WHAT IF? CONNECTICUT AND SMALLPOX
16 Mar 2003
What If? Connecticut and Smallpox
It is the scariest thing: a disease spread across our land by terrorists. We wouldn't even know it was here until some of us started getting sick. What would we do?
By WILLIAM HATHAWAY, Courant Staff Writer
The phrase "weapons of mass destruction" makes a dull impact on the ear - a construct with meaning mainly to diplomats, foreign policy wonks or politicians gearing up for war.
The words smallpox, anthrax or nuclear weapons are more visceral, so much so most of us prefer not to learn much about what those weapons actually can do.
Yet health officials say our survival one day may depend on our ability to react coolly and calmly to such an eventuality.
The fictional scenario presented here is based on federal and state planning documents and interviews with about a dozen people in Connecticut who would be directly involved in responding to a smallpox attack. The story describes what might happen after a single Connecticut resident falls victim to smallpox, a scourge that killed tens of millions of people before being eradicated in nature in 1977.
In the past six months, "post event" smallpox response plans have been drafted and, with varying degrees of urgency, are being implemented nationally.
Connecticut was the first to vaccinate health-care workers to prepare for a smallpox attack, although the number of doctors and nurses here and nationally who have actually received shots is far short of what was originally envisioned.
Despite the magnitude of effort required to react to an attack with smallpox, Connecticut is prepared to meet such an emergency and is ahead of most of the rest of the country in preparing for the unthinkable, said Dr. Joxel Garcia, commissioner of the state Department of Public Health.
The reality is that nobody really knows how such an event would unfold.
• • •
DAY 1 - Thursday
Randy has two hours to kill at Chicago's O'Hare airport when his return flight to Hartford is delayed.
The 39-year-old mid-level executive wanders down Concourse H, starts for a Cinnabon, thinks better of it and strolls into a gift shop. He usually doesn't buy gifts on two-day business trips, but this time the Farmington man buys his wife, Linda, a box of chocolates, a sleeveless Chicago Bulls jersey for his 8-year-old son Henry and a stuffed pink elephant for his 4-year-old daughter Sarah.
As he grabs his change, he turns, and the man standing behind him coughs.
"Excuse me," says Randy.
Randy has just been infected with smallpox.
Randy and the rest of the world will not know it for two weeks, but the United States has just been attacked by terrorists. They have unleashed a feared pestilence that was eradicated in nature a quarter of a century ago.
What happens next in this nightmare scenario depends upon the circumstances of the attack, the alertness of public health officials and the reaction of Americans when they hear the news.
In Connecticut, life will change immediately and dramatically in the hours after the first diagnosis. Officials will struggle to confine the highly contagious virus by sealing state borders, quarantining people exposed to the disease under armed guard, and commandeering schools, hotels and factory buildings as impromptu clinics or quarantine facilities.
As businesses shut down across the state, understaffed local health departments will struggle to open up scores of mass vaccination clinics within 24 hours - praying that enough volunteers show up to help give shots and keep order as each clinic tries to immunize as many as 5,000 people a day for 10 days.
Despite all efforts by authorities, some people will die in great pain, with the trademark pustules of smallpox covering face and extremities like stings from a swarm of wasps.
"The eradication of smallpox was the 20th century's medical hallmark. To have it come back, on purpose by man, would be an act of evil beyond imagining," says Dr. Brian Cooper, chief of infectious diseases at Hartford Hospital.
Estimates vary widely about how many would die from an attack using smallpox, which has killed more people than any other pathogen in history, with the possible exception of bubonic plague. Perhaps a dozen or fewer would die in an unsophisticated attack if the virus were quickly corralled. Other estimates say the toll could rise to tens of thousands or even more if the attack were highly orchestrated or used a strain of smallpox resistant to vaccines.
All the estimates are based on assumptions that a nation steeped in a tradition of liberty and free of almost all deadly infectious diseases for generations would react rationally and calmly in this type of a national emergency - and that layers and layers of plans to deal with such a catastrophe would be implemented without a hitch.
That may be the most implausible scenario of all.
• • •
DAY 12 - Monday
Nine days after he returned from his business trip, Randy on Saturday is laid low by a bad fever and a backache. After staying in bed most of the weekend, he has a slight sore throat, but generally feels better and heads to work. He prides himself on never missing work.
He tries unsuccessfully to stifle a cough on the packed elevator of the Gold Building in Hartford.
Randy makes a brief presentation at a morning meeting, goes out to lunch with a friend and stops by Coach's for a beer before going home. Waiting at a traffic light, he idly scratches a slight rash on his cheek.
• • •
DAY 13 - Tuesday
The next morning he goes to the gym, but hops off the treadmill after doing just 2 miles of his usual 5-mile run. He is exhausted, and sweat irritates an odd rash that is breaking out on his arms, hands, legs and feet. A man comes over to ask if he is all right. Randy leaves work early that day.
That night Randy gives a kiss to Sarah and her stuffed elephant, which she has named Nuzzles. Sarah had just finished a tea party with Nuzzles, and Randy compliments his daughter on her crayon portrait of the stuffed toy. Exhausted, Randy is asleep moments after Sarah.
• • •
DAY 14 - Wednesday
The rash looks worse the next day and his throat is worse. On a whim, Randy stops by a walk-in clinic on his way to work.
The doctor looks at the raised rash and says, "You have chicken pox."
"But I had it when I was a kid," Randy says.
The doctor responds, "Well, you have it again."
Since Sept. 11, 2001, federal, state and local officials have drafted thousands of pages outlining steps to combat an outbreak of smallpox. All the plans boil down to two basic strategies:
The first is an ancient method used to contain any contagious scourge - the quick isolation and quarantine of people exposed to the disease.
The second is to vaccinate. In the case of a large outbreak over wide areas of the country, national health officials plan to vaccinate the entire population of the United States.
Each step of the response plans is built upon some optimistic assumptions. For instance, will a doctor who has never seen a case of smallpox be able to recognize it quickly? Will citizens willingly accept having themselves or their loved ones carted off to an isolated and guarded quarantine facility? Will tens of thousands of people volunteer in a variety of capacities to combat a horrific disease that can envelop an entire body with deadly lesions?
To know the enemy is to fear it.
Smallpox lurks in the body between 7 and 17 days before symptoms appear, and during that time the patient is not contagious. But then the patient usually experiences a few days of high fever with body aches, particularly in the back, and perhaps some vomiting. Some patients may become contagious at this point. By the time the rash appears, usually as the initial fever subsides, the patient can definitely transmit the virus. Smallpox is spread by face-to-face contact, as the infected person breathes droplets of virus into the air. The rash itself can also be a source of transmission. It will be a few more days before the rash spreads and reveals its terrible pox-like qualities, and during that time, the patient can easily infect others. Smallpox remains contagious until the scabs fall off, usually within three weeks of the appearance of the rash.
Bioterrorism experts say terrorists wielding smallpox would be drawn to airports, where large numbers of travelers might be easily infected and spread the virus across the continent and seas, making it more difficult for health officials to cordon it off.
In some scenarios involving an airport attack, health officials might have a fighting chance to limit the disease's spread.
Analysts at the RAND Center for Domestic and International Health Security, a nonprofit think tank, estimated recently in The New England Journal of Medicine that 26 Americans probably would die in an attack by a few self-infected terrorists wandering around airports deliberately coughing at people and brushing up against them.
Much more deadly would be a coordinated attack on multiple airports using sophisticated nebulizers, which can disperse large amounts of aerosolized virus into the air and infect large numbers of people. RAND analysts predicted more than 40,000 Americans might die, even if health officials initiated a mass vaccination program.
• • •
DAY 15 - Thursday
By Thursday morning, Randy's condition has badly deteriorated. The rash has turned into bumps, which first appeared on his face and now are sprouting on his hands and feet. They have grown harder, like pellets under the skin. Randy's fever has climbed to 102.
While Randy lies in bed, Linda quickly shuffles Henry to the bus stop and asks a neighbor to drop Sarah off at her day-care center. In 10 years of marriage, Linda has never seen Randy this sick. During one beach vacation her mother, who watched Randy run every morning and eat heaping portions of salads every night for dinner, joked, "You don't have to worry about outliving this one, honey."
Linda calls the family doctor and in a hurried whisper describes Randy's symptoms to the nurse, including the clinic doctor's diagnosis of chicken pox. The nurse is suspicious of that diagnosis - and becomes increasingly frightened as Linda describes the bumps on his skin.
Linda repeats her story to the doctor, who tells Linda to take Randy to the emergency room at the University of Connecticut Health Center immediately.
The doctor, who has seen health officials' descriptions of smallpox but never an actual case, calls the head of the emergency room at John Dempsey Hospital.
"I may be sending a smallpox case your way," she says.
While thousands of pages of government plans outline what to do in the first 24 to 48 hours after the diagnosis of a case of smallpox, the sheer volume of events triggered by a single diagnosis almost guarantees chaos. The lives of millions of people will change - from the priorities of the president of the United States to the retired nurse in Cheshire who had promised her local health director in a brief chat at the grocery store that she would be willing to help out in case of an emergency.
By definition, a case of smallpox that appears anywhere outside a laboratory setting will be considered an act of war, an aggression that may remain hidden for weeks as the virus insinuates itself in the host's cells.
Once symptoms appear, the virus has exploded, replicating ruthlessly in the victim. Unleashed in nature, smallpox has the power to quickly proliferate in whole populations.
Two immediate questions will demand immediate answers - yet also call for a conflicting set of tactics from different federal and state agencies.
Who did it? And who has been exposed?
Smallpox is viewed as a weapon of mass destruction. Administration officials have said use of such weapons will subject perpetrators to full retaliation by the United States, including possible use of nuclear weapons. Military planners will need to know what nation or group to target. As casualties mount, so will public pressure to strike back at those responsible.
Some planners also might push for a delay in announcing the case to give investigators time to track down the perpetrators.
But from a public health perspective, any delay will be a disaster.
It may take a week or more from the appearance of the first smallpox symptoms for health officials to recognize a smallpox case. Each exposed victim can infect dozens of people before being diagnosed, making it difficult to lasso the virus.
The vaccine can prevent smallpox only if it is given within four days' exposure to a contagious carrier - making a swift response more urgent.
Any efforts to suppress information about a case probably will be futile, as those in the know quickly alert their friends and family.
If the first case occurs in Connecticut, there will be great pressure on the governor and federal officials to seal state borders, to try to trap the virus within a single geographical area. In the meantime, other countries almost certainly will forbid the entry of any ship, plane, train or car from the United States.
Most experts say even a single case in Connecticut will trigger an unprecedented effort to vaccinate every state resident within 10 days with live vaccinia virus or, after 2004, a safer vaccine.
The current vaccine carries risk, particularly for those with skin diseases or compromised immune systems, which is why some health care workers have declined to be inoculated.
But once contracted, there is no effective treatment for the disease.
"There is a false sense of security that medicine has an answer for this," says Steven Huleatt, director of the West Hartford-Bloomfield Health District. "It will be the challenge of 21st century medicine to corral it and knock it out."
• • •
Day 15, Thursday - 9:40 a.m.
When Linda drives Randy up to the emergency room entrance, a doctor and two nurses are waiting. All previously were vaccinated against smallpox. The doctor takes one look at Randy and orders him into an isolated respiratory unit. He then calls an infectious disease specialist to confirm his suspicions.
"I don't want to be the one who brings all this down on our heads," he says to one of the nurses.
The infectious disease specialist looks at the uniform nature of the eruptions, the small indentations on the pustules and their location on Randy's body. "Smallpox. No doubt," he whispers.
However, blood specimens are taken and shipped to the Centers for Disease Control and Prevention in Atlanta for a definitive diagnosis. The viral specimens will provide crucial clues in identifying the strain of the virus and possibly its origins. The smallpox symptoms look like variola major, which is fatal in about 30 percent of the cases. At the CDC, investigators will determine whether the virus could be something much worse - a genetically modified strain designed to be even more deadly.
Linda too is sent to an isolated room. Within 10 minutes, hospital and state health officials begin to grill her about Randy's whereabouts during the past three weeks.
Linda is an accountant, but as fear creeps into her soul she is having a hard time ordering the events in ways that make any sense. She knows Randy has something bad, but what? She tries to remember everything she can about exotic diseases and bioterrorism. Was it Ebola? Anthrax? Then she freezes.
"Smallpox. You think my husband has smallpox," she says.
A cellphone rings and one of the investigators nods as he answers.
He quickly looks back at Linda and says, "Yes, we do. We need to conduct tests to be sure. But if it is smallpox, a lot of people are in danger and we need your full cooperation."
"My God, my children? What's going to happen to my children?" Linda cries.
"We need to take them someplace where they can be looked after. Let me know where they are and we will get them," the man with the cellphone says.
For more than two hours, Linda pieces together everything she can remember about Randy's movements during the past few weeks. The interviewers - state and local health officials - are especially interested in the timing of his business trip and alert federal agents in San Jose and Chicago that a potential smallpox case might have come through their cities.
By the time the interview is completed, federal agents already are walking up and down Concourse H at O'Hare airport looking for a shop that sells pink elephants and Bulls jerseys.
Linda misses some of Randy's stops - his workouts at the gym, his lunch with friends - and dozens of people whom he may have infected.
"Post-event planning" sounds like a cleanup committee for a church social, but it is bureaucratese for a breathtaking suspension of civil rights health officials say is essential to combat a smallpox outbreak.
Within hours of the first diagnosis, a team of more than 50 health officials, aided by local police and later by investigators from the CDC, will fan out across the state and try to round up people who may have been directly exposed to the smallpox victim. Health officials say that there may be an average of 150 people for each smallpox case. The team's investigators will examine and quarantine anyone - forcibly if necessary - until there is no possibility that they can infect others.
The state will move to take over hotels, schools or other buildings it might deem necessary to provide vaccinations, care for the ill or segregate those exposed to the virus.
Those quarantined will be divided into three categories, depending on each individual's level of risk: those with full-blown smallpox; those who have been exposed and show signs of illness; and those known to have been directly exposed to a smallpox patient but who have not become ill. That third group may be quarantined in their own homes. The quarantine period for most will be roughly 18 days. Even armed with the ability to detain citizens, health officials acknowledge that smallpox will be extremely difficult to contain.
Day 15, Thursday - Afternoon
When word reaches the governor, he orders a mass vaccination and authorizes health officials to ask the federal government for enough vaccine to inoculate the entire state. They tell him that officials at the National Pharmaceutical Stockpile Program have promised to deliver vaccine under armed guard within 12 hours.
"I hope the feds weren't pulling our chain when they said they had enough for everybody," a health official whispers at headquarters of the state's emergency response team, which is assembling at the State Armory in Hartford. "If this spreads, everybody in the country will be trying to get this stuff."
Health officials tell the governor that they will try to isolate all those who were directly exposed to Randy, but they have to assume Randy's case is not isolated - that others in the state might have been exposed at the same time as Randy and are now contagious.
"So how soon might we see other cases?" the governor asks.
"We'll know more in the next few days, but right now we just don't know."
In an information vacuum, fear will spread faster than the virus. Local health directors will be on the front lines, facing an increasingly frightened public.
Under the state's smallpox response plan, Connecticut is divided into more than 40 mass vaccination regions, and local health directors in those regions are charged with opening up about 70 clinics within 24 hours. Each clinic is supposed to be capable of vaccinating up to 50,000 patients in 10 days - every man, woman and child in Connecticut.
Health directors were told late last year to recruit thousands of volunteers, who will have to vaccinate the vaccinators, give inoculations to the public, keep records, provide information - and assure order and the security of vaccine supplies.
No money to operate the clinics has been allocated to the health directors, who in some districts of the state have a staff of a secretary and a volunteer nurse or two.
Literally overnight, each clinic coordinator will be confronted by tens of thousands of citizens who want a vaccine that may save their lives.
Day 15, Thursday - Still Afternoon
Investigators by this point are able to get little coherent information from Randy, who now is burning up with fever. There is no treatment for smallpox. Doctors can do little more than hook him up to an intravenous tube to make sure he remains hydrated and try to keep his fever down with painkillers. The next few days will determine whether he lives or dies, the doctor tells one of the nurses.
Doctors immediately vaccinate Linda, even though they know it probably won't be effective because she has been exposed to the virus for more than four days. However, they hope that administering the vaccine might lessen any symptoms if the disease develops. They keep her isolated until that evening, when she is escorted to a hotel in Rocky Hill that the state has commandeered.
By 1 p.m., health investigators begin to fan out across the state. As fellow employees watch, about a dozen people in Randy's office who worked most closely with him are escorted from the building. They are told there has been a public health emergency and that health officials need to interview them.
Several object when police collect their cellphones. Police tell them the phones will be returned later. Randy's co-workers are ushered into vans and told there is a possibility they have been exposed to a dangerous infectious disease and that they may have to stay at a hotel. When one man objects, saying he has to get home for his daughter's concert, a health official tells him the disease is highly contagious and potentially fatal. The van falls silent. Within hours, they, too, will have been vaccinated and set up in the hotel where they can be watched to assure that they don't come down with smallpox.
Health officials reach Henry's elementary school at 1:15. They tell the principal that Henry might have been exposed to an infectious disease and that they need to take him for observation. They also ask for a list of Henry's classmates, with their addresses and phone numbers. Health officials will want to call their parents over the next several weeks to make sure they are not developing symptoms.
Minutes later, a third group of investigators arrives at Sarah's day-care center.
Margo, the day-care director, says she has been trying to reach Sarah's parents all morning.
"She is burning up with fever," she says.
The investigators take the sick child directly to Hartford Hospital.
By 4 p.m., rumors of a smallpox case have reached the media. The governor schedules a 6 p.m. press conference to announce that investigators believe they have identified a possible case of smallpox and that terrorism is suspected.
Even though no official confirmation of the case has been made yet, by 5 p.m. hundreds of people begin to swarm into hospitals around the state, clamoring for smallpox vaccines. They are turned away, and told to await instructions. Police arrest one man at New Britain General Hospital, who is particularly adamant about getting a vaccine for his family.
As the governor begins to speak and the nation stops to watch events unfolding in Connecticut, a national news broadcast breaks into the speech to say that another suspected case of smallpox has been reported in Terre Haute, Indiana.
Under smallpox response plans, mass vaccination clinics should be opened within 24 hours of the announcement of an emergency. In 2002, health directors were charged with identifying sites that could handle large amounts of traffic and people. Many selected schools. In East Hartford, the plan is to use an empty hangar on Pratt & Whitney property.
The public will not get shots the first day a clinic opens. Previously vaccinated staff will travel across the state to inoculate hundreds of workers who will give shots, and administrative staff and security personnel who will staff the clinics.
Officials estimate that each clinic will need at least 250 volunteers to operate two eight-hour shifts. Health directors were told to line up those volunteers - whose job will be not only to provide medical support, but to feed workers and control unruly crowds.
But as one police chief told a local health director, "You know you won't be able to shut down once you open."
Two 12-hour shifts are more likely, with clinics operating around the clock until everyone is vaccinated.
"Once it happens, I'll grab a lot of coffee and a lot of power bars because all I will be doing for days is giving vaccinations," says Dr. Thomas Regan, attending physician at UConn Health Center.
Security will be especially crucial on the first day as the clinic inoculates only the volunteers it needs to give thousands of shots. Then the plan is for officials from each clinic area to draw letters from a hat in the days that follow. If the last name of your household begins with, say, H, P, or R, you should report for vaccination. Each day, new letters will be drawn.
Will volunteers turn out when they are needed? Or will a handful of health workers go for days without sleep trying to vaccinate thousands of impatient, panicky citizens? Will people cooperate and wait their turn, knowing that the safe margin between exposure and vaccine protection is only four days?
"I really believe Americans will step forward," says Baker Salsbury, East Hartford's director of health and social services and president of the Connecticut Association of Directors of Health. "We have a habit of stepping right up to the plate. The more dire the situation, the more people step up to the plate."
DAY 16 - Friday
The day after Randy was wheeled into the emergency room, two other smallpox cases in Connecticut are identified, in Stamford and Beacon Falls. Both patients appear to have been in Chicago about the same time as Randy.
Nationally, the tally of cases has grown to about 120, although officials fear that in rural areas many others remain uncounted. The first death - of an elderly man in Joliet - is reported.
The medical examiner's office in Chicago does an autopsy on a man with smallpox lesions found dead in an apartment building. Investigators believe the man may have been a terrorist who infected himself, and they begin looking for other people who died mysteriously.
By now, hospital emergency rooms are being patrolled by the National Guard. Hundreds of people line up outside hospitals. Many have rashes they believe to be smallpox. Teams of doctors do triage on these patients. If the rash does not have the uniform appearance of classic variola major, they are sent home.
No new cases turn up at Connecticut hospitals. But health officials now worry that second-generation cases - people infected by victims of the initial terrorist attack - might begin appearing in a week.
• • •
DAY 17 - Saturday
At 4:30 a.m. at one of the state's mass vaccination clinics - the first day the clinic is to be open to the general public - the director of nursing for a local health district turns over on her cot in the high school principal's office where she stayed overnight. She had slept poorly, awakened several times by troops ordering people who had been lining up all night away from clinic doors. The day before had been a nightmare, as police and soldiers tried to separate those who had been called to volunteer for duty at the clinic from those who pretended to be volunteers in order to get a vaccination.
A handful of people who were given shots simply disappeared. But many more had come and stayed.
The nursing director is already exhausted and knows she will get little sleep in the coming week.
The radio says highways are gridlocked at some locations by people trying to flee the state and by others jamming the exits near vaccination clinics. Government spokesmen continued to discount rumors that the national vaccine supply had been used up.
The nursing director pulls back the shades of the office and looks into the dim pre-dawn light where people stretch in a tight pack well beyond the blacktop parking lot, all the way across the soccer field and into the high school football stadium.
"My God," she says.
The same day, Randy's fever begins to drop and doctors are guardedly optimistic. Smallpox itself does not kill, but it can lead to the failure of a variety of organs or overwhelming shock and infection. Randy shows no signs of organ failure.
Linda and Henry, both still in the Rocky Hill hotel, have shown no signs of the disease.
Sarah's fever has worsened and a rash has appeared on her hands and face. She had already been taken to a mobile hospital unit, where she could not infect anyone else. Despite Linda's pleas, she is not allowed to visit. And health investigators have chilling news for the parents of Sarah's day-care classmates: Their children have been exposed and need to be quarantined.
In this fictional scenario, the terrorists managed to infect hundreds during two days at Chicago's O'Hare airport, but through yeoman efforts of tens of thousands of volunteers, the smallpox was contained in the United States. Twenty-five people in the United States died during the outbreak. However, several cases were reported in South America, Africa and Singapore. Public health officials were busy trying to isolate the disease once again, as they had in the decades before. However, they were unable to reach two reported cases in a war-torn part of Colombia, leading to fears that smallpox had again established a home among humans.
This scenario does not include the crippling economic consequences of the attack, nor the pain and havoc caused by the military retaliation for it.
• • •
Randy survives, but as the smallpox runs its course, it leaves his face pitted and scarred.
Although she gets a rash, Linda never develops a full-blown case of the disease. Investigators say she may have been protected by the vaccination at the hospital or by a vaccination she had in the 1970s when her family took a trip to Africa.
Henry never shows any symptoms at all. The virus bypasses him for unknown reasons.
Sarah dies a week after the pustules appear.
Nuzzles, the stuffed elephant, is burned along with many other of the family's possessions that health officials fear might harbor the deadly virus.