Smallpox too much for health system

No hospital in the country is fully prepared for a serious bioterrorist epidemic, says a hospital group.

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By SARA FRITZ

© St. Petersburg Times,
published November 4, 2001

WASHINGTON -- If a person with smallpox turned up at a hospital emergency room today, would the nation's public health care system be ready to handle a fast-spreading bioterrorist epidemic?

The answer, everyone agrees, is no.

Not one hospital in the United States has all the resources needed to deal with a serious bioterrorist attack, says the American Hospital Association. Likewise, the Centers for Disease Control and Prevention and officials of 3,000 state and local public health departments across the country admit they do not have the necessary personnel or communications tools.

While the federal government is prepared to supply localities with a wide variety of medicines within 48 hours, smallpox vaccine could take much longer to get. And with nursing care and hospital beds already at a premium in most places, smallpox victims might find themselves confined to a cot in the local high school gymnasium.

Indeed, preparedness for a serious bioterrorist attack is so inadequate that AHA president Dick Davidson says it would be "amateur hour" for the nation's medical establishment.

Accordingly, public health officials have begun to take steps to increase the likelihood that smallpox would be recognized and treated. The New York Times reported that the disease centers last week vaccinated about 140 members of epidemiologic teams that could be summoned at a moment's notice to examine a suspected case anywhere in the country.

Some regions are more prepared than others. Florida's public health system is believed to be among the stronger ones, and Hillsborough County has just activated the first-in-the-nation computerized system to detect early warning signs of an epidemic.

Before Sept. 11, odds of a smallpox attack were assumed to be negligible because the virus is not readily available to terrorists. Only Russia and the United States are known to have the living virus in their stockpiles of biological weapons.

But the threat of a smallpox attack is no longer inconceivable, and some experts think it is already in the hands of a number of rogue states. Without a doubt, smallpox is the one virus that public health officials fear most, because, unlike anthrax, it is so contagious it could spread around the globe before anyone realized it.

"Smallpox would be catastrophic," says John Sinnott, professor and director of the infectious disease division at Tampa General Hospital. "It would destroy our society more than nuclear weapons."

Elizabeth A. Fenn, author of Pox Americana, a new book documenting the spread of smallpox in North America in the 18th century, agrees. "If smallpox got loose, it would not be just a localized disaster; it would be a global human tragedy," she says.

Unfortunately, the threat of serious bioterrorist attack comes at a time when the U.S. health care system is already overburdened with possible anthrax cases and short on resources as a result of years of cost-cutting. Even the anticipated winter outbreak of influenza, combined with the current anthrax scare, is expected to stretch the capacity of the public health system.

Medical experts say the fear of a bioterrorism attack could ultimately reverse the current trend toward managed care and other measures designed to limit health cost inflation. Jim Bentley, the hospital association's bioterrorism expert, predicts it will precipitate far-reaching national debate over the future of health care spending.

"I don't see managed care as going to be helping the effort against biological warfare and, in fact, it probably hinders it," says Sinnott. "It certainly would limit diagnosis. I don't know who's going to pay for the laboratory tests, which are quite expensive."

What the public health system needs immediately, according to Bentley and others, is more money from Congress. Hospitals are asking for an immediate $11-billion; public health departments want about $10-billion. But even if these requests were funded immediately, it would be too late to help the victims of an attack this year.

Would spread far, fast

No one knows the odds of a smallpox attack.

Donald A. Henderson, of Johns Hopkins University, speculates the chances are "not very high." But Tampa General's Sinnott has no doubt that terrorists have access to virus purloined from stocks of the former Soviet Union.

"The Soviets had 30,000 physicians working on biowarfare," Sinnott said. "It is inconceivable that some of these people didn't go to work for rogue nations and take their viruses with them."

Americans could be infected either by detonation of a weapon or by contamination of things used in everyday life. In 1767, during the French and Indian Wars, the British spread smallpox among the Indians by giving them infected blankets.

What makes smallpox so deadly is that it does not show symptoms during the first 12 days. By the time infected people become contagious, with deep, dense lesions on their faces, arms and legs, they could have traveled very far, taking the virus with them.

When these people begin to seek help at hospitals, it's also possible their disease could be misdiagnosed. Thus nurses and doctors could easily be infected with smallpox while examining patients.

"Most physicians and nurses have never seen cases of certain diseases, such as smallpox or plague, and some biological agents initially produce symptoms that can be easily confused with influenza or other less virulent illnesses, leading to a delay in diagnosis or identification," says a report by the General Accounting Office, the investigative arm of Congress. "Medical laboratory personnel require training because they also lack experience in identifying biological agents such as anthrax."

As part of a preparedness test in Pittsburgh, for example, 17 emergency room doctors reportedly were asked to diagnose patients pretending to have smallpox. Some thought it might be lupus; others guessed it was toxic shock syndrome. Only one physician got it right.

In Tampa, Sinnott conducted a seminar for personnel at Tampa General on Friday to familiarize them with the symptoms of smallpox and other viruses that could be used as weapons by terrorists. Some other hospitals are giving their doctors and nurses similar training.

While only about one-third of the people infected with smallpox would die, the others would need hospitalization. But because of the limited number of available beds in most hospitals, Bentley says, the patients would have to be quarantined in makeshift wards in schools, armories and nursing homes.

Confusion could add to the death toll. In a simulation carried out last summer known as "Dark Winter," the government tested what would happen if the smallpox virus were released in Oklahoma City. Officials involved in the simulation confronted many ethical issues that were difficult to resolve. In the end, they concluded that more than 1-million would die under similar circumstances.

Sinnott says a smallpox epidemic in Florida would likely be worse than in many other states, in part because the state has such a highly mobile population, including tourists from all over the world.

Because no American has been vaccinated for smallpox since 1972, when the disease was said to be eradicated, the population would be particularly susceptible. Although the government still has 15-million doses of the smallpox vaccine, it probably would not be enough. In addition, officials warn, the vaccine itself would likely produce a few live cases.

The federal government recently pledged to increase the stockpile of smallpox vaccine, probably by diluting the existing doses. But Robert Belshe, whose studies at St. Louis University have shown the diluted vaccine can be effective, says the United States cannot have the necessary 300-million doses until "sometime next year."

Bay area better prepared

Ideally, the local public health department would be the agency to spot an epidemic of smallpox in the making. Then the department would mobilize all local, state and federal resources to halt the spread of the virus.

But these agencies may not be able to rise to the occasion. "Public health departments nationwide are not fully prepared to handle these growing bioterrist attacks," says Mohammad Akhter, executive director of the American Public Health Association.

Only 20 percent of the nation's local public health agencies have drawn up comprehensive plans for responding to a serious bioterrorist attack, according to a recent survey. A quarter of them have no plan, and the remainder are in the process of developing one.

Most health departments do not have a full-time epidemiologist who can identify the first signs of an epidemic. In fact, many health departments, particularly in rural areas, do not even employ a physician or a full-time nurse.

And because most health department employees work 9 a.m. to 5 p.m., Monday through Friday, says Akhter, "if a bioterrorist attack occurred on a Friday afternoon, there would be no report of it until Monday morning."

In recent years, Congress has cut funding for the Centers for Disease Control and Prevention in Atlanta, as well as for the public health departments across the nation. Money subtracted from their budgets has been invested, instead, in medical research at the National Institutes of Health.

The hospitals are also unprepared, although most of them at least have plans for responding to garden-variety emergencies such as traffic pileups.

Just recently, the American Hospital Association published a list of improvements that most of the nation's 4,900 acute care hospitals must make to be prepared for a serious bioterrorism attack.

It called for beefing up communications, disease surveillance, decontamination facilities, training, mental health resources and space for in-patient care. It also said that hospitals, which no longer keep a big inventory of surgical and pharmaceutical supplies, need to stockpile these necessities, and provide hospital personnel with protective equipment.

None of the hospitals in the United States has satisfied the AHA's requirements for emergency preparedness.

"We've got a long way to go," acknowledged AHA's Davidson, who insists the anthrax scare has shown hospital administrators the error of their ways. "I think hospital employees are now concerned about bioterrorism in a way they were not 30 days ago."

On Thursday, according to Sinnott, Tampa public health officials inaugurated the first-in-the-nation computerized system to allow them to monitor diagnosis patterns at local hospitals. If hospitals report an unusually high number of patients with similar symptoms, the department will immediately investigate for a possible bioterrorist attack.

"The bay area is perhaps the best prepared area in the country," says Sinnott.

He says Florida, unlike many states, has supplemented federal funding for public health. This is why, he says, the state responded so rapidly to the first sign of anthrax in Boca Raton.

There is no cure for smallpox, although a vaccination up to three days after contamination can halt the progress of the disease. Most patients would have to be quarantined and provided with nursing care, however. The AHA recommends hospitals develop "surge capacity" to increase patient beds on short notice.

Another important task facing every community would be the disposal of the bodies of the victims of smallpox. Sinnott predicts health departments would require all victims be cremated before burial to prevent further contamination.

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