Disclaimer

The event and situations described in this scenario have been fictionalized for instructional and illustrative purposes.

This scenario takes place in the Orlando/Orange County, Florida Metropolitan Area, a popular tourist destination. This area has a population of over 1.5 million and hosts over 43 million visitors a year. Of the total number of visitors, 39 million are domestic visitors and 4 million are international visitors.

In this scenario, an outbreak of Rift Valley Fever (RVF) occurs in the area. The source of the outbreak is not known. Most people with RVF typically have either no symptoms or a mild illness associated with fever and liver abnormalities. However, in some patients the illness can progress to hemorrhagic fever (which can lead to shock or hemorrhage), encephalitis (inflammation of the brain, which can lead to headaches, coma, or seizures), or ocular disease (diseases affecting the eye). Patients who become ill usually experience fever, generalized weakness, back pain, dizziness, and extreme weight loss at the onset of the illness. Typically, patients recover within two days to one week after onset of illness. There is no established course of treatment for patients infected with RVF virus. To see more information on Rift Valley Fever, visit the National Center for Infectious Diseases (http://www.cdc.gov/ncidod/).

In this scenario, it is not clear whether the outbreak is naturally occurring, or the result of bioterrorism.

Local media have chosen to present the worst-case outcomes of patients with RVF, thus causing alarm in local citizens and the many visitors to the area. Hospital emergency rooms are flooded with patients requesting RVF testing.

Many visitors choose to leave the area, clogging interstate highways leaving Orlando.

Please note that this scenario is based on a scenario developed by Clete Di Giovanni Jr., MD., National Naval Medical Center.

Ask Yourself:

During a sultry August in Orlando, Florida, local physicians and area hospitals are seeing a rise in patients with flu-like symptoms.

Orlando, Florida - Monday, August 25. An Orlando television station runs a 30-second report on the evening news, sandwiched between other stories, stating that the area seems to be experiencing a surge of flu cases. The Assistant Director of Public Health for the Orlando/Orange County Health Department, commented in the report that this is quite early in the flu season to see this many cases. Commenting "this is an indication of a potentially severe flu season," he encouraged all people "at risk" to receive their flu shot early.

August 28 - At 5:00 p.m., the local television station reports the laboratory at the Orlando Regional Medical Center has detected the Rift Valley Fever virus from a flu patient hospitalized there. The station will devote its entire 30-minute, 6:00 p.m. newscast to RVF.

At 6:00 p.m., the local station presents special coverage on RVF reporting the following:

• RVF is a relative of the Ebola Virus.
• Newscasters highlighted the following outbreaks of RVF:
  • An outbreak of RVF in northeastern Kenya and in Somalia infected 89,000 people and killed more than 400. The Food and Agricultural Organization of the United Nations (UN) has categorized the outbreak as an international disaster because of fears that infected mosquitoes and animals may spread the disease to other countries.
  • In Egypt, 200,000 fell ill, 18,000 clinical cases were confirmed, with 598 deaths. Human infection rates ran as high as 35%. Retrospective studies indicate that RVF was not present in Egypt before this occurrence.
  • RVF broke out in Mauritania, resulted in more than 200 deaths.
• Up to ten percent of patients will suffer some permanent vision loss.
• Approximately one percent of patients will die.
• Although the human mortality rate is unknown, pregnant livestock infected with RVF lose 100% of their fetuses.
• There is no established course of treatment for the disease.
• A human live attenuated vaccine, MP-12, is currently undergoing trials, but is not approved for human use.

By 7:00 p.m., two local hospitals report their emergency rooms are operating at full capacity. As a result, they have activated their mass casualty disaster plans. Two other local hospitals are overwhelmed with alarmed visitors from tourist attractions requesting RVF testing.

At 8:00 p.m., a national news program pre-empts its previously scheduled talk show to present, "Crisis in Central Florida, the Killer Virus." The British Ambassador to the United States appears on the program and urges all British citizens visiting Central Florida to leave the area.

Ask Yourself:

At 9:00 p.m., the mayor is notified that a crisis of potentially major proportions is unfolding. Traffic bottlenecks form on all area transportation arteries. Interstate 4 and the Florida Turnpike are at standstills. Thousands of passengers crowd the Orlando International Airport to get flights out of the area.

At 11:00 p.m., the governor activates the State Emergency Operations Center (EOC) in Tallahassee. Throughout government and the media, there is speculation that this outbreak is a bioterrorist event. Local law enforcement and public health officials appear on the late night news, stating that the source of this occurrence of RVF is unknown.

Ask Yourself:

August 29 - The network morning talk shows broadcast live pictures of the long lines outside local hospital emergency rooms. Interviews with crying and panic-stricken pregnant women dominate the news coverage.

At 9:00 a.m., the governor declares a state of emergency and formally requests a Presidential declaration of a major disaster. Pending the President's decision on whether or not to declare a disaster, the governor asks for Section 403(C) of the Stafford Act (http://www.fema.gov/library/stafact.shtm). The White House is briefed on the incident.

At 10:00 a.m., The White House Press Secretary issues a statement that Rift Valley Fever virus has, for the first time, entered the United States. The announcement is careful neither to attribute this development to terrorists, nor to rule out their possible involvement. The brief announcement attempts to assure the nation that the outbreak appears to be localized to Central Florida, that the Federal Government will do everything in its power to keep it from spreading as well as to eradicate it. To assist Florida, the President has declared Central Florida a disaster area. The statement says experts on Rift Valley Fever from the CDC, the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), and the Department of Agriculture are being dispatched to Central Florida. As soon as the White House statement ends, the governor announces that he is calling up elements of the National Guard to assist in mosquito control and is considering quarantining Orange County (For information on the Model State Emergency Act, see http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf).

At 11:00 a.m., a preliminary situation report indicates that only one person is dead. The number of affected pregnant women is unknown. Concern among tourists continues to mount over their health and the potential of bioterrorism.

Ask Yourself:

A FEMA Region IV representative requests that the Florida EMA identify potential locations for the Disaster Field Office (DFO). The DFO coordinates the overall response in accordance with the Federal Response Plan (FRP). The Florida EMA coordinates with the Orlando EOC to determine the best sites for DFO establishment. An Emergency Response Team-Advanced (ERT-A) is on its way from the FEMA Headquarters in Washington, D.C.

At 12:00 noon, area hospitals request resources to manage the number of patients. The Orlando EOC requests assistance from the State EMA and the FEMA. Concerned relatives, desperate for information regarding the fate of their loved ones, overload the local telephone exchange, causing it to fail. Within 30 minutes, cell phone networks fail.

Ask Yourself:

At 1:00 p.m., the media are notified that a news conference with representatives from the CDC, the FBI, USAMRIID, the Department of Agriculture, and FEMA has been scheduled for 5:00 p.m. today.

Ask Yourself:

At 5:00 p.m., all major networks cover a live news conference from Orlando. Hosted by State health officials, Rift Valley Fever experts from the CDC, USAMRIID, and the Department of Agriculture provide detailed information about the illness and answer questions. They credit the Florida State officials for promptly recognizing the occurrence of something unusual in their community as well as notifying the Federal Government. Federal experts then assure the public that, although the disease has not previously been reported in the United States, they have had ample opportunity over past few decades to study it in the laboratory and in Africa, where it is endemic.

They state confidently that the virus is spread through the bite of mosquitoes, and that vigorous mosquito control measures should contain its spread. They also state that the virus cannot be spread directly from person to person through coughing or casual contact. Infected persons can carry the virus in their blood for three or four days after the onset of their illness. During this time, the concentration of virus in their blood can be sufficient to infect biting mosquitoes, which then can infect other people. They also announce that they will be issuing detailed guidelines to health care workers who provide care to RVF patients. In summary, there is no danger as long as standard barrier precautions are used. Patients can be treated safely in regular hospital rooms if windows are shut or screened to prevent patients from being bitten by mosquitoes.

They describe the clinical course of the illness - an incubation period of two to six days, followed by fever with generalized aches and pains that gradually resolve in most people. However, some can develop serious complications, such as liver necrosis, renal failure, visual problems, and/or encephalitis. They note that the overall mortality rate in Africa in recent years has been about one percent. They acknowledge there is no specific treatment for the disease, other than supportive care.

During the question and answer period, the USAMRIID representative acknowledges that there is a vaccine available in limited supply, but it is not approved by the FDA. The USDA representative tells the audience that Rift Valley Fever virus attacks cattle, sheep, and goats. Among these animals, those which are pregnant usually abort, and those which are younger tend to succumb to the infection in higher numbers than the older animals. He announces that the possibility of quarantining animals in Central Florida is under review.

Following this news conference, most TV networks produce their own panels of experts for further coverage of this event. The vector role of mosquitoes is prominently noted, but questions are raised about the transmission of this disease by aerosol. A professor from the Harvard School of Public Health cites articles from the medical literature about "the aerosol infectivity and risk of dissemination of the virus," and the "susceptibility of dogs and cats to Rift Valley Fever by inhalation or ingestion of the virus." A discussion then ensues about the differences between infection by aerosol in the laboratory or barn, and person-to-person infection through coughing and sneezing.

Another question raised by all the news networks is how this virus got into Florida, whether "someone has declared biological war on us." Most experts respond that the answer, thus far, is unknown. They point out that Rift Valley Fever virus can be spread by many species of mosquitoes in the United States, and we have been vulnerable, but fortunate that it has not hit us until now. They cite the example of West Nile Fever virus that entered the U.S. a few years ago for the first time, and has now spread to several states along the Eastern and Southeastern parts of the country, including Florida. The experts conclude that whether the invasion of Rift Valley Fever is an intentional biological release or a natural occurrence, we may be facing a health and economic crisis of significant dimensions.

Another point raised by reporters concerns the dangers of RVF virus to health care workers. Experts, quoting from a CDC jWeb site, state "infection through transmission of RVF virus has resulted from contact with laboratory specimens containing the virus." These experts also note that the virus is considered a BioSafety Level-3 hazard, and that scientists and physicians who work in military research laboratories with this virus are protected by a RVF vaccine.

Another "expert" notes that RVF is listed on the CDC's Web site as one of the hemorrhagic fevers, "like Ebola." This expert notes the apparent contradiction between CDC's assertion that people do not get infected through exposure to sneezes and coughs by other people, and the CDC's extensive requirements to protect laboratory workers.

August 30 - Thus far, 52 persons have been diagnosed with RVF. Four have died.

At 7:00 a.m., a national television news service carries a story that restaurants throughout Florida are reporting their customers are avoiding all meat products and are ordering only chicken, fish, or seafood. Restaurant owners fear the lost income from meat inventories "going bad." A Saudi Arabian diplomat in Washington says, in a television interview, that the same thing happened in his country in the fall of 2000 when it experienced its outbreak of RVF along its border with Yemen. "Regardless of what we told them, people shunned meat," he says.

At a White House press conference, the Presidential Press Secretary announces "the immediate curtailment in the movement" of cattle and other farm animals in the "affected area."

At 9:00 a.m., the stock exchanges are in turmoil as traders consider the possible devastation to America's livestock industries and export. Corn and soybean futures decline sharply with the prospect of fewer animals to feed. At 10:18, trading is temporarily halted. Among the harder hit companies are those involved with tourism.

By noon, most area hospitals are receiving telephone calls from some of their afternoon shift employees who are informing the hospitals that they will not be reporting to work. They claim family illness or sudden plans to travel elsewhere. Employees, when threatened with administrative action, tell their employers that their health and the health of their families are more important than anything else. Some physicians also express their anxieties about taking care of these patients, but most do not. However, clinical laboratory workers are especially worried about handling potentially infectious blood and tissue specimens. These lab workers are told that all they have to do is to use the same precautions that they use for any specimen, for example, a specimen that might contain HIV. The laboratory workers point out that these precautions may be inadequate because military laboratory personnel who work with RVF virus are required to get vaccinated against RVF.

In the early afternoon, the president of the local morticians' association informs the mayor's office in Orlando that the members of the association decided at last night's meeting not to offer funeral services for victims of RVF unless the bodies are cremated. He also issues a press release to a local newspaper and to the local TV stations. As soon as the story is carried by local TV stations, the mayor's office begins receiving complaints from relatives of the deceased and dying patients because cremation violates their religious beliefs or the wishes of their relatives. Some of these family members provide on-the-street interviews to journalists.

At 2:00 p.m., officials say that the White House is studying the possibility of directing the Army to release 2,000 doses of its RVF vaccine for use in the Orlando metropolitan area. They say that the Army has more, but other lots need to be potency tested, and potency testing takes a long time. They say that the vaccine has been used primarily for the protection of laboratory workers who study RVF virus, not the general public, and that it is classified by the Food and Drug Administration (FDA) as an Investigational New Drug (IND) and is authorized for use only under a highly specific protocol. However, because of the emergency in Florida, and the possibility that the vaccine may be released for use there, FDA is developing a new and more permissive protocol that could enable the vaccine to be used under less stringent regulations. At issue is the prioritization in distribution of the vaccine. Some vaccine experts recommend that lab workers who work with potentially infected blood and tissue specimens should be early recipients of the vaccine, as should veterinarians, while other experts suggest that the outbreak might better be controlled by using the vaccine on animals, not people.

Some emergency workers in hospitals, clinics, and in various municipal departments begin demanding that not only they, but also their families, receive the vaccine first. Some imply that vaccination of themselves and their families is a quid pro quo for their remaining on duty.

At 3:00 p.m., the governors of Alabama and Georgia demand that the Federal Government take steps to keep RVF from spreading to the human and livestock populations of their states.

By mid-day, the Office of Emergency Preparedness is receiving reports that truckers headed towards the city are turning back, and that attendants at gas stations on the major arteries leading out of the city are refusing to allow vehicles coming from the direction of Orlando to fill up at their pumps. One of the airlines serving Orlando cancels its flights to Orlando for fear mosquitoes may infest aircraft awaiting departure.

Ask Yourself: