A three-month study by the State Health Departments of Minnesota, Wisconsin and Iowa has concluded that users of high-absorbency tampons have a greater risk of developing toxic shock syndrome than do women who use less absorbent tampons.

The study itself was not made available, but rather a news release describing the study. Dr. Michael Osterholm, an epidemiologist for the Minnesota Department of Health who spoke for the study group, said he hoped that the study itself would be published in a scientific journal ''very quickly.''

Dr. Osterholm said that neither he nor his colleagues would have recommendations for the Federal Food and Drug Administration about whether such products should stay on the market or advice for women about whether to use tampons.

Despite the research, which examined 80 women who had the disease from Oct. 1, 1979, to Sept. 19, 1980, and a control group of 160 women of the same ages who lived in the same neighborhoods but did not contract the disease, it was clear that the causes of toxic shock syndrome have yet to be detailed with precision, though the finding on absorbency supported speculation that had been discussed publicly for several months.

No Conclusions on Correlation

But according to Dr. Osterholm, the Minnesota-Iowa-Wisconsin study has made no conclusions about why the absorbency factor was correlated with the incidence of the disease.

He also said that the research had not been able to develop a definitive profile of who might be at greater risk, although more than half the women studied who had the disease were under 19 years of age.

Nor did the researchers produce firm data on whether changing tampons more often reduced risk or whether the materials used in tampons made any difference.

''We looked at the chemical, we looked at the applicator, we looked at the outside material around the tampon, and we looked at the string which is used for the removal of the tampon,'' Dr. Osterholm said, ''and we could not find any association with any one of these particular components and the development of toxic shock syndrome.''

Effect of Media Reports

Dr. Osterholm also retreated from his earlier speculation that the disease might occur more frequently in the Middle West. ''We at this time feel very strongly that surveillance plays a very important part in the reporting of this disease,'' he said. ''The disease will fluctuate with news media reporting.''

Dr. Osterholm said that he could not define a high-absorbency tampon and that there were no industry standards to determine the absorbency of tampons.

In the last quarter of 1980, the incidence of toxic shock seemed to be dropping in Minnesota. Dr. Osterholm said this might be due, in part, to the removal from the marketplace Sept. 23 of the Rely tampon, which had been suspected of placing its users at higher risk of getting the disease.

Decline of Tampon Sales

Other factors, Dr. Osterholm said, might be that women are removing tampons quickly if they get fever and diarrhea while having their menstrual periods and that tampon sales are generally declining.

In Cincinnati, Ohio, Geoffrey Place, a vice president of the Procter & Gamble Company, the maker of Rely, issued a statement calling the new study ''the most thorough and comprehensive study of T.S.S. available to date.'' He said that it ''confirms our own findings that Procter & Gamble's voluntary withdrawal of Rely tampons from the marketplace has in no way caused a major reduction in the risk of T.S.S.''

A spokesman for the Federal Centers for Disease Control in Atlanta hailed the study as ''an important addition to the growing body of knowledge about T.S.S,'' but had a different interpretation of its findings on the Rely tampon.

''The study has confirmed results of earlier studies that demonstrated an association of T.S.S. with tampons in general and with Rely brand tampons in particular,'' the spokesman said.

Toxic shock syndrome, the rare but sometimes fatal disease that strikes primarily at young women who use tampons, appears to have declined dramatically in the United States during the last months of 1980. Between the end of September and the end of the year, the number of new cases reported monthly and verified by the Centers for Disease Control in Atlanta fell by more than 60 percent.

The reasons for the decline are not yet entirely clear to researchers at the centers, but two factors are being evaluated. One is the removal of the Rely tampon from the market last September; the other is that tampon sales have generally fallen in the same period of time.

But there is no doubt that the decline is real and not just a statistical fluke.

Special Significance

The decline takes on a special significance because it follows a period in which toxic shock syndrome has received a great deal of publicity. Under normal circumstances, this would generate more reporting from family doctors and health departments all over the country. Even with the new emphasis on toxic shock and alert reporting nationally, the numbers showed a decline.

Since last August, the worst month for toxic shock cases since the Government began keeping track, the number of those cases nationally have been verified thus: August, 119; September, 106; October, 58; November, 42; and December, 37.

New cases may yet be reported for November and December, but researchers at the centers do not believe the numbers will change significantly. Indeed, they withheld the figures until now because they wanted to give state health departments additional time to report new year-end cases.

The Federal centers plan to release the latest findings today, in the Morbidity and Mortality Weekly Report, the same publication that announced the emergence of toxic shock as a national health problem last May 23.

A total of 941 cases of the disease have so far been reported in this country, about 90 percent of them in menstruating women. The rest have occurred in men and in nonmenstruating women. Of the total, 725 were reported in 1980 alone.

Last spring, when medical authorities were making their first serious effort to evaluate the health problem posed by toxic shock, they thought it might occur in about 3 of every 100,000 menstruating women a year.

Researchers at the centers now think the rate at present might be almost anywhere from 1 in 100,000 to 15 in 100,000, with 10 perhaps a more accurate number than 3. But with the rate of decline as sharp as it is, they cannot say what the rate will finally work out to be.

It is not yet possible to say if the rate of decline will continue or level off, and until the mystery associated with the disease is finally cleared up, no one can rule out another surge in the disease. Fatalities have occurred in nearly 8 percent of the cases.

Beginning of Decline

Statistics indicate that the disease began to decline last October, but researchers working under Dr. Kathryn N. Shands, who heads the centers' toxic shock research effort, are cautious about drawing firm conclusions about the reasons.

However, studies conducted last summer indicated that women who used Procter & Gamble's Rely tampon had an eightfold greater risk of developing toxic shock syndrome than users of most other brands. Government scientists did not say that Rely had caused toxic shock. However, there was a statistical association between use of the tampon and the disease.

On Sept. 22, Procter & Gamble voluntarily withdrew Rely from the market. The company's chairman, Edward G. Harness, said that the withdrawal had been ordered to remove Rely from the controversy ''despite evidence that the withdrawal of Rely will not eliminate the occurrence of TSS even if Rely's use is completely discontinued.''

Factors in Change

Although the removal of Rely may be a factor in the decline of the disease, it probably is not the only factor. Since September, all tampon use has declined nearly 20 percent, according to some industry estimates. Until last September, 70 percent of all menstruating American women used tampons. The proportion now is probably between 50 and 55 percent, according to reliable industry sources. Many women have begun to use sanitary napkins.

But toxic shock cases reported to the Centers for Disease Control have declined three times as fast as the rate of decline of tampon use. Rely's possible role in somehow making it easier for the vagina to be colonized by the Staphylococcus aureus, the bacterium that contains the as yet unidentified toxin believed to cause toxic shock, thus remains the object of concern and inquiry.

Caution From Producer

In Cincinnati, a spokesman for Procter & Gamble said the company had no quarrel with the Government's new data but emphasized that toxic shock syndrome was ''a continuing health problem'' and that care had to be taken in the interpretation of such data.

The spokesman noted the general decline in tampon use and suggested that because of the widespread concern over toxic shock, women might be using their tampons in different ways.

''We can't be sure, and it is just speculation at this point,'' the spokesman said. ''But it may be that women are so aware of this problem that if they feel themselves getting some of the symptoms associated with toxic shock during a menstrual period, they may remove the tampon or do something that simply precludes a severe case of the disease.''

The research done by Dr. Shands and her associates appears to have yielded results that are at some variance with the research reported by Dr. Michael Osterholm, chief of acute disease epidemiology at the Minnesota Department of Health.

Last Jan. 13, Dr. Osterholm conducted a news conference in Minneapolis and announced the results of a study conducted by the health departments of Minnesota, Wisconsin and Iowa.

Risks Are Discussed

He said that the risks of toxic shock were greater among users of high-absorbency tampons than among women who used less absorbant tampons.

But researchers working with Dr. Shands in Atlanta found that among the reduced number of women who use tampons, the same percentage use high-absorbancy tampons as they did last September. As a result, there is doubt that the absorbancy of tampons plays the role outlined by Dr. Osterholm.

Scientists at Atlanta have also given consideration to the possibility that toxic shock may be seasonal. That theory does not seem to hold either. In 1979, the greatest number of cases were reported in December and one of the lowest numbers were reported in August, essentially the reverse of the situation in 1980.

Researchers at Atlanta continue to try to find proof that a protein toxin within the Staphylococcus aureus is the cause of toxic shock. Dr. Shands has reported they have ''several candidates'' among the protein toxins that are promising, but there is nothing conclusive as yet.

Meanwhile, the disease continues to be an enigma. Sweden has reported at least 20 cases and Canada has had more than a dozen. Other countries in Western Europe have reported a few cases as well. But in Japan, there are still no cases known to researchers at the Centers for Disease Control.

Dr. Shands was asked about this recently and said, ''There are differences in the way tampons are used in different countries. That question has to be investigated much more before any conclusions are drawn.''

TOXIC shock syndrome has begun to fade as a cause of intense concern among American women. The sale of tampons, with which the disease has been linked, is slowly reviving after falling sharply last autumn. By winter, the reported incidence of the disease had dropped to less than half of its peak in the summer, and it has leveled off.

But among scientists, the disease -a rare and sometimes fatal illness that occurs mostly in menstruating women who use tampons - remains a source of vigorous debate. Recent findings suggest that the researchers are close to a much better understanding of the disease.

For the scientists the major issue has been the need to isolate the toxin. The toxin can then serve as an aid in early detection and treatment.

Two of the major researchers, whose independent findings have been published by two medical journals, are sure they have the protein toxin that causes the disease. But they do not agree that they have found the same culprit, nor do they agree on names for what they have found.

Because of the continuing uncertainty, the National Academy of Sciences plans to hold a conference later this year to pin down what is known about the scope of the disease - its diagnosis, etiology and pathology.

The newest scientific leads are being pursued as some tampon industry spokesmen continue to take strong issue with the suggestion that tampon use has been a factor in causing toxic shock syndrome.

The industry is scheduled to file comments with the Food and Drug Administration, which is considering a proposal to force the manufacturers to put a warning label on each tampon package. The advice of Government experts is still that women can almost entirely eliminate the risk of toxic shock by not using tampons and that they can reduce the risk by not using them continuously, substituting napkins and pads. They also say that if a woman comes down with toxic shock symptoms - a drop in blood pressure, scaling of skin and fever - she should stop using tampons at once and call a physician.

One of the main researchers in the field, Dr. Patrick M. Schlievert of the University of Minnesota, says that the protein he found is an exotoxin, a type that is excreted by the bacteria. He has decided to call it Pyrogenic Exotoxin C to distinguish it from two other pyrogenic exotoxins that may also be found in Staphylococcus aureus, the bacterium that has been associated with toxic shock. The term ''pyrogenic'' refers to the toxin's ability to cause fever.

But another researcher, Dr. Merlin Bergdoll of the University of Wisconsin, thinks the protein in question is an enterotoxin, a kind of exotoxin that principally affects the gastrointestinal tract. He calls it Enterotoxin F, to distinguish it from A, B, C, D, and E, which he says may also be found in the bacterium.

Dr. Schlievert's findings appear in the April issue of the Journal of Infectious Diseases, which is being distributed only now. Dr. Bergdoll's paper appeared in the May 9 issue of The Lancet, a British journal. At the Federal Centers for Disease Control in Atlanta, scientists who have cooperated with both researchers suspect the two may be talking about the same protein.

In an effort to clarify the issue, Dr. John Bennett, assistant director for science at the Center for Infectious Diseases, which is part of the Atlanta facility, has offered the name ''migmatoxin,'' based on the Greek word for mixture. Neither scientist is enthusiastic about the name or the suggestion that they have found the same thing.

Meanwhile the marketers of tampons are urging more research, and none are more eager for it than the Procter & Gamble Company, which voluntarily removed its Rely tampon from the market last Sept. 22. The company took the action after Government studies indicated that menstruating women using Rely tampons ran a three times greater risk of getting toxic shock than those who used other tampon brands. Researchers at the Centers for Disease Control emphasized then that there was no firm evidence that Rely actually caused toxic shock. They said that they did not yet know the basis for the statistical association.

Company Finances a Study

Procter & Gamble, which is involved in litigation with a growing number of women over Rely, is currently financing 14 research projects into toxic shock, at a cost to it of around $2 million.

A spokesman for Procter & Gamble contends that the way the Centers for Disease Control collect data on toxic shock is too slow and that the incidence of the disease as it occurred after Rely was taken off the market was ''grossly under-reported.''

In October, after Rely was gone, the number of reported toxic shock cases fell sharply, then declined gradually for the rest of the year. Dr. Kathryn N. Shands, who has headed the centers' toxic shock research team, says that the decline may be attributed to several factors, among them the removal of Rely and the fact that fewer women were using tampons of all kinds.

Industry sources estimated that in July and August of last year, about 70 percent of American women were using tampons. By November and December, the number had fallen to 55 percent. It has since started to slowly rise again, according to industry sources.

Effect of News Coverage

Procter & Gamble further asserts that there are now as many cases as there were at the same time last year, before they climbed in the summer. The company contends that the ''bulge'' of cases in August and September was in great measure due to the wide coverage the disease received in the press and on television.

The company has done its own computation of the 1980 toxic shock data, which its scientists, like those of the Centers for Disease Control, have received from health departments in all 50 states.

The month-by-month totals, as computed by the company, were for the most part slightly higher than those given by the Federal agency. The companies said that in 1980 there had been a high in August of 134, compared with the Government's 121, and a low in February of 30 compared with 32. Although there are no figures from the companies for 1981, the disease centers say that the cases have leveled off at around 50 a month.

Scientists at the agency are not ready to exonerate Rely because of the small differences between the two sets of data. They note that if the numbers were plotted on a graph they would be parallel. The chief reason for the differences, they say, is that the company's researchers call health departments in all 50 states with considerable regularity, whereas the Centers for Disease Control wait for health departments to report by mail.

Dr. Shands said that many physicians do not bother to report their toxic shock cases to state health departments. She feels that whoever compiles the statistics, the numbers probably only represent 15 percent of the cases, whenever they are gathered.

Possibility of Duplication

She also noted that because the Centers for Disease Control get the names of toxic shock victims, usually denied to Procter & Gamble by medical privacy, the Government is able to preclude redundancy. A toxic shock victim who lived in one state and attended college in another could not accidentally be counted twice.

As for Procter & Gamble's feeling that the August-September jump in cases was due to publicity, Dr. Shands recalled that news interest in toxic shock syndrome remained high through the fall and into December, while the number of cases reported declined slightly in those months. She thinks the August-September bulge represents a real increase in the number of cases, not just an anomaly caused by news coverage.

Fears about the safety of tampons have apparently had a beneficial effect on the sales of one brand. A spokesman for Tampax said that the company had resumed selling an all-cotton tampon it calls ''Original Regular,'' the version it introduced in 1936 but removed from the market in 1978. According to a Tampax spokesman, the decision to put it back on the market was made before toxic shock arose as a national concern.

Safety of All-Cotton Tampon

Dr. Shands was asked if there was any scientific reason why an allcotton tampon might be safer than others.

''It is possible that an all-cotton tampon might be safer but there are no laboratory findings to confirm this as yet,'' she said. ''The evidence is circumstantial because there is a temporal association between the emergence of toxic shock and the introduction of superabsorbent materials.''

However, she noted the three-month study by a team under Dr, Michael Osterholm, an epidemiologist of the Minnesota Department of Health. The Minnesota researchers concluded last January that users of high-absorbency tampons had a greater risk of developing toxic shock syndrome than women who use the less absorbent variety, but made no conclusions about the cause of that correlation. Richard Severo

The incidence of toxic shock syndrome in the United States appears to be well below what it was in 1980, when it reached a peak, but the disease gives no sign of disappearing, according to the latest data compiled by the Federal Centers for Disease Control in Atlanta.

Dr. Walter Schlech, an epidemiologist with the special pathogens branch of the Government agency, said yesterday that 1,660 cases of the disease had been confirmed since the earliest documented case in 1970. Toxic shock is now occurring at the rate of 30 to 50 cases a month, he said.

Most instances have occurred in menstruating women who used tampons and who had a high rate of cervical or vaginal cultures found to contain a form of bacteria called Staphylococcus aureus.

But investigators have also documented the disease in 55 men and in 154 cases of women who were not menstruating when the disease struck. The youngest victims were a 1-year-old girl and a 1-year-old boy. The oldest woman among the victims was 64, and the oldest man was 75.

Symptoms of Toxic Shock

Among the symptoms of the disease are a rapid drop in blood pressure, which results in shock, vomiting, high fever, diarrhea and a skin rash.

Eighty-eight of the known victims have died. Dr. Schlech said the percentage of victims who died from the disease, which stands at 5.6 percent for all cases reported, appeared to have fallen to 3.3 percent for 1981. The worst year was 1980, when 867 cases were reported. One of the most recent deaths from the disease was reported Wednesday. The victim, a 20-year-old student at Princeton University, had used tampons and was menstruating when struck by the disease, her physician said.

There has been some decline in tampon use nationally. Sources at the Centers for Disease Control decline to speculate on what role that might play in the incidence of toxic shock. However, scientists elsewhere have reported in recent weeks on studies suggesting that the risk of toxic shock syndrome is closely associated with tampon fluid capacity. One such study is reported in the April issue of The Journal of Infectious Diseases, in which researchers were led by Dr. Michael Osterholm of the Minnesota Department of Health.

Dr. Claire Broome, a epidemiologis at the special pathogens branch who is in charge of gathering toxic shock data, said she could not say whether the drop in the incidence of the disease could be attributed to a decline in the use of tampons or to some other cause, such as a decline in the voluntary reporting of the disease by state departments of health.

Product Removed From Market

''It has not gone away,'' she said, although some people had hoped that with the removal of the Rely tampon in 1980, that the disease would simply vanish. Rely was voluntarily withdrawn from the market by its manufacturer, Procter & Gamble, which still contends that there is no proof that Rely actually caused toxic shock.

On April 22, a Federal jury in Cedar Rapids, Iowa, found the company liable for the toxic shock death of a woman who had used Rely and awarded her husband $300,000 in damages. In March, a Federal jury in Denver found that the company was negligent and offered a defective product when it put Rely on the market, but it did not award any damages to a Colorado teen-ager who had sued the company.

Dr. Schlech said data compiled by Federal authorities showed the following breakdown of reported cases of toxic shock syndrome: 1972, three cases; 1973, five; 1974, three; 1975, seven; 1976, eight; 1977, 15; 1978, 48; 1979, 140; 1980, 867, and 1981, 492.

To the Editor:

I'm sure you were well-intentioned in ''A Treacherous Paradox: Aids Tests'' (editorial, Nov. 30). But why estimate about false positive acquired immune deficiency syndrome tests in Peoria, Ill., when actual tests of more than 250,000 low-risk people have shown not one false positive in Minnesota!

Dr. Michael Osterholm, Minnesota's state epidemiologist, and Dr. Brooks Jackson of the St. Paul Red Cross will soon publish these results. They have tested what you must concede is a low-risk population - voluntary blood donors! Of the 250,000-plus donors, there were 15 positives after repetitive Elisa (enzyme-linked immunosorbent assay) tests and confirmatory Western blot tests.

The actual AIDS virus was cultured from the blood of all 13 patients who came in to date for testing. The 14th donor was already symptomatic with AIDS; the 15th also admitted to being in the high-risk category. Indeed, all 15 positives admitted to high risk. And there was not one false positive in more than 250,000 real people.

Yet, your editorial quotes new estimates made by Lawrence Miike of the Congressional Office of Technology Assessment, in which he theorized that if a low-risk group - like blood donors in Peoria, for instance -were screened for AIDS by the Elisa test, with its positive results confirmed by the Western blot test, then 80 people out of 100,000 would be falsely described as carriers of the virus!

This prompted a lengthy telephone conversation with Dr. Miike:

''What about labs like Minnesota? Can't Peoria do it if the Twin Cities can?''

Dr. Miike explained that they had omitted all the good ''reference'' labs. ''We weren't worried about the good labs, so they weren't part of the study,'' he said.

Then he had additional interesting information: The Army contracted its AIDS tests out to a commercial laboratory. It sent 40 dummy known serum samples each month mixed in with the others to test the lab's accuracy. If the lab made mistakes, it wasn't paid for that month. The cost was $4 a person, and this included repetitive Elisa tests and the Western blot confirmatory test.

In your editorial, I was erroneously accused of urging the members of the American Medical Association, of which I am a member, to test all their patients. Make that all patients who are high risk, who have had blood transfusions or consider themselves at slight risk for reasons best kept to themselves. In Indiana, incidentally, we keep people with AIDS in their jobs for as long as they are able to work. CORY SERVAAS, M.D. Indianapolis, Dec. 3, 1987 The writer, a member of the Presidential AIDS Commission, is editor of The Saturday Evening Post.

A family doctor who practices in the Minneapolis area has sent letters to 328 of his patients telling them he has the AIDS virus and urging them to be tested by the state.

The doctor, Philip Benson, 39 years old, continued to perform invasive procedures, including delivering babies and conducting oral, rectal and gynecological examinations, after the virus was diagnosed last September, state health officials said.

At a news conference on Saturday at which he read a statement but refused to answer questions, Dr. Benson said he wore two pairs of gloves while examining patients.

"Given the medical knowledge we had at the time," he said, "I was taking the necessary precautions to prevent the transmission of the virus."

30 Patients Are Babies

State health officials said that no evidence had yet been found that any of the doctor's patients had been infected but that they had set up special testing procedures for the 328 patients. Thirty of those patients are babies.

"While we believe the risk is extremely low, we believe they should be tested," Marlene Marschall, the State Health Commissioner, told The Minneapolis Star Tribune. She said it was possible that the sores on Dr. Benson's hands "may have leaked blood and fluid."

At the time, Dr. Benson was suffering from an unrelated skin condition that had caused open sores on his hands.

The state's epidemiologist, Dr. Michael Osterholm, told The Associated Press that because up to 1 percent of surgical gloves may be defective wearing gloves was not considered a sufficient precaution.

State health officials said that they were notified soon after Dr. Benson tested positive for the AIDS virus and that they allowed him to continue to practice. It is not clear why Dr. Benson decided to notify his patients now.

'Difficult Time for Me'

In his statement, Dr. Benson said, "This is an extremely difficult time for me personally, but my patients' welfare is my chief concern." He said he had told his patients in the letter he had "every reason to believe your test results will be negative," adding, "I sincerely hope this is the case."

Telephone calls to Dr. Benson and the state officials on Sunday were not returned.

Dr. Benson practices at two medical clinics in the Minneapolis area: the Riverside Medical Center in Minneapolis and the Palen Heights Medical Clinic, in Columbia Heights.

He said he treated 1,369 patients after he tested positive for the human immunodeficiency virus, which causes AIDS. Of those patients, only 328 were contacted, because the remainder did not undergo invasive procedures.

Dr. Osterholm said he could not divulge how Dr. Benson became infected with the AIDS virus.

The Federal Centers for Disease Control has reported only one case in which a health care worker apparently transmitted the virus to patients. At least five patients of a Florida dentist have the same strain of the AIDS virus as the dentist.

• People in the United States are sickened by their food once a year, on average. But the food poisoning that suddenly appeared in White City, Ore., in December 1981 was something else.
• It was terrifying, and dramatic, and it seemed to have no cause. In the end, however, that mini-epidemic turned out to be the first show of force by a new strain of bacteria that is now infesting the food supply, infecting as many as 20,000 Americans a year and killing 500.
• This is a scientific detective story about those bacteria, known as E. coli O157:H7. It is a story that is continuing and that, in the end, may lead to sweeping changes in the way food is regulated in the United States.
• The bacteria that puzzled scientists 16 years ago have turned up in some of the most notorious food poisoning episodes in recent history, including one involving Jack in the Box restaurants in the Northwest in 1993 where four children died after eating hamburgers and hundreds of people became ill.
• The bacteria surfaced in 1996 in cases traced to contaminated apple juice and lettuce, then dominated headlines last August when 17 people in Colorado got sick after eating hamburgers from beef processed by a Hudson Foods plant in Nebraska. Hudson, based in Rogers, Ark., recalled 25 million pounds of its ground beef, the largest meat recall in history, and the plant closed its doors.
• Normally, Escherichia coli bacteria live innocuously in the intestines of people and animals. But the new E. coli strain can cause diseases from standard diarrhea to kidney failure and death. The bacteria still befuddle medical doctors, who have misdiagnosed their infections as everything from appendicitis to blocked blood vessels of the colon.
• Once someone is infected, there is no effective medical treatment to combat the disease, and all doctors can do is prevent dehydration, wait for the disease to run its course, and hope for the best.
• ''I say the 'E' in E. coli stands for evil,'' said Nancy Donley, a Chicago mother whose son, Alexander, died in 1993 from an E. coli O157:H7 infection.
• In just four days, it ''destroyed all of Alex's internal organs and liquefied parts of his brain,'' Mrs. Donley said. It is, she added, ''a terrible, terrible bug.''

The Hunt : At a Meat Plant, The Smoking Gun

• The search for the killer strain of E. coli began when about a dozen people showed up one week in December 1981 in the emergency rooms of White City, a working-class city near the California border. The patients described terrifying symptoms: diarrhea attacks occurring several times an hour accompanied by abdominal cramps that women said were worse than labor pains and men said felt like a hot sheet of metal had been placed on their abdomen. At first, the patients said, they had watery stools, but within hours, their diarrhea looked like pure, bright red blood. And it lasted for days.
• White City doctors tested patients' stools for a long list of bacteria and parasites, but could not find a culprit. It was not even clear whether the disease was caused by an infectious organism, like a bacterium or a virus, or whether it was due to a toxic chemical. Finally, on a cold damp day in February 1982, frustrated officials of the Oregon public health department called in Dr. Lee Riley, who had recently begun work as a medical detective for the Centers for Disease Control and Prevention in Atlanta, and who is now a professor of infectious disease and epidemiology at the University of California at Berkeley.
• Dr. Riley immediately flew to White City. ''We figured that whatever we were dealing with had to be completely new,'' he said.
• The first question Dr. Riley tackled was, What did the patients have in common that their friends, family members and neighbors did not? One clue was that they had eaten at a local McDonald's restaurant.
• Still, the association might have been purely coincidental. And if the source was McDonald's food, it was not certain what item was causing the illness. The hamburgers? Unlikely, Dr. Riley reasoned. The meat patties were cooked at such a high temperature, he said, that ''we couldn't believe that that kind of cooking would allow a microorganism to survive.''
• While Dr. Riley dissected the Oregon cases, the disease struck again, this time in Michigan in May 1982. Again, the patients had just eaten at a McDonald's restaurant.
• At the same time, working on the mystery disease at the disease control centers, Dr. Joy Wells, a microbiologist, noticed something suspicious. Nine of the 12 patients whose stools were obtained at the start of the illness contained a type of E. coli designated O157:H7, a label based on the proteins found on the surface of that strain. When the stool of healthy people was tested for comparison, the strain was absent. But the medical investigators were leery.
• ''We just didn't think E. coli could do something like that,'' Dr. Riley said. It was possible that E. coli O157:H7 was a perfectly harmless bacterium that just happened, by chance, to be in those patients' stools.
• Finally, in July 1982, the investigators found what they needed. A plant in Ohio that had supplied meat to the McDonald's in Traverse City, Mich., had happened, as part of its quality-control program, to have saved ground beef from the suspected lot. Lurking in that meat was the same strain, E. coli O157:H7.
• It turned out, Dr. Riley said, to be the smoking gun.
• But if it was a common strain, it could well have been a coincidence that the E. coli were in the patients' stools and in the hamburger. So Dr. Wells began searching a database of more than 3,000 E. coli samples that had been stored for years at the disease control centers. Only one was E. coli O157:H7. It had been isolated in 1975 from the stool of a 50-year-old California woman who was a naval officer in Oakland at the time.
• ''We tried to track down this patient,'' Dr. Riley said, ''but we couldn't find her.''
• He did, however, get her medical records from the Navy. They showed that the woman had had a bloody diarrhea that was identical to the diarrhea that struck the patients in Oregon and Michigan.
• Until then, said Dr. Patricia Griffin, who is a director of epidemiology research at the disease control centers, the case was shaky.
• ''You could say, 'Maybe that's just a nice bacteria that happens to be in food,' '' she said. But, ''finding that woman in 1975 who had had bloody diarrhea, and who had the same E. coli strain in her stool, that's when you start to get chills.''
• The researchers now knew that there was a new strain of E. coli that could get into food and make people seriously ill.

The Bacteria :   A Virulent Strain Never Seen Before

• Yet a fundamental question remained. How, or why, did these bacteria make people sick?
• A crucial clue came from a seemingly unrelated investigation going on at the same time. Dr. Mohamed Karmali, who is the head of microbiology at the Hospital for Sick Children in Toronto, had been tormented over a mysterious illness. In 1980, in the space of 10 days, 14 children were admitted to his hospital, all with the same symptoms. Their illness began with diarrhea. About a week later, their kidneys failed. Two children died and others were left with severe, permanent damage to their kidneys and bowels.
• Like Dr. Riley, Dr. Karmali and his colleagues asked what these children had in common.
• ''There weren't too many leads,'' Dr. Karmali said. ''We were looking at all sorts of poisons and chemicals.'' One hint, significant mainly in retrospect, was that the children had visited a farmers' market on the outskirts of Toronto and had drunk unpasteurized apple juice.
• ''I was working day and night,'' looking for infectious organisms that could have caused the strange illness, Dr. Karmali recalled. ''Then we had sort of a break,'' he said. An 18-month-old boy died, and the autopsy showed that the boy had E. coli bacteria in his bowel that were making a potent, unidentified toxin.
• Dr. Karmali began looking for the bacteria in the feces of children admitted later with the kidney disease, called hemolytic uremic syndrome, but he could not find them, probably because the children's active diarrhea had already ended.
• So Dr. Karmali searched for the toxin instead. ''To our surprise,'' he said, ''we found the toxin in the stool.''
• Laboratory tests showed that the toxin killed monkey kidney cells and a type of human cell grown for research. That sounded familiar to Dr. Alison O'Brien, a microbiologist at the Uniformed Services University of the Health Sciences in Bethesda, Md., who heard about the research at a scientific meeting. Dr. O'Brien worked with a different bacterium, Shigella, that exudes a toxin with exactly the same properties. It could be, she reasoned, that the E. coli had picked up the gene that causes bacteria to make Shigella toxin. If so, the new E. coli was armed with ''a nasty little toxin,'' she said -- indeed, probably the third most-dangerous bacterial toxin known, after tetanus and botulism.
• Dr. O'Brien examined the rogue E. coli, and sure enough, discovered that it had somehow taken on the Shigella toxin gene. Moreover, in many of the E. coli, that gene was slightly altered in a way that made the bacterium produce toxin even deadlier than the original toxin made by Shigella.
• No one knows exactly how the Shigella toxin genes jumped to E. coli, but Dr. O'Brien has an educated guess. Viruses that infect bacteria can sometimes pick up a gene from one bacterium and carry it to another.
• But if that was the seminal event, Dr. O'Brien said, it probably did not occur in the United States, where Shigella bacteria do not have the dangerous toxin gene. Shigella in Central America do have that gene, however, and in the 1970's, that area was hit with a pandemic of Shigella dysentery. As the Shigella mixed with harmless E. coli in people's intestines, or as it mixed with harmless E. coli that inhabited animal manure, a virus may have carried Shigella toxin genes to E. coli. The result would have been a strain that had never been seen before: the toxin-armed E. coli O157:H7.
• However the toxin does its work -- and scientists still do not know for sure -- the result is that it can injure cells that line blood vessels, plugging them with blood clots. When this happens, the first symptom is bloody diarrhea. But a small proportion of people, especially young children and the elderly, develop hemolytic uremic syndrome, the actual destruction of the kidneys that occurs when blood vessels in these organs are destroyed. The syndrome can lead to kidney failure or can be fatal. Infections with E. coli O157:H7 are now the leading cause of kidney failure in children, the disease control centers says, with at least 1,000 children a year developing kidney failure from these infections, and 3 percent to 5 percent of them dying.
• Older people also tend to develop another complication, thrombotic thrombocytopenic purpura, a sort of leakage of the blood vessels that feed nerve cells. The result is an encephalitis-like disease, with psychosis, comas or seizures.
• The bacteria are surprisingly tough and virulent. For example, said Dr. Marguerite Neill, chief of the division of infectious diseases at Brown University School of Medicine, most bacteria do not produce disease unless a person is exposed to millions of them. But as few as 10 or so E. coli O157:H7 can produce illness -- far too few to see or smell.
• While most bacteria, including botulism bacteria, cannot live in acidic environments, E. coli O157:H7 is undaunted, able to grow in foods like unpasteurized apple cider and commercial mayonnaise.

The Epidemics :   From Dairy Cows To Food Supply

• As researchers studied the organism and its effects, E. coli O157:H7 epidemics kept ticking away, usually going unreported because they were sporadic and few doctors thought to test for E. coli. But some outbreaks were hard to miss. In September 1984, 34 out of 101 people living in a Nebraska nursing home became ill with E. coli infections. They had eaten contaminated hamburgers.
• In October 1988, 32 junior high school students from a school in Minneapolis developed bloody diarrhea from eating contaminated hamburgers in the school cafeteria.
• Nonetheless, said Dr. James Marsden, a professor of meat science at Kansas State University, ''other than among scientists, I don't think it really sank in what a serious issue this was until the Jack in the Box outbreak,'' in 1993, when four children died and hundreds of people became ill.
• Ridding meat of the new E. coli strain became ''the biggest challenge ever to face the industry,'' Dr. Marsden said.
• Public health officials also changed their tack. The disease control centers made a video about E. coli O157:H7 and sent it to public laboratories, suggesting they look for the bacteria. Suddenly, the E. coli were everywhere.
• ''We used to recognize outbreaks every couple of years,'' said Dr. Griffin, the epidemiologist for the centers. ''Now we see 25 to 30 a year.''
• And the list of foods that caused outbreaks keeps growing. ''We look at that list and say, 'Wow,' '' Dr. Griffin said.
• But how, scientists asked, were the E. coli entering the food chain? Because the first outbreaks seemed to be associated with ground beef, scientists looked into cattle and other farm animals.
• Initially, the scientists came up empty handed. In 1982, the Department of Agriculture could not find E. coli O157:H7 in any animals in the country, indicating that the infected cows that contaminated the McDonald's hamburgers must have been rarities. But now, said Dr. Michael Doyle, the director of the University of Georgia Center for Food Safety and Quality Enhancement in Griffin, Ga., as many as 1.5 percent to 5 percent of dairy cows carry the organism. Dairy cows and other cattle seem to be the Typhoid Marys of the epidemics, carrying the bacteria harmlessly in their feces. From there, the bacteria enter the food supply. In modern meat plants, a single contaminated carcass can be ground up with scores of other cows to produce hamburgers.
• E. coli O157:H7 has also gotten into apple cider, possibly because farmers fertilized their crops with cow manure, Dr. Doyle said. It has also gotten into lettuce and alfalfa sprouts.
• Other animals can carry E. coli as well. Dr. Doyle said he helped investigate a case in Oregon where 11 family members got sick after eating venison jerky. The deer had been infected and the E. coli, he said, ''survived the brine process.''
• He added, ''There are reports of kids who went to petting zoos on farms and got sick from petting goats.''
• The outbreaks have pushed the Government into revamping regulation of the food industry. Meat plants are starting to replace the decades-old ''sniff and poke'' system of inspection with high-tech microbial tests. The Clinton Administration is seeking greater power to levy fines and order recalls.
• The Food and Drug Administration recently approved irradiation for meat, a method that can kill E. coli. Non-irradiated hamburger, safety experts say, should be cooked until the inside reaches 160 degrees. They also advise thoroughly washing produce and avoiding raw milk and unpasteurized apple juice.
• ''I really credit the U.S.D.A. and the F.D.A. for new initiatives,'' said Dr. Michael Osterholm, an epidemiologist at the Department of Public Health in Minnesota who in summer 1996 traced an outbreak that sickened scores of children in a Twin Cities day-care center to a cow carcass one child's family had in their freezer. ''But if you gave me all the money in the world, I'm not sure I could keep these bacteria out of the food supply.''
• But that, Dr. Griffin said, is no excuse for complacency from regulators or the food industry.
• ''The bottom line should be, Is it reasonable that if a consumer undercooks a hamburger that their 3-year-old child dies?'' she asked. ''Even if only a small number of children die each year, 50 or 100, I think it galls consumers and that's understandable. They are asking, Can't we have better control of how our food is produced?''

Representatives of the nation's public health service told a Senate committee yesterday that the country was woefully unprepared for a biological terrorist attack and criticized Government spending on biological defense as misguided because so much of it goes to the Pentagon instead of public hospitals and doctors.

Witness after witness described shortages of trained medical personnel, the lack of high-security laboratories in which lethal, highly contagious microbes can be tested and identified, public health clinics with rotary phones and no computers or ready access to disease data banks.

Senator Lauch Faircloth, the North Carolina Republican who chaired the hearing, called the testimony ''frightening,'' a sentiment echoed by his witnesses.

''There's nothing that scares the hell out of me like this issue, Senator,'' said Michael Osterholm, Minnesota's state epidemiologist who spoke for the American Society for Microbiology.

Dr. Osterholm criticized the $300 million recently set aside for the National Guard to set up rapid-response units, which he said would only play a ''minor'' role in responding to an infectious outbreak. ''The public health system has not been brought into any of this,'' he said.

Luther L. Fincher Jr., the fire chief of Charlotte, N.C., where there was a recent bioterrorism threat that turned out to be a false alarm, noted that while the Department of Defense was supposed to leave $300,000 worth of equipment in his district to help combat biological and chemical terrorism after police officers, firefighters and other ''first responders'' are trained this fall, there were no plans for further training.

Ralph D. Morris, the president of the National Association of County and City Health Officials, listed the problems faced by the nation's 3,000 public health officials. About half of all local health departments do not have the use of E-mail, and at least 1,000 of them have no access to any online or Internet service. Seventy percent of the health directors said their staff had little or no expertise in using online services and data. Twenty percent of local health departments still use rotary phones.

''They just cross their fingers that they can reach the right people by phone or that the fax goes through,'' Mr. Morris said.

The witnesses agreed that a biological attack would be different from one involving chemical, nuclear, or other weapons of mass destruction, in that hours, perhaps days might pass before it was known that a target had been attacked.

Donald A. Henderson, the professor at Johns Hopkins University School of Public Health who did not testify but recently urged that smallpox vaccine be produced and stockpiled again, said public health care facilities and personnel were the first line of defense.

''If we are willing to spend $300 million on the National Guard, why not invest a billion dollars in our real first line of defense, our hospitals,'' Mr. Henderson said in an interview.

James M. Hughes, director of the National Center for Infectious Diseases, said that because none of the biological agents considered most likely to be used as weapons are public health problems in the United States, ''we have limited capacity to diagnose them, either at the state, local or Federal level.''

Mr. Hughes also said that while he now had 10 to 12 people studying the plague, no one on his staff was working on anthrax, one of the most attractive agents for terrorists because its highly lethal spores are durable.

1. "Dark Winter": A Bioterrorism Exercise, June 2001

   1. 1. Links to http://wearcam.org/decon/dark_winter_scen_smallpox.htm#darkwinter 

2. Scenario: An Intentional Smallpox Epidemic, February 1999

   1. 1. Links to http://wearcam.org/decon/dark_winter_scen_smallpox.htm#intentional  

3. Scenario: Smallpox Attack on a Shopping Mall

   1. 1. Links to http://wearcam.org/decon/dark_winter_scen_smallpox.htm#livingterrors 

A two-day bioterrorism exercise, code-named "Dark Winter", was held at Andrews Air Force Base, Washington D.C., June 22-23, 2001. Developed and produced by the Center for Strategic and International Studies, Johns Hopkins Center for Civilian Biodefense Studies, and ANSER Institute for Homeland Security. Sponsorship was provided by the McCormick Tribune Foundation and the Oklahoma City National Memorial Institute for the Prevention of Terrorism (MIPT).

"Dark Winter" is a role-playing exercise based on a fictional bioterrorist attack on the U.S. Former senior government officials play the roles of National Security Council (NSC) members, with former Senator Sam Nunn as the U.S. President, former Central Intelligence Agency director R. James Woolsey as the head of CIA, Jerry Hauer as FEMA director, and Dr. Margaret Hamburg as Secretary of Health & Human Services. Medical experts included Dr. Tara O'Toole of Johns Hopkins Center for Civilian Biodefense Studies.

This is a fictional scenario. The background to the story goes like this: six months earlier, the U.S. lifted sanctions against Iraq and ceased enforcement of the "no-fly zones." Since then, Saddam Hussein has aggressively worked to strengthen his military forces, including imports of equipment and material that could be used to produce chemical and biological weapons. Several top scientists from the former Soviet bioweapons program have been recruited to Iraq. Al Daura, a vaccine plant outside Baghdad, closed by U.N. inspectors after the Gulf War, is now back in full production. Officially it manufactures vaccines against Foot & Mouth disease, but western intelligence sources suspect that it's actually weaponizing germs for warfare. 

In the scenario, Iraq has recently moved large military forces into offensive positions near the Kuwaiti border, officially as a part of a routine military exercise. Kuwait, the United Arab Emirates and Bahrain have asked for American, British and France military forces to defend the area against a possible attack. Russia and China oppose Allied troops.

The role-playing begins: as the U.S. National Security Council discusses the Iraq-Kuwait situation, the Centers for Disease Control (CDC) reports one confirmed and twenty suspected cases of smallpox in Oklahoma City. Presumably, this is a bioterrorism attack, with the virus deliberately introduced. 

Emergency rooms in Oklahoma City soon become extremely crowded, while many hospital staff don't show up for work the day after the first case is reported on CNN. The Governor of Oklahoma requests that each and every one of the 3.5 million citizens of the state receive the smallpox vaccine within the next 72 hours. The Oklahoma National Guard is put on alert. The Governor declares a state of emergency, and requests that the President invoke the Stafford Disaster Relief and Emergency Assistance Act. (The Stafford Act provides extra assistance to state and local authorities in catastrophic disasters, and also allows the national government broader powers to respond to the crisis, such as the use of active-duty soldiers.)

The exercise outlines a fictional scenario where Iraq has launched a covert bioterrorism attack with smallpox against shopping malls in three U.S. states — Oklahoma, Pennsylvania and Georgia. Nine days after the presumed exposure there are 20 lab-confirmed and 14 suspected cases in Oklahoma City, 9 suspected cases in Georgia and 7 in Pennsylvania. 

For the purposes of this exercise, the U.S. stock of smallpox vaccine is estimated at 12 million doses. (In reality, the U.S. had stockpiled 15.4 million doses, and recently it was discovered that more than half of the doses had been destroyed, or were of questionable quality. Experts estimate that less than 7 million people could be vaccinated as of 2001.)

In the exercise, the total world supply is estimated at 60 million doses, with half in South Africa. There are concerns that some non-U.S. vaccine may be ineffective, and may also have a higher rate of side effects.

Initially 100,000 doses of vaccine are released for Oklahoma, with the same amounts prepared to be sent to Pennsylvania and Georgia, pending lab confirmation of suspected cases in those states. Because of the limited vaccine stock, the decision is made to minimize the use of vaccine. The only civilians to be vaccinated are close contacts, healthcare personnel and investigators in case states. 2.5 million doses are reserved for the military and the National Guard. 

At the early stages of the outbreak smallpox patients and suspected cases are isolated at hospitals and quarantine centers, but quarantine is not forcibly imposed. With the numbers of cases rising, some states have attempted to keep smallpox patients and contacts in their homes, but it is difficult to supply food and supportive care to those affected. The Department of Justice has received credible claims that individuals with symptoms similar to smallpox have been illegally arrested or locked up in designated "isolation wards." Some otherwise healthy people have been placed in quarantine units without vaccination — together with people who have the disease. 

[ picture was http://wearcam.org/decon/pix/CDCPublDom_SmallpoxVictim2.jpg ]

Man with smallpox. Photo: CDC/NIP/Barbara Rice.

As the scenario progresses, two weeks after the presumed attack there are 2000 cases in 15 states, with 300 deaths. A total of three million doses of smallpox vaccine have been sent to Oklahoma, Pennsylvania and Georgia. Shipments of 500,000 doses delivered to each of 12 affected states. Five days after the first case was diagnosed only 1.25 million doses of vaccine remain. 

TV stations show footage of a mother in tears, pleading for vaccine, while being pushed back by riot police. The National Guard has been called in to suppress violence at vaccination clinics, where angry crowds demand vaccination. Educational institutions, sporting events and other public gatherings have been closed. Some states have closed transportation links, including airports. The Governor of Texas has decided to use his emergency powers to order Texas National Guard Units to assist the State Police in suspending individuals from Oklahoma trying to enter Texas without proof of recent smallpox vaccination. Many countries have closed their borders to unvaccinated travelers from the U.S. The economical impact might result in billions of dollars in international trade losses. Food shortages are reported from some cities. Dangerous misinformation and rumors are spread on the Internet and in other mass media.

A National Security Council committee of medical and public health experts make recommendations on disease containment, including: 

• "mandatory isolation of all smallpox victims in hospitals or preferably dedicated facilities"

• support from the Department of Defense to run "dedicated smallpox treatment centers" 

• voluntary home isolation of people who have been in contact with smallpox cases, with DoD and National Guard staff to provide food and medical monitoring.

• federal travel restrictions

• cancellation all public gatherings in states with smallpox cases

By day six of the crisis, vaccine supplies are dwindling. An additional supply, from the United Kingdom (500,000 doses) and Russia (4 million doses), last for only a couple of days. The NSC develops a plan to use private pharmaceutical facilities in the U.S. to produce about 12 million doses of an unlicensed smallpox vaccine per month. But first delivery would be 5 weeks from the current time.

Near the end of the role-playing exercise, about three weeks after the fictional bioterrorism attack, a second generation of cases begins to appear. During the past 48 hours, the number of cases has skyrocketed with 14,000 new smallpox patients confirmed in 25 states, among them the large population centers of New York, California and Florida. 

Smallpox is an extremely contagious disease. A single case can infect 10 to 20 others, and this can go on for generation after generation (or wave after wave), with a rapidly increasing number of infections at each step. The second generation, outlined in this exercise, would be followed by a third, a fourth and so on. 

The exercise closes with a simulated projection of generations 3 and 4. The participants project 30,000 new cases and 10,000 deaths at the end of generation 2, followed by 300,000 cases two and a half weeks later (end of generation 3), and 3 million cases, with 1 million deaths, an the end of generation 4. 

With a vaccine supply enough to immunize less than 5 percent of the population, the infection rate would continue to increase tenfold every two to three weeks, according to medical experts. Continuing this grim calculation, that would mean 30 million cases, with 10 million deaths in the fifth wave. And then, two to three weeks later, a final wave sweeping the nation and killing off nearly one out of every three Americans. 

Lessons From "Dark Winter"

The "Dark Winter" role-playing exercise brought to light major weaknesses in the U.S. health care system:

• U.S. doctors and nurses have no smallpox experience

• no rapid diagnosis of the disease 

• no treatment available for those infected

• a lack of protective clothing, masks, gloves, and gowns 

• isolation rooms at hospitals for highly contagious smallpox patients is in short supply

• no surge capacity; lack of staff and hospital beds

• the public health system and hospitals get overwhelmed by the enormous increase in patient demand 

• insufficient supply of smallpox vaccine

The exercise also exposed many serious weaknesses in U.S. bioterrorism preparedness. The most serious weakness is probably the insufficient supply of smallpox vaccine. Without a much larger supply of vaccine, the contagion would continue to run its course, until there are no more victims to be found. 

"If there is only one dose of smallpox vaccine for every 23 Americans, whom do you vaccinate?" asked former senator Sam Nunn (D) in a testimony before the House Government Reform Committee, Subcommittee on National Security, Veterans Affairs and International Relations. 

Frank Keating, the governor of Oklahoma, who played himself in the exercise, said "Vaccination cannot stop the spread if you don't have enough of it."

The drill also raises questions about civil liberties in a time of bioterrorism crisis. "Do you seize hotels and convert them to hospitals?," asked Nunn. "Do you close borders and block all travel? What level of force do you use to keep someone sick with smallpox in isolation?"

Another important lesson, echoed by multiple other exercises and studies, is that state and local public health agencies don't have the necessary resources to handle a bioterrorism attack. 

"We have a fragmented and underfunded public health system — at the local, state and federal level — that does not allow us to effectively detect and track disease outbreaks in real time," said Keating.

When it comes to a bioterrorist attack, too much focus has been placed on the military and too little on the public health side, said Tara O'Toole, deputy director of the Johns Hopkins Center for Civilian Biodefense Studies, who portrayed a top federal health official in the exercise.

The CDC has a budget of only $40 million each year to help modernize local public health agencies with bioterrorism training, updated labs and surveillance systems. And while last year Congress backed an increase to $500 million per year, the money has not been approved, said O'Toole. 

The simulation also exposed "fault lines" and "disconnects" between local, state and federal officials, raising serious questions about who would spearhead activities in the event of an attack.

"Our Lack of Preparation is a Real Emergency"

"Dark Winter showed just how unprepared we are to deal with bioterrorism," said Jerome M. Hauer, the former head of emergency management in New York City and now a bioterrorism consultant to Tommy G. Thompson, the secretary of the Department of Health and Human Services. "It pointed out that there were significant challenges to all levels of government." 

"I was honored to play the part of the President in the exercise Dark Winter", said Sam Nunn in his House Committee testimony. 

"You often don't know what you don't know until you've been tested. And it's a lucky thing for the United States that — as the emergency broadcast network used to say: 'this is just a test, this is not a real emergency.' But Mr. Chairman, our lack of preparation is a real emergency."

Visit the Johns Hopkins Center for Civilian Biodefense Studies site to find out much more about "Dark Winter."

Sources: Johns Hopkins Center for Civilian Biodefense Studies; Washington Post, Reuters and Yahoo News/AP, July 24, 2001. 

SCENARIO: An Intentional Smallpox Epidemic

February 16-17, 1999 

A scenario held at the First National Symposium  on Medical and Public Health Response to Bioterrorism [link to http://wearcam.org/decon/links.htm#firstsymp ]  Among the participants; Tara O'Toole, D.A. Henderson, Michael Osterholm and Jerry Hauer.

In this role-playing exercise, the scenario is that a terrorist group with suspected links to a "rough state" (a country unfriendly to the U.S.) makes an aerosol attack with smallpox at a local university in the fictional city of Northeast, during a visit by the vice president. 

Eleven days later two patients visit the university hospital emergency room. Both patients, with flu-like symtoms, are sent home with instructions to drink fluids and take ibuprofen. The next day four more students come to the same emergency room with similar symptoms, and are sent home.

Two weeks after the attack the first patient returns to the ER after collapsing in class. The patient, now acutely ill, has blisters on her face and arms. She's diagnosed with chickenpox and admitted to an isolation room. The following day the second patient, very ill, comes in with similar symptoms. He's also diagnosed as having chickenpox and is assigned to an isolation room. A swab specimen examined by electron microscopy shows an orthopoxvirus consistent with the smallpox virus.

The hospital epidemiologist declares a contagious disease emergency and the two patients are moved to isolation rooms specially designed to control contagion. City and State Health Departments, the the Centers for Disease Control and Prevention (CDC) and the FBI are contacted. The CDC sends a three-person "Epidemic Intelligence Service" team to assist the local health authorities. Biological samples are sent to the CDC's Biosafety Level 4 laboratory in Atlanta, Georgia. The diagnosis of smallpox is confirmed.

The emergency is discussed in conference calls between the CDC, FBI, HHS, the National Security Council, and state health authorities. After considering a full quarantine of Northeast, including shutting down the city airport and banning rail traffic, the group agrees such a step is neither realistic nor necessary. The state health commissioner pushes for enough smallpox vaccine to vaccinate the entire city of Northeast. The CDC and FBI are unwilling to begin mass vaccinations at this stage. Instead, the group decides that all hospital staff and visitors to the floor where the patients are located should be vaccinated, as should other contacts of the patients. The long phone conference ends with a decision to vaccinate all healthcare personnel, first responders, police, and firefighters in any city with confirmed cases of smallpox.

A decision is made to turn the university hospital into a smallpox hospital, accepting new patients and patients from other hospitals. The state health commissioner activates a state disaster plan, which convert the armory into an emergency hospital for the possible quarantine of a larger number of smallpox patients. 

The next day, 35 more cases are diagnosed in the city of Northeast, with 10 addional cases in a nearby state.

Seventeen to eighteen days after the attack, about 30,000 selected individuals are vaccinated in Northeast.

By day 19, the number of confirmed cases have climbed to 50.

By day 20, 80,000 have been vaccinated. 

Three weeks after the attack, a second generation of cases are recognized by the CDC. An additional 300 new cases of potential smallpox are reported, with most of the cases in the original state, but including cases in eight other states. Two cases are reported from Montreal and one case in London.

The U.S. government announces that 90% of available vaccine stocks will be distributed to affected states, but cautions that this stock of vaccine will only be enough to vaccinate about 15% of the population in infected states. Federal officials also announce an accelerated crash vaccine production program that will cut smallpox vaccine production time to two years.

Three days later. There are now more than 700 reported cases worldwide.

During the third generation of the epidemic, days 46 to 59, the vaccine supplies are exhausted. About 7,000 cases will have been reported.

Sixty days after the attack, a fourth generation of cases ensues. Fifteen thousand cases of smallpox will be reported in the United States. The cases are spread over twenty states and four countries. The death rate is 30%.

This is where the scenario ends, with no ending of the outbreak in sight. 

Michael Osterholm, epidemiologist, bioterrorism expert and co-author of the book Living Terrors, about the bioterrorism threat, commented:

"I don't want the audience walking away thinking, 'Damn, there's nothing we can do.' If this meeting does nothing else, it should ensure we get an adequate supply of smallpox vaccine (stored) as soon as possible."

Sources: ERRI Daily Intelligence Report, Vol. 5 — 053, February 22, 1999. Nando Times, Associated Press, February 20-21, 1999. First National Symposium on Bioterrorism:

Smallpox: An Attack Scenario by Tara O'Toole, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.

Scenario: An Intentional Smallpox Epidemic Table Top exercise with D. A. Henderson, John Bartlett, Michael T. Osterholm, Jerome Hauer and others.

Aftermath of a Hypothetical Smallpox Disaster

Jason Bardi, freelance writer. 

Scenario: Smallpox Attack on a Shopping Mall

Michael T. Osterholm, an epidemiologist and bioterrorism expert, and John Schwartz, science reporter at the New York Times, have outlined an anthrax bioterrorism scenario in their book Living Terrors: What America Needs to Know to Survive the Coming Bioterrorist Catastrophe.

In this scenario, the terrorist is a Russian immigrant in the United States, a former scientist from the Soviet Union biowarfare program. Yuri becomes unemployed when President Yeltsin closed a Biopreparat germ factory in Noviosibirsk. (Biopreparat was the name of the former Soviet Union's biowarfare program.) He is approved for a U.S. visa, and leaves Russia with a tiny sample of the smallpox virus, three miniature metal vials hidden inside a fountain pen. He is not afraid to smuggle it into the U.S., because he has already been vaccinated, and because he knows it will be worth an astronomical amount of money.

He is disappointed by his new homeland and has come to hate it. He was angry and lonely even back in the "good old days" in Russia, when he weaponized lethal germs for a living. Now, he is more than just a disappointed researcher. He is ready to commit terrorism.

Yuri makes an attempt to contact Middle Eastern terrorists by approaching an Arab organization in Chicago. They don't seem interested, but one day he finds an anonymous letter slipped under his door. The letter tells him he will soon earn big money. 

A second note follows two days later, with instructions for meeting in a public place. After about an hour the two men have a deal. Yuri promises to get ready to deliver the smallpox virus, with seventy-two hours notice, at a place chosen by his client. The payment for this "little errand" is $50,000, just for starters. 

He uses his small homemade laboratory to grow a smallpox culture in eggs from a local store. At Thanksgiving, he gets another message. This one tells him to deliver his deadly weapon at a large, well-known mall during the first day of Christmas shopping rush. 

Yuri attaches an aerosolizer with a timer to a wall close to an air circulation vent. Half an hour later an invisible, odorless, thin mist of smallpox virus fills the seven-story building and thousands of shoppers will breathe it into their lungs. Many of the 100,000 shoppers who are visiting the mall will become like smallpox weapons themselves, unknowingly spreading the disease to others. 

Nearly two weeks after the attack a large number of patients show up at doctors' offices and emergency rooms in the area. Most of the patients have fever, headaches, backaches and vomiting. But it's flu season, so these patients are diagnosed as such and sent home with the advice to drink fluids and rest. Some of the most severe cases are tested for meningitis and other diseases with flu-like symptoms, but the results are negative and nobody suspects smallpox — an eradicated disease of the past.

A day later, one of the first patients returns to the hospital. He's now seriously ill, is acting delirious, and has red blisters on his face. The doctors suspect chickenpox and the patient is given an isolation room. 

The following day, an infectious disease expert walks through the ER and recognizes the characteristic smallpox rash on many patients. She convinces the city's health director to contact the CDC to raise the alarm. 

The city health department of Chicago learns that many deathly ill patients have been admitted to local hospitals, and that there are at least hundred cases of smallpox in the city. Additional cases are reported from other places in the region. The public reacts with fear when the outbreak is announced, and many families rush to their supermarket to stock up on food and other necessities.

By the next day people are flooding local hospitals, creating a desperate shortage of beds and staff. The Secretary of Health of Human Services suggests the creation of a tent city in the outskirt of town for the growing number of smallpox patients. The health commissioner rejects the proposal, pointing out that there is already a shortage of trained personnel. The governor insists on an immediate airlift of vaccine, but the HHS replies that such a decision is up to the government.

The city's health director suggests a system where smallpox cases are taken to treatment facilities (where no treatment is currently available), and exposed family members are forcibly quarantined at home. The police chief refuses to order his officers to use force-for fear that they may even shoot unarmed civilians who may be infected. The HHS secretary replies that not enforcing quarantine will kill many more people, possibly hundreds of thousands. 

The first wave of smallpox includes nearly 9,000 diagnosed cases in ten states, with 75% in the urban areas. Two weeks later, it's estimated that more than 80,000 people will be infected, with about 60,000 in cities. A third wave, another two weeks later, could infect 300,000 to 1 million people. A third of all smallpox cases will die if they don't receive smallpox vaccine at a very early stage of the disease. 

The scenario continues with the authors describing how things are starting to fall apart in the city. Power is out in some neighborhoods, and broken water and sewer pipes aren't fixed because people are not going to work. Beef sales from the area have plummeted because people in other parts of the country fear that the meat supply might be contaminated with smallpox.

A small supply of vaccine has been sent to the city. Because of an extreme shortage of smallpox vaccine, this supply is for use by healthcare workers only. 

The authors tell the story of one character that avoids quarantine in a treatment facility — where he knows he will be infected. He is shot to death while trying to escape the city because he doesn't want to be quarantined. 

The scenario ends with an outline of a successful response to a smallpox outbreak in nearby Milwaukee. Here, public health officials, medical professionals and others are better prepared to handle such a crisis. The number of cases in Milwaukee levels off at 5,000, with 1,300 deaths. In Chicago, there are already 140,000 deaths, and no end of the epidemic in sight. 

Osterholm and Schwartz deliver many important insights into how a smallpox outbreak might be contained. The most important is probably this one: " Smallpox is like a fire — the quicker a fire wall can be built, the better." Another insight, closely related: we need to produce and stockpile larger quantities of the smallpox vaccine.

Source: What America Needs to Know to Survive the Coming Bioterrorist Catastrophe, by Michael T. Osterholm, John Schwartz, Delacorte Press, 2000.

Public health officials across the country were buffeted by calls yesterday from jittery people afraid that they might have been exposed to deadly anthrax bacteria.

The anthrax scares, none of which turned up evidence of the bacteria, were part of a wave of concern as Americans nervously reacted to the news that workers in an office building in Boca Raton, Fla., had been exposed to anthrax, and federal agents tried to determine whether the incident was an act of bioterrorism.

The calls from jittery citizens have been most intense in Florida, where a photo editor at The Sun newspaper in Boca Raton died of anthrax last Friday, and two co-workers have been exposed to anthrax spores.

Florida officials have received more than 100 calls about suspicious substances, none of which turned out to be hazardous.

But with public concern running high and members of Osama bin Laden's Al Qaeda organization vowing to carry out more terror attacks on American soil, local law enforcement and public health officials have been treating most reports as potential emergencies.

After answering 19 calls on Monday, Miami police were running low on disposable protective jump suits they use for every call involving potentially hazardous material.

Similar incidents have been reported across the country.

In New Jersey, two office buildings in downtown Trenton were evacuated yesterday after occupants reported opening packages containing a white, powdery substance that they feared might be anthrax, state officials said. Tests revealed that the powder was harmless.

In Watertown Center, N.Y., near the Canadian border, employees and patients at a physician's office were evacuated after a white substance was found there.

A small office building in Darien, Conn., was also evacuated yesterday after a powdery substance was found on a desk. In Covington, Ky., the authorities sealed off part of an Internal Revenue Service processing center on Monday and quarantined 200 people after an employee opened an envelope containing an unidentified white powder.

In Honolulu, a supermarket and a Mormon tabernacle were evacuated yesterday after at least seven people were exposed to a powdery substance found in a garbage bin.

Law enforcement officials said they have also been getting an increased number of calls about suspicious packages, and bomb threats.

Two crossings on the United States-Canadian border were closed yesterday -- one north of Burlington, Vt., the other in Champlain, N.Y. -- after they received bomb threats.

Officials at Bloomsburg University, in Bloomsburg, Pa., evacuated their campus Tuesday after receiving bomb threats and decided to remain closed for the rest of the week.

A university spokesman, Jim Hollister, said school officials made their decision after the police convinced them that the threats were credible.

''If a decision seems extreme and leans to that side, we feel a lot better about it than the other way,'' Mr. Hollister said.

At both of the incidents in Trenton, one at the former Trenton Trust building, a block from the State House, and the other in a state office building, local officials responded by sending an array of fire trucks, police cars, ambulances and hazardous material crews.

Ralph Persico, director of emergency management for Mercer County, said the hazardous materials response team determined that the suspicious substance found in the Trenton Trust building appeared to be excess dried glue used to seal the envelope.

John R. Hagerty, a spokesman for the New Jersey State Police, said that officials from the state's Department of Environmental Protection tested the powdery material at the other building, and determined that it was ''inert and did not pose any type of public safety threat.''

Experts in biological terrorism, who say the likelihood of an attack is extremely slim, warned that local authorities might be fueling a sense of hysteria by responding to the scares with sirens, flashing red lights, crime-scene tape and technicians donning hooded protective jump suits.

''There's no need for any of that,'' said Michael Osterholm, director of the University of Minnesota's Center for Infectious Disease Research and Policy. ''Even if there were real anthrax spores in an envelope and the envelope were open,'' he said, ''this is not going to spread throughout the building, unless the envelope is shaken or moved or dropped.''

• JOE PALCA, host:   This is TALK OF THE NATION: SCIENCE FRIDAY from NPR News. I'm Joe Palca. Ira Flatow is away. Diseases such as avian influenza, Ebola and SARS have been showing up more often, but health officials may not be looking in the right places to spot the next outbreak of one of these emerging infectious diseases. That's the finding of an international team of researchers writing this week in the journal, Nature. The scientists looked at data collected over decades from hundreds of different disease outbreaks and mapped out likely hot spots where new outbreaks were most likely to occur. The team found that the developing world contains many of these hot spots. They're especially common in areas where humans and animals come in very close contact. Joining me now to talk about the work is one of the authors of the paper, Peter Daszak, he's executive director of the Consortium for Conservation Medicine at the Wildlife Trust here in New York, but he joins me today from the campus of UCLA in Los Angeles. Welcome back to the program, Dr. Daszak.
• Dr. PETER DASZAK (Executive Director, Consortium for Conservation Medicine, Wildlife Trust, New York): Hi. Great to be here.
• PALCA: Great to have you. And also joining us is Michael Osterholm. He's director of the Center for Infectious Disease Research and Policy at - professor in the School of Public Health and an adjunct professor in the Medical School at the University of Minnesota. Welcome back to the program, Dr. Osterholm.
• Dr. MICHAEL OSTERHOLM (Director, Center for Infectious Disease Research and Policy; Professor, School of Public Health; Adjunct professor, Medical School of the University of Minnesota): Thank you, Joe.
• PALCA: And if you want to join us, give us a call. Our number is 800-989-8255. That's 800-989-TALK. If you want more information about what we'll be talking about this hour, go to our Web site at www.ScienceFriday.com where you'll find links to our topic. And you can also find us in Second Life on the SCIENCE FRIDAY island. So, Dr. Daszak, can you give me a little background on what you were looking at - how did you go about looking for these hot spots and was that the main thrust of this work?
• Dr. DASZAK: Well it's the sort of the holy grail of emerging diseases to be able to say, where is the next HIV or SARS going to emerge from. And, you know, predicting things is what we all ultimately would like to do, and it's very hard to do. So what we're trying to do is to get as good as we could get - close as we could get to that predictive approach. We made a list of every known emerging disease of people for the last 40-50 years, build this into a database and spent a couple of years trying to target - as good as we could get it - the point origin of each of those diseases. And then we created a statistical model where we tested various factors that are known to drive emergence, things like human population growth and wildlife diversity and whereabouts on the planet where latitude - rainfall. And just to see what correlates with emergence. But I think the most important thing we did is we corrected for the number of people working on diseases because if you just go on what's known, you end up tracking where scientists are working…
• PALCA: Yeah.
• Dr. DASZAK: …rather than where disease really emerged.
• Dr. OSTERHOLM: Right.
• Dr. DASZAK: So, once we did all that, we found a couple of - in the form of points. First, that, you know, this isn't hyped. These diseases really are on the raise. And it's statistically proven now that over time, over the last 60 years, there's been a significant rise in the number of emerging diseases every decade corrected for the number of scientist increasing every decade. And also a couple of important groups of diseases to watch out for despite a lot of people focusing on the exciting diseases like Ebola and SARS, which I'll talk about in a minute, and drug-resistant microbes are very significant threat to global health and representing about 20 percent of the diseases that have emerged over the past 60 years. And finally the really high impact diseases tend to be zoonotic diseases that emerge from wildlife like HIV did, like SARS did.
• PALCA: Zoonotic is the disease that starts off in animals and then somehow jumps to the human population.
• Dr. DASZAK: Yeah, that's right. And these diseases often come from very bizarre routes like with SARS, the wildlife trade, and ultimately they probably originated in bats.
• PALCA: Mm-hmm.
• Dr. DASZAK: So can we predict anything by that? Well, yes. Once you create the statistical model, you can plot that on the map where the most likely origin of the next zoonosis is and it tends to be in the very high diversity areas of the tropics where there's lot of wildlife diversity and therefore a lot of potential new pathogens that wildlife carry. The more wildlife you have in the region, the more likely unknown pathogens are out waiting to emerge. And in those areas where humans are encroaching and populations are growing and clashing with wildlife there and especially where they exploit wildlife for food and for habitat, that's where we're going to see the next emerging diseases.
• PALCA: Right. And so I guess the next question that springs to mind is, well, if the numbers are going up and it's not just because we're looking better, why?
• Dr. DASZAK: Well, that's a very important question and it seems to me that what our paper really says is that emerging diseases are driven by us. It's the things we do to the environment, to livestock production, in wildlife trade and in our own demography, the way we grow our populations and move out into new areas that drive emergence. And I think that, you know, this isn't a dim and gloomy message. What we're really saying is that we need to slightly change the way we're looking at emerging diseases and really take them on board as a cost of doing business, globally. And it's a bit like, you know, whenever we think we're going to do something to the environment, we have an environmental impact assessment or maybe we also need a sort of emerging disease impact assessment and just look at what potential that would have to cause a disease to emerge and just modify the way we do things slightly.
• PALCA: Okay. Mike Osterholm, what's - you know, you've worked in public health as a state official and now you're in academics. What's the importance of having this information? What does it do for you?
• Dr. OSTERHOLM: Well, first of all, it helps to let the population know that what has happened is just a snapshot of what will happen in the future and that's important because we obviously need to continue to not only detect these infections early, but also do the research that goes with it and that takes resources. And we often - in government, in academia, live by biennial budgets of state and federal agencies. And so that it's not unusual, for example, just this past year - in fact, the past month, we just had $750 million cut out of our funds needed for pandemic influenza work because of a veto by the White House. One of the points that this makes is that in fact we have to be prepared for the future because more of these illnesses are going to occur and we can't stop working on them.
• PALCA: But is there - I mean, does this paper give you any idea of maybe doing a better job of detecting them so that you don't have to worry quite so much about dealing with them if they get here?
• Dr. OSTERHOLM: Well, I think, first of all, Peter's paper which was a very thoughtful approach at looking at emerging infectious diseases, I think, does give us a sense where you might want to look. But I think also we have some new developments in the last 10 years that were not really reflected in the data of emerging infections of 20 and 30 years ago. Today, with the world of the Internet and the ability to communicate, we're finding out about these outbreaks of new emerging illnesses much quicker than we ever did before. Even in developing world countries, in the central jungles of the world, we're hearing much more about it. If avian influenza, as we now know it, was occurring 25 years ago. Much of what whas happening in Asia would be unknown to us. Today, we're finding out about it often within hours.
• PALCA: Yeah.
• Dr. OSTERHOLM: So I think we are doing a better job today at finding these. But I think the point that you raised, Joe, is what can we do about it. And as Peter has pointed out, you know, this is a complex issue. And when you have the number of people we have today on the face of the earth, 6.5 billion, one out of every nine people who has ever lived since the caves is now on the face of the earth. If you look at all the production animals we have: the cattle, the pigs, the poultry - to feed that population and then you mix that with our ever increasing encroachment on other land areas. We're cutting into the rainforest and so forth, there isn't a lot we can do in a sense of we're just going to interface these infections more and more frequently. The best we can hope for is once they start to get into the human population to try to control them or limit them as we can. And I think that's going to be an important issue. The final piece I would just say is one of the other inevitable problems we have is that as the late Josh Lederberg once said, the famous Nobel Prize winner, who actually was one of the ones who coined the term "emerging infections," said the bugs were here before us, they're going to be here while we're here and they're going to be here after we're here. And antibiotic resistance fits into that pattern of what Dr. Lederberg was talking about as we have microbial evolution, every 20 to 30 minutes, a new generation. And as we have used antibiotics over the past 20 to 50 years, we obviously have challenged through evolutionary pressures these microbes. And we're only going to see more of the drug-resistant infections that Peter talked about over the next 20 or 30 years and again we're all worried about that and trying to do what we can to minimize that, but that's inevitable with evolution.
• PALCA: All right, let's go and listen to some of what our - what some of the listeners have to say about this and let's go first to Daniel(ph). Is it Rice Lake, Wisconsin?
• DANIEL (Caller): Yeah.
• PALCA: Welcome to the program.
• DANIEL: Hello. Should we expect one of the consequences of global warming to be the spread of diseases into other regions, like malaria, once again endemic in the Mississippi Valley?
• PALCA: Ah, interesting. Peter Daszak, what about that?
• Thank you Daniel.
• Dr. DASZAK: Yeah. You know, that's really the next stage in our research is what will happen when things like, you know, future trends in global warming and population growth. How will that change the dynamics of the hot spots? I think we will see infections moving into new areas. We'll see vectors that the insects that carry those infections moving into new areas. I think most people - most scientist agree with that. But I don't think places like the Mississippi Delta are going to see very large significant outbreaks because, you know, we are in a country that can afford air-conditioning and, you know, nets on the windows. And we can afford anti-malarial drugs. I think that climate change spells problems ahead for a lot of other countries that can't afford those treatments. And you know, and I think that they're all messages to - with this sort of approach, we can target a little bit better the limited resources we've got to maybe get ahead of the curve on the countries that are going to be suffering from that.
• Dr. OSTERHOLM: Now if I can add to that, I think…
• PALCA: Sure.
• Dr. OSTERHOLM: …an important consideration is the fact that none of us yet know what climate change is really going to do in terms of temperature or precipitation and available water. There are a number of different models out so there's no doubt that the world will warm, and it will warm significantly. But, for example, one of the most recent NASA models actually shows potential reversal of the Gulf Stream, such that instead of warm water coming up through the Caribbean and up along the northeastern part of the United States, it may reverse it because of the melting of the Artic ice cap. If that were the case, the United States may actually cool down and other parts of the world will warm up dramatically. So one of the things that we need to do is constantly be at the top of our game with surveillance, of understanding where are these climate changes taking us, and what is happening. What is happening with precipitation? What's happening with people movement? What's happening with food supplies, meaning where are we growing food? Where are cattle at? That's going to help us predict where to look for these new emerging infections that Peter just talked about. And that's not clear yet. This is going to take a lot of work for us to stay on top of this one.
• PALCA: Okay. Well, we're going to have to leave it there for a few minutes because we got to take a short break. We're talking with Peter Daszak, the director of the - executive director of the Consortium for Conservation Medicine at the Wildlife Trust; and Mike Osterholm, he's the director for Infectious Disease Research and Policy at the University of Minnesota. And we're going to take a short break and continue our discussion about where and when and how much emerging infectious diseases are going to affect us in the coming decades, and hopefully we'll be around to face them, I guess, is the main thing, so stay with us, we'll be right back.

[...]

• PALCA: From NPR News, this is TALK OF THE NATION: SCIENCE FRIDAY. I'm Joe Palca. We're talking this hour about emerging infectious diseases around the world. My guest are Peter Daszak, he's executive director of the Consortium for Conservation Medicine at the Wildlife Trust in New York; and Mike Osterholm, he's director of the Center for Infectious Disease Research and Policy, a professor in the School of Public Health and an adjunct professor in the Medical School at the University of Minnesota. And you can call us - our telephone number is 800-989-8255. That's 800-989-TALK. And let's take another call now and let's go to Ray(ph) in Phoenix, Arizona. Ray, welcome to SCIENCE FRIDAY.
• RAY (Caller): Yes. Thank you very much for taking my call.
• PALCA: Sure.
• RAY: My question has to do with the household pets. We have a dog and a cat and we don't let the dog come to our bedroom very muc,h but the cat seems to have a free pass all over our faces and everything at night. And I'm concerned - how does this - household pets, in general, impact this transmission of infectious diseases to human, and I'll take my answer off the phone. Thank you.
• PALCA: Okay, Ray. Thanks.  Mike Osterholm, maybe.
• Dr. OSTERHOLM: Well, first of all, today, all of us would tell you that companion animals are one of the best things that we can talk about in society in terms of all of the positive and sociologic benefits, so it has to be kept in mind that this is a very positive thing.
• Having said that, of course, they do represent a potential avenue for new diseases getting to humans. And when you say new diseases, one of the things where you think about today, for example, is where are your pets get their food supply from. Only this past year did we understand that there was a certain chemical that was in the dog food supply that came from China, that in this case, was not something that humans had to worry about, but there was this very complex and complicated route in which this contamination got into the dog food supply, originating from China.
• Today, infectious agents can be in the same way and we're working up an increasing number of outbreaks of illness where the food may have been contaminated for that pet that you bought at a pet store and therefore could transmit that onto humans.
• In addition, where there are pets, you also have a potential for tick factors, meaning, ticks may come onboard your pet into your household and in some locations, that can also play a role. So in general, this is not a major source of infections to individuals, particularly in North America. Other parts of the world, one last illness is of great importance as we still have major concerns about rabies in many parts of the world.
• I just came back from Thailand and worked over there. And on an average year, up to 400 people in Thailand die from rabies as a result of dog bites. So that there's still those concerns that we deal with, but fortunately, we've not had any new and major exotic emerging infectious diseases per se come from the typical companion animals.
• Now the question though that I think really is one that should be addressed here - and I think Peter would agree with this - is we're seeing an increasing trade in exotic wild animals that become pets. And as a result, we are seeing other serious infectious diseases issues, emerging infections, from those Gambian rats that come from Africa or from raccoon dogs which are actually a rodent that come from China. And so that anyone buying a non-traditional companion animal like a dog and a cat, need to be very aware that there is a real risk of any number of infectious diseases. And we have a very limited handle on that problem right now as the trade in exotic animals has grown dramatically over the past two decades.
• PALCA: Gambian rat, wow, okay.
• Let's take another caller now and go to Ronald(ph) in Manahawkin, New Jersey.
• Ronald, welcome to SCIENCE FRIDAY.
• RONALD (Caller): Well, thank you. Thank you for having me. My question is what are you doing about the airports and people are taking off their shoes especially in the summertime and their feet - people have them shoes - they're all kind of - I have contracted athlete's feet that way myself. I've contacted congressmen, Homeland Security, the Center for Disease Control, newspapers and health departments. I've been working on this for four years - everybody ignores me.
• PALCA: Well, it's an interesting point, Ronald. Let me ask Peter Daszak. I mean, how big of a part does air travel play in spreading these diseases around the globe.
• Dr. DASZAK: Well, you know, I mean, athlete's foot is not an associative(ph) disease as some of the things we've been talking about and although it is a nuisance, air travel does, however, play a major role in driving disease emergence. It's not really that air travel is where diseases originate, but it's a great way for diseases to spread around. And either through humans that are infected get on an airplane in one region and spreading a pathogen to a completely new part of the world; or in the trade, as Michael said, the trade in wildlife which is growing every year. Now there are dates on the global trade - global and travel, and they show pretty clearly this rising, despite the fuel costs, and it's predicted to continue to rise and in some places more than others. So I think what this does is it makes those more at risk of a pandemic from one of these emerging diseases. What our paper really talks about is where disease will originate. Some of those diseases won't really go very far because the conditions aren't right for them to move out of that region, but when you get increased air travel, you start to project an increase in the number of pandemics that can emerge. And again, it provides a way to target a bit better, so we really should be looking seriously at the trade in wildlife. And there are very little mandated surveillance on wildlife trade even into the U.S., and even for mammals which we know carry a lot of potentially lethal pathogens. And it's not even the known. It's the unknown that trade has a potential to carry. So I think that the two aspects of air travel are pretty important for the global spread of disease. But don't worry too much about athlete's foot.
• PALCA: Thank you. It's good to maintain perspective here. We have a question from Second Life, from Bauer(ph) who says, who asks, how does the accessibility or lack of access to health care in developing regions affect the spread of diseases to the developed nations. Mike Osterholm, any thoughts on that?
• Dr. OSTERHOLM: Well, clearly, the ability of a disease to become an emerging infection means that it's relatively new in humans, and so just the ability to get health care in and of itself doesn't mean that the emerging infectious diseases are going to occur. So as we've talking about on this call, in the show here, most of the diseases that we're seeing of recent years have had a wild animal or an animal reservoir there. What happens, however, is once that disease does make the cross between the animal to human species barrier, now it is in humans and, of course, that can be a problem in and of itself in that local area. But the ability to get out of that native population of the developing world, is in part related to, first of all, how is the agent transmitted, is it respiratory, is it blood borne, is it only in stool, how we transmit it. The second thing is how frequently they have contact with the outside world and what does that mean in terms of - like SARS, for example. One infected physician from China stayed at a hotel one night in Hong Kong and infected a number of people that it took to three continents within days. And that was merely just being on the same floor of the hotel he was in because the air was contaminated. So that it's not directly related to the health care per se, but it surely does impact at the local area. If a new disease should happen there, how much can it be transmitted? One example of when we were always concerned about while it gets a lot of publicity, obviously, it's not a major public health problem, but Ebola virus, is a virus that actually is transmitted via the blood-borne route. We think today that certain subhuman primates or monkeys and even bats may play a role in getting it to humans. But in the African experience, the way the big problem unfolds is in hospitals because they have one syringe or two syringes. They have two pairs of gloves and that's it. And once you have one person come in with it and they get blood contamination on these, it spreads quickly to the rest of the hospital. Those we can contain quickly, that's poor health care, but we can contain them once we know about that. But in general, I'd say it's not really just a function of the health care per se that makes the exotic new emerging infection flame up and spread to the rest of the world.
• PALCA: I think we have time for one more quick call on this topic, so let's go to Shelley(ph) in Antrim, New Hampshire. Shelley, welcome to SCIENCE FRIDAY.
• SHELLEY (Caller): Hi. Thank you.
• PALCA: You're welcome.
• SHELLEY: I was a little bit interested in how you feel about the limited resources using it more for prevention rather than constantly sticking fingers in the dike and stop - trying to stop this disease or that disease, educate the medical profession to stop using blood spectrum in antibiotics, breeding super resistant microbes, which you've already said account for 20 percent of emerging diseases, focus on not polluting our bodies and environment either with pollutants or stress which suppresses our immune systems and to - rather than everybody focusing on this disease or that disease, deal with our dysfunctional culture. I know it's a big thing to ask.
• PALCA: Right. It's a lot to ask, Shelley…
• SHELLEY: I know. I know…
• PALCA: …but let me get Mike Osterholm…
• SHELLEY: And as for a sociological - for animals - they have more than a sociological function, they have a physiological impact…
• PALCA: Exactly.
• SHELLEY: …helping to reduce stress, so whatever they might carry, I think is more than they'd hope for in the positive impact they have in helping our bodies to be strong enough to deal with diseases and fight them off…
• PALCA: Excellent question. Hold on. Go ahead, Peter Daszak.
• Dr. DASZAK: That depends on what you actually do with wildlife. I mean, if you trade wildlife in very dense market places and then chop them up and eat them, and you run a risk of getting infected and I don't think - I think what our paper is saying are two things. One is that exploiting wildlife and moving into other habitat has a risk attached to it of catching some pathogens that they carry. So that's a poster(ph) message because conservation efforts to protect those wildlife may also reduce the risk of emerging diseases. Secondly, you know, the misallocation of resources is really what - if you - I agree to with you're saying essentially that we shouldn't - too often we rely on technological fixes, vaccines and drugs, and we expect that they will be available to solve our problem when it emerges. And all our paper's trying to do is to provide a way of just getting ahead of the curve a little bit and just saying let's use some of those resources that would otherwise wait to be used when the disease is emerging. Let's try and prevent it emerging in the first place. Let's increase our surveillance on things like respiratory infections, encephalitis in developing countries that look like they could be from wildlife. Let's try to investigate those averages a bit more efficiently, working with local governments. And let's try and protect wildlife areas a little bit better and let's try and just get ahead of that curve slightly.
• PALCA: Okay. Well, I'm afraid that's where we're going to have to leave it. Gentlemen, thank you both very much.
• Dr. DASZAK: My pleasure.
• Dr. OSTERHOLM: Thank you.
• PALCA: Okay. That was Peter Daszak and Mike Osterholm. Peter Daszak is the executive director of the Consortium for Conservation Medicine at the Wildlife Trust here in New York, but he joined us from L.A. in the campus of UCLA; and Mike Osterholm is the director of the Center for Infectious Disease Research and Policy, professor at the Public School of Public Health and an adjunct professor in the Medical School at the University of Minnesota.

Every time there is a major infectious disease outbreak that scares us — Ebola in West Africa in 2014, Middle East Respiratory Syndrome (MERS) on the Arabian Peninsula in 2012 and in South Korea in 2015, and now the Zika virus in South and Central America and the Caribbean — government leaders, the public and the news media demand explanations, guidance and predictions, and often express indignation that not enough was done to prevent it. Today everyone is asking about Zika: How did this crisis happen, and what do we need to do to make it go away? We immediately forget about the outbreak that came before it, and don’t plan for the ones we know are on the horizon. Almost no one wants to talk about Ebola or MERS now, or what we have or haven’t done to try to prevent an ugly recurrence.

When it comes to diseases, we have a very short attention span, and we tend to be reactive, rather than proactive. Instead of devoting ourselves to a comprehensive plan to combat microbial threats, we scramble to respond to the latest one in the headlines. There are lessons from previous infectious disease outbreaks that could and should have left us much better prepared than we are.

First, the mosquito that transmits this disease, the species Aedes aegypti, has never been more numerous or lived in more locations. Think of Aedes aegypti as the Norway rat of mosquitoes; it has evolved to live in close quarters with humans, and the trash that humans create. This is quite different from most other species of mosquitoes, like the ones that transmit West Nile virus, which tend to lay their eggs in marshes, rice fields, ditches, the edges of streams and small, temporary rain pools.

The world has changed dramatically in the past 40 years with regard to increasing the habitat for Aedes aegypti breeding. An explosion of plastic and rubber solid waste now litters virtually all parts of the globe, particularly in the developing world. Non-biodegradable containers, used tires and discarded plastic bags and wrappers — whether in the backyard, a roadside ditch or an abandoned lot — make ideal habitats for these mosquitoes to lay their eggs. All they need is a little rainfall.

This species is currently present in 12 states in the United States, mostly in the Southeast. But its close cousin, Aedes albopictus, known as the Asian tiger mosquito, came to the United States in the 1980s and is now in some 30 states, including the entire Eastern Seaboard up to New York City. For now, fortunately, this species does not appear to be a significant factor in the transmission of Zika to humans. What we in North America have to worry about is whether the Asian tiger mosquito can become a more effective transmitter of the virus to humans. If that happened, we would face a very serious risk of an outbreak here.

One of the solutions to this problem is called “vector control.” It involves both eliminating the places where these mosquitoes breed, or chemically treating those sites, and spraying chemical insecticides to kill adult mosquitoes, or at least keep them away from where humans live, work and play. We must clean up the garbage to have any hope of reducing Zika infections in humans.

From the 1950s through the 1970s, there was a major initiative to eradicate Aedes aegypti from the Americas by public health organizations, nonprofits and national governments. It almost succeeded. In part, that was because eliminating these mosquitoes’ breeding sites was much simpler before the spread of plastic and rubber waste. But governments and nonprofit agencies decided too early that the job had been done, and dismantled these programs to save money. Now the mosquito is back.

This is not new science or new policy. Now we’ve got an outbreak on our hands, and although the symptoms of Zika itself are absent to mild for most, for some there can be devastating consequences to infection. An increasing number of infected women have given birth to babies with microcephaly, which causes small heads and brain damage. We’re learning that Zika can lead to Guillain-Barré syndrome, a dangerous autoimmune disorder that can cause paralysis. Some believe we need more scientific data to confirm these more severe manifestations. I don’t agree; I believe the evidence is already compelling.

We shouldn’t have needed thousands of babies born with severe birth defects or people of all ages developing life-threatening autoimmune paralysis to remind us that mosquitoes pose a serious health threat. Dengue viruses, which are also transmitted by these two mosquito species, caused 2.3 million cases of dengue fever and far more serious dengue hemorrhagic fever in 2013 in the same countries in the Americas that have been, or will be, affected by Zika. These included more than 37,000 severe illnesses and 1,300 deaths. And yet these numbers hardly raised an eyebrow in the United States. If we had paid more attention then, we might be more prepared now.

Zika is here to stay in the Western Hemisphere; it will be part of life for many years to come. Even if we make vector control efforts a major initiative, it will only reduce, but not eliminate, the risk of Zika. What we need next, urgently, is a vaccine.

Some critics are suggesting that such vaccine research for Zika should have been done years ago, but this isn’t entirely fair. It was only in the past two years that there was any indication this virus could cause serious human disease. Now we have to catch up. But it’s going to be complicated. If Guillain-Barré syndrome is indeed caused by the patient’s immune response to the virus, as happens with other infectious diseases, could the vaccine itself put us at risk? This will take careful research to determine. And it will take time.

The point is, we should have anticipated that the large increase in mosquitoes would create a major health crisis. Just as we should have anticipated that a deadly hemorrhagic disease caused by the Ebola virus would emerge one day from the remote forests and threaten the vast slums of the rapidly growing megacities of Africa. We should now anticipate that the MERS virus will result in more deadly outbreaks outside of the Arabian Peninsula, as it did in Seoul, South Korea. We should anticipate that viruses such as Venezuelan equine encephalitis may spread from their jungle homes and be even more deadly than Zika.

Even more than these viruses, we should be afraid of a planet-wide catastrophe caused by influenza. The best way to avert a pandemic is to develop a game-changing universal influenza vaccine. All these crises are largely predictable and we can do much in advance to lessen the effects and diminish the spread. And believe me, the cost of acting now will be infinitely less than the cost of not acting in the long run.

In a small, first-floor office on the University of Minnesota campus, Jill DeBoer plans for worst-case scenarios.  DeBoer, the director of the Academic Health Center’s Office of Emergency Response, has bookshelves holding binders filled with detailed response plans — “playbooks” — for every disease that has been a threat to students since the team organized in 2004. 

DeBoer said similar groups formed nationwide after the anthrax attacks following 9/11, but those groups have shifted in recent years to prepare for more than bioterrorism — be it a case of meningitis on campus, a bridge collapse or something that hasn’t yet been seen. 

The AHC-OER is now forming a Zika virus playbook, DeBoer said. The team has sent information and travel warnings to all University students studying in affected countries. 

“The first partner we call is the GPS Alliance because often these infectious disease issues start off in other countries, and so with H1N1, with Ebola, with Zika, that’s our first call,” DeBoer said.

There’s a specially tailored response team for every scenario, she said. The size of the team varies with the scope of the threat, ranging from a handful of people to more than 50. Each team member has two backups.

DeBoer said the AHC-OER works with the Minnesota Department of Health — which has its own emergency team — and monitors the spread of diseases around the world.    “We have to be prepared for anything,” she said. “I feel our response system should be able to coordinate and respond to almost anything.”

School of Public Health and Medical School professor [Dr. Michael Thomas Osterholm (born 1953)], who is also the director of the University’s Center for Infectious Disease Research and Policy, addressed global infectious disease preparedness in a lecture last week. 

“The next pandemic is going to happen,” he said at the talk. “It could happen tomorrow; it could be happening today.”

[Dr. Michael Thomas Osterholm (born 1953)] said no group is ready for the next pandemic because global systems are disjointed and broken.   “There are so many holes in this ship,” he said at the lecture. “Even if we bail it out as much as we can with all our strength, we might still be sinking.”

[Dr. Michael Thomas Osterholm (born 1953)] said influenza is the biggest threat, and when — not if — an outbreak happens in Minnesota, there won’t be enough vaccines to go around, he said.  “Today, many of our key drug producers are offshore. If we have a pandemic that interrupts travel and trade, that will be a challenge,” he said. “I don’t care how prepared you are at a state level, if you have a vaccine or not makes all the difference.”

University biochemistry junior Melanie Raphael attended the lecture and said she was worried that people know too little about the importance of vaccines.

She said college students lack awareness of diseases that threaten other parts of the world.  “It took me a while to even hear about [the Zika virus],” Raphael said. “Here in college, we are kind of isolated from the rest of the world.” 

Infectious diseases can come to the U.S. from other parts of the world through travel, like what’s happened with the Zika virus, said MDH infectious disease epidemiologist Richard Danila.     “We are always on the lookout for the next big event, whether that’s an influenza virus or a pandemic like Zika,” he said.

When a new disease makes headlines, it’s hard for scientists to prevent misinformation in the media, Danila said. 

MDH strategically shares information with Minnesotans to control panic due to bad information, said Cheryl Petersen-Kroeber, deputy director of MDH Emergency Preparedness and Response.   “Epidemiologists base their decisions on the science they have at the time,” Petersen-Kroeber said. “Sometimes it’s hard because the science is always changing.”

While the Trump administration is proposing significantly increased military spending to enhance our national security, it seems to have lost sight of the greatest national security threat of all: our fight against infectious disease.

We already spend far more on our military than any other country in the world. To help pay for the increases, President Trump wants to cut back many federal programs, including those that prepare us to wage war against microbes, the greatest and most lethal enemy we are ever likely to face. This is where “defense spending” needs to increase, significantly.

President Trump’s budget would cut funding for the National Institutes of Health by 18 percent. It would cut the State Department and the United States Agency for International Development, a key vehicle for preventing and responding to outbreaks before they reach our shores, by 28 percent. And the repeal of the Affordable Care Act would kill the billion-dollar Prevention and Public Health Fund, which provides funding for the Centers for Disease Control and Prevention to fight outbreaks of infectious disease. (While the budget also calls for the creation of an emergency fund to respond to outbreaks, there is no indication that it would offset the other cuts, or where the money would come from.)

Those cuts will not protect American citizens. They will diminish research and vaccine development and our ability to respond to the growing threats of antibiotic resistance and new infectious diseases.

Those agencies are already falling short, as we saw last year, when they couldn’t effectively respond to the Zika threat. What will they do when we face a real pandemic? With 7.4 billion people, 20 billion chickens and 400 million pigs now sharing the earth, we have created the ideal scenario for creating and spreading dangerous microbes. Trade and travel have connected most points on the globe in a matter of hours. More and more people are living in the microbe-rich megacity slums of the developing world.

By some estimates, the 1918-19 “Spanish” influenza killed more people than all the wars of the 20th century combined. Today, an influenza pandemic could be more devastating than an atom bomb. We are already witnessing an outbreak of influenza in birds — the H7N9 strain, in China — that could be the source for the next human pandemic. Since October, over 500 people have been infected; more than 34 percent have died. Most victims had contact with infected poultry, yet three recent clusters appear to be from person-to-person transmission. Will H7N9 mutate to become easily transmitted between humans? We don’t know. But without sufficient supplies of a vaccine, we are not prepared to stop it.

The spread of antibiotic-resistant microbes also continues at an ever faster rate. Last year a comprehensive review predicted that, if left unchecked, drug-resistant infections will kill more people worldwide by 2050 than cancer and diabetes combined. Without a global effort led by the United States to halt the spread of this resistance and support for development of new antibiotics, we are in danger of returning to a pre-antibiotic world in which a cut could prove deadly and surgery would not be worth the risk of infection.

Yellow fever, a mosquito-borne disease that can kill up to 50 percent of those who get seriously sick, is on the cusp of a major outbreak in some of Brazil’s largest cities, while MERS — Middle East Respiratory Syndrome — continues to infect people on the Arabian Peninsula. If an effective vaccine is not developed, it will continue to be transmitted around the world and cause fatal outbreaks like the one that closed Samsung Medical Center in Seoul to new patients for weeks. A similar outbreak could occur at the Mayo Clinic or Johns Hopkins Hospital.

And three years after the 2014 Ebola crisis, we still have no licensed vaccine or a plan for how to deploy one to prevent future outbreaks.

Finally, there is the danger of diseases deliberately spread by terrorists. Bill Gates, who has put much of his sizable financial resources as well as his brainpower into public health, wrote in the New England Journal of Medicine in 2015: “Of all the things that could kill more than 10 million people around the world, the most likely is an epidemic stemming from either natural causes or bioterrorism.” More recently, at this year’s Munich Security Conference, on the possibility of terrorist-engineered viruses he noted: “They are probably the only thing that can kill a billion.” For example, the science exists to reconstruct the smallpox genome from readily available lab materials, with the added possibility of altering the virus just enough that our existing vaccine would be ineffective.

The military has figured out how to convince congressional funders that the only way to maintain defense is to appropriate money before a crisis. You don’t start building the weapons and training all the soldiers after the first shot has been fired. The only way we can win the inevitable microbe wars is to do the same — to have new vaccines and antibiotics and trained personnel ready before the crisis hits. We cannot rely on pharmaceutical companies to create drugs and vaccines for markets that do not yet exist. Only the government can do this. The additional expenditures would be truly economical in terms of lives saved.

We are talking about national security on the most existential level.

Michael T. Osterholm is an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. Mark Olshaker is a documentary filmmaker. They are the authors of “Deadliest Enemy: Our War Against Killer Germs.”

Michael Osterholm alerted Congress to the dangers of a viral pandemic that would overwhelm hospitals, kill millions and devastate the global economy in 2005.

Epidemiologist Michael Osterholm, who famously predicted a global pandemic years ago, is Minnesota's best-known science geek, with an international reputation. Since his prophecy became devastatingly true last year, the self-described "disease detective" has been advising President Joe Biden's team on how to combat COVID-19. Dr. Anthony Fauci relies on him to bounce ideas back and forth, too. And his popular new podcast has cemented his status as a public-health celebrity, with the What Would Osterholm Do? T-shirts to prove it. Weekly episodes reveal a softer side to the blunt, serious scientist, nicknamed "Bad News Mike" by his detractors.

Osterholm has long used his position to inform and influence. He alerted Congress to the dangers of a viral pandemic that would overwhelm hospitals, kill millions and devastate the global economy back in 2005, when he was new to his current role as director of the University of Minnesota's Center for Infectious Disease Research and Policy (CIDRAP). He appears in the national press any time there's a large disease outbreak, such as the Ebola and Zika scares of recent years. But last March, with his CIDRAP-sponsored "The Osterholm Update: COVID-19," he began to speak directly to the public.

In hourlong episodes, Osterholm serves up the science on everything from testing protocols to virus variants. He uses statistics and analytics to "scare us into our wits, not out of them," as he's fond of saying. But he also plays a less-expected role of collective healer, offering sympathy for lives and livelihoods lost, for families fractured and other social ills the virus has wrought. One moment he's explaining herd immunity; the next he's reading poetry.

"This isn't a pandemic of just a virus," he explains. "This is a pandemic of emotion. This is a pandemic of pain and suffering that has to do with lost jobs and lost persons. … This is not just a public health journey. This is really a personal journey for all of us."

Science and connection

Osterholm has spent decades investigating disease outbreaks, from toxic shock to hepatitis B to AIDS to foodborne illnesses, including 15 years as Minnesota's state epidemiologist. This experience honed his ability to synthesize data into insight almost instinctively, the way a center fielder finds the spot where a fly ball will meet his glove.

Though Osterholm's career has taken him around the globe in the course of advising multiple presidential administrations and even the late King Hussein of Jordan, his roots are in the small farming community of Waukon, Iowa. Growing up, his interests in science and mysteries coalesced by reading the Annals of Medicine column in the New Yorker. The wife of the local newspaper's publisher, who employed Osterholm's father, passed issues of the magazine along to him.

One fall night, when Osterholm was a senior in high school, he came home to find his father, a violent alcoholic, had beaten his mother. Osterholm ousted him from the house and the family never saw him again. That winter, his mother was too poor to outfit six children in snow boots, so some trudged to school wearing shoes wrapped in bread sacks.

Osterholm recently shared this story on the podcast, in sharp contrast to how he can sometimes sound like a human spreadsheet as he spits out statistics on daily cases, hospitalizations and deaths.

The podcast has shown Minnesotans — and those far beyond — a more human side to a man many know only as a wonk. At times, Osterholm resembles a charismatic preacher, imploring his followers to "stop swapping air" to avoid a coronavirus infection, or sharing how he teared up watching the first American health care worker get vaccinated on TV. He's veered into folksy, once reciting the lyrics to "Rainbow Connection" and, another time, answering a listener's query about the safety of gifting her usual Christmas krumkake. (Yes, so long as there's a contactless drop-off.) He even broadcast his annual tradition of reading "The Polar Express" to his now-adult children and young grandchildren.

Now he's known as Minnesota's COVID expert, but Michael Osterholm has been at the forefront of public health issues for decades, including speaking about the state's H1N1 flu preparedness in 2009.

Before President Biden's inauguration, when there was scant national acknowledgment of the virus' human toll, Osterholm helped fill the gap. On air, he pays tribute to those who have died of COVID-19. He's also established a fund to support the families of health care workers who lost their lives to the virus with the St. Paul and Minnesota Foundation. Each week on "The Osterholm Update," he buoys his audience with listener-supplied acts of kindness, such as the story of a girl with Down syndrome who spreads socially distant cheer by biking around greeting her neighbors.

In a recent interview, Fauci calls Osterholm "a very important presence in the entire arena of global health and pandemic outbreaks" and says he earned his reputation for his depth and breadth of knowledge of, and experience with, so many types of disease outbreaks, as well as his good judgment.

Dr. Kristine Moore, CIDRAP's medical director, says her longtime colleague distinguishes himself from his peers with his excellent communication skills, which also make podcasting a natural fit.

"He can take complex ideas and break them down in a way that people can easily grasp," she says. "He also speaks from the heart, which I think people relate to. He always tells the truth, and people really appreciate that — they know they can trust him."

Osterholm frequently acknowledges how much his listeners' engagement has benefited him: "Here's this epidemiologist, this science egghead, and you've given me a sense of connection, which I believe is so essential at times like these," he says on a recent episode. "You are not just the receivers of this, you are truly part of the family."

DARLENE PFISTER, MINNEAPOLIS STAR TRIBUNE

February 16, 1986 State Epidemiologist Michael Osterholm says quarantine of people carrying AIDS virus is not the answer; 1930s-era quarantine signs for other diseases are on his office wall. February 7, 1986 

The long game

Osterholm has enough fervent fans that some of the podcast-themed merch has already sold out. ("That was not my idea — I protested loudly," Osterholm says of the T-shirts, pins and mugs. He relented, knowing sales could help fund the constant free news stream CIDRAP puts out.)

Of course Osterholm is also used to his share of criticism, but one thing he didn't anticipate about the pandemic's arrival is the degree of vilification scientists have faced. "Death threats are just a way of life," he says.

But, professionally, Osterholm plays the long game. It's an approach he espouses personally, too, through a lifelong devotion to distance swimming. Three times he's attempted to swim the English Channel, once coming quite close to his goal.

"I tend to approach a lot of what I do from that same mind-set: You got to get through right now, but what's the long term?" he says.

And he wants to make sure we understand the long game we're playing with infectious diseases is nowhere near its end.

"This is not the big one," he said of our current circumstance. "If we have another 1918-like influenza pandemic, that could be much more severe than this."

If this prediction also comes true, hopefully we will cultivate the same sense of community Osterholm's podcast has created to help ourselves get through it.

Dr. Michael Osterholm, an adviser to President-elect Joe Biden, said in a phone interview late Thursday that he has not discussed with the incoming administration his earlier proposal to lock down the country for several weeks to try to curb a rising tide of coronavirus cases.

“I’ve never discussed any of this with them,” Osterholm told ABC News.

He also said he doesn’t think there’s a national consensus for it anyway.

“Nobody’s going to support it. It’s not going to be supported out of the administration. It’s not going to be supported in Congress," Osterholm said.

Osterholm raised eyebrows this week after accepting a role on the Biden team and then referring to his August lockdown proposal in an interview in Yahoo Finance Live online.

In an Aug. 7 op-ed in the New York Times, Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, and Nel Kashkari, president of the Federal Reserve Bank of Minneapolis, argued that if the government paid people for lost wages, the nation could lock down to the stop the spread of the virus and spare the economy greater pain.

“We could pay for a package right now to cover all of the lost wages for individual workers, for losses to small companies, to medium-sized companies or city, state, county governments. We could do all of that,” he told Yahoo Finance Live of his August proposal. “If we did that, then we could lock down for four to six weeks and if we did that, we could drive the numbers down.”

The comments raised questions about whether Biden's team was seriously considering the idea because Osterholm was announced earlier in the week as joining Biden's 13-member COVID-19 advisory team.

When asked about Osterholm's comments, Biden's communications director Kate Bedingfield told CNN's Jake Tapper that Biden is focused on the plan he laid out during the campaign, which called for encouraging mask mandates nationwide and boosting testing.

"He's going to be informed by the best expertise and public health expertise out there," she said, adding that he's "going to move forward on the plans he laid out in the campaign."

In a brief interview later that night, Osterholm said his comments to Yahoo Finance Live on his August lockdown proposal shouldn’t have been interpreted as representing the Biden team.

But, he added, the problem is growing and that he still thinks there should be a way to compensate businesses and workers disproportionately hit by economic losses, he said.

“We will get well north of 200,000 cases a day even more … and we’re still doing to have to figure out what we’re going to do here,” he said.

Dr. Anthony Fauci, the nation's top infectious disease expert, has said the country wouldn't tolerate another lockdown and that it’s probably not necessary if the country is able to embrace other options like masks and avoiding social gathering

"If we can do the public health measures, we wouldn't have to do that," Fauci said on ABC's "Good Morning America" Thursday. "The best opposite strategy to locking down is to intensify the public health measures short of locking down. So if you can do that well, you don't have to take that step that people are trying to avoid, which has so many implications both psychologically and economically. We'd like not to do that."

Fauci also said "help is really on the way," referring to a vaccine.

"You know, if you think of it metaphorically -- the cavalry is coming here … if we could just hang in there, do the public health measures that we're talking about, we're going to get this under control, I promise you," Fauci said.

At a recent ABC News town hall before the election, Biden said he didn't think there would be a need for a lockdown, but said he would listen to science.

"You can contain the pandemic by being rational, and not crush the economy," Biden said. "You can open businesses and schools if, in fact, you provide them the guidance that they need, as well as the money to be able to do it."

ABC News' Molly Nagle and Jordyn Phelps contributed to this report.