False alarm shows how area might respond to smallpox outbreak

By JOHN A. DVORAK and LEE HILL KAVANAUGH

Just before noon last Monday, an ambulance pulled up to the emergency room at St. John Hospital in Leavenworth.

The patient had symptoms that made the medical staff pause: the lesions on his body didn't look like typical chickenpox.

Could it be smallpox?

Worried health-care providers chose the cautious path. Workers donned masks. Isolated the patient. Locked down the emergency room. Alerted health departments.

The governors and disaster planners in Kansas and Missouri were notified. So were experts at the Centers for Disease Control and Prevention in Atlanta and even the Office of Homeland Security in Washington.

By 2:30 p.m., a Kansas Highway Patrol car was speeding down the interstate to a Topeka lab with a blood sample. As the evening news rolled, lab results confirmed chickenpox.

The reaction offers a glimpse into how government would respond in the event of a bioterrorism attack. Even one case of smallpox -- a disease eradicated from the world years ago -- would mean the United States was under attack.

Are disaster planners ready?

They're more ready than before 9/11. But they're not as ready as they want and need to be.

"The metropolitan area is in pretty good shape, relatively speaking," said Mike Selves, Johnson County emergency management director. "I don't think anyone can say they're absolutely prepared for something like this."

Rex Archer, a physician and the director of the Kansas City Health Department, said the area trails no other in its readiness.

"Yes, we can make ourselves respond better, but we're moving incrementally forward," Archer said.

In Missouri and Kansas, state and local planners have been working hard for months on this scenario: a terrorist spreads smallpox, and days later, with no warning, the first victim shows up in an emergency room.

Dozens, hundreds, maybe thousands of victims could follow.

The reaction would be monumental, as health workers and law enforcement mobilized. Kansas City officials even talk of commandeering hotels for the sick or those exposed.

Ultimately, mass immunizations could be required. At least 20 public buildings would become vaccination centers. A smallpox response plan just released by the Centers for Disease Control (CDC) lays out a model program with a goal of vaccinating one million people in 10 days.

Such a task would be overwhelming. Authorities think they could do it on the Missouri side of the metropolitan area. Officials on the Kansas side say they probably need more time to get ready.

"It would take us 7,000 medical volunteers to run 20 to 30 clinics, 16 to 24 hours a day," Archer said.

The metro area could be covered, he said, because lay people would be trained to give the vaccinations.

"Giving vaccinations is not the hard part; that skill is easily taught," Archer said. "What we can't teach is the medical background on how to triage a patient, or how to explain all the medical issues, or how to counsel people on whether they want the shot or not."

Combating a deadly foe

Dealing with smallpox requires a knowledge of the disease, and firsthand knowledge isn't plentiful.

Disaster planners come to the table with a wealth of experience in tornadoes and floods. Smallpox? They've never seen it.

Smallpox is contagious and can prove fatal for up to 30 percent of those infected. The disease was declared eradicated from the world more than two decades ago, about the same time that the United States ended routine vaccinations.

Worldwide, smallpox immunity is now virtually nonexistent. Stocks of smallpox virus remain at the CDC and in Russia, but no one can say for sure that some hasn't fallen into the hands of a rogue nation or terrorists.

Chien Liu, a physician and professor at the University of Kansas Medical Center, knows the dark side of the disease because he helped treat victims of smallpox more than a half-century ago in China.

"We should prepare," he said. "It can go just like fire."

The CDC said smallpox symptoms begin usually two weeks after the initial exposure. Symptoms mimic the flu, with a fever, malaise, head and body aches.

Then a rash emerges, signaling the period where the victim is most contagious. Small red spots pop out on the tongue and mouth, then turn into sores. Virus particles become airborne as the victim breathes.

After two days, the rash grows into bumps resembling BB pellets embedded under the skin. Scabs develop over oozing pustules. Infected people are very contagious until the scabs fall off.

So why not just immunize everyone as a preventative measure?

Complications.

Little about the smallpox vaccine has changed since it was developed in the 18th century. It contains a live pox virus called vaccinia, harvested from infected calf skin.

The vaccine is dangerous because it uses virus that hasn't been weakened. In most people, vaccinia causes a mild infection that triggers immunity. But in some people, the virus runs amok.

Even people with minor reactions to the vaccine can spread the vaccinia virus to others. Such risks were deemed acceptable when smallpox was active and killing 30 percent of those infected.

But today, some of the vaccine's casualties and their families likely would file lawsuits. The federal government is working out a plan to protect from liability those who administer a mass inoculation program.

As many as 50 million Americans, including babies, pregnant women, people with the common skin rash eczema, and those with weakened immune systems may be vulnerable to the vaccine's risks. Immune globulin, an antibody treatment, could help some people with bad side effects, including encephalitis. But globulin is in short supply.

Like a ghoulish lottery, for every million people immunized, one will die.

Still, as talk grows about war with Iraq, a plan is emerging of an expedited vaccination program for about 500,000 hospital workers, people who would be the most likely to meet the first wave of victims in a biological attack.

Step-by-step approach

If Leavenworth had been Ground Zero for a smallpox attack, mass vaccinations wouldn't have occurred right away.

The first step calls for "ring vaccinations." For every patient who becomes ill with smallpox, a ring of persons around him -- family members, good friends, health-care workers -- will be tracked down, documented, vaccinated and/or monitored.

Timeliness is essential. After pustules emerge, the average person has about four days to be vaccinated for the vaccine to protect.

It's possible not everyone in the metro area would be in danger, that the ring of contacts would be small. It's also possible the number exposed could be huge.

If additional victims turned up, additional rings of vaccinations would take place, especially if the victims had been traveling. With a mass exposure, the CDC ultimately could recommend nationwide inoculations.

Hospitals, law enforcement and federal, state, city and county government officials have been studying these scenarios for months.

Two months ago, Missouri opened its bioterrorism command center at a secret location in Jefferson City. The Department Situational Room is equipped with 10 computers, dozens of phone lines, a big-screen television and global positioning satellite maps denoting hospital locations.

Kansas now operates a secure Internet site for local health agencies to receive critical information. Within 15 minutes, agencies would be notified of a potential emergency and told to get on the Web. Part of that system operated during last Monday's scare.

At KU Med, Ruth Schukman-Dakotas, safety director, said the hospital and university have been working closely with disaster planners to lay out the medical center's role in a bioterrorism attack.

The hospital has four special rooms suited for patients with communicable diseases. Other space could be made available. Doctors and nurses from the health-care complex could be mobilized.

Said Schukman-Dakotas: "We definitely have more planning to do."

Explaining how these disaster plans unfurl would be the media's role.

Pam Walker, director of Missouri's Center for Emergency Response and Terrorism, said using the media to reach the public could prevent panic.

"We'll avoid rumors by replacing them with facts from experts. The situation will be one that's constantly fluid and changing, and we'll need to stay on top of it," she said. "The media can do that.

"In this time of crisis, we'll be telling the public to trust us. And to do that, information needs to be accurate and clear and honest."

Lessons from anthrax

Last October, Joe Connor, director of the Unified Government Health Department in Kansas City, Kan., got a lesson in bioterrorism disaster planning.

Anthrax had contaminated a postage stamp order center in Kansas City, North. Although many workers at the Missouri center lived in Kansas, Connor was not notified of the health problem. He heard about it while he was trick-or-treating with his children.

Local government officials learned two valuable lessons from the anthrax experience: They had to communicate with their counterparts across the state line, and they had to adapt quickly to shifting scientific information.

"At times, we were learning something new about anthrax every half hour," Archer recalled. Because the anthrax was weapons grade, it contaminated quickly.

"...Make sure people understand that the treatment may change when we get better science on what we're dealing with. With smallpox, it might be an altered form of the virus."

The anthrax experience also showed the need for cooperation between governments. Now, county and city health directors across the metro area meet with new conviction. Called the Metropolitan Official Health Agency of the Kansas City Area, the group is drafting plans to share resources under different bioterrorism scenarios.

"In an emergency, we'll be blind to state lines," said Connor, who is also the group's president.

Preparedness varies

The terrorist attacks of Sept. 11, 2001, ratcheted up terrorism planning worldwide. A General Accounting Office report showed that local and state governments were unprepared.

Earlier this year, final approval came in Washington for the CDC to distribute $900 million of federal bioterrorism planning money. Missouri will receive $17 million, Kansas $11 million. Plans have progressed rapidly in the Kansas City area. But outside the metropolitan area, disaster planning is uneven.

"Some counties are farther along than others, as you could expect," said Gianfranco Pezzino, Kansas state epidemiologist. "All counties are farther along than six or 12 months ago."

There can be difficulties in smaller locales. After all, the population in some rural counties may not exceed 5,000.

"Most rural health departments in the state have neither the staffing nor the training to deal with serious communicable disease outbreaks," a study completed by the Kansas Health Institute earlier this year found.

All problems aside, last Monday's incident in Leavenworth shows that disaster planners can react quickly when necessary, said Walker, who knew about the incident within an hour of the patient entering the hospital. "The early heads-up communication system worked pretty well."

Before the Sept. 11 attacks, she said, planners would encounter competition among hospitals, public health offices and first responders.