Last Updated

13 Dec 2002

Source: Wall Street Journal, December 18, 2001.

SPECIAL REPORT: AFTERMATH OF TERROR

CDC Trains State, Municipal Officials To Handle Outbreaks of Smallpox

By CHAD TERHUNE, Staff Reporter of THE WALL STREET JOURNAL

ATLANTA -- Terrorists release smallpox and within days hundreds of people fall ill. Thousands more may be exposed. Where do you put them all? The big downtown hospital or a motel on the outskirts of town?

That was among the biggest questions Monday for more than 200 state and municipal health officials attending the first federal training session for smallpox response in three decades. The U.S. Centers for Disease Control and Prevention convened the three-day conference in Atlanta to share information on diagnosis, treatment and containment of the deadly disease.

Mike Lane, retired director of the CDC's smallpox eradication program in the 1970s, told the audience he favored the "Motel 6 scenario" where smallpox patients and people they have come in contact with are isolated in a suburban motel or remote government building, such as a state mental hospital.

Peter Havens, professor of pediatrics and epidemiology of the Medical College of Wisconsin in Milwaukee, told the group hospitals could successfully treat some smallpox cases.

But Dr. Lane argued that the disease would spread easily in a large hospital due to the number of patients there with weakened immune systems. "You can bring care to the patient if you elect to use the Motel 6 on the edge of town," Dr. Lane said.

Dr. Havens acknowledged that "in-hospital spread seems certain."

Smallpox, caused by a virus known as variola, is typically spread through an infected person giving off saliva droplets during face-to-face contact. The disease kills between 20% to 30% of those infected, but smallpox researchers said new treatments available today may lower the mortality rate.

Ross Brechner, an attendee and Maryland's state epidemiologist, said he is drawing up his list of quarantine sites now, focusing on state buildings that could be emptied fast and turned into smallpox wards. "I think when trying to set up the logistics of this it will almost be insurmountable," Dr. Brechner said. "Who will I call? Who is triaged first?"

The last known case of smallpox in the U.S. was in 1949, and the disease was eradicated globally by 1980. But in the wake of the Sept. 11 terrorist attacks and the recent spread of anthrax through the mail, health officials are rushing to prepare for a possible reintroduction of the disease.

CDC officials and veterans of the earlier smallpox eradication effort instructed health officials from nearly every state and several major cities on setting up "smallpox strike teams" that would search for potential cases and anyone they were in face-to-face contact with.

These strike teams would isolate patients, their families and their contacts. That ring of people would be vaccinated to "break the chains of transmission. "Early detection is critical because a post-exposure vaccine can be a highly effective treatment within four days of infection," said Walter Orenstein, director of the CDC's National Immunization Program. Mass vaccination isn't recommended.

It remains unclear how different health officials would enforce isolation and quarantine measures. Some health officials would order suspect cases to a self-imposed isolation at home during the general incubation period for the disease of seven to 17 days and have people report back if symptoms arise. Other public health leaders argued for tougher measures, such as a mandatory quarantine of anyone coming into contact with known cases.

Smallpox experts offered clues to differentiate between the disease and chickenpox. A "thumb test" can detect hard, firm pustules for smallpox compared with a softer lesion for chickenpox. Smallpox feels like "a hard pea in the skin," said Stanley Foster, visiting professor of international health at Emory University in Atlanta and veteran smallpox clinician.

Another debate among public health leaders is whether hospital workers, firefighters and other "first responders" should be vaccinated in advance of a smallpox outbreak. CDC officials and medical professors at the meeting argued against pre-exposure vaccination due to the adverse effects from immunization and high turnover among front-line health workers.