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Table Top \'Worst Case Scenario\' on Smallpox with Pandemic Flu Applications

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Table Top Exercise.Linkedin

  1. 1. TABLE TOP EXERCISE: Black Strike Scenario Prepared for the French High Committee for Civil Defence Under EHSA with the support of Acambis Drs. Jill Dekker-Bellamy
  2. 2. «  Strategic Stockpiling: A Framework for Preparedness and Response » <ul><li>Historically, smallpox has been one of the most deadly diseases known to mankind, killing between 300 and 500 million in the last century alone, far more than, plague or the 111 million people killed in all of the Twentieth century’s wars combined. It’s highly communicable, kills 30% of those infected, normally scars and may blind survivors. Smallpox was declared eradicated in 1980 by the World Health Organization. During the 1980’s after signing the Biological and Toxin Weapons Convention in 1976, the Soviet Union acknowledged maintaining a secret biological weapons program that employed 60,000 technicians and scientists, only 15% of the Biopreparat programme was legitimate. </li></ul>
  3. 3. <ul><li>Today, a major concern is that strains from the former Soviet Biopreparat programme may have been sold or diverted to terrorists or the states that support them. Another concern is that while smallpox is officially retained at only two repositories: Vector in Novosibirsk, Russia and the CDC in Atlanta, USA, several nations may have retained strains either deliberately or inadvertently during the WHO Global eradication campaign. </li></ul><ul><li>Black Strike is a fictitious table top exercise to assess preparedness for a smallpox attack with in the European Community. </li></ul>
  4. 4. Background <ul><li>Prior to negotiating the sale of a smallpox battle strain from a state defence laboratory, a terrorist group with close ties to Al Qaeda, procured smallpox vaccine from a Russian scientist of Georgian dissent. The Russian scientist is sympathetic to their cause and had access to both smallpox vaccine and several strains. Lack of security at the defence laboratory allowed the scientist to divert several doses of vaccine, bifurcated needles, masks, and more significantly live smallpox. During a medical conference in North Ossetia, the scientist met with members from the terrorist organization and exchanged materials for money. </li></ul>
  5. 5. <ul><li>The terrorists are well funded and backed by Georgian paramilitary groups associated with the respective intelligence service. Two of the terrorist leaders hold graduate level degrees, one in micro-biology the other in aerosol-particle physics. They have undertaken a number of smaller scale attacks using botulism to infect a lake region where a large number of Russian citizens became ill with several casualties cited in the local press. They have also attempted to release anthrax at a Russian military base on the border with Chechnya. Russian news did not release the number of casualties. Both previous attempts were successful and the group has a strong history of successfully deploying biological agents. </li></ul>
  6. 6. <ul><li>Citing Russian atrocities in Chechnya and European failures to intervene in what the terrorists view as a war against Islam, the group plans a multi-nation attack on several European cities. A few weeks prior to the planned attack, they vaccinated themselves and their families against smallpox and spent months training in the Pankisi Gorge with small commercial dispersal devices which they purchased off the internet. </li></ul>
  7. 7. <ul><li>Part of the group’s ideology is apocalyptic, so blow-black is not an issue for this terrorist organization; although they have taken precautions to prevent their own demise. They completed the purchase of a weaponized strain from the same Russian scientist who sold them vaccine. In preparation for their attack each of five terrorists has been living in the designated area where they plan to release the smallpox to familiarize themselves with schedules and locations and conduct reconnaissance. </li></ul>
  8. 8. <ul><li>On May 1st during the run up to the UK general election, MI6 receives credible intelligence that a former Russian scientist of Georgian descent has sold smallpox samples from his defence laboratory to terrorists and one of the targets may be London City. Unable to confirm the credibility of this threat, Six decide not to release the information immediately but to wait and see if the information obtained from a Russian informant can be cohobated. </li></ul>
  9. 9. <ul><li>On May 5th, the terrorist organization with reported links to Al Qaeda claims responsibility, in a video sent to the BBC, for a multi-nation attack with the deadly pathogen smallpox. In their statement they announce they’ve released weaponized-(aerosol) smallpox with commercial sprayers at Victoria Station in London, on the TGV from Paris to Marseille, aboard a ferry from Marseille to Algeria, at the EU Parliament building in Brussels, at the Malpensa Airport in Rome, Italy and in St. John’s Cathedral in Warsaw, Poland. The terrorists promise more attacks in the up-coming days if their demands to release a list of Georgian prisoners from Russian state penitentiaries is not met within 48 hours. </li></ul>
  10. 10. <ul><li>The group claim they have enough smallpox for several more attacks and will hit countries so far untouched citing Germany, Sweden and Norway as next on their list. The group appears well organized, financed and educated. </li></ul>
  11. 11. Briefing Report <ul><li>10:00 am </li></ul><ul><li>During an international meeting of the World Health Organization in Geneva, national health delegations preparing to attend the annual World Health Assembly are informed that three suspected cases of smallpox are being reported at a hospital in London. Within half an hour twenty eight suspect cases are reported in Brussels, with 19 suspected cases reported in Italy. </li></ul>
  12. 12. <ul><li>What are the immediate health and security issues which must be addressed? </li></ul><ul><li>Which nations have smallpox plans and cross-border agreements to deal with a major public health crisis? </li></ul><ul><li>Who’s in charge of the vaccination champagne? </li></ul><ul><li>Which institution or Ministry is in charge of risk communication? </li></ul>
  13. 13. Victoria Station, London
  14. 14. <ul><li>“ There are no accepted benchmarks to estimate a country's ability to handle a potential pandemic or bioterrorist attack, but it is clear that some countries have made significant investments, whereas others have made none .- Atlantic Storm </li></ul>
  15. 15. <ul><li>12:00 pm </li></ul><ul><li>The Public Health Authority of the UK announce there are now 17 confirmed cases in Ealing Hospital, Great West Hatch Hospital and Kings College Hospital with an additional 82 suspected cases at hospitals throughout the city and three suspected cases in Edinburgh. </li></ul>
  16. 16. Fact Sheet 1 <ul><li>On May 8th 1980 the World Health Organization announced the eradication of smallpox and the consolidation of all laboratory samples to be held at Vector in Novosibirsk Russia and the CDC in Atlanta-USA. </li></ul><ul><li>It’s strongly suspected some nations did not turn in all their samples, either accidentally or deliberately. </li></ul><ul><li>There have been no known cases of smallpox since 1978. </li></ul><ul><li>Vaccination of civilians has ended in most countries severely reducing herd immunity. </li></ul>
  17. 17. Fact Sheet 1 continued <ul><li>Increased immunodeficiency across global populations means previous outbreak modeling may no longer capture the reality today. </li></ul><ul><li>A terrorist attack with smallpox is likely to vary in scale, scope and intensity compared to a natural release. </li></ul><ul><li>Genetic modification may make amplify infectivity; </li></ul><ul><li>One study estimated that because global populations have reduced heard immunity and are consider immuno-niave having little or no resistance to the extinct virus, an initial release which infected just 10 people would spread to 2.2 million people in 180 days. </li></ul>
  18. 18. Clinical Indicators <ul><li>Humans are the only known host for smallpox </li></ul><ul><li>There are two rare forms of smallpox: hemorrhagic and malignant. In the former, invariably fatal, the rash was accompanied by hemorrhage into the mucous membranes and the skin. Malignant smallpox was characterized by lesions that did not develop to the pustular stage but remained soft and flat. It was almost invariably fatal. </li></ul><ul><li>Smallpox outbreaks typically occur in two-week intervals. Initially, just a few people get sick. Fourteen days later, a larger number of people develop the disease, and in another two weeks, even more cases appear. This pattern reflects the incubation period of the virus as well as its exponential spread. </li></ul>
  19. 19. <ul><li>During the incubation period which can be from 7 to 17 days-the patient is not infective. </li></ul><ul><li>The prodrome phase is when the patient becomes symptomatic-but is not presenting with rash. During the prodrome phase the patient presents with fevers and flu like symptoms and is highly infectious. </li></ul><ul><li>The rash phase begins after the prodrome. It is in this phase, or a day before this, that the patient is most infectious. That is, he is able to transmit the disease to other individuals. However, the patient can be infectious perhaps to a lesser extent during the prodrome. This we know because the virus can be isolated in the oral cavity during the prodrome. </li></ul>
  20. 20. Fact Sheet 2 <ul><li>Smallpox virus, called by one expert &quot;the world's most dangerous prisoner,&quot; is among the deadliest biological agents to ever plague human society ( Tucker 2001 ) [1] </li></ul><ul><li>Smallpox is a fatal, contagious disease responsible for killing an estimated 500 million people worldwide in the 20th century alone-more than all wars and HIV infections combined. </li></ul><ul><li>Of all potential biological weapons, smallpox is considered the most dangerous and historically the most feared. </li></ul><ul><li>[1] TUCKER, Jonathan B. (2001) Scourge: The Once and Future Threat of Smallpox New York: Grove Press, 2001 </li></ul>
  21. 21. Fact Sheet 2 continued <ul><li>Smallpox is one of the most communicable of infectious diseases. Studies have shown that approximately 30% of susceptible contacts became infected. Only measles and influenza have a consistently higher attack rate. </li></ul><ul><li>Smallpox is a disfiguring, communicable disease with a case-fatality rate of 30% [ 8 , 9 ]. </li></ul><ul><li>There is no effective medical treatment [ 9 ]. </li></ul><ul><li>The World Health Assembly officially declared smallpox eradicated worldwide in 1980 [ 10 ]. </li></ul><ul><li>Since its eradication, smallpox vaccination programs and vaccine production have ceased globally with the exception of a few nations. [ 6 ]. </li></ul><ul><li>The main issues which heighten our perception of this threat are drawn from factors which have not been considered relevant to other potential BW agents. </li></ul>
  22. 22. Fact Sheet 2 continued <ul><li>Most of the world’s population has never been immunized against smallpox; </li></ul><ul><li>When smallpox was endemic, it was recommended individuals should be vaccinated every three years so it is probable that those who were vaccinated more than two decades ago would no longer be protected now; </li></ul><ul><li>Terrorists associated with Al Qaeda have expressed an interest in acquiring smallpox and plague; </li></ul><ul><li>Several state programmes are believed to now be conducting advanced research on smallpox. </li></ul><ul><li>Global air-travel would likely spread this disease more quickly today where it’s the pace not the space that is significant. </li></ul>
  23. 23. <ul><li>12:15 </li></ul><ul><li>The Military Institute of Hygiene and Epidemiology in Warsaw, Poland notify 23 suspected cases of smallpox and due to insufficient vaccine stockpiles begin to mobilize for a mandatory quarantine. </li></ul>
  24. 25. <ul><li>12:30 </li></ul><ul><li>As more cases are suspected, reports of unvaccinated first responders and hospital staff refusing to treat potential cases are now being reported across Europe. News services announce vaccine lines have begun to form in some member states as citizens demand vaccination. </li></ul>
  25. 26. <ul><li>As hospitals become overwhelmed, what national plans exist to cope with surge capacity? </li></ul><ul><li>How will limited supplies of vaccine be distributed? </li></ul><ul><li>Who is in charge of the distribution? </li></ul><ul><li>If or when supplies run out what is the national plan to obtain what would be thousands of more doses? </li></ul><ul><li>Should the military be mobilized to provide rapid, non-hospital setting vaccination? </li></ul>
  26. 28. <ul><li>12:45 </li></ul><ul><li>More than 160 people are now suspected of having smallpox in Brussels alone and the number of exposed individuals appears to be rapidly climbing. Hospitals are overwhelmed and many staff has fled. The European Commission buildings are closed due to fear of further exposure. All public meetings are prohibited. </li></ul>
  27. 29. <ul><li>How many first responders per region are vaccinated and can treat smallpox cases? </li></ul><ul><li>How will we triage cases? </li></ul><ul><li>Who gets limited doses of vaccine? </li></ul><ul><li>What plans are in place if older generation stocks are no longer efficacious? </li></ul><ul><li>What are the national standards on dilution? The EU standard on dilution? </li></ul>
  28. 30. <ul><li>13:00 </li></ul><ul><li>France announces its first suspected cases in Marseille and Paris, while reports of a ferry carrying over 500 passengers and crew has announced several people are presenting with symptoms consistent with smallpox. The ferry, under French and Algerian flags, remains in international waters 50 nautical miles off the coast of Algeria. </li></ul>
  29. 31. FACT SHEET 3 <ul><li>It’s estimated only a few virions are required to cause human smallpox infection, therefore the total quantity of virus necessary to cause 3000 infections in humans is extremely small [ 9 ]. </li></ul><ul><li>For example, William Patrick, a senior scientist in the US offensive biological weapons program before its termination in 1969, has stated that 1 g of weaponized smallpox would be sufficient to infect 100 people via an aerosol attack [ 21 ]. </li></ul><ul><li>Accordingly, as little as 30 g of smallpox could cause 3000 infections. </li></ul><ul><li>Given the small infectious dose required to cause disease, and considering that the former Soviet Union was able to produce smallpox by the ton, an attack resulting in 3000 infections is scientifically plausible. </li></ul>
  30. 32. FACT SHEET 3 continued <ul><li>The transmission rate for smallpox is not a static characteristic of the smallpox virus that can be readily determined, but a complex, dynamic, fluctuating phenomenon contingent on multiple biological (both host and microbial), social, demographic, political, and economic factors [ 17 , 19 ]. </li></ul><ul><li>As such, the smallpox transmission rate within any given population is highly context dependent. Therefore, any effort to estimate how smallpox might spread through contemporary societies must account for contextual differences, to the extent possible. </li></ul><ul><li>The first recognition of a covert attack with smallpox virus will likely occur when people infected in the initial attack begin showing signs of infection and start appearing in emergency departments and doctors' offices [ 16 ]. </li></ul>
  31. 33. Fact Sheet 3 continued <ul><li>At this point, those people will have become capable of transmitting smallpox to others. Thus, by the time a covert attack is discovered, the disease will already be spreading to the next generation of cases, known as &quot;second-generation&quot; cases. </li></ul><ul><li>Given that very few doctors currently practicing medicine have ever seen a case of smallpox, and given that there is currently no widely available, rapid diagnostic test for smallpox, it is likely that the diagnosis of initial smallpox cases will be delayed, further promoting spread of disease. These factors are crucial in estimating the transmission rate. </li></ul><ul><li>Another important factor in such estimations is the level of national and global susceptibility to smallpox virus infection. </li></ul><ul><li>Human beings are considered universally susceptible to smallpox virus, unless they have been vaccinated or have been infected previously with an orthopox virus [ 17 ]. </li></ul>
  32. 34. Fact Sheet 3 continued <ul><li>Given the absence of endemic smallpox in the world and the absence of vaccination programs since the 1970s, the global susceptibility to smallpox virus is higher than it has ever been in modern history [ 6 ]. </li></ul><ul><li>Data from the 2000 US Census indicate that 42% of the US population is aged <30 years and, therefore, has never been vaccinated against smallpox [ 22 ]. </li></ul><ul><li>For those who have been vaccinated, the susceptibility to smallpox infection is uncertain, because acquired immunity is known to wane over time. Exactly how long and to what extent smallpox immunity endures is unknown. </li></ul>
  33. 35. Fact Sheet 3 continued <ul><li>Epidemiologic data offer some information and insights into the expected duration of immunity and the benefits of past revaccination: &quot;an increased level of protection against smallpox persists for 5 years after primary vaccination and substantial but waning immunity can persist for 10 years; antibody levels after revaccination can remain high longer, conferring a greater period of immunity than occurs after primary vaccination alone&quot; ([ 23 ], pp. 34). </li></ul><ul><li>Some experts have recently argued that immunologic memory in response to vaccination against smallpox may last considerably longer than hypothesized [ 25 ] and, consequently, that the level of herd immunity may be higher. However, for now, that remains a matter of conjecture. </li></ul><ul><li>Tara O’Toole, Michael Mair, and Thomas V. Inglesby, “Shinning Light on Dark Winter”, Clinical Infectious Diseases, 2002; 34:972-983. </li></ul>
  34. 36. Voluntary or Comulsory Quarantine?
  35. 37. <ul><li>By 13:30 several hospitals have closed. Brussels is brought to a virtual standstill as people are afraid to take public transport. Rome announces it has 72 cases and will close Malpensa Airport to all non-essential flights. </li></ul>
  36. 38. <ul><li>14:00 </li></ul><ul><li>Al Jazera releases a pre-taped video by terrorists claiming responsibility for the attacks and promising more attacks within the next few days. </li></ul><ul><li>Several unaffected states within the EU are considering closing their borders to non-essential travel and transport. To prevent further infection airports are closed in some European states. </li></ul>
  37. 39. <ul><li>In light of potential outbreaks in neighboring counties will the French and Dutch governments donate their own vaccine when they may need it to protect their own citizens? </li></ul><ul><li>Will the Dutch and French public agree to donate part of their stockpiles over to Poland? </li></ul><ul><li>What will the respective governments do if civil unrest breaks out as a result of announced donations to Poland? </li></ul>
  38. 40. There is no known cure for smallpox
  39. 41. <ul><li>14:15 </li></ul><ul><li>Hundreds of cases are now arriving at Belgium hospitals; Guy Verhofstad announces his country will ask the Netherlands and France for vaccine donations. </li></ul><ul><li>France announces several suspected case at a hospital in Lille on the Belgian border and the UK has halted all Eurostar traffic from the continent as they announce nearly 1000 possible cases now coming into casualty wards across the UK. However as the incubation period is from 7 to 17 days (during the incubation phase you can’t infect others-you are only infective from the onset of rash) the length of time from infection is difficult to determine and thousands of passengers have already passed through the international terminals across Europe. </li></ul>
  40. 42. Passengers wait in the rain after being prevented from checking in at Heathrow
  41. 43. <ul><li>“ Leaders would be far less inclined to pursue drastic actions if there were ready supplies of vaccine or medicine and if there were effective systems to get them to the people who need them. - Werner Hoye </li></ul>
  42. 44. <ul><li>Local Issues: </li></ul><ul><li>Are all first responders vaccinated? </li></ul><ul><li>How and where will unvaccinated first responders be vaccinated? </li></ul><ul><li>What is the role of NATO, or national defence? </li></ul><ul><li>How is vaccine distribution ensured? </li></ul><ul><li>What are the contingencies available once hospitals close and or become overwhelmed? </li></ul><ul><li>How, where and by whom will mass vaccination in a non-hospital setting be conducted? </li></ul>
  43. 45. <ul><li>14:40 </li></ul><ul><li>The BBC begins airing news footage of hospitalized cases followed by local news programmes detailing smallpox symptoms. The World Health Organization begins a campaign of risk communication to the international community. </li></ul>
  44. 47. <ul><li>14:45 </li></ul><ul><li>The Algerian Port Authority denies entry to the ferry suspected of carrying infected passengers and crew. A coast guard vessel is seen guarding the ferry to prevent it from docking. A second light amphibious craft with armed soldiers is seen patrolling the waters around the ferry. </li></ul>
  45. 48. International Issues: <ul><li>What do we do with in-bound and out-bound flights who departed prior to the announcement; some of whom may have landed in other locations across Europe and internationally? </li></ul><ul><li>Which organization(s) will handle the international crisis? WHO? CDC? ECDC? </li></ul><ul><li>Will EU nations who may be directly affected donate their limited stockpile to African and Mid-East states? </li></ul>
  46. 49. <ul><li>15:00 </li></ul><ul><li>Romania has reported nearly 90 cases. Lacking sufficient stockpiles Romania is asking for vaccine donations from other EU states placing a significant burden on states holding a 1 to 1 ratio of vaccine. </li></ul><ul><li>Where are the critical control points for vaccine distribution? </li></ul><ul><li>Who is in charge of the logistical aspects of distribution? </li></ul><ul><li>What role should NATO or EU play given that both have a ‘virtual’ stockpile? </li></ul><ul><li>What role for the European Centers for Disease Control in Sweden? </li></ul>
  47. 50. <ul><li>15:15 </li></ul><ul><li>Several governments are coming under intense pressure to provide their populations with mass vaccination. News stations across Europe begin running continual news feeds on outbreak areas and issuing travel warnings. 15 EU states are now announcing suspected cases. </li></ul>
  48. 52. <ul><li>15:30 </li></ul><ul><li>In a move to control public panic and limit the threat to public health, the Netherlands announces it will begin vaccinating all its citizens. </li></ul><ul><li>This move is viewed as alarming for citizens of other nations who do not posses a stockpile and who are now trying to cross the border into Holland. Vaccine lines are forming around community hospitals as people demand vaccination. </li></ul>
  49. 53. <ul><li>15:45 </li></ul><ul><li>OECD members and attending delegations are shown a map of Europe and a list of available vaccine stockpiles. </li></ul>
  50. 56. <ul><li>16:00 </li></ul><ul><li>Italy announces it has confirmed 480 cases. News is coming in that Zimbabwe, Sierra Leone and Somalia are reporting possible cases of smallpox and pleading for international help. </li></ul>
  51. 57. <ul><li>“ If the EU—nations that are so closely aligned that most share the same currency—is unable to agree on how to share a security asset as critical as the smallpox vaccine, the prospects for broader international sharing mechanisms appear bleak”.-Atlantic Storm </li></ul>
  52. 58. <ul><li>16:15 </li></ul><ul><li>Finland has four confirmed cases, however it has announces its vaccine supply does not appear to be efficacious, as scores demand vaccination and lines form outside hospitals; police forces struggle to control the ensuing panic. </li></ul>
  53. 60. 16:30 Riot police arrive to control crowds now threatening hospitals and medical staff in Brussels and Lille.
  54. 61. <ul><li>16:45 </li></ul><ul><li>Charleroi announces that riots have broken out in a suburb where illegal immigrants are not granted health protections under Belgian law and are excluded from all vaccination plans when they cannot demonstrate citizenship. France is also reporting riots and demonstrations in their immigrant population who are not provided health protections under French law. The Dutch announcement to vaccinate all citizens regardless of demonstrated citizenship is placing more pressure on nations who do not provide illegal or non-eligible immigrants with vaccine. Furthermore there are several reported incidents of asylum processing centers being set on fire. </li></ul>
  55. 62. Charleroi
  56. 63. <ul><li>17:00 </li></ul><ul><li>The UK announces it will begin a campaign of isolation for index cases and mass quarantine of all persons suspected of contact with index cases. In a joint support operation civil-military health teams begin the quarantine with citizens required to prove vaccination, which most are unable to demonstrate. </li></ul>
  57. 65. <ul><li>17:15 </li></ul><ul><li>The ferry, carrying now, confirmed infected passengers heads back to sea and begins to negotiate with the French government for right of entry and emergency medical assistance. </li></ul>
  58. 66. <ul><li>17:30 </li></ul><ul><li>Romania announces it has begun a mandatory quarantine and will use prisons and abandoned buildings to detain patients. Martial law is declared in Romania and it closes all its boarders and shuts down all transportation. Three hours after this announcement, Albania follows suit, closing all boarders and declaring martial law. </li></ul>
  59. 67. <ul><li>17:45 </li></ul><ul><li>Algeria is negotiating with the French government to send specialized medical teams to the stricken ferry while there are reports of an infected and deceased body being thrown over board in an attempt to prevent further spread on the ship. </li></ul>
  60. 68. <ul><li>What international agreements exist to provide medical assistance in international waters for nationals of third party states? </li></ul><ul><li>What role would NATO play in assisting national governments? </li></ul><ul><li>Who is responsible for launching an investigation? Civil? Military? Supranational institutions such as the UN? WHO? OSCE? </li></ul><ul><li>Who is responsible for tracking and detaining the terrorists who launched this catastrophic attack? </li></ul><ul><li>What role for the intelligence community and security services? </li></ul><ul><li>RAS-BICHAT? </li></ul>
  61. 69. <ul><li> “ Unless we forge new health security alliances, the emergence of a pandemic causing massive death and suffering, or an attack of mass lethality, is not a matter of 'if', but 'when'.”- Atlantic Storm </li></ul>

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