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Local doctors fail their test on diagnosing germ terrorism

Sunday, February 13, 2000

By Jonathan D. Silver, Post-Gazette Staff Writer

By any measure, smallpox is a terrifying killer.

 
  Dr. Michael Allswede stumped 17 local emergency doctors with his test to see if they could spot a hypothetical outbreak of smallpox. (Joyce Mendelsohn, Post-Gazette)

For the past two decades, it has lain silent because of an eradication program by the World Health Organization. The last known outbreak of the virus occurred in Africa in 1977, and it's been so long since a case has appeared in the United States -- more than 50 years -- that many doctors in emergency rooms these days would be likely to have trouble diagnosing it quickly, if at all.

If the variola virus returned, as some hypothesize it could by way of a terrorist attack, hundreds might be dead or beyond help by the time it was identified and vaccines were distributed from the federal Centers for Disease Control and Prevention.

"Physicians and nurses are not going to recognize many of these exotic agents, should they appear," said David Piposzar, environmental health administrator for the Allegheny County Health Department. "The [World Health Organization] indicated that it was eradicated. Why should we know to look for it?"

Early last month, Dr. Michael Allswede, an expert in biological and chemical weapons and an emergency room physician at Allegheny General Hospital, set out to test how well the region's emergency personnel would respond to a hypothetical outbreak of smallpox.

Consulting with the FBI and the Pittsburgh Police Bureau, Allswede dreamed up a scenario in which a foreign dignitary and his retinue visiting Pittsburgh are intentionally infected with smallpox in a perfume bottle given as a gift.

The smallpox is ferried to the United States by a willingly infected foreign college student sympathetic to a terrorist group. The student volunteers to be a "mule," much as a person who smuggles drugs by swallowing them. That student is assumed to have infected his roommates and others in his dormitory.

During the next week, the dignitary comes into contact with a large number of people, and smallpox begins spreading exponentially.

Allswede challenged 17 doctors in seven local hospitals to figure out what malady afflicted the imaginary patients. The results of the study confirmed the suspicions of local emergency officials: Pittsburgh's health care facilities are poorly prepared to cope with an outbreak of biological terrorism.

"Our data suggests that our clinical practitioners in Pittsburgh are unable to diagnose the stigmata of variola, currently one of the most probable biological weapons agents, and historically one of the world's great killers," Allswede's study concluded.

That finding comes at a key time. On Feb. 24, emergency officials from Pittsburgh, Allegheny County, the federal government and three area hospitals will meet to role-play how they would cope with a contagious, untreatable virus unleashed in an attack.

"We always believed we'd be knee-deep in bodies before anyone realized what was happening," said Raymond DeMichiei, operations supervisor for the city's Emergency Operations Center and one of the role-playing exercise's leaders. "We were right. They had no idea what was going on."

It's considered a low probability that a biological attack would happen anywhere in the nation, much less in Pittsburgh. Although some experts discuss such an event as if it were inevitable, others caution about overestimating its likelihood.

"In a society like ours, we're potentially infinitely vulnerable. You have to ask yourself, 'Why doesn't it happen all the time?' " said John Parachini, a Washington-based national security analyst with the Monterey Institute for International Studies. "We should take out some insurance against a threat in the future, but let's get the magnitude of the threat right."

It is known that the former Soviet Union ran a biological weapons program long after the United States disbanded its own under the Nixon administration. Whether vials of smallpox were spirited away by rogue scientists during the Soviet Union's breakup is a matter of debate. And even if they were, experts say, there would be obstacles in creating an aerosol system capable of spraying smallpox or other biological compounds over cities.

Assessing the risk of a terrorist threat is not an exact science, and for that reason, government officials believe it prudent to adopt a never-say-never strategy in preparing for the unimaginable.

In the past fiscal year, the federal government spent $158 million to prepare for bioterrorism. Nationally, the number of FBI investigations into biological, chemical, nuclear or radiological threats rose to more than 250 cases last year, up from 74 in 1997.

In 1997, the Pittsburgh FBI field office handled one such investigation. Last year, local agents handled more than 10, with the majority of threats involving biological compounds.

Bolstered with a $400,000 federal grant, Allegheny County officials are looking to buttress Western Pennsylvania's public health network against terrorism.

They hope to transform a system that is "marginally prepared" to cope with a biological threat, according to Piposzar, into one capable of rapidly detecting an outbreak, handling mass casualties and large-scale disposal of remains, and cleaning up a contaminated environment.

Role-playing exercises enable officials to uncover flaws in their emergency response plans. How well do they work together? Are they asking the right questions? How would officials respond to media inquiries? Would a quarantine be feasible, and if so, how could it be done?

Originally, the role-playing drill -- designed by a Washington, D.C., consultant -- assumed that it would not take long for area physicians to call in the Centers for Disease Control and Prevention in the event of a mysterious illness. Allswede's study was born from skepticism about whether doctors would even recognize smallpox systems in the first place.

Testing theories

Allswede, 37, is a stocky Midwesterner with sandy hair, a boyish face and glasses. A Desert Storm veteran, he wears a rainbow-colored scrub shirt to delight young patients.

While in the Army, Allswede worked with a special medical unit trained to treat people injured by biological or chemical weapons. Over the years, he has served as a consultant and trainer to police, physicians and paramedics in responding to biological and chemical attacks.

In Allswede's imaginary tale, with 20 people infected initially, the epidemic would kill 800 people in three weeks and leave nearly 300,000 exposed. His calculations assumed that each person would infect 20 others, and a third of those infected would develop smallpox.

Allswede and two other doctors who have been trained in dealing with biological threats visited seven area hospitals that agreed to participate in the study: Allegheny General Hospital, Mercy Hospital, UPMC Presbyterian, UPMC Shadyside, St. Francis Medical Center, Western Pennsylvania Hospital and Mercy Providence Hospital.

Over 10 days, they interviewed 17 physicians, explaining that they were conducting a biological weapons readiness exercise. They asked the doctors -- seven emergency room physicians, eight inpatient practitioners and two infectious disease specialists -- how they would treat patients who came in complaining of a variety of symptoms.

Initially, the symptoms are no different from those caused by the common cold. But within several days, the doctors were told, the patients return, complaining of nausea, diarrhea and a facial rash. Two days later, the rash erupts all over the face and torso.

Displaying photographs of people with the characteristic blistering look caused by smallpox, Allswede asked the physicians how they would diagnose the mysterious illness.

With the doctors' sleuthing skills put to the test as they struggle to identify and treat the mysterious epidemic, the bodies keep piling up.

Sixteen physicians couldn't figure it out. They considered dozens of diseases -- such as lupus and toxic shock syndrome -- but in most cases, smallpox didn't even make it to the list. In one case, Allswede said, an emergency room worker who had received training in dealing with biological threats identified smallpox after peering at a photograph of a victim over a doctor's shoulder. The doctor rejected the suggestion out of hand.

"We as American medical practitioners share a significant blind spot in diseases that we don't [typically] see," Allswede said, noting that federally funded training for health care workers in dealing with "weapons of mass destruction" is voluntary, and many physicians don't participate. "The EMS people generally show a great deal of interest and enthusiasm. The medical personnel generally have not."

Only one physician in Allswede's study, an infectious and tropical disease specialist at UPMC Shadyside, recognized the virus for what it was.

"I read about it. I've seen pictures of it," Dr. Nalini Rao said. "Just from the distribution of the lesions and the appearance of the lesions, I could tell this wasn't just another rash of some sort. This was smallpox."

Rao said emergency room doctors could recognize and cope with a smallpox outbreak if they were made aware of it.

Allswede acknowledged that his study was not as scientifically rigorous as it could have been. He said, for instance, that critics might say he and his colleagues did not present the cases to doctors in exactly the same way. Or in real life, doctors might have had time to consult with one another, which they did not do in the study.

But Allswede said his research was not meant to assess how many of Allegheny County's doctors are capable of recognizing smallpox. Rather, it was to test how well on-duty personnel in emergency rooms -- the front line of defense against an invisible menace -- would do in the event of an outbreak.

"I think there's some validity to what [Allswede] says. It's clear that a lot of physicians by their training might not recognize an unusual disease," said Dr. Bruce Dixon, director of the county Health Department. "I think the bigger thing we want them to understand is [that] we want them to be suspicious. If seeing a combination of symptoms that is not in keeping what they recognize, we want them to get some help."

Both emergency room and primary care physicians could stand to review diseases that are not usually encountered, Dixon said.

Dixon believes that the county's medical establishment is just as prepared as any other city's, perhaps more so. But, Allswede said, there's an added incentive for local physicians to brush up on their knowledge of exotic pathogens and stay ahead of the curve.

"If you were looking for a demonstration city" to test a biological weapon, Allswede said, "you would pick Pittsburgh or you would pick Denver. And the reason is Pittsburgh's geography is such that it's a tight, compact city in the bottom of a valley, which makes aerosol dissemination quite efficient."

Winds could blow a biological agent up the Ohio River Valley, Allswede suggested, adding that its source would be difficult to locate. In Denver, a biological agent would sit atop the city, hemmed in by the mountains, he said.

If it happened tomorrow in Allegheny County, the results would be nightmarish.

"How could you possibly quarantine an entire city? You can't. How could you know who was even exposed? It would be an international disaster," Piposzar said. "What do we do about that? Pray that it never happens."



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