Exercise Mataika: White Paper on response to a smallpox bioterrorism release in the Pacific

Abstract

Smallpox was declared eradicated in 1980, with known seed stock retained in two high security Biosafety Level 4 laboratories in the United States and Russia. Experts agree the likelihood of theft from these laboratories is low, and that synthetic creation of smallpox is a theoretical possibility. Until 2017 it was believed that synthetic smallpox was technically too complex a task to be a serious threat. However, in 2017, Canadian scientists synthesised a closely related orthopoxvirus, horsepox, using mail order DNA and $100,000. Simultaneously, terrorist groups have declared intent to conduct biological attacks. In this context an exercise was held on August 16th 2018, with international and cross-sectoral stakeholders to review preparedness for a bioterrorism attack in the Asia-Pacific region and globally. The exercise was conducted by The National Health and Medical Research Council (NHMRC) Centre for Research Excellence, Integrated Systems for Epidemic Response, with contextual input from the Ministry of Health and Medical Services Fiji. The scenario involved a deliberate release in Fiji, followed by a larger release in a more populous Asian country. Mathematical modelling was used to underpin epidemic projections under different conditions. The exercise alternated between clinical, public health, emergency and societal responses, with participants making real-time decisions on cross-sectoral response across the region and the world. Key weak points which are influential in determining the final size and impact of the epidemic were identified (based on mathematical modelling of transmission in Fiji and globally). We identified potential gaps in preparedness for smallpox and factors which influence the severity of a smallpox epidemic. This included identifying which determinants of epidemic size are potentially within our control, and which are not. Influential factors within our control include: preventing an attack through intelligence, law enforcement and legislation; speed of diagnosis; speed and completeness of case finding and case isolation; speed and security of vaccination response, including stockpiling; speed and completeness of contact tracing; protecting critical infrastructure and business continuity; non-pharmaceutical interventions (social distancing, PPE, border control); protecting first responders; operational support and logistics; social mobilisation and risk communication. Based on discussion at the workshop between diverse stakeholders, recommendations were made to guide improved prevention, mitigation and rapid response, thus providing a holistic, cross-sectoral framework for prevention of a worst-case scenario smallpox pandemic.

Health system capacity in Sydney, Australia in the event of a biological attack with smallpox

“…Improving diagnosis requires triage protocols and rapid diagnostics, the latter being useful only if the diagnosis is suspected clinically in the first instance. Other avoidable delays in response could include having pre-vaccinated first responder teams, pre-designated isolation and quarantine facilities, and rapid human resources and surge capacity scale up plans [36].…”

The risk of selective investment in downstream pandemic planning

“…Forethought, legislation, surveillance, planning, capacity building, training and the ability to effect rapid surge capacity in physical space and human resources can prevent or control an epidemic. Planning should focus on identifying influential factors we can control to mitigate epidemics (31), which are present along the entire spectrum depicted in Figure 1. There is much we can do to prevent and mitigate epidemics, and all opportunities for prevention are equally important.…”

On a knife’s edge of a COVID-19 pandemic: is containment still possible?

“…In 2018, we undertook a training simulation of a pandemic in Sydney, underpinned by mathematical modelling, which went through precisely the issues we are dealing with now in trying to contain the spread of coronavirus disease 2019 (COVID-19) -namely mass quarantine, travel restrictions, stricken cruise ships, mass surveillance, finding enough beds for case isolation and mass contact tracing. 1,2 Governments everywhere plan for pandemics, because their impact can cause sharp shocks to economies and societies and require a substantial surge in health system capacity. 3 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, probably emerged in late 2019, and began infecting humans in December 2019.…”