Outbreak: What a Real Bioterrorism Incident Would Look Like

March 17, 2003
The first day of a bioterrorism event would look like any other day. So would the second, and probably the third and fourth as well.

by Alan S. Brown

It might take a week or longer for the first symptoms to show. And because the early stages of many bioterror agents look like the flu, the true nature of the disease may go unrecognized. A community may not realize it is under siege until hospitals start filling up and patients begin dying.

First responders, used to manning the front lines of any emergency, would find their roles changed. Doctors, nurses and EMTs would be in the thick of any crisis. Fire and police would find themselves providing support. Fire crews may find their station houses converted into clinics, and those with EMT training pressed into medical service. Police may be asked to guard medical supplies from looting, or to enforce quarantines.

It's a chilling scenario. Although experts repeatedly underscore the difficulty of using disease as a weapon of terror, any intentional release would have the potential for great damage. What would such an event look like? What roles will first responders play? How should we prepare? Here are some answers:

The Threat

The Centers for Disease Control and Prevention (CDC) lists anthrax, smallpox, botulism, plague, tularemia and hemorrhagic fever as Class A bioterror threats. They are easily transmitted, have high mortality rates and might spark public panic.

Smallpox has attracted the most attention. It incubates quietly for 9-14 days before its distinctive lesions appear and it becomes contagious. Before 1977, when it was eradicated, it killed about one-third of its victims. Today it would enter a world where no one has natural immunity. Several nations likely retain samples of the virus, including Iraq, North Korea and France.

Just how a terrorist would release a virus is an open question. Worst-case scenarios visualize weaponized germs, highly potent viruses or bacteria treated so that they disperse readily in air. A terrorist could release them into the heating or cooling system of a stadium, convention center, auditorium or office building. This would infect thousands, who would spread the disease without knowing it.

Fortunately, weaponizing germs is not easy. Japan's religious cult Aum Shinrikyo, which killed 12 in a nerve agent attack on the Tokyo subway in March 1995, tried to do this. Despite a team of scientists and physicians and millions of dollars in equipment, it could not isolate, aerosolize or disperse bioterror agents.

This does not rule out the success of others. Terrorists might buy weaponized agents on the black market. They could disperse them through the mail like anthrax, or infect suicide volunteers to walk through crowded stadiums or airports.

Fortunately, bioterror diseases are usually treatable. But first, doctors have to correctly diagnose them.


Most biowarfare diseases look like the flu. They cause high fever, weakness, muscle pain, nausea and headaches. Victims are likely to take aspirin and stay in bed. Those who seek medical care may not raise a flag because doctors used to dealing with everyday cases are unlikely to look for or recognize nonspecific bioweapon symptoms.

Doctors might, for example, mistake smallpox for chicken pox. "The distribution, type and location of lesions, and their look and feel at different stages distinguish smallpox," says Dr. Howard Schwid, an anesthesiology professor at University of Washington (Seattle).

"If a first responder could tell symptoms at a glance, that would be very valuable," he continues. "If I saw someone with a characteristic smallpox rash and high fever, I would immediately ask for a vaccination myself. I would have about three days after first exposure to receive that vaccination."

Schwid helped Anesoft Corp. (Issaquah, Wash.) develop software that trains health care workers to recognize and treat bioterrorism symptoms. Even so, he suspects that physicians would not diagnose an agent of terror until the first death.

One reason for delays is that doctors rely on laboratory tests to identify diseases that resist conventional treatments or cause unexpected deaths. These tests do not screen for bioterrorism threats. It may take days or even weeks before someone runs the right tests and understands the true nature of an outbreak. By then, those with the infection may have spread it to hundreds or thousands more.

The CDC and several states and cities hope to recognize a crisis earlier by monitoring EMS traffic, hospital admissions and patient symptoms. New York City, for example, samples flu-like symptoms and diarrhea cases at a series of "sentinel" hospitals and nursing homes for unusual upswings. Unusually heavy EMS traffic, a spike in school absences or even an increase in dead animals may also raise flags.

Statistical methods could provide a warning in the earliest phases of an outbreak, when only a handful of cases have appeared at each of a city's hospitals. Otherwise, health workers may not see the big picture until the sick and dying overwhelm them. Then it will become a race against time to contain the disease.


Experts have tried to understand how a plague would unfold by simulating bioterrorist attacks. Operation Topoff, a U.S. Department of Justice simulation held in Denver in May 2000, assumes a covert attack of aerosolized plague (Yersinia pestis) on 2,000 people at a concert.

Within four days, 16 city hospitals report 783 cases and 123 deaths. Two days later, this rises to 3,700 cases – at least 780 transmitted by those initially infected – and 950 deaths. Cases appear in at least six states outside Colorado.

Plague's short incubation time overwhelms local hospitals. So do demands for treatment from the walking worried; healthy people who fear they have symptoms. Although federal authorities send vaccines and antibiotics, the distribution system in Denver breaks down. The governor decides to use remaining stocks to treat health care workers rather than close contacts of infectious cases.

In the end, assessors conclude that Denver would require 2,000 outside medical personnel within 24 hours to keep its health care system from collapsing. Otherwise citizens, some plague-infected, would start to leave Denver to seek help elsewhere.

One year after this simulation, the Johns Hopkins Center for Civilian Biodefense Studies (Baltimore) held Dark Winter. It simulated the 13-day spread of smallpox after aerosolized release at shopping malls in Oklahoma City, Philadelphia and Atlanta.

The Dark Winter scenario assumes that 30 grams of smallpox causes 3,000 infections, and that each victim infects an average of 10 others. The first 20 cases are diagnosed nine days after exposure. By the end of the 13-day scenario, hospitals in 25 states report 16,000 smallpox cases – 14,000 in the past 24 hours – and 1,000 deaths.

Experts predict that 17,000 new cases will emerge over the next 12 days, leaving 10,000 dead. But this assumes successful mass vaccination and disease containment. A breakdown in the system could catapult the number of dead to 100,000 or more.

Medical Response

Once the first case has been diagnosed, the clock starts ticking. The community has to find enough medicine, hospital beds and health care professionals to treat the ill and vaccinate the well.

Everything starts with retaining medical personnel, says Amy E. Smithson of the Henry L. Stimson Center, a Washington, D.C., national security think tank. In her landmark report on U.S. bioterrorism preparedness, she interviewed several physicians who said that half their staff would "run for the hills" if an incident occurred. She advocates first immunizing doctors, nurses, EMTs and other health professionals – and their families – so they will feel safe enough to remain on the job. Police and fire should also receive preventive antibiotics so that they remain at their posts.

Bringing in outside medical help is more problematic. Military doctors are a possibility, and several organizations are seeking ways to create a voluntary response team of physicians and nurses that would fly to emergencies.

Until help arrives, stricken areas must fend for themselves. Tucson fire battalion chief Les Caid, who helped organize a bioterrorism exercise in Arizona in November 2002, expects to draft EMTs, pharmacists, veterinarians, and student nurses and doctors. Oklahoma State EMS director Shawn Rogers, who participated in the April 2002 Sooner Spring bioterrorism exercise, expects to use police and fire fighters with EMT training to dispense medication in an emergency.

Cities are also likely to run out of beds. Even seasonal flu outbreaks overtax the capacity of many hospitals, Smithson points out. A bioterror incident would quickly strip hospitals of their ability to house and isolate contagious patients.

To cope with the onslaught, hospitals must share the burden, Smithson continues. Some facilities must remain open and uncontaminated for ordinary medical emergencies. Others will need every available bed to treat disease. Some preexisting patients must be evacuated, while others will be too sick to move. Cities may need to quickly transform schools, heating/cooling centers and fire stations into clinics.

It will take a well-practiced plan to move fast enough to head off the crisis. "Most communities still don't have a collective game plan for burden sharing," says Smithson. "The front lines will be all around them, and in the midst of disaster there is no time to exchange business cards."

The Stockpile

Communities will also need enough medicine and supplies to treat the sick. Most hospitals now stock only a few days' supplies. They will vanish within hours as hospitals inoculate their staffs, first responders and their families. Local warehouses will empty nearly as quickly.

The National Pharmaceutical Stockpile was created for that contingency. It consists of three 94,000-lb caches of palletized, ready-to-ship pharmaceuticals and medical equipment in Denver, Los Angeles and Winston-Salem, N.C. (A fourth cache remains in Washington, D.C.)

Although the system relies on 35-member volunteer medical teams, it is designed to roll within 4 hours. "It takes 18 to 24 minutes from the time we arrive to receive the first patient," says Robert Cornish, who manages the program for the U.S. Office of Emergency Response.

However, plenty of things could go wrong during deployment. Arizona's exercise moved the stockpile to a warehouse without a loading dock. It took half an hour to unload each of the 18 trucks transporting the cache. Nor did the warehouse have the Internet connection needed for logistics control.

Vaccinating the public will also take logistics planning. In its bioterror exercise, Arizona opted for collection points where people boarded buses to dedicated dispensing sites. Sooner Spring authorities took over local drive-through restaurants. "We expect cars to line up for blocks and blocks, so this allows the easiest flow of traffic," says Shawn Rogers.


Any emergency plan will call for rapid, highly coordinated responses from many different agencies. Lots can go wrong, and each new difficulty puts pressure on the system. "The health care system could collapse under pressure from the exposed and walking worried," says Smithson.

What would a collapse look like? "Hospitals shutting their doors because they can't treat any more patients," she replies. "People leaving the area in search of health care services in other areas. People breaking into pharmacies to get drugs. Panic."

That means a high police profile at hospitals, clinics, drug dispensing centers and even pharmacies. "Police will need to identify sites where citizens might go to take things into their own hands if things got bad," says Smithson. "Imagine how a panicked community would react if some reporter got on the air and said, 'You can get this at your local pharmacy.'"

Caid agrees. "There are going to be thousands of very anxious folks lined up at dispensing centers," says Caid. "What if someone starts a rumor about lack of medication? By the time it got to the back of the line, people would be going crazy. The potential for problems at dispensing sites is huge."

During Arizona's exercise, police manned clinics and dispensing stations. They also secured the National Pharmaceutical Stockpile landing site and warehouse, as well as routes used to distribute pharmaceuticals. "Pharmaceuticals would be more valuable than gold," says Caid. "We wanted to know who would be in charge. Local police? State? We wanted our plans to be really specific so we had no miscommunications."

"It's not just about manpower, but appropriate use of force," adds Smithson. "If someone breaks down a hospital door, what level of force do local police use? Are we talking about a bull horn? Pepper spray? Rubber bullets? Lethal force?"

Quarantines and Communications

Any discussion of quarantines raises similar questions. Oklahoma's Rogers is adamant: "You can't quarantine a city – it's not realistic unless you ring a city with troops and shoot to kill."

This raises sticky issues for first responders. Police would have to enforce any restrictions. Police, fire fighters and EMS would also have to enter the same isolated areas to provide food, medical care and other essential services. How would they fare in a city that spent its last supplies of medicine to treat first responders, then sent them into neighborhoods where disease was rampant?

Issues of force will cause many communities to shy away from quarantines. Others claim that modern forms of transportation make quarantines almost impossible to enforce. "You don't have enough police in an entire state to quarantine certain city areas," says Smithson.

Instead, governments must convince citizens to stay at home, says Michael Mair, a senior research assistant at Johns Hopkins Biodefense who participated in Dark Winter. "We think people are normally calm, rational and work together in these situations," he explains. "We always get a better response when we use the least restrictive means possible that prevents spread of disease. That shows more respect for people's civil liberties."

Public communication often takes the backseat in a crisis. A bioterror event would demand an extraordinary amount of clear communications. Citizens need to hear a single message so there is no doubt what steps they must take to keep the disease from spreading.

"The ways and speed at which information is communicated may be a major factor in limiting a terrorism attack," says John Sorensen, director of Oak Ridge National Laboratory's Emergency Management Center. He notes that the anthrax scare did not cause mass hysteria, and that people tend to be more apathetic than responsive. "People have a tendency to deny that something will happen to them, and think that it will happen to other people," he explains.

Yet he also admits that no one really knows how a city will react to a large-scale bioterrorist attack. His advice: Provide lots of information. Do not withhold information. Acknowledge where there are uncertainties and why they occur. Never cover up or sugarcoat things.

He also suggests engaging a wide variety of people, from scientists to community leaders, to discuss the situation. "Multiple sources of information are the key to reaching even impoverished areas without social support networks," he says.

Addressing this, Smithson suggests getting out early with frequent updates and making sure everyone is on the same page. Contradictory statements cause confusion and panic. Given the number of different local, regional, state and federal organizations that will be working together for the first time, this may be difficult.

The End?

What happens next? Assume for a moment that one or more U.S. cities have been attacked. We have identified the disease. We fly in the National Pharmaceutical Stockpile and press anyone with medical training into emergency service to treat and vaccinate the public. Everyone does a good job of communicating. Most people stay indoors, and EMS comes to get them if they call in sick.

What then?

The scariest thing about most simulations and exercises is not just the numbers, which are terrifying enough. It is that simulations are designed to last only a certain number of days. When they end, the disease is still spreading. Thousands are infected. Not all of them know it.

How does it stop? When does it stop?

No one knows the answer because nothing like this has ever happened before. And, because bioterrorism is so difficult to practice, it may never happen.

Meanwhile, the best option is to remain alert. Learn the symptoms. Look for unusual statistics. And know and practice the plan before we need it.

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