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Scenarios: Smallpox

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Smallpox Bioterrorism Scenarios

"Dark Winter": A Bioterrorism Exercise, June 2001
Scenario: An Intentional Smallpox Epidemic, February 1999
Scenario: Smallpox Attack on a Shopping Mall

DARK WINTER: A Bioterrorism Exercise
June 2001

A two-day bioterrorism exercise, code-named "Dark Winter", was held at Andrews Air Force Base, Washington D.C., June 22-23, 2001. Developed and produced by the Center for Strategic and International Studies, Johns Hopkins Center for Civilian Biodefense Studies, and ANSER Institute for Homeland Security. Sponsorship was provided by the McCormick Tribune Foundation and the Oklahoma City National Memorial Institute for the Prevention of Terrorism (MIPT).

"Dark Winter" is a role-playing exercise based on a fictional bioterrorist attack on the U.S. Former senior government officials play the roles of National Security Council (NSC) members, with former Senator Sam Nunn as the U.S. President, former Central Intelligence Agency director R. James Woolsey as the head of CIA, Jerry Hauer as FEMA director, and Dr. Margaret Hamburg as Secretary of Health & Human Services. Medical experts included Dr. Tara O'Toole of Johns Hopkins Center for Civilian Biodefense Studies.

This is a fictional scenario. The background to the story goes like this: six months earlier, the U.S. lifted sanctions against Iraq and ceased enforcement of the "no-fly zones." Since then, Saddam Hussein has aggressively worked to strengthen his military forces, including imports of equipment and material that could be used to produce chemical and biological weapons. Several top scientists from the former Soviet bioweapons program have been recruited to Iraq. Al Daura, a vaccine plant outside Baghdad, closed by U.N. inspectors after the Gulf War, is now back in full production. Officially it manufactures vaccines against Foot & Mouth disease, but western intelligence sources suspect that it's actually weaponizing germs for warfare.

In the scenario, Iraq has recently moved large military forces into offensive positions near the Kuwaiti border, officially as a part of a routine military exercise. Kuwait, the United Arab Emirates and Bahrain have asked for American, British and France military forces to defend the area against a possible attack. Russia and China oppose Allied troops.

The role-playing begins: as the U.S. National Security Council discusses the Iraq-Kuwait situation, the Centers for Disease Control (CDC) reports one confirmed and twenty suspected cases of smallpox in Oklahoma City. Presumably, this is a bioterrorism attack, with the virus deliberately introduced.

Emergency rooms in Oklahoma City soon become extremely crowded, while many hospital staff don't show up for work the day after the first case is reported on CNN. The Governor of Oklahoma requests that each and every one of the 3.5 million citizens of the state receive the smallpox vaccine within the next 72 hours. The Oklahoma National Guard is put on alert. The Governor declares a state of emergency, and requests that the President invoke the Stafford Disaster Relief and Emergency Assistance Act. (The Stafford Act provides extra assistance to state and local authorities in catastrophic disasters, and also allows the national government broader powers to respond to the crisis, such as the use of active-duty soldiers.)

The exercise outlines a fictional scenario where Iraq has launched a covert bioterrorism attack with smallpox against shopping malls in three U.S. states — Oklahoma, Pennsylvania and Georgia. Nine days after the presumed exposure there are 20 lab-confirmed and 14 suspected cases in Oklahoma City, 9 suspected cases in Georgia and 7 in Pennsylvania.

For the purposes of this exercise, the U.S. stock of smallpox vaccine is estimated at 12 million doses. (In reality, the U.S. had stockpiled 15.4 million doses, and recently it was discovered that more than half of the doses had been destroyed, or were of questionable quality. Experts estimate that less than 7 million people could be vaccinated as of 2001.)

In the exercise, the total world supply is estimated at 60 million doses, with half in South Africa. There are concerns that some non-U.S. vaccine may be ineffective, and may also have a higher rate of side effects.

Initially 100,000 doses of vaccine are released for Oklahoma, with the same amounts prepared to be sent to Pennsylvania and Georgia, pending lab confirmation of suspected cases in those states. Because of the limited vaccine stock, the decision is made to minimize the use of vaccine. The only civilians to be vaccinated are close contacts, healthcare personnel and investigators in case states. 2.5 million doses are reserved for the military and the National Guard.

At the early stages of the outbreak smallpox patients and suspected cases are isolated at hospitals and quarantine centers, but quarantine is not forcibly imposed. With the numbers of cases rising, some states have attempted to keep smallpox patients and contacts in their homes, but it is difficult to supply food and supportive care to those affected. The Department of Justice has received credible claims that individuals with symptoms similar to smallpox have been illegally arrested or locked up in designated "isolation wards." Some otherwise healthy people have been placed in quarantine units without vaccination — together with people who have the disease.

Man with smallpox. Photo: CDC/NIP/Barbara Rice.

As the scenario progresses, two weeks after the presumed attack there are 2000 cases in 15 states, with 300 deaths. A total of three million doses of smallpox vaccine have been sent to Oklahoma, Pennsylvania and Georgia. Shipments of 500,000 doses delivered to each of 12 affected states. Five days after the first case was diagnosed only 1.25 million doses of vaccine remain.

TV stations show footage of a mother in tears, pleading for vaccine, while being pushed back by riot police. The National Guard has been called in to suppress violence at vaccination clinics, where angry crowds demand vaccination. Educational institutions, sporting events and other public gatherings have been closed. Some states have closed transportation links, including airports. The Governor of Texas has decided to use his emergency powers to order Texas National Guard Units to assist the State Police in suspending individuals from Oklahoma trying to enter Texas without proof of recent smallpox vaccination. Many countries have closed their borders to unvaccinated travelers from the U.S. The economical impact might result in billions of dollars in international trade losses. Food shortages are reported from some cities. Dangerous misinformation and rumors are spread on the Internet and in other mass media.

A National Security Council committee of medical and public health experts make recommendations on disease containment, including:

  • "mandatory isolation of all smallpox victims in hospitals or preferably dedicated facilities"
  • support from the Department of Defense to run "dedicated smallpox treatment centers"
  • voluntary home isolation of people who have been in contact with smallpox cases, with DoD and National Guard staff to provide food and medical monitoring.
  • federal travel restrictions
  • cancellation all public gatherings in states with smallpox cases

By day six of the crisis, vaccine supplies are dwindling. An additional supply, from the United Kingdom (500,000 doses) and Russia (4 million doses), last for only a couple of days. The NSC develops a plan to use private pharmaceutical facilities in the U.S. to produce about 12 million doses of an unlicensed smallpox vaccine per month. But first delivery would be 5 weeks from the current time.

Near the end of the role-playing exercise, about three weeks after the fictional bioterrorism attack, a second generation of cases begins to appear. During the past 48 hours, the number of cases has skyrocketed with 14,000 new smallpox patients confirmed in 25 states, among them the large population centers of New York, California and Florida.

Smallpox is an extremely contagious disease. A single case can infect 10 to 20 others, and this can go on for generation after generation (or wave after wave), with a rapidly increasing number of infections at each step. The second generation, outlined in this exercise, would be followed by a third, a fourth and so on.

The exercise closes with a simulated projection of generations 3 and 4. The participants project 30,000 new cases and 10,000 deaths at the end of generation 2, followed by 300,000 cases two and a half weeks later (end of generation 3), and 3 million cases, with 1 million deaths, an the end of generation 4.

With a vaccine supply enough to immunize less than 5 percent of the population, the infection rate would continue to increase tenfold every two to three weeks, according to medical experts. Continuing this grim calculation, that would mean 30 million cases, with 10 million deaths in the fifth wave. And then, two to three weeks later, a final wave sweeping the nation and killing off nearly one out of every three Americans.

Lessons From "Dark Winter"

The "Dark Winter" role-playing exercise brought to light major weaknesses in the U.S. health care system:

  • U.S. doctors and nurses have no smallpox experience
  • no rapid diagnosis of the disease
  • no treatment available for those infected
  • a lack of protective clothing, masks, gloves, and gowns
  • isolation rooms at hospitals for highly contagious smallpox patients is in short supply
  • no surge capacity; lack of staff and hospital beds
  • the public health system and hospitals get overwhelmed by the enormous increase in patient demand
  • insufficient supply of smallpox vaccine

The exercise also exposed many serious weaknesses in U.S. bioterrorism preparedness. The most serious weakness is probably the insufficient supply of smallpox vaccine. Without a much larger supply of vaccine, the contagion would continue to run its course, until there are no more victims to be found.

"If there is only one dose of smallpox vaccine for every 23 Americans, whom do you vaccinate?" asked former senator Sam Nunn (D) in a testimony before the House Government Reform Committee, Subcommittee on National Security, Veterans Affairs and International Relations.

Frank Keating, the governor of Oklahoma, who played himself in the exercise, said "Vaccination cannot stop the spread if you don't have enough of it."

The drill also raises questions about civil liberties in a time of bioterrorism crisis. "Do you seize hotels and convert them to hospitals?," asked Nunn. "Do you close borders and block all travel? What level of force do you use to keep someone sick with smallpox in isolation?"

Another important lesson, echoed by multiple other exercises and studies, is that state and local public health agencies don't have the necessary resources to handle a bioterrorism attack.

"We have a fragmented and underfunded public health system — at the local, state and federal level — that does not allow us to effectively detect and track disease outbreaks in real time," said Keating.

When it comes to a bioterrorist attack, too much focus has been placed on the military and too little on the public health side, said Tara O'Toole, deputy director of the Johns Hopkins Center for Civilian Biodefense Studies, who portrayed a top federal health official in the exercise.

The CDC has a budget of only $40 million each year to help modernize local public health agencies with bioterrorism training, updated labs and surveillance systems. And while last year Congress backed an increase to $500 million per year, the money has not been approved, said O'Toole.

The simulation also exposed "fault lines" and "disconnects" between local, state and federal officials, raising serious questions about who would spearhead activities in the event of an attack.

"Our Lack of Preparation is a Real Emergency"

"Dark Winter showed just how unprepared we are to deal with bioterrorism," said Jerome M. Hauer, the former head of emergency management in New York City and now a bioterrorism consultant to Tommy G. Thompson, the secretary of the Department of Health and Human Services. "It pointed out that there were significant challenges to all levels of government."

"I was honored to play the part of the President in the exercise Dark Winter", said Sam Nunn in his House Committee testimony.

"You often don't know what you don't know until you've been tested. And it's a lucky thing for the United States that — as the emergency broadcast network used to say: 'this is just a test, this is not a real emergency.' But Mr. Chairman, our lack of preparation is a real emergency."

Visit the Johns Hopkins Center for Civilian Biodefense Studies site to find out much more about "Dark Winter."

Sources: Johns Hopkins Center for Civilian Biodefense Studies; Washington Post, Reuters and Yahoo News/AP, July 24, 2001.

SCENARIO: An Intentional Smallpox Epidemic
February 16-17, 1999

A scenario held at the First National Symposium  on Medical and Public Health Response to Bioterrorism. Among the participants; Tara O'Toole, D.A. Henderson, Michael Osterholm and Jerry Hauer.

In this role-playing exercise, the scenario is that a terrorist group with suspected links to a "rough state" (a country unfriendly to the U.S.) makes an aerosol attack with smallpox at a local university in the fictional city of Northeast, during a visit by the vice president.

Eleven days later two patients visit the university hospital emergency room. Both patients, with flu-like symtoms, are sent home with instructions to drink fluids and take ibuprofen. The next day four more students come to the same emergency room with similar symptoms, and are sent home.

Two weeks after the attack the first patient returns to the ER after collapsing in class. The patient, now acutely ill, has blisters on her face and arms. She's diagnosed with chickenpox and admitted to an isolation room. The following day the second patient, very ill, comes in with similar symptoms. He's also diagnosed as having chickenpox and is assigned to an isolation room. A swab specimen examined by electron microscopy shows an orthopoxvirus consistent with the smallpox virus.

The hospital epidemiologist declares a contagious disease emergency and the two patients are moved to isolation rooms specially designed to control contagion. City and State Health Departments, the the Centers for Disease Control and Prevention (CDC) and the FBI are contacted. The CDC sends a three-person "Epidemic Intelligence Service" team to assist the local health authorities. Biological samples are sent to the CDC's Biosafety Level 4 laboratory in Atlanta, Georgia. The diagnosis of smallpox is confirmed.

The emergency is discussed in conference calls between the CDC, FBI, HHS, the National Security Council, and state health authorities. After considering a full quarantine of Northeast, including shutting down the city airport and banning rail traffic, the group agrees such a step is neither realistic nor necessary. The state health commissioner pushes for enough smallpox vaccine to vaccinate the entire city of Northeast. The CDC and FBI are unwilling to begin mass vaccinations at this stage. Instead, the group decides that all hospital staff and visitors to the floor where the patients are located should be vaccinated, as should other contacts of the patients. The long phone conference ends with a decision to vaccinate all healthcare personnel, first responders, police, and firefighters in any city with confirmed cases of smallpox.

A decision is made to turn the university hospital into a smallpox hospital, accepting new patients and patients from other hospitals. The state health commissioner activates a state disaster plan, which convert the armory into an emergency hospital for the possible quarantine of a larger number of smallpox patients.

The next day, 35 more cases are diagnosed in the city of Northeast, with 10 addional cases in a nearby state.

Seventeen to eighteen days after the attack, about 30,000 selected individuals are vaccinated in Northeast.

By day 19, the number of confirmed cases have climbed to 50.

By day 20, 80,000 have been vaccinated.

Three weeks after the attack, a second generation of cases are recognized by the CDC. An additional 300 new cases of potential smallpox are reported, with most of the cases in the original state, but including cases in eight other states. Two cases are reported from Montreal and one case in London.

The U.S. government announces that 90% of available vaccine stocks will be distributed to affected states, but cautions that this stock of vaccine will only be enough to vaccinate about 15% of the population in infected states. Federal officials also announce an accelerated crash vaccine production program that will cut smallpox vaccine production time to two years.

Three days later. There are now more than 700 reported cases worldwide.

During the third generation of the epidemic, days 46 to 59, the vaccine supplies are exhausted. About 7,000 cases will have been reported.

Sixty days after the attack, a fourth generation of cases ensues. Fifteen thousand cases of smallpox will be reported in the United States. The cases are spread over twenty states and four countries. The death rate is 30%.

This is where the scenario ends, with no ending of the outbreak in sight.

Michael Osterholm, epidemiologist, bioterrorism expert and co-author of the book Living Terrors, about the bioterrorism threat, commented:

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

Sources: ERRI Daily Intelligence Report, Vol. 5 — 053, February 22, 1999. Nando Times, Associated Press, February 20-21, 1999. First National Symposium on Bioterrorism:

Smallpox: An Attack Scenario by Tara O'Toole, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.
Scenario: An Intentional Smallpox Epidemic Table Top exercise with D. A. Henderson, John Bartlett, Michael T. Osterholm, Jerome Hauer and others.
Aftermath of a Hypothetical Smallpox Disaster
Jason Bardi, freelance writer.

Scenario: Smallpox Attack on a Shopping Mall

Michael T. Osterholm, an epidemiologist and bioterrorism expert, and John Schwartz, science reporter at the New York Times, have outlined an anthrax bioterrorism scenario in their book Living Terrors: What America Needs to Know to Survive the Coming Bioterrorist Catastrophe.

In this scenario, the terrorist is a Russian immigrant in the United States, a former scientist from the Soviet Union biowarfare program. Yuri becomes unemployed when President Yeltsin closed a Biopreparat germ factory in Noviosibirsk. (Biopreparat was the name of the former Soviet Union's biowarfare program.) He is approved for a U.S. visa, and leaves Russia with a tiny sample of the smallpox virus, three miniature metal vials hidden inside a fountain pen. He is not afraid to smuggle it into the U.S., because he has already been vaccinated, and because he knows it will be worth an astronomical amount of money.

He is disappointed by his new homeland and has come to hate it. He was angry and lonely even back in the "good old days" in Russia, when he weaponized lethal germs for a living. Now, he is more than just a disappointed researcher. He is ready to commit terrorism.

Yuri makes an attempt to contact Middle Eastern terrorists by approaching an Arab organization in Chicago. They don't seem interested, but one day he finds an anonymous letter slipped under his door. The letter tells him he will soon earn big money.

A second note follows two days later, with instructions for meeting in a public place. After about an hour the two men have a deal. Yuri promises to get ready to deliver the smallpox virus, with seventy-two hours notice, at a place chosen by his client. The payment for this "little errand" is $50,000, just for starters.

He uses his small homemade laboratory to grow a smallpox culture in eggs from a local store. At Thanksgiving, he gets another message. This one tells him to deliver his deadly weapon at a large, well-known mall during the first day of Christmas shopping rush.

Yuri attaches an aerosolizer with a timer to a wall close to an air circulation vent. Half an hour later an invisible, odorless, thin mist of smallpox virus fills the seven-story building and thousands of shoppers will breathe it into their lungs. Many of the 100,000 shoppers who are visiting the mall will become like smallpox weapons themselves, unknowingly spreading the disease to others.

Nearly two weeks after the attack a large number of patients show up at doctors' offices and emergency rooms in the area. Most of the patients have fever, headaches, backaches and vomiting. But it's flu season, so these patients are diagnosed as such and sent home with the advice to drink fluids and rest. Some of the most severe cases are tested for meningitis and other diseases with flu-like symptoms, but the results are negative and nobody suspects smallpox — an eradicated disease of the past.

A day later, one of the first patients returns to the hospital. He's now seriously ill, is acting delirious, and has red blisters on his face. The doctors suspect chickenpox and the patient is given an isolation room.

The following day, an infectious disease expert walks through the ER and recognizes the characteristic smallpox rash on many patients. She convinces the city's health director to contact the CDC to raise the alarm.

The city health department of Chicago learns that many deathly ill patients have been admitted to local hospitals, and that there are at least hundred cases of smallpox in the city. Additional cases are reported from other places in the region. The public reacts with fear when the outbreak is announced, and many families rush to their supermarket to stock up on food and other necessities.

By the next day people are flooding local hospitals, creating a desperate shortage of beds and staff. The Secretary of Health of Human Services suggests the creation of a tent city in the outskirt of town for the growing number of smallpox patients. The health commissioner rejects the proposal, pointing out that there is already a shortage of trained personnel. The governor insists on an immediate airlift of vaccine, but the HHS replies that such a decision is up to the government.

The city's health director suggests a system where smallpox cases are taken to treatment facilities (where no treatment is currently available), and exposed family members are forcibly quarantined at home. The police chief refuses to order his officers to use force-for fear that they may even shoot unarmed civilians who may be infected. The HHS secretary replies that not enforcing quarantine will kill many more people, possibly hundreds of thousands.

The first wave of smallpox includes nearly 9,000 diagnosed cases in ten states, with 75% in the urban areas. Two weeks later, it's estimated that more than 80,000 people will be infected, with about 60,000 in cities. A third wave, another two weeks later, could infect 300,000 to 1 million people. A third of all smallpox cases will die if they don't receive smallpox vaccine at a very early stage of the disease.

The scenario continues with the authors describing how things are starting to fall apart in the city. Power is out in some neighborhoods, and broken water and sewer pipes aren't fixed because people are not going to work. Beef sales from the area have plummeted because people in other parts of the country fear that the meat supply might be contaminated with smallpox.

A small supply of vaccine has been sent to the city. Because of an extreme shortage of smallpox vaccine, this supply is for use by healthcare workers only.

The authors tell the story of one character that avoids quarantine in a treatment facility — where he knows he will be infected. He is shot to death while trying to escape the city because he doesn't want to be quarantined.

The scenario ends with an outline of a successful response to a smallpox outbreak in nearby Milwaukee. Here, public health officials, medical professionals and others are better prepared to handle such a crisis. The number of cases in Milwaukee levels off at 5,000, with 1,300 deaths. In Chicago, there are already 140,000 deaths, and no end of the epidemic in sight.

Osterholm and Schwartz deliver many important insights into how a smallpox outbreak might be contained. The most important is probably this one: " Smallpox is like a fire — the quicker a fire wall can be built, the better." Another insight, closely related: we need to produce and stockpile larger quantities of the smallpox vaccine.

Source: What America Needs to Know to Survive the Coming Bioterrorist Catastrophe, by Michael T. Osterholm, John Schwartz, Delacorte Press, 2000.


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