DDP Newsletter, September 2019, Vol. XXXV, No. 5
Of all the potential mass casualty events that could affect the United States, the most devastating cause is biologic. Biologic agents, unlike radioactive fallout, have a doubling time, not a half-life. Whether the agent comes from a deliberate biologic warfare attack, or the natural emergence of a novel virus, the results could be devastating.
In 1918, more people died in the first 11 months of the influenza pandemic than in 4 years of the Black Death in the 1300s. Yet despite spending $80 billion on a National Biologic Defense, the U.S. is arguably no better prepared than it was in 1918, state Steven Hatfill, M.D., Robert J. Coullahan, and John J. Walsh, Jr., Ph.D., in their new book Three Seconds until Midnight, available on amazon.com.
Because of air travel, more people packed into dense urban areas, and greater dependence on technological infrastructure and just-in-time inventories, the population may be even more vulnerable now. There could be mass casualties even among uninfected people because of lack of essential services.
Other disasters such as nuclear war would have similar consequences—medical facilities overwhelmed, utilities and transportation disrupted, lack of food, civil unrest, and inadequate law enforcement. Self-help would be essential.
Hatfill et al. emphasize what people need to know to treat lethal influenza at home—without the whole family succumbing. Useful, readily available references include: Bird Flu: a Virus of Our Own Hatching by Michael Greger, M.D., which can be purchased or read online (https://tinyurl.com/sna8g2n), and “Good Home Treatment of Influenza” by Grattan Woodson, M.D. (https://tinyurl.com/s3wugbm).
Non-pharmaceutical interventions (NPI) would be key. Effective vaccine and antiviral medications, even if they exist, would probably be too little, too late. People would need to be able to avoid public places, like grocery stores, until the epidemic subsided. To care safely for sick family members, they would need eye protection, N-95 face masks (for patients too), disposable gloves, hand sanitizer (or rubbing alcohol plus glycerin to make it: 4 tsp glycerin per quart of alcohol), alcohol to disinfect surfaces, plastic bags for contaminated items, a plastic or disposable apron, and other items. Check your inventory!
Though expensive, small commercially available UV air purification systems can help disinfect the air. Hatfill et al. recommend a review site (https://tinyurl.com/wh4q9nv).
The don’t-do list includes giving aspirin, which can cause lethal Reye’s syndrome. It is probably best to avoid antipyretics, including ibuprofen and acetaminophen, instead using a cool cloth to the forehead and a tepid sponge bath for comfort. The exception is to use Tylenol syrup in children under five to prevent febrile convulsions, the authors state.
Virus can be shed for 24 hours before a patient becomes symptomatic and remain suspended in the air for hours. In a patient’s home, more than half the objects may be contaminated with influenza virus, which can last up to 12 hours on porous surfaces. One strain (H5N1) has lasted up to 6 days on some surfaces. Another (H3N2) has lasted on paper money for 17 days. Exposing them to sunlight might help.
Should you stockpile antivirals? The U.S. has supplies of oseltamivir (Tamiflu), enough to treat half the population if it could be distributed. It might not be effective, and there are many side-effects. Japan stockpiles favipiravir (Avigan), which inhibits influenza RNA polymerase and may be effective against other RNA viruses including Ebola, but it is not approved for use in the U.S. The authors do not comment on high-dose vitamin C.
Use and potential abuse of smartphones for rapid communications; research vessels to monitor biodiversity hotspots for emerging diseases; developing a surge capacity force; addressing environmental factors, such as circulating banknotes, that could contribute to widespread transmission; new methods for screening travelers for asymptomatic infections, such as nitric oxide (NO) in breath; and many other technologies and processes discussed in the book need to be seriously considered by defense and public-health agencies for cost-effective preparedness for existential threats.
Hospital trains were developed by the British in the late 19th century, and by the outbreak of World War I, state-of the-art hospital trains were in operation. The authors advocate the concept of the Disaster Train as a rapidly deployable method to respond to all types of mass casualties. It could include Biosafety Level-4 cars.
MEDIEVAL DISEASES RE-EMERGING IN U.S.?
Crowded and unsanitary conditions owing to homeless camps on the streets of Los Angeles and San Francisco have led President Trump to consider federal intervention. The Environmental Protection Agency has cited California for “piles of human feces” and potential water quality impacts. Also, San Francisco discharges more than a billion gallons of “sewage and stormwater” into San Francisco Bay and the Pacific Ocean annually, and 200 water systems have “health-based exceedances that put the drinking water of nearly 800,000 residents at risk” (https://tinyurl.com/w8ujft9).
An outbreak of typhus in downtown LA raised public alarm (https://tinyurl.com/rrefw6l). Dr. Steven Hatfill suggested that bubonic plague, which is endemic among rodents in the area but could easily spread to humans through fleas, was an even greater worry and might have already occurred had there been more rain in the area last summer. The situation is even more dire than is being described, he writes, referring to what are known as the Colonias. These are high-density, unregulated, ramshackle developments built on expanses of undeveloped land. Most of these communities have no water or sewage services. More than 2,000 Colonias have been identified in Arizona, California, and New Mexico. There are more than 1,800 designated Colonias in Texas, with 500,000 individuals living along the border in communities that lack clean drinking water, paved roads, and electricity. The Centers for Disease Control and Prevention (CDC) provides a map of counties with confirmed cases of plague (https://www.cdc.gov/plague/maps/index.html).
Leprosy could also re-emerge, writes Dr. Marc Siegel, owing to repeated close contact with respiratory secretions. More than 20,000 new cases per year are reported in Central America and South America (https://tinyurl.com/y3kp53pk).
Tuberculosis in migrants is most likely the source of the resurgence of TB in this country after having been previously eradicated. Guatemalans are 83 times more likely to have tuberculosis than Americans and seven times more likely than legal immigrants, writes Daniel Horowitz (tinyurl.com/y2yjwxj8). The state of Virginia has refused to track the number of refugees it resettles who are diagnosed with active TB (tinyurl.com/trlezt4).
A warning (https://tinyurl.com/urne844) mocked in 2005 has proven prescient. “Have we become so political as a nation that political correctness will allow us to revert to the 18th Century health standards?” Horowitz asks.