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MPH 510
Demon in the Freezer
Discussion Guide
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STEPS OF THE FIELD INVESTIGATION PROCESS
• Establish the existence of an epidemic (or outbreak) -Well the outbreak in this case
appeared after the monkeys had been inoculated with two different strains of smallpox at
the CDC. The Bangladesh outbreaks from 1974-1975 or small pox. 1978 outbreak of
small pox- Ali Maow Maalin in Birmingham, England. Robert Stevens-anthrax in 2001
in Palm Beach County, Florida. Small pox outbreak of Peter Los in 1970 in Meschede,
Germany. Small pox outbreak of Barbara Birke in 1970 in Duisburg, Germany.
• Confirm the diagnosis -Day two of the experiment Hensely detected DNA of smallpox
in the blood of the monkeys. On day 5 Doctors confirmed anthrax in the case of Robert
Stevens by preforming a spinal tap. In the Peter Los case the small pox diagnosis was not
confirmed until Janurary 16, 1970, over two weeks after Peter had originally gone to the
hospital. Doctors did not expect smallpox especially because Peter had received two
small pox vaccines recently both of which obviously did not take. In the case of Barbara
Birke the symptoms appeared eleven days after Peter Los had arrived at the hospital. The
book does not say exactly when the diagnosis was made but they knew what it was right
away since Barbara Birke worked at the hospital but was not directly exposed to Los.
• Establish criteria for case identification - Clinical information about the disease was
established prior to inoculating the monkeys. The two strains given were the Harper
strain and the India strain, four monkeys in each group.In the case of Robert Stevens
doctors confirmed that the it was indeed anthrax and it was gram positive and Bacillus
anthraces. Peter Los had the confluent-type ordinary smallpox. Barbra Birke had
hemorrihagic small pox.
Since this relates to monkeys in this instance there is not much information on the
characteristics of what type of monkeys were used.
The location of the outbreak was in the lab at the MCL West in the CDC building
Anthrax outbreak of Robert Stevens was in Palm Beach County, Florida. The Peter Los
case happened in Meschaede, Germany. The Barbra Birke case occurred at the St.
Walerberga Hosptial in Germany close to Duisburg.
The outbreak occurred when two monkeys died. This happened on day four of the
exposure for the Harper group and day three for the group exposed to the India strain.
• Search for missing cases- In this case there was no search for missing cases because the
monkeys were contained to cages.The doctors did not seem to do a search for missing
cases in regards to Robert Stevens because at the time this was an isolated case and their
had not been a case like this in long time. In the Peter Los case it was found that Peter
infected 17 others one was Barbra Birke. In both the case of Peter Los and Barbra Birke
the doctors and staff continued to look for case as the others were treated.
• Count cases -All monkeys were found to have either the Harper or India strain of
smallpox in their DNA, in the end only one monkey survived the virus but was put to
sleep due to protocol.In the Robert Stevens case the case was an isolated incident. Robert
Stevens was an isolated cases. Peter Los infected 17 others including Barbra Birke.
• Orient the data according to person, place, and time-Every thing that happened was in
the CDC building and occurred between June 2 2001 and June 20, 2001. The only risk of
this outbreak spreading was to the investigators of the study, if they did not follow strict
guidelines in regards to safeguarding themselves against the smallpox virus.
• Classify the epidemic -This epidemic only affected 7 monkeys so would be considered
small. I am not sure the Robert Stevens case is considered an outbreak since it only
affected him. The Peter Los case could be considered a small epidemic since it infected
17 others.
• Determine who is at risk of becoming a case-the only people who would be a risk of
becoming a case were the investigators. if the investigators of the study got infected with
smallpox they then could infect family member and other staff and this could turn into a
major problem. These investigators followed very strict protocol, therefore making this
very unlikely.In Regards to anthrax in general anybody could be targeted and sent
anthrax. It appears that during this incident that only journalist were targeted. In the Peter
Los case many were at risk, all the staff and patients at the hospital and anyone coming in
and out of the hospital.
• Analyze the data-The data is that out of 8 monkey only one survived. Six died of
hemorrhagic smallpox and one of the classical pustule smallpox strains.In the Robert
Stevens case he was the only case and it was fatal. In the Peter Los case where 17 others
were infected, Peter Los survived. Barbra Birke's case was fatal and the book not
mentioning how many survived out of the rest of 16 who became infected with small pox.
• Formulate a hypotheses- Both the Harper and India strain of smallpox are very serious
and usually fatal. The hemorrhagic smallpox seems to be more fatal than the classical
pustule type.Anthrax appears to be quite fatal although this was only one incident and not
realized right away, it is possible that with early detection of anthrax that treatments
could save lives.
• Test hypotheses-After the original group of monkeys was complete; the team infected
two more sets of monkeys. In round two of the study they infected six monkeys, five of
which died. In this round one got pustule smallpox and one got human black poxvirus. In
the final round of the study, they lowered the dose and gave it to nine monkeys. None of
these monkeys got sick at all. In the Robert Stevens case their was no one to test the
hypothesis on.
• Develop reports and inform those who need to know-Because this study proved that the
smallpox virus can be imitated in a similar to fashion than in humans this study is useful
in creating antiviral and vaccines for the FDA. The FDA was informed.In the Robert
Stevens case the CDC was called October 6th just a few day after Stevens had fist fell ill.
• Execute control and prevention measures-the entire study was very controlled and
followed strict prevention measures.In the Robert Stevens case the FBI was called in to
take over.
• Administration and planning activities-The investigators continued to work on the
smallpox virus up until the morning of the Sept 11th tragedy.Researchers continued to
work on investigating anthrax and found that others had been sent it as well but it was
caught in time to not infect anyone else.
B.PURPOSES/ROLES/ACTIVITIES OF EPIDEMIOLOGY/EPIDEMIOLOGISTS:
Not much is mentioned in the book on some of this section but I will answer the
questions for both smallpox and Anthrax in general terms.
• Identifying risk factors for disease, injury, and death-Risk factors for smallpox would be
anyone exposed. Death is a risk for anyone who has been infected with smallpox.
Anthrax has the same disease and risk rate as smallpox; anyone who is exposed could
become ill and die.
• Describing the natural history of disease. - Smallpox is one of the oldest known viruses
know to man. Estimates are that between 300 and 500 million people have died of
smallpox thought history.
• Identifying individuals and populations at greatest risk for disease- At this time only
anyone who has access to the smallpox virus, such as researchers if smallpox was ever
made available for research again. If smallpox was still active, I assume children; the
elderly and anyone with a compromised immune system would be at greater risk.
Anthrax especially if it was used as bio-warfare in its aerosol form is very dangerous with
historically a 92% mortality rate but no if treated early a mortality rate of 45%. Inhaled
Anthrax however cannot be spread from person to person. But anyone who inhales
Anthrax endospores is at extreme risk of contracting Anthrax.
• Identifying where the public health problem is greatest- In regards to public health there
is not that needs to be don at this time in the way of the smallpox virus since it has been
eradicated. Public health professionals should however be educated on this complex virus
and the massive destruction it has caused throughout history. At this time the public does
not need to know a lot about the Anthrax virus but if it was ever used as bio-warfare the
public health must be educated on the importance of emergency care if they think they
have had contact with Anthrax especially because the survival rates can almost double if
the infected person receives care quickly.
• Monitoring diseases and other health-related events over time-It are imperative to have
both smallpox and Anthrax monitored so we can learn from these. Both of these viruses
could potentially be used, as bio-warfare if gotten into the wrong hands and a cocktail of
the two could be extremely fatal. Both can be fatal and there was a cocktail of the two
who knows what the outcome could be.
• Additional activities- I believe education is always key in informing both public health
professionals and the general public.
• Evaluating the efficacy and effectiveness of prevention and treatment programs-As
stated above if Anthrax was used as bio-warfare than treatment is key. Prevention would
be hard but importance of making sure people do not open letters and packages from
unknown sources if it seems that Anthrax was a threat. Of course it smallpox was taken
off the list of eradication, prevention and treatment both would be on the forefront of
objectives.
• Providing information useful in health planning and decision making for establishing
health programs with appropriate priorities. Information on the history and the outbreaks
of both these viruses would help establish health programs if these viruses ever go to
epidemic proportions or were used as bio-warfare.
• Assisting in carrying out public health programs-Like with any other disease, virus or
health issue these programs would have to be carried out by using potential governmental
funds and private funds and be staffed by knowledgeable health professionals from
various sectors.
• Being a resource person-Health professionals would be resource people as well as those
in leadership positions whether that is at the local level or the national level depending on
the size of the outbreak or epidemic.
• Communicating public health information-Both health professionals and those in
leadership roles would once again be the people to communicate pubic health
information.
C.DESCRIPTIVE EPIDEMIOLOGY – Examples and/or Evidence (should be in
bulleted form)
● Anthrax-Robert Stevens, John F. Kennedy Medical Center in Palm Beach
County, October 2-6th 2001
● Smallpox, Peter Los, Meschede, Germany, Early 1970
● Smallpox, Barbara Birke, Duisburg, Germany, January 22, 1970
● Smallpox, infected group of 8 monkeys, Atlanta, Georgia, June 2, 2001
D. ANALYTIC EPIDEMIOLOGY – Examples and/or Evidence [use bulleted format]
● Peter Los-17 other people were directly infected by contact with Los and two
from those seventeen additionally.
E. PROCEDURES AND TECHNIQUES USED IN THE INVESTIGATION OF
SMALL POX AND ANTHRAX
(procedures and techniques are discussed in Chapter 12 of the textbook) – [Use bulleted
format]
Agent
● The agent in both smallpox is a virus. Variola major is the virus that causes
smallpox and Variola minor the virus that causes a variant of smallpox. An India
and Harper strain were used on the study of monkeys.
The agent that causes the Anthrax disease is a bacterium called Bacillus
anthraces. This bacterium can cause dormant endospores.
● Infectivity- smallpox is very infectious and can be passed from one person to
another while Anthrax is not infectious and cannot spread from person to person.
● Pathogenicity- Both smallpox and Anthrax have high levels of pathogenicity
● Virulence-Both smallpox and Anthrax have high rates of virulence. As shown
with the monkeys 7 out of 8 died due to smallpox.
● Toxigenicity- I do not believe smallpox causes a toxin, I am not sure if the
postulates themselves would be considered toxins? In Anthrax the fungal spores
are the toxin.
● Resistance- I believe the resistance levels of both smallpox and Anthrax are
moderate because both can be controlled by vaccines.
● Antigenicity-Smallpox and Anthrax both have antigen qualities that is why
vaccines can work for both of these. Smallpox vaccines are the reason the virus
has been eradicated. Although smallpox can induce antibodies the smallpox
vaccine does wear off over time and lose its effectiveness.
Host
● Active- Both smallpox and Anthrax are active
● Passive- Smallpox and Anthrax are not passive
● Natural, active-I believe that neither smallpox nor Anthrax have natural active
qualities. If you get infected with either and survive you can still get the virus or
bacterium again.
● Artificial active- Both smallpox and Anthrax would be considered artificial active
becoming immune due to the vaccine.
● Natural, passive-I do not believe either smallpox or Anthrax can be cause
short-term immunity to a newborn.
● Artificial, passive-I do not believe either smallpox or Anthrax have
artificial/passive qualities.
Environment
Direct Transmission
● Smallpox can be transmitted directly. Anthrax cannot be transmitted from
person to person.
Indirect transmission
● Both smallpox and Anthrax can be spread indirectly though vehicles, formats
and vectors.
F.EPIDEMIOLOGICAL MEASURES (including measures of effect) and POTENTIAL
DATA INTERPRETATION ISSUES (e.g. bias and confounding) [Use bulleted format]
● The only bias I would possible see in the book is that one of the monkeys in the
smallpox study was favored. They even named him Harper after the strain he
received and he was given a lot of extra attention and special foods that the other
monkeys did not receive.