Smallpox: An attack scenario.

Smallpox virus, which is among the most dangerous organisms that might be used by bioterrorists, is not widely available. The international black market trade in weapons of mass destruction is probably the only means of acquiring the virus. Thus, only a terrorist supported by the resources of a rogue state would be able to procure and deploy smallpox. An attack using the virus would involve relatively sophisticated strategies and would deliberately seek to sow public panic, disrupt and discredit official institutions, and shake public confidence in government. The following scenario is intended to provoke thought and dialogue that might illuminate the uncertainties and challenges of bioterrorism and stimulate review of institutional capacities for rapid communication and coordinated action in the wake of an attack. April 1 The vice-president visits Northeast, a city of 2.5 million. His itinerary includes an awards ceremony, an appearance at a local magnet school, and a major speech at the local university. A crowd of 1,000 people, including students, is gathered in the university auditorium. Hundreds more wait outside, where the vice-president stops to shake hands and respond to queries from the media. The Federal Bureau of Investigation (FBI) has information suggesting a possible threat against the vice-president from a terrorist group with suspected links to a rogue state. The group is known to have made inquiries about acquiring biological pathogens, including smallpox, and is suspected of having procured aerosolization equipment. FBI decides its information is too vague and too sensitive to pass on to the Department of Health and Human Services, local law enforcement authorities, or the state health department. April 8 FBI informants report rumors that something happened while the vice-president was in Northeast. April 12 A 20-year-old university student goes to the university hospital emergency room with fever and severe muscle aches. She is pale, has a temperature of 103°F, and is slightly leukopenic, but the physical exam and laboratory results are otherwise normal. She is presumed to have a viral infection and is sent home with instructions to drink fluids and take aspirin or ibuprofen for muscle aches. Later that day, a 40-year-old electrician arrives at the emergency room with severe lower backache, headache, shaking chills, and vomiting. He appears pale and has a temperature of 102°F and a pale erythematous rash on the face. The patient is a native of Puerto Rico, where he visited 10 days earlier. A diagnosis of …