She tried to think of all possible ramifications of a major health crisis the size of the one they were facing. “It’d make things easier if all our cases were in one general location, but they’re scattered all over the eastern half of the country for God’s sake.”
Dr. Heche started pacing. “Which is why this could be a monumental disaster,” he said, holding his head, as if it were going to explode.
11
By early afternoon Dr. Silverthorn had participants hooked up by videoconference link: CDC’s Dr. Raymond Heche, Deputy Director Beverly Mason, and Associate Director for Communication Judith Gleason; Richard Walters from the Office of Public Health and Preparedness, and Dr. Catherine Collins, Deputy Director of the Office of Infectious Diseases. Law enforcement and health and human services were also represented: Assistant Director Robert McGraw from the FBI’s Counterterrorism Division; Phillip Reiser, special agent in charge of the counterterrorism analysis section; and Michael Knapp, Office of Emergency Preparedness for HHS. Listening in were special agents in charge of the FBI’s field offices in Boston, New Orleans, Atlanta, Memphis and New York, along with police chiefs in those same cities.
“For the first time in most of our lifetimes,” Heche began, “we’ve got confirmed cases of smallpox in New York, New Orleans, and Atlanta, with suspected cases in at least four other major cities.” He looked over at Dr. Silverthorn for a moment and returned to his monitor. “For those of us in the medical community, this presents a demanding and frightening challenge. If the contagion cannot be effectively contained in the next ten to fourteen days, we’re looking at thousands, maybe hundreds of thousands, of deaths.” He let the dire prognosis sink in for a few moments. “We have no time to waste and no time for guesswork. Our infectious disease specialist, Dr. Collins, will brief you on the characteristics of the disease.”
The screens switched to an image of a grim brunette in dark-rimmed glasses who glanced at her notes and began to speak. “I wish I could be more optimistic, but things could hardly be worse. Smallpox is considered the most devastating of all infectious diseases. Caused by a virus, it’s untreatable, fast to develop, and extremely contagious. Patients who get it are infectious for several days before obvious symptoms develop, making it particularly hard to diagnose early.”
She briefly switched to a grainy photo of a smallpox victim that appeared to have been taken thirty years ago or more, then continued. “The virus grows silently for a week to seventeen days–twelve to fourteen on average–before any obvious signs of the disease appear. So it could be a while before we can even estimate how many persons have been affected. More than likely, two weeks or more. The preliminary phase of infection is followed by two to four days of flu-like symptoms–aches and pains, plus usually a high fever–which, again, make it hard to diagnose, since it is so easily confused with other flu-like illnesses.”
“Unless they’re intentionally looking for it,” Heche added.
“Right. If our emergency room or primary care doctors aren’t specifically looking for smallpox, it’s unlikely the disease would be identified as such at the outset. Typically, the characteristic smallpox rash develops a few days after onset of fever and starts as small red spots on the tongue and in the mouth. These spots then become sores, which break down and shed the virus. That’s when the patient is most infectious. The rash spreads over the body and develops into pustules, or pocks, filled with fluid. Those, over the course of days or weeks, begin to rupture. At that point, there’s no mistaking it for any other disease. The infected person will either die or begin to recover over the next two weeks.”
“What percentage die?” Knapp asked.
“Assuming we have the more common form, the ordinary variola major, overall fatality rate historically is about thirty percent. If, God forbid, we have the more rare hemorrhagic type, it’s almost always fatal.”
There was silence for a few moments until Judith Gleason asked, “What are signs the patient is recovering?”
“Recovery begins when the pustules begin to scab over. These scabs eventually fall off, leaving sunken scars, although the patient will remain contagious until all scabs are gone. And be aware, the scabs themselves are just as contagious as the pocks.”
“Any lasting effects once the patient recovers?”
“Some. The smallpox scars may disfigure the survivors and even cause blindness. One bright spot, however, if you can call it that: Persons who do contract the disease and recover will have a long-lasting immunity to the disease. On average, however, thirty percent of people who contract smallpox will die.”
No one spoke for several more moments, until Atlanta’s police chief asked, “And there’s no treatment available?”
Dr. Collins shook her head. “Afraid not. There is no antiviral medicine available to treat smallpox. Once infected with the virus, doctors can only offer supportive care–meaning IV fluids and antibiotics for secondary infections.” Collins rechecked her notes and continued, “Smallpox is generally spread when an infected person coughs out particles of the virus from sores in her mouth or lungs, which are then either inhaled or inadvertently ingested or rubbed into the eyes of the next infected person.”
“What about someone touching a contaminated object?” Walters asked.
“A slight possibility of contagion there–handling contaminated clothing or bed linens, particularly.”
“And how long will someone with smallpox remain infectious?”
“The infectious period generally runs from the first signs of flu-like symptoms until the scabs fall off, about three weeks. About half of those exposed who are not immune to smallpox will develop the infection. It will only infect human beings and must be transmitted from human to human in an unbroken chain or will eventually die out. The only way to control the outbreak, therefore, is to limit the contact an infected person has with a susceptible person–that is, someone who hasn’t already had the disease or a recent vaccination.”
“It’s also particularly easy to disperse,” Mason added. “As one of the smallest living organisms on Earth, it can easily be prepared as an aerosol and released into the air in a crowded place, like a shopping mall or stadium. One infected patient can infect ten to twenty others–and that can go on for wave after wave, with a rapidly increasing number of infections at each step. Obviously, the quicker we isolate the carriers, the more quickly we can control the outbreak.”
“Meanwhile, every person who came in contact with any of these patients must be quarantined for at least fourteen days to ensure they are not infected,” Collins warned. “A person vaccinated within a few days of exposure may escape infection, but it’s not guaranteed. That person needs to be quarantined for the full period, as well. The outbreak is controlled when it’s been three weeks from the last infection.”
The FBI’s McGraw asked, “Assuming we’re talking about a terrorist attack here, are Russia and CDC still the only two places where this virus is kept?”
Dr. Silverthorn fielded the question. “First, there’s no assumption about it; this most certainly is terrorism. And the answer to your question is a qualified yes. Once smallpox was declared eradicated in 1980, political pressure forced US labs holding it to either transfer their collections to CDC in Atlanta or destroy them. CDC and the Soviet–now Russian–State Research Center for Virology and Biotechnology in Koltsovo were designated as the only labs permitted to retain the virus. We learned years later that the Soviet Union moved its stocks of smallpox to several secret locations without informing the rest of the world. A defector who ran the Soviets’ biological warfare operations admitted they produced thousands of pounds of smallpox virus in violation of the Biological Warfare Treaty. We also have reason to believe at least some of the Soviet stocks have made their way via the black market to unstable countries in the Middle and Far East–Pakistan and Syria, for example.”
“Great,” said a voice at the end of the table, sarcastically.
“And you all remember the inc
ident a couple of years ago when live samples from our lab here at CDC mysteriously turned up at the National Institutes of Health,” Heche added. “So it’s highly unlikely but possible that some samples have disappeared from our own lab, as well.”
“Yeah,” Silverthorn mumbled and shook her head. “And mistakenly sending a dangerous strain of bird flu to the Department of Agriculture was quite the black eye for us, too. But there are other possibilities. Smallpox may be found in synthetic form in various labs in our own and other countries. We also have to assume it’s available on the world market at the right price for use as a bioterrorism weapon.”
Dr. Heche continued, “For the mayors and police chiefs participating in this discussion, I’ll point out that the greatest threat to our cities may not be deaths from the virus, but rather civil disorder and panic. The federal government and most of our cities do not have adequate response plans for this type of outbreak–often for political reasons. Mass immunization costs for smallpox would have been much lower than other security measures taken since 9/11, but such immunization has been strongly opposed by many public health experts, including our own at CDC. Opponents argue the vaccine would be too dangerous to persons with comprised immune systems–AIDS patients, for example.
Silverthorn added, “The public is also suspicious of government motives in general, which ties into the current anti-vaccination paranoia we’ve been dealing with. Consequently, the federal government has done little in terms of preparedness. Most public health systems would be overwhelmed if hit by such an outbreak.”
Richard Walters of CDC’s Office of Public Health and Preparedness agreed. “In fact, the few biowarfare exercises we’ve conducted in recent years have shown just how unprepared and vulnerable we are to bioterrorism. The number one problem that comes up in each exercise is not having enough vaccine on site. If that’s the case, whom do you vaccinate? Do we strictly limit it to health workers and law enforcement types at the outset? We also have to consider civil liberties issues. Do we seize all major hotels and convert them to hospitals? Close our borders and block all travel? Arrest and jail someone–shoot him, if necessary–if he doesn’t want to be quarantined?”
No one spoke for a few moments.
“Besides an underfunded public health system,” Walters continued, “we have questions about who is to be in charge of the effort. Is it CDC? The attorney general? We need an answer now, not two years from now after several study groups have had a chance to ponder it.”
Silverthorn broke in. “Because time is of the essence, my suggestion is that CDC coordinate the national response. We learned from the Dallas Ebola experience how important it is that CDC take charge early and make sure infectious control procedures are followed to the letter.”
“Is that the case here now?”
“Yes,” Silverthorn said. “We’re in the process of sending hospital infection control teams to each hospital that has or had a smallpox patient–Atlanta, New York, and New Orleans. It’s imperative we control the spread of this disease immediately. If our basic strategy for countering this attack is to prevent infected persons from coming into contact with those not yet infected, yet susceptible–continuing that process until everyone either recovers or dies–we have our best shot at containment. If we fail, the result will be loss of a lot of people and destruction of our economy. That alone could easily lead to civil disorder and breakdown of the state.”
“The solution must begin with our hospitals and city health departments,” Walters said. “If a case of smallpox is even suspected, hospital staff must immediately isolate the patient–in a room specially designed to control contagion–and get a tissue sample to CDC as fast as possible. Once we’ve identified the infection as smallpox, the next step would be to notify all necessary organizations within your respective city governments: police department, local emergency management office, health commissioner’s office, and mayor’s office.”
Heche added, “We also suggest every state designate smallpox response teams consisting of doctors, epidemiologists, nurses, lab workers, and law enforcement officers either currently immunized with the vaccine, or who have had the vaccine in the past five years. We can decide at that point whether or not to do mass vaccinations.”
“We have enough doses in our stockpile now to vaccinate every person in the US if necessary, but getting it to the appropriate locations in time to prevent a massive outbreak will be the challenging part.”
Knapp said, “New York did an emergency preparedness drill last year, testing the delivery of emergency medications in the event of a biological attack. Under that scenario, nearly half of their citizens would have died–largely because they didn’t mass vaccinate.”
“That’s what I’m afraid of,” Mason added. “CDC and the governors can urge mass vaccination, but it still has to be mandated, and ultimately it’s the president’s decision to make.”
Silverthorn said, “Of course, although I doubt he’d ignore the combined suggestions of CDC, NIH, and a majority of our governors and decide against it.”
“It’d be unconscionable,” Dr. Collins added. “But mass immunization without regard to risk status can be dangerous, too. Our researchers figure about one percent of the population would be at risk of serious or fatal complications following this type of vaccination.”
“I agree, it’s not a no-brainer. President Bush announced a program to vaccinate military personnel and health care workers in case something like this happened,” Walters said. “But it was stopped once they measured the potential adverse reactions versus the risk of getting smallpox.”
“Right, although certain military units are still getting it. Terrorists and governments hostile to the US may have stockpiles of the stuff, and we expect our military to be on the job, not back in the States.”
“And we have an outbreak now,” McGraw added.
They all sat in stunned silence for a few moments, while his comment sank in.
“Let’s also not forget about the growing segment of the population opposed to vaccinations of all types on religious or medical grounds,” Dr. Collins said.
“The nut cases,” Reiser said. “It’s bad enough they make those types of decisions for themselves; they make them for their kids, too.”
There was another period of silence, until Silverthorn finally said, “We need to start interviewing our patients, their friends and relatives as soon as possible, to try to determine the origin of this outbreak–where they’d been, with whom they’d been in contact, presumed dates of infection, means of travel... anything and everything we can use that might be relevant.”
“And since we’re also starting a criminal investigation,” McGraw added, “we need to preserve specimens sent to CDC as evidence for eventual prosecution.”
Heche nodded. “Right now, though, we have to concentrate on maintaining order. There will be widespread panic once rumors of an outbreak of smallpox begin to spread. Hospital workers may stay home or walk off the job, and that could lead to serious understaffing problems.”
“And increased stress for those providers still working,” Silverthorn added.
“Hell, yes,” Collins said. “During the 2003 SARS outbreak in China, healthcare workers–particularly nurses–suffered measurable and dramatic feelings of social isolation and post-traumatic stress disorder because of their hospital work.”
“And we don’t want to ignore or minimize that,” Heche said. He gave the participants final instructions about keeping them informed so that CDC could act as communications hub and decision maker for containing the outbreak. He added they would hold regular daily videoconference meetings to discuss progress and failures until the disease was contained. Once it was clear how big a problem they faced, they would issue recommendations about mass immunization.
Drs. Heche and Silverthorn disconnected their videoconference feeds and moved to the doctors’ lounge down the hall from the conference room. Heche poured each of them a mug of black coffee and
plopped down into a padded chair. “Janet, if we don’t stop this thing quickly, we’ll have a tsunami of panic and contagion sweeping the country.”
Silverthorn shook her head, with a look of resignation. “You mean the world.”
12
Princeville, Kauai, July 3rd
The hotel’s staff conference room was connected to Janine’s office by a narrow hallway adorned with framed photos of Kauai seascapes and famous guests who’d spent time at the resort. The hotel had entertained notables for years on a regular basis, from Hollywood types to corporate bigwigs and occasional politicians.
Tom and Janine moved all of Brad’s personal items, notes, laptop, and correspondence from inside her safe and closet to a koa-wood conference table surrounded by six padded executive chairs. Janine arranged for coffee, cold drinks, bottled water, and snacks to be delivered for what they assumed would be a long afternoon of poring through documents, emails, and notes, before she went back to managing hotel business.
Marchetti smirked as Tom eyed the finger sandwiches neatly arranged on a pewter serving tray. If he didn’t intervene and grab a few for himself, Tom would eat most of them in the first hour and be looking for more.
“What’ve you got so far?” Marchetti asked.
Tom pointed to a stack of notes he’d piled in front of him on the eight-foot table. “The first items I came across dealt with the General McNeil case–a binder filled with notes, copies of Washington Post articles, a hand-drawn diagram showing connections to parties involved... stuff like that.”
“Which has been well publicized already. A member of the Joint Chiefs has an affair with a staff member, blabs to her about classified material during their frequent pillow talk, pulls strings to keep her working at the Pentagon, and gets investigated–serious stuff, but not shocking.”
The Omega Covenant Page 6
