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Homeland Security

Homeland Security Planning Scenarios

Scenario 4: Biological Attack - Plague


Casualties 2,500 fatalities; 7,000 injuries
Infrastructure Damage None
Evacuations/Displaced Persons Possibly
Contamination Lasts for hours
Economic Impact Millions of dollars
Potential for Multiple Events Yes
Recovery Timeline Weeks

Scenario Overview:

General Description - Plague is a bacterium that causes high mortality in untreated cases and has epidemic potential. It is best known as the cause of Justinian's Plague (in the middle sixth century) and the Black Death (in the middle fourteenth century), two pandemics that killed millions. In this scenario, members of the Universal Adversary (UA) release pneumonic plague into three main areas of a major metropolitan city - in the bathrooms of the city's major airport, at the city's main sports arena, and at the city's major train station.

Timeline/Event Dynamics - Plague cases rapidly occur in the United States and Canada. As a result of foreign and domestic travel, rapid dissemination to distant locations occurs. By Day 3, the plague spreads across both the Pacific and Atlantic oceans and by Day 4, the plague is confirmed in eleven countries other than the United States and Canada.

Secondary Hazards/Events - As the financial world in Major City and elsewhere begins to realize the likelihood of an epidemic, a huge sell-off occurs in the markets. There is a high absentee rate at banks, other financial institutions, and major corporations. Adding to these complications is the fact that bank and other financial customers may be staying home. As a result, the phone systems at financial institutions may become completely tied up, with far fewer transactions than normal occurring. The fear of plague has raised memories of the anthrax incidents of 2001, which may cause many citizens to be afraid to open their mail.

Key Implications:

Morbidity and mortality totals by the end of the fourth day are indicated in Table 4-1. Although the specific assumptions that underlie these totals are not generally available, nor can they be reliably recreated, the parameters affecting these figures include length of incubation period following primary exposure, rate of secondary transmission, incubation period following secondary exposure, and timing and effectiveness of the intervention.

Illnesses and Fatalities by Country
Illnesses Fatalities
United States 7,348 2,287
Canada 787 246
Other Countries 33 10
Total 8,168 2,543
Table> 4-1 Total illnesses and fatalities by country by the end of the fourth day (end of the exercise)

Although the actual physical damage to property will be negligible, there will be an associated negative impact of buildings and areas that were or could have been contaminated. Service disruption will be significant for call centers, pharmacies, and hospitals due to overwhelming casualty needs. It will be necessary to close or restrict certain transportation modes. The threat of reduced food supply will cause food prices to rise. A huge sell-off in the economic markets is possible, and loss of life will result in a decline in consumer spending and subsequent loss of revenue in the metropolitan area. An overall national economic downturn is possible in the wake of the attack due to loss of consumer confidence.

Many people will be killed, permanently disabled, or sick as a result of the plague. The primary illness will be pneumonia, although the plague can also cause septicemia, circulatory complications, and other manifestations. The long-term effects of antimicrobial prophylaxis in large numbers will require follow-up study. The associated mental health issues relating to mass trauma and terrorism events will also require assessment.

Mission Areas Activated:

Prevention/Deterrence/Protection - This area requires knowledge of persons with the skills to grow and aerosolize plague, reconnaissance of supplies and laboratories, and public health protection measures.

Emergency Assessment/Diagnosis - Although health professionals should rapidly recognize the seriousness of the incident, diagnosis of the plague may be delayed. Detection of the plague should initiate laboratory identification of the strain and a determination of the potentially known antimicrobial drug resistance. Origin of the initial contaminant should be traced back to the source.

Emergency Management/Response - Identification of drug-resistant plague strains would require full utilization of personal protective equipment (PPE) and quarantine measures. Response will require provision of public alerts, mobilization of the National Strategic Stockpile, activation of treatment sites, traffic and access control, protection of special populations, potential quarantine measures including shelter-in-place recommendations, requests for resources and assistance, and public information activities. Effective communication between U.S. and Canadian governments is vital.

Incident/Hazard Mitigation - Victims must receive antibiotic therapy within 24 hours to prevent fatality. Exposed victims must be isolated and minimizing disease spread will require epidemiological assessments, including contact investigation and notification.

Public Protection - Victims must be evacuated and treated (and/or self-quarantined), and antimicrobial prophylaxis will be necessary for exposed persons, responders, and pertinent health care workers. Mobilization of the Strategic National Stockpile for additional critical supplies and antibiotics will be necessary. The public should be informed of signs and symptoms of plague.

Victim Care - Victims will require treatment or prophylaxis with ventilators and antibiotics, as well as information measures for preventing spread of the disease. Advanced hospital care will be required for those with pneumonia. The U.S. Department of State's Bureau of Consular Affairs will need to be involved in order to assist foreign populations residing in the United States, or U.S. citizens exposed or ill abroad.

Investigation/Apprehension - Point-of-source exposures and plague strain must be determined using victim trace-back, criminal investigation, and laboratory analyses.

Recovery/Remediation - Extensive decontamination and cleanup will not be necessary because plague cannot live long in the environment and is viable to heat and sunlight exposure. However, some efforts should be undertaken to support political/public confidence.

Pandemics in History

Plague is an infectious disease caused by bacteria called Yersinia pestis. These bacteria are found mainly in rodents, particularly rats, and in the fleas that feed on them. Other animals and humans usually contract the bacteria from rodent or flea bites. Historically, plague destroyed entire civilizations. In the 1300s, the "Black Death," as it was called, killed approximately one-third (20 to 30 million) of Europe's population. In the mid-1800s, it killed 12 million people in China.

Bubonic plague is the most common form of plague. This occurs when an infected flea bites a person or when materials contaminated with Y. pestis enter through a break in a person's skin. Patients develop swollen, tender lymph glands (called buboes) and fever, headache, chills, and weakness. Bubonic plague does not spread from person to person.

Pneumonic plague is both rarer and more frequently fatal than bubonic plague. Pneumonic plague occurs when Y. pestis infects the lungs. This type of plague can spread from person to person through the air. Transmission can take place if someone breathes in aerosolized bacteria. Pneumonic plague is also spread by breathing in Y. pestis suspended in respiratory droplets from a person (or animal) with pneumonic plague. Becoming infected in this way usually requires direct and close contact with the ill person or animal. Pneumonic plague may also occur if a person with bubonic or septicemic plague is untreated and the bacteria spread to the lungs. Patients are unlikely to survive primary pneumonic plague if antibiotic therapy is not initiated within 18 hours of the onset of symptoms. Without treatment, mortality is 100% for pneumonic plague.

The biblical book of I Samuel records what may be the oldest reference to bubonic plague. In approximately 1320 BC, the Philistines stole the Ark of the Covenant from the Israelites and returned home. Then, I Samuel continues: "[t]he Lord's hand was heavy upon the people of Ashdod and its vicinity; he brought devastation upon them and afflicted them with tumors. And rats appeared in their land, and death and destruction were throughout the city... "

After this time, plague became established in the countries bordering the eastern Mediterranean Sea. In 430 BC, Sparta won the Peloponnesian War partly because of the plague of Athens. Some scholars believe that this was the bubonic plague, but others suggest that it may have been due to other bacterial or viral diseases.

Procopius gave the first identifiable description of epidemic plague in his account of the plague of the Byzantine empire during the reign of Justinian I (AD 541-542), which is considered to be the first great pandemic of the common era. By one account, as many as 100 million Europeans, including 40% of the population of Constantinople, may have died during this pandemic. Repeated, smaller epidemics followed this plague.

The second plague pandemic, known as the Black Death, thrust this dread disease into the collective memory of western civilization. Plague bacilli in fleas on the fur of marmots (a rodent of the genus Marmota) probably entered Europe via the trans-Asian silk road during the early 14th century. In 1346, plague arrived in Caffa (modern Feodosiya, Ukraine), on the Black Sea, and spread to major European ports such as Pera, a suburb of Constantinople, and Messina, in Sicily. By 1348, plague had already entered Britain at Weymouth. The Black Death took the lives of 24 million people between the years 1346 and 1352 and claimed perhaps another 20 million by the end of the 14th century. In 1353 Giovanni Boccaccio finished writing The Decameron, a fictional narrative that opens with a description of the 1348 outbreak of Black Death in Florence, Italy. The average mortality for the Black Death was consistently 70%-80% of those infected.

In May 1665 the Great Plague of London begans, and over 30,000 people died of plague between May and August 1665. In 1722 Daniel Defoe published A Journal of the Plague Year, a fictional recounting of the great Plague of London in 1665. The plague continued in Europe through 1720, with a final foray into Marseilles. Thirty percent to 60% of the populations of major cities such as Genoa, Milan, Padua, Lyons, and Venice succumbed during the 15th to the 18th centuries. The second great pandemic slowly died out in Europe by 1720.

A major pandemic, known as the Third Pandemic, probably started in 1855 in China [other accounts date this pandemic to 1894]. It spread throughout the world, with China and India affected the most. The modern plague pandemic spread throughout the world via modern transportation. The Manchurian pneumonic plague epidemic of 1910-1911 caused 50,000 deaths. The modern pandemic arrived in Bombay in 1898, and during the next 50 years, more than 13 million Indians died of plague. The disease officially arrived in the United States in March 1900; the disease appeared in New York City and Washington state the same year. New Orleans, Louisiana, was infected in 1924 and 1926. After general rat control and hygiene measures were instituted in various port cities, urban plague vanished - only to spread into rural areas, where virtually all cases in the United States have been acquired since 1925.

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