Saturday, April 19, 2014

Aralsk-7: What a Biological Weapon Accident can Teach us about Containing Disease during Conflict

As the Ebola outbreak in West Africa unfolded I wrote this piece on containment, isolation and quarantine. I will be up-dating this shortly, with a focus on Russian efforts to end the most devastating outbreak of Ebola the international community has ever witnessed.

The potential of loosing command and control of a clandestine military laboratory infrastructure, due to conflict and war, such as exists today in Syria, increases the risk of theft, diversion and the potential for accidental release of highly pathogenic agents into the environment. Where few resources exist to contain epidemics or treat exposed persons, global public health is at increased risk. Modern air travel which can ferry in disease as we have seen with the WPV1 (polio) outbreak in Syria, or carry it out as we see with the Ebola outbreak in Guinea place the intentional community at some risk. Conflict and disease share a long history, but what if an outbreak occurred during a field test where no risk to command and control existed? Containment, in what can only be described as perfect conditions, teaches us about containment during conflict. Two examples stand out: one an 'accident' and the other, a naturally occurring event. In the first instance, in 1971, the Soviet's suffered an accident during a BW test which unfortunately resulted in the deaths of three people. While any loss of life is significant, its worth noting that this was a relatively limited accident, in part due to the immediate measures taken by the Soviet's. Wikipedia has a nice outline on the Aralsk-7 incident which has been widely research to the point of evisceration, but for the purpose of this blog, the basics noted are relatively accurate (see:http://en.wikipedia.org/wiki/Aral_smallpox_incident)

The deserted complex of Aralsk-7 www.karakalpak.com

"According to Soviet General Pyotr Burgosov (Peter Burgasov), field testing of 400 grams of smallpox at Renaissance Island caused an outbreak on July 30, 1971.(6) Burgasov, former Chief Sanitary Physician of the Soviet Army, former Soviet Vice-Minister of Health and a senior researcher within the Soviet BW program, described the incident: 'On Vozrozhdeniya Island in the Aral Sea, the strongest recipes of smallpox were tested. Suddenly I was informed that there were mysterious cases of mortalities in Aralsk (Aral). A research ship of the Aral fleet came to within 15 km of the island (it was forbidden to come any closer than 40 km). The lab technician of this ship took samples of plankton twice a day from the top deck. The smallpox formulation--400 gr. of which was exploded on the island--'got her' and she became infected. After returning home to Aralsk, she infected several people including children. All of them died. I suspected the reason for this and called the Chief of General Staff of Ministry of Defence and requested to forbid the stop of the Alma-Ata-Moscow train in Aralsk. As a result, the epidemic around the country was prevented. I called (future Soviet General Secretary Yuri) Andropov, who at the time was Chief of KGB, and informed him of the exclusive recipe of smallpox obtained on Vozrashdenie Island.(7)(8). It may never be known whether the release of smallpox was purposeful, but the research ship Lev Berg inadvertently traveled into the plume of this bioweapons release, initiating the smallpox outbreak in Aral. (Some have contended however, that Burgasov was wrong and that the first patient may have contacted the disease while visiting Uyaly or Komsomolsk-on-Ustyurt, two cities in what is now Uzbekistan where the boat docked." (9)(10)

While the outbreak itself has been analyzed to the point of exhaustion, mainly to focus attention on the Soviet BW program, response to the Aralsk-7 outbreak has been relegated to second place, when in fact, the response has quite a bit to offer in terms of 'lessons learned,' and extracting this from whatever political sensitivities one may hold regarding offensive open air field testing, which many states engaged in prior to the 1970's including the United States.  




Medicins Sans Frontieres (MSF) staff attend an Ebola patient inside an isolation ward in Bundibugyo December, 12, 2007 in this picture released by MSF. rt.com

"A massive public health response to the smallpox cases in Aral ensued once the disease was recognized. In less than 2 weeks, approximately 50,000 residents of Aral were vaccinated. Household quarantine of potentially exposed individuals was enacted, and hundreds were isolated in a makeshift facility at the edge of the city. All traffic in and out of the city was stopped, and approximately 54,000 square feet of living space and 18 metric tons of household gods were decontaminated by health officials.(15). (http://en.wikipedia.org/wiki/Aral_smallpox_incident) Johnathan B. Tucker and Raymond A. Zilinskas wrote an outstanding and comprehensive analysis of the Aralsk smallpox outbreak in their paper entitled: The 1971 Smallpox Epidemic inAralsk, Kazakhstan, and the Soviet Biological Warfare Program," available at: http://cns.miis.edu/opapers/op9/op9.pdf I highly recommend their publication it is the best analysis I have ever read on the Aralsk incident.  To touch upon the highlights of Soviet containment strategies, Tucker and Zilinskas provide the following:

"Strict quarantine measures were the only way of stopping the further spread of the disease beyond the city, because of late hospitalization and isolation of patients, late diagnoses, and the inability to establish the source of infection. Up until September 26, the quarantine measures were enforced by the police, then beginning at 00 hours on September 26, by the military units of the local garrison and by a SAVO-64411 unit.11 The total length of the cordon around the city was 20-21 km, with soldiers placed at intervals of 700 to 800 meters; in other words, where they were directly visible to each other. The cordon was manned by 23 posts with a total of 200 soldiers. According to Directive No. 4, issued by the district ChPK on September 26, procedures for leaving and arriving at the locale were established, as well as a procedure for tracking and registering outgoing economically vital shipments, whether by road, sea, or rail. " (http://cns.miis.edu/opapers/op9/op9.pdf)

"In order to monitor vaccinations and trans-shipments, a total of 5 checkpoints and medical control points were set up near roads leading to Aralsulfat, the Aralsk collective farm, railway junctions No. 86 and 87, and the seaport. Each checkpoint and medical control point was provided with 2 tents for a shift of 4 people and for the medical personnel (2 nurses). Each checkpoint shift was supplied with boiling water, fuel, disinfection equipment and supplies, and hot food. The cordon posts, each of which had 3 personnel, were similarly equipped. The medical control point personnel consisted of 14 nurses and 1 physician. The following work was done at the medical control point: examination and vaccination of 620 people arriving in the city and involved in shipping activities; examination of 82 vehicles with various types of cargo; and disinfection of 32 vehicles. Twelve ships and barges were also monitored. While the quarantine was in effect, several people were detained for violating the quarantine. Ten people were fined, while five were arraigned and had their drivers’ licenses revoked. Internal quarantines covered a zone of medical and preventive facilities, where smallpox patients were identified; i.e., departments of surgery and infectious diseases, skin and venereal disease clinics, as well as newly organized special facilities. The police were responsible for maintaining the quarantine over the hospital, the field hospital, the isolation ward, and the observation facility. A total of 7 posts with 23 personnel were set up. Round-the-clock security was provided for office buildings, with shifts 8 to 12 hours in length." See: http://cns.miis.edu/opapers/op9/op9.pdf From a purely public health perspective, Soviet efforts were impressive as were efforts undertaken by Tito during a smallpox outbreak in 1972. Unfortunately today such strategies would no longer be allowed under most civil society/democratic state law. It is worthwhile to consider that both the Aralsk-7 outbreak and the Yugoslav outbreak were 'accidental.' The use of HPA in a deliberate attack with modified pathogenic agents would present challenges to containment, most states are not willing, let alone prepared to consider. 

The second notable outbreak of highly pathogenic disease, from which lessons can be learned, occurred in Yugoslavia in 1972. Maria Ikovic wrote an excellent comparative analysis entitled: "The 1972 Smallpox Outbreak in Yugoslavia: A Comparison to U.S. Bio-defense," while the paper was written some time ago, the facts remain the same and offer us a chance to consider how gaps in containment strategies today may well effect our ability to contain outbreaks of disease, particularly in conflict zones. pahttp://archive.today/UHqLo Ikovic's excellent piece notes the following points: 

Epidemiology:

  • Over the course of human history, smallpox killed hundreds of millions of people, more than plague and all the wars of the twentieth century combined. It has a 30% fatality rate and severely disfigures most survivors.
  • Smallpox is an orthopox virus that is spread from person to person. There are no known animal or insect hosts.
  • The virus is most transmittable in cold weather.The Yugoslavian outbreak occurred during February-April, after a single infected person (the index case) returned from a Muslim pilgrimage inSaudi Arabia, passing by bus through Iraq (infected with smallpox at the time).
  • The incubation period (from the moment of infection until the onset of symptoms) lasts 7 to 17 days. Persons with the virus are not contagious during the incubation period. No one else on the bus to Yugoslavia contracted smallpox (there were 25 other passengers on the bus).
  • After the incubation period patients spread smallpox primarily to household members, friends, and hospital workers. This is due in part to the fact that transmission of the virus occurs in conjunction with the onset of symptoms including fever and rash. In other words, the virus is communicable only when a person is typically bedridden. The Yugoslavia case confirms this generalization: Muzza infected 38 people, all but one of whom were hospital contacts. However, the index case experienced a mild form of the disease; he was not bedridden and was therefore able to spread it to Muzza.
Transmission:
  • Once communicable after the incubation period, the virus spreads primarily through droplet nuclei oraerosols expelled from the host by exhaling or coughing. When the virus is breathed in it infects the respiratory passages, spreading to the lymph nodes and elsewhere.
  • Infection may also occur through contaminated bed linen and clothing.
  • Rates of transmission are disputed: Some estimate that each infected person infects a further 10-13; others estimate that each infected person infects 1-3 others. The Yugoslavian transmission ration was 1:13. Other studies, however, looked at past outbreaks and estimated average rates of transmission to be lower than 2.
Diagnosis:
/Users/mivkovic/Desktop/Smallpox/Picdevelopedpox.jpg
Photo taken of smallpox patient in Kosovo, 1972
  • Diagnosis is often difficult, particularly when healthcare providers are not familiar with symptoms. In Yugoslavia prior to the 1972 outbreak, the last death from smallpox was registered in 1926. As a result healthcare providers were unfamiliar with the disease. When Muzza was hospitalized (at various hospitals in Yugoslavia) doctors misdiagnosed him as having an allergic reaction to penicillin, when in reality he was affected with a highly fatal form of smallpox.
  • After the incubation period the patient first experiences influenza-like symptoms, such as fever, malaise, and prostration. This is followed by the onset of a rash, the bumps of which are in the skin, not on it. The rash becomes severe, turning into pustules that are hard and round.
  • Smallpox is often confused with chickenpox. However, the smallpox rash is centrifugal: it is concentrated more on the head, hands, and feet than it is on the trunk. The chickenpox rash is the opposite: it appears primarily on the trunk, and never on the palms or soles of hands and feet. 
  • The rash eventually turns into scabs that fall off and typically leave deep pits on the skin. The person is considered contagious until the last scab separates.
Control of Outbreaks:

/Users/mivkovic/Desktop/Smallpox/fieldimmunization.jpg
Checking immunization reaction, Kosovo, 1972
  • The Vaccine is extremely effective, but gives the recipients full immunity from smallpox for 3-5 years, with decreasing immunity thereafter. The Yugoslavian index case likely experienced a mild case of smallpox because he had been immunized just months before.
  • Vaccination complications: For every one million people inoculated, one will die, 14 will be infected with life-threatening illness, and 48 will suffer less serious illnesses. 
  • Two main ways to inoculate during an outbreak:Mass Vaccination and Ring Vaccination. With the latter, only suspected contacts are vaccinated. The former method was used in Yugoslavia: a state's entire population is vaccinated (or as was typically the case in Yugoslavia revaccinated)
Key points in the Yugoslavia Epidemic
  • It was a natural outbreak
  • There was a high transmission rate DESPITE PRIOR VACCINATIONS. One infected person infected     13 others, on average. The high transmission rate was probably aggravated by winter temperatures and late diagnosis.
  • Containment strategy=Mass (re)vaccination and Quarantine.
  • Tito was ruling at the time; political system (authoritarianism) was suited for draconian measures. Emergency procedures included the isolation of Dakovica province, shutting down borders, quarantining all persons suspected of coming into contact with the virus, and prohibiting public events, meetings and weddings. 20 million people were vaccinated and 10,000 contacts were quarantined.
  • Over a 9 week outbreak, 175 people were infected, 35 died. OUt of 175 affected persons, 105 (60%) had been previously vaccinated against smallpox, whereas 37.7% had not been immunized; the vaccinal status was unknown for 2.3% of the affected persons. See: http://archive.today/UHqLo
"West Africa is seeing the 'most challenging' outbreak of Ebola virus since the disease was discovered 40 years ago. It comes as the death told reaches over 101, the World Health Organization reported. This is the most challenging Ebola outbreak we have ever faced," Keiji Fukuda, Assistant Director General of the World Health Organization (WHO) told a news briefing. See: http://rt.com/news/ebola-who-challenging-disease-369/

Considering the recent outbreak of Ebola in Guinea, there have been 21 reported cases in Liberia with 10 fatalities, and 9 suspected cases in Mali. Most concerning are the 20 cases reported in Conakry, the capital, 16 of which have been laboratory confirmed. "Médecins sans Frontières (MSF/Doctors without Borders) is helping the Ministry of Health of Guinea in establishing treatment and isolation centers in the epicenter of the outbreak. In Liberia, several international organizations including the International Red Cross (IRC), Pentecostal Mission Unlimited (PMU)-Liberia, and Samaritan’s Purse (SP) Liberia are aiding the Ministry of Health of Liberia by supporting awareness campaigns and providing personal protective equipment (PPE) for healthcare workers. The Institute Pasteur in Lyon, France, the Institute Pasteur in Dakar, Senegal, the European Consortium mobile laboratory, and the Metabiota/Tulane University laboratory in Kenema, Sierra Leone, and CDC Atlanta are some of the laboratories collaborating to test samples. To date, 56 cases from Guinea and Liberia have been laboratory confirmed by PCR for Ebola virus. CDC is in regular communication with its international partners, WHO, and MSF regarding the outbreak and a 5 person CDC team is currently in Guinea assisting the Guinea MOH and the WHO-led international response to this Ebola outbreak."Based on Guinea’s MoH Epidemiological Bulletin, Liberia’s MoH, and the WHO update 5 April, 2014. 

A brief note on the difference between isolation and quarantine, provided on the HHS website:http://answers.hhs.gov/questions/4120    Isolation and quarantine are public health practices used to stop of limit the spread of disease. Isolation is used to separate ill persons who have a communicable disease from those who are healthy. Isolation restricts the movement of ill persons to help stop the spread of certain diseases. For example, hospitals use isolation for patients with infectious tuberculosis. Quarantine is used to separate and restrict the movement of healthy persons who may have been exposed to a communicable disease to see if they become ill. These people may have been exposed to a disease and do not know it, or they may have the disease but do not show symptoms. Quarantine can also help limit the spread of communicable disease. 

Similar to Ebola, outbreaks of smallpox, which swept across Europe killing over 300 million in the Twentieth Century alone, caused panic and loss of life. Fortunately, smallpox is now a vaccine preventable disease, Ebola is not. The utility of quarantine should not be underestimated particularly in the absence of a vaccine or other medical counter-measures.
In contrast to perfect conditions where quarantine, isolation and vaccination can be swiftly implemented with few civil rights issues,  outbreaks which happen in conflict zones are cause for far greater concern. When we consider outbreaks of disease in Syria or even the recent outbreak of Ebola in Guinea, containment strategies utilized in Aralsk and Yugoslavia, which include isolation, quarantine and if possible vaccination (only experimental vaccines are available for Ebola), are enviable. Today it would be nearly impossible to institute such effective strategies.  Inability to impose strict isolation and quarantine, make research and development of medical countermeasures all the more urgent. Providing public health care during war requires modelling which thus far has not been terribly impressive, even in states with adequate resources. 

Dragon voice recognition


No comments:

Post a Comment

Note: Only a member of this blog may post a comment.