July 2014: One of the deadliest diseases on earth is right here in our own back yard, so to speak…with no vaccine, fatal without antibiotics, and on the CDC’s “Category A List” of potential bioterrorism agents.
Don’t panic just yet. The disease also occurs naturally, as is the case in this month’s outbreak.
However, overnight I’ve changed my outlook on the disease. What I’ve recently described to my students as highly unlikely is instead alive and well on the prairie. I’ve gone from believing I’d never encounter this infection to thinking it’s entirely possible. The next time I see a patient who’s coughing up blood, my mind won’t go immediately to bronchitis or lung cancer. It may jump straight to plague.
As a medical student about three decades ago, I saw a patient with Cryptococcal meningitis. He was a young guy with no good reason to be sick, at least none that we knew. Having just learned of the entity, I asked the attending physician whether it might be AIDS. He laughed, condescendingly, at the oddball suggestion of a neophyte. But it was indeed, and this same meningitis is now considered a sign of HIV, until proven otherwise. That doctor missed the diagnosis because his antenna was down. The disease was too new, too unexpected, and never before seen in the suburbs of Cleveland, Ohio.
In 1987 a Kentucky nurse told me a young woman I was treating likely had AIDS. Sure, she had a pneumonia and thrush, but AIDS? She was right. Why? This nurse knew the family and that the patient’s cheating husband was bisexual. Her antenna was definitely up.
A doctor can’t diagnose a disease that’s off their radar. It’s guaranteed; your doctor isn’t thinking of plague and has never seen it.
So what makes pneumonic plague an ideal bioterrorist agent? First, it’s openly available. The disease is spread through flea bites and direct contact with animals carrying the bacterium Yersinia pestis. Just harvest some fleas from an infected animal (without killing yourself in the process), and you have your weapon. Next, the infection kills quickly. With an incubation period of only 1–6 days from exposure to onset of symptoms, the disease can spread and kill before it’s even diagnosed. Antibiotics must be started within 24 hours of onset or you die. Thirdly, pneumonic plague can spread from person to person via droplets, the same as a cold or flu (secondary cases). Lastly, initial symptoms are non-specific (fever, chills, headache, muscle aches, nausea, vomiting, fatigue) and may lead to a delay in diagnosis. These four characteristics together create the “perfect storm” of a disease.
This isn’t science fiction. As early as 1347, the Tartars used plague as a bioweapon, catapulting plague-ridden corpses into Kaffa, thus spreading the Black Death to Italy. (I’m wondering how they protected themselves?) The Japanese dropped ceramic bomblets of infected fleas on China during WWII. During the Cold War both the Americans and Soviets devised means to aerosolize the Yersinia pestis bacteria.
In May 2000, Denver hospitals participated in a full-scale bioterrorism exercise simulating a release of aerosolized Yersinia pestis at a performing arts center. Their report, “Lessons Learned from a Full-Scale Bioterrorism Exercise” , is fascinating reading. In the simulation, after only one day there were 783 cases of pneumonic plague and already 123 deaths. After two days, the numbers jumped to 1,871 cases and 389 deaths. After the third (and final) day of simulation, 3,700 cases were reported along with 950 deaths, with at least 780 secondary cases and infection spreading to six states outside Colorado– a true Stephen King scenario.
So what lessons did the State of Colorado learn? Long story short, they weren’t prepared. Despite a two-month warning, they found communications were inefficient, staffing was inadequate, appropriate isolation became impossible, and city-wide quarantine was mandated…with little expectation of success. Prophylactic antibiotic distribution was initiated, but the issue of whom to treat was controversial.
The single most important lesson cited was that unless both the spread of the disease and the treatment of ill persons were equally and simultaneously addressed, “the demand for health-care services will not diminish,” meaning the plague could not be stopped.
Diagnosis of the initial case was not the problem. Although currently the disease is rare, it is considered endemic in Colorado, and so health authorities are familiar with the public health management of isolated cases. The problem was the wildfire spread, with secondary cases occurring within two or three days of the initial exposure. If the (greater than) daily doubling death rate continued, by two weeks nearly two million deaths occur. The series looks like: 123, 389, 950, 1900, 3800, 7600, 15200, 30400, 60800, 121600, 243200, 486400, 972800, 1945600. By another eight days, the potential death count exceeds the entire population of the United States.
So what should you do to protect your loved ones and yourself?
- Avoid contact with potentially infected hosts, such as squirrels, prairie dogs, rabbits, and rodents, particularly in endemic areas. If living in or visiting the Southwest, don’t let your pups play amongst the prairie dogs…avoid them like the plague.
- Avoid all exposure to fleas. Keep your pets treated and away from wild critters. Don’t investigate a rodent die-off on your own; the hungry fleas will be looking for a new host.
- Prepare to quarantine your own family for a potentially prolonged period– at least several weeks without leaving your house. Do not allow outsiders in, without first quarantining them in secured isolation (without exposure to the outside world) for a period of at least 10 days.
- Prepare an isolation room (preferably an outdoor tent), where a potentially infected person can be safely cared for. Don’t forget gloves and masks and perhaps even gowns.
- Develop a communication network within your family and community. Communication difficulties were a major obstacle in the Denver simulation.
- Procure some doxycycline and/or ciprofloxacin. Take this article or the study cited above along with you to your next doctor visit and request a personal supply. If your physician is not willing or able to cooperate (there are lots of regulations these days), consider an alternative source, such as antibiotics from another country or an A-B rated USP-grade aquarium antibiotic.
For post-exposure prophylaxis, the recommended dose is given orally for seven days after close contact (and of course repeated after each contact):
- Doxycycline 100 mg twice daily for adults, pregnant women, and children >45 kg
- Doxycycline 2.2 mg/kg twice daily for weight <45 kg, max 200 mg/day
- Ciprofloxacin 500 mg twice daily for adults, including pregnant women
- Ciprofloxacin 20 mg/kg twice daily (max 1,000 mg daily)
- Currently doxycycline is quite expensive, whereas ciprofloxacin is quite affordable.
For treatment of actual disease, injectable medications are preferred, primarily streptomycin or gentamicin, or possibly injectable doxycycline, ciprofloxacin, or chloramphenicol. The medication is switched to the oral route once the patient improves.
Lacking access to injectables, the prophylactic antibiotics listed above should be given for treatment for at least 10 days, preferably 2 weeks, or at least for 2 days after the fever subsides. Remember, antibiotics must be given within 24 hours of onset of symptoms or death is inevitable. By the time pneumonia sets in and you’re coughing up blood, it may be too late.
Pneumonic plague is truly horrific. However, though public authorities now understand they lack the resources to protect everyone, it is still definitely possible to protect your loved ones, yourself, and perhaps your local community.
Cynthia J. Koelker, MD is SurvivalBlog’s Medical Editor. Bioterrorism is one of the many topics covered in her Survival Medicine Workshops, which you will find at www.armageddonmedicine.net.