sick as others and may have a better chance of surviving.

Health and Human Services Secretary Tommy Thompson says he is against implementing a plan to inoculate all Americans against smallpox, noting the number of severe side effects associated with the shot. The Wall Street Journal recently suggested that inoculating about 280 million Americans might result in 600,000 vaccination-related deaths. However, many doctors insist the new vaccine likely will be less dangerous, reducing mortality rates.

"The vaccine is relatively safe," says Jon Adler, a Harvard-based emergency physician at Massachusetts General Hospital and chief medical officer of eMedicine, an educational Website for health-care professionals. "Previous data show that about one in 1.1 million who get the vaccine will die. Most of those people die from reaction and infection in the brain."

Most experts believe the smallpox threat is not as severe as the mass media have portrayed it. Between 1980 and 1999, the State Department reported 9,925 worldwide terrorist acts, but only 16 were biological or chemical attacks that injured five or more people, according to the Center for Nonproliferation Studies in California and the Henry L. Stimson Center in Washington.

The Bush administration has downplayed the threat, suggesting that other scenarios are more likely, such as terrorist strikes against bridges. A smallpox attack "tends to be more of a Hollywood scenario. I see it as a threat. I don't see it as an immediate threat," said Vincent Cannistraro, former chief of counterterrorism operations for the CIA, in testimony before the House International Relations Committee.

Yet Insight has learned that behind the scenes the administration is preparing for the unthinkable. Hospitals are on alert for any strange outbreak and the CDC has provided a list of recommendations to the 50 state governors — including using sports stadiums to quarantine victims of the disease. Public-health officials also are looking for ways to close roads and airports and even to quarantine whole cities should an outbreak occur.

There is no way U.S. hospitals could find beds for the many hundreds of smallpox patients should an outbreak occur. Doctors likely would prefer that smallpox patients stay at home where they could be treated by on-call health-care workers. There is in any case very little that doctors can do other than to make patients as comfortable as possible by giving them pain medication.

"If you get smallpox within one or two weeks you are going to have high fevers, backaches and be pretty sick," Adler says. "This is before you get that rash. You tend not to feel like going out, and that will help limit the disease. The good news is you are not as contagious until you get that rash."

Meanwhile, the nation is far from prepared for that first harbinger of epidemic. "A recent simulation of smallpox in three Western states called 'Dark Winter' showed the weaknesses of the American health-care system to deal with such a crisis," says Jim Matthews, an associate professor of pharmacology at Northeastern University's Bouve College of Health Sciences in Boston. The simulation, devised by the Johns Hopkins University Center for Civilian Biodefense Studies, presumed a covert attack with leading politicians and the public as targets of bioterrorism using smallpox.

The result? The nation's health-care system quickly was overwhelmed in the simulation and thousands "died." The study found that the paucity of vaccine to prevent the spread of disease limits management options and that the U.S. health-care system is unprepared to deal with mass casualties. Therefore the actions of private citizens will be critical if this contagious disease is to be contained, says Douglas E. Goldstein, author of e-Healthcare: Harness the Power of Internet e-Commerce & e-Care.

It takes only about 1 gram, or one-quarter of a teaspoon, of this biological weapon to infect 100 people, Goldstein says. "In security terms, the initial outbreak starts small and builds in successively larger waves approximately two weeks apart. Failure to stop an outbreak early and fast means that the waves will accumulate into a tsunami spreading across the country and globe."

Nevertheless, Matthews believes the chance of an outbreak is very small as long as the current stocks of smallpox remain secure. A terrorist would have to grow the virus in eggs or animal cells and then find a method to disseminate it. "Only state-sponsored groups could develop this type of weapon" and produce an efficient delivery system, Matthews adds. "However, if the terrorists did not care about survival, as Sept. 11 might indicate, they could infect a few colleagues and travel to targets during the incubation stage and spread the disease on airplanes, subways — anywhere people crowd — once the rash begins."

If that happens, doctors fear they are far from ready to deal with it. Adler says, "Most of us have had no experience dealing with smallpox other than maybe a brief 10-minute lecture in med school. We are now playing catch-up with seminars and courses." And the crash courses may not be enough.

Audrey Kunin, the president of DERMAdoctor.com Inc. in Kansas City, Mo., warns that terrorists are fully aware of U.S. vulnerability. Kunin, who speaks frequently on the dangers of bioterrorism, says American charity could be the instrument of our next bioterrorism threat. As the holiday season approaches the nation will engage in thousands of clothing, blanket and food drives, she notes. "Can you imagine the devastation that could be wrecked by a terrorist cell infecting large numbers of blankets and clothing with smallpox particles," she asks, "and dropping them off to unsuspecting volunteers, leading to undetected widespread infection?"

Kunin says, "Turning our charity against us would be warped and evil. But it's as easy as throwing a letter in a mailbox since blankets dropped at a Salvation Army collection bin could be laced with smallpox. Charitable organizations therefore need to be on the lookout for large donations so that they can track them back." She also emphasizes that those handling such items need to take precautionary steps such as wearing gloves and diligently tracking donations by requesting identification from donors.

The smallpox virus is invisible. "Short of dropping a Clorox-based solution on the items when you collect them, not much can be done," Kunin adds. "But there has to be an awareness. Every charitable group needs to have some mechanism in place with standards for dealing safely with donations."

Goldstein advocates setting up a nationwide reporting Website that physicians could go to for help. Some of the anthrax victims "could have been saved through early detection and rapid response," he says. If a terrorist released smallpox in an airplane carrying 40 passengers and 10 days later the victims show up in hospitals across the nation, having a reporting system available via the Internet to connect all health-care workers would be crucial. "We need reporting tools for medical professionals to identify medical patterns of illnesses," Goldstein says. "The Internet can be used to energize hospital and health-care leaders. We have to be ready. This is a public-health issues, and the medical profession must come up to speed."

Frederick Harchelroad, director of medical technology at Allegheny General Hospital, says that recently he had a patient come in with a rash and wondered if the outbreak had started. Fortunately, the patient did not have smallpox. But "we will quickly be depleted of health-care professionals if there is an outbreak," Harchelroad says. "It is going to take a million dollars per hospital to get up to speed to handle an outbreak."

While Congress is considering a number of bills to pump millions of dollars into the public-health industry, there appears to be some hope for possible treatment. Epidemiologists tell Insight they believe the vaccine itself, if given three or four days after infection, may prevent or reduce the seriousness of the illness.

In addition, cidofovir, an antiviral drug produced by Gilead Sciences of Foster City, Calif., holds some promise. Sold under the name VISTIDE, the drug won FDA approval in June 1966 for treatment of cytomegalovirus retinitis, a sight-threatening illness associated with AIDS. Since then, the U.S. Army Medical Research Institute of Infectious Disease has reported that cidofovir has been used to prevent death and disease linked with a pox illness in monkeys (monkeypox, which is similar to smallpox in humans).

In the meantime, Harchelroad says Americans should listen to what "your mother told you" for your own protection. "Wash your hands, don't drink from the same cup, don't cover your mouth when you cough but cough away from yourself," he advises. "And if someone coughs in your face, slap them silly."

Timothy W. Maier is a writer for Insight.