Demon in the Freezer Discussion Guide



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Demon in the Freezer

Discussion Guide
Brittney King
As you read the book, simply and briefly cite at least 1-2 examples or evidence of the


  1. Steps of the Field Investigation Process /Cluster Investigation – as evident both in the smallpox and anthrax investigations

  2. Purposes/Roles/Activities of Epidemiology and Epidemiologists

  3. Descriptive Epidemiology

  4. Analytic Epidemiology

  5. Procedures and techniques used in the investigation of small pox and anthrax

  6. Epidemiological Measures (including measures of effect)/ Potential Data Interpretation Issues

  7. Five Principles of Morality – application/dilemmas

  8. Ethics Guidelines for Epidemiologists – fulfillment and conflicts


  1. STEPS OF THE FIELD INVESTIGATION PROCESS



  1. Establish the existence of an epidemic (or outbreak)

-October 16, 2001: Anthrax began killing more than just opened contaminated letters, and started affecting the health of mail carriers. As more and more mail carriers began getting sick, Jahrling realized that the spores were leaking through enclosed envelopes, affecting more people than they ever thought.

-When 19 people became infected with smallpox after Peter Los was quarantined from all others. It was obvious the virus has spread from him, but in a way other than personal contact.



  1. Confirm the diagnosis

-Dr. Larry Bush found cloudy grey matter in Robert Steven’s spinal tap, and an autopsy with found anthrax spores in Steven’s lungs and airways proved anthrax as his cause of death.

-Smallpox: High fever that antibiotics cannot break followed by pustules developing across a human’s entire body, causing the skin to be “on fire”.



  1. Establish criteria for case identification

-Robert Steven’s physicians present the possibility to public health professionals who then take all information and perform post-death autopsy on Steven’s body to confirm.

-Identifying similar symptoms in patients who developed smallpox after Pere Los.

-Establishing similar symptoms among monkeys used in smallpox research by Hensley, Jahrling, and Geisbert.


  1. Search for missing cases

-Bhola Island, as the search for smallpox cases continued from 1974-75

-Geisbert’s work to find if something is laced in the anthrax that killed Robert Steven’s

-Cases that could have occurred in the hospital where Peter Los was contaminated


  1. Count cases

-Cases counted after Peter Los developed smallpox and was isolated

-Cases counted among Monkey smallpox studies

-Cases counted among mail carriers and mail recipients as anthrax scare began

-Cases documented on Bhola Island, as seen in photo found on page 93



  1. Orient the data according to the person, place, and time

-Robert Stevens’ actions and daily happenings were investigated after his death

-Monkey deaths from smallpox in Jahrling’s monkey experiments

-Jackson-Ramshaw paper that explained the mutation to smallpox that was made when attempting to eliminate mice.

-Recording anthrax cases, post-9/11 attacks



  1. Classify the epidemic

-Smallpox: Breakout amongst citizens of Bhola Island

-Anthrax: As epidemiologists like Jahrling and Geisbert study anthrax and its transmission via mail to determine the level of exposure among American citizens

-Discussion of the possible threats that could come with the research being done by Dr. Urakov, and other Russian researchers.


  1. Determine who is at risk of becoming a case

-Exposure rates for family members of Robert Stevens’: Potential for spread through the mail and how and who this will affect from that information.

-Attempt to find the way Peter Los’ smallpox spread, despite being confined and isolated

-Discussion of the smallpox work being done in Australia to kill mice, and the potential risks that could come with altering smallpox.


  1. Analyze the data

-Hensley analyzing data after the deaths of the monkeys in the smallpox study

-Geisbert who discovered glass in the anthrax spread after 9/11

-Professionals who traced the cases of smallpox back to Peter Los’ use of a window to smoke.


  1. Formulate a hypothesis

-Discussion of the anthrax found in Robert Stevens’ lungs in the post-death examination, and where it came from.

-Geisbert realizing that the anthrax being spread was laced with something else (eventually finding glass particles)

-Smallpox spread via a vent near the window Peter Los used while isolated with the virus

-Cause of death among monkeys in the smallpox study



  1. Test hypothesis

-Opening of window in Peter Los’ isolation room to test the possibility of smallpox spreading via ventilation

-Testing smallpox on monkeys for effectiveness on animals species other than humans

-Geisbert searching for an agent within the anthrax other than anthrax (in this case glass shards)

-Investigations done within Russian facilities to find the use of smallpox outside of the WHO.



  1. Develop reports and inform those who need to know

-Jahrling used the results of his monkey research to persuade D.A. Henderson of the value of keeping smallpox virus samples.

-The IL-4 variola mousepox developed by Australian scientists Jackson and Ramshaw

-Reports of anthrax provided by Geisbert and Jahrling to the FBI and CDC (Dispute between the two in terms of who would receive the information and what to do with it)


  1. Execute control and prevention measures

-Extreme lock down of mail distribution after anthrax deaths began

-Control measures were used in the MCL (Maximum Containment Lab) to ensure safety of the professionals working within the lab, as well as to prevent exposure and spread of the virus (blue suits, Lysol shower afterward)

-Control measures taken after Hensley thought she may have cut through her glove and exposed herself to smallpox.

-The secure measures taken to prevent exposure or spread of anthrax when performing post-death autopsy on Robert Stevens.



  1. Administration and planning activities

-Planned autopsies on those who died from anthrax (Robert Stevens) and smallpox (monkeys in study)

-FBI’s steps taken to gain information and protect Americans through anthrax scare

-CDC’s action plans in moments of potential danger or exposure

-D.A. Henderson’s plans to eliminate all smallpox from the United States vs. Peter Jahrling’s want to keep it for potential future use.

-America’s investigation of Russia’s possible use of smallpox for illegal purposes.

Evidence/Examples of Disease Clusters/Investigation

B. Purposes/Roles/Activities of Epidemiology/Epidemiologists

1. Identifying risk factors for disease, injury, and death

Identifying the risk factors for the spread of anthrax after Robert Stevens’ death was essential to preventing further casualties. Epidemiologists did this by assessing his body and internal organs, as well as tracing his steps before becoming sick.

The same research was done when considering smallpox by doctors after Peter Los became ill with smallpox, was isolated, but somehow still affected the health of so many other people in the hospital.

The FBI and CDC turned to epidemiologists when countless unknowns presented themselves after the start of the anthrax outbreaks.

Jahrling and Geisbert wanted to keep strains of smallpox available for future research, while others wanted to destroy it. The two fought for the virus and its potential use for discovering risk factors and possibilities for mutations.

2. Describing the natural history of disease

The Bhola Island chapter gives a brief summary of how smallpox evolved to such a powerful, human-killing virus. It also explained its natural affects on insects, and all other animals. All of this information comes from data and research done by epidemiologists to better understand the nature of the virus.

3. Identifying individuals and populations at greatest risk for disease

Epidemiologists did research with the smallpox virus on monkey’s to determine how different strains of the virus affect monkeys, and potentially humans.

Anthrax was tracked from Robert Stevens’ to other victims, and was targeted as spreading via the mail. This connection allowed epidemiologists to better understand populations at risk, and individuals with greatest risk. However it also left lots of questions, as the possibilities were endless as to who may be affected.

4. Identifying where the public health problem is greatest

American epidemiologists researched the work being done in Russia to determine if smallpox was being used for potential bioterrorist attacks.

Determining if smallpox should be eradicated or kept for further studies was a huge topic of interest in this book, because of its potential for becoming a public health problem in the future.

Determining where mail laced with anthrax originated from, to find other possible threats and where the problem would have the greatest impact.

5. Monitoring diseases and other health-related events over time

Data retrieved from Bhola Island over time, demonstrating the spread and containment of cases

Monitoring monkeys in Jahrling and Hensley’s smallpox monkey trials.

6. Additional activities

Epidemiologists served as a primary source of answers and information when FBI agents were unsure of what to do.

Without the research and efforts of epidemiologists in this book, little would be known of the cause of death for many people like Robert Stevens’ who died so suddenly.

7. Evaluating the efficacy and effectiveness of prevention and treatment programs

Information presented by Jackson and Ramshaw as they mutated the smallpox virus.

Cheng’s findings after creating the superpox strain, showing that true eradication of smallpox was going to be next to impossible to achieve.

8. Providing information useful in health planning and decision making for establishing health programs with appropriate priorities

Epidemiologists provided FBI and CDC with next steps to be taken in regards to proceeding with the anthrax scare, and understanding what was happening

The smallpox discussion among epidemiologists on whether priorities should be on destruction or use for future findings.

9. Assisting in carrying out public health programs

The preventative measures epidemiologists took to contain smallpox on Bhola Island.

10. Being a resource

Served as a main resource for FBI when anthrax scare began by researching and performing necessary tests to find answers.

11. Communicating public health information

Communicated with government officials and FBI when answers were found in relation to anthrax scares.

Within hours after Robert Stevens’ body was proven to have anthrax, public health officials had all communicated with one another and were working together to find the cause and where to go from there.



DESCRIPTIVE EPIDEMIOLOGY – Examples and/or Evidence (should be in bulleted form)

-Cross-Sectional study of smallpox cases of Bhola Island

-Study of anthrax findings after Robert Stevens’ death

- D.A. Henderson’s work with the Smallpox Eradication Program



ANALYTIC EPIDEMIOLOGY – Examples and/or Evidence [use bulleted format]
-Tests of smallpox on monkeys (controlled environment), Experimental studies

- Jackson and Ramshaw’s work done with mice in Australia

-Cheng’s work with the information provided by the Australians to create “Superpox”

-Hensley’s work with the Ebola Virus

-Dr. Richter did research on the pus of Peter Los’ blood and sores

-Work being done in Russia with smallpox, although little is known or understood of it




PROCEDURES AND TECHNIQUES USED IN THE INVESTIGATION OF SMALL POX AND ANTHRAX

(procedures and techniques are discussed in Chapter 12 of the textbook) – [Use bulleted format]


Smallpox

-Descriptive studies by finding cases and tracking prevalence and spacing

-Analytic studies done on Monkeys

-Tests done by Russians to experiment with smallpox

-Maximum Containment Lab

-Blue suits system and procedures in place with Lysol showers for safety from viruses

while working with them

-Mutating the virus to better understand it


Anthrax

-Autopsies on bodies like Robert Stevens’ and others who died from anthrax (to study its

attack on the human body)

-Microscopic analysis of anthrax strands and its contents

-Hypothesizing about potential contents within the anthrax

-All findings were given directly to FBI and government agencies for

analysis and for further steps to be taken
EPIDEMIOLOGICAL MEASURES (including measures of effect) and POTENTIAL DATA INTERPRETATION ISSUES (e.g. bias and confounding) [Use bulleted format]
Measures of Incidence/Frequency: Prevalence was measured for both smallpox (by

region and areas) as well as anthrax



Duration: How long the stages of smallpox last, as well as the incubation period of

anthrax


Potential Bias:

-Hensley seeing what she wanted to see in the lab instead of what actually

occurred.

-American’s interpretation of Russian experiments in fear of possible negative

outcomes

-Treatment given to Harper the ape in the monkey studies

-Reported cases on smallpox within Bhola Island due to deaths and lack of

communication

-Lack of uniform environment for patients to describe symptoms


FIVE PRINCIPLES OF MORALITY: [Evidence/examples where these principles were applied and/or moral dilemmas arose]

1. Value of Life: No harm was done to humans in studying smallpox. Animals that were used were treated like pets and taken care of. Harper was even nursed back to health. Patients with smallpox, although little can be done for them, were cared for in the best way possible, even though they were in isolation.

2. Principle of Goodness/Rightness: Americans wanted to break in to Russian research facilities, but respected boundaries and attempted to find information on a morally and ethically correct level. The rights of all patients when assessing anthrax cases needed to be maintained at all times.

3. Principle of Justice: Dedication of epidemiologists to their research to better our world. Smallpox studies and emergency anthrax studies took all hours of the day for all epidemiologists involved, but they did what was necessary to find the answers needed to save lives.

4. Principle of Autonomy: Americans respected Russian privacy, while still doing whatever was necessary to find the answers they needed. They remained respectful of Russia, while being loyal to America. Hensley and Geisbert respected their clinical trial on monkeys by putting Harper the monkey to sleep even if they didn’t want to. But they remained true to the trial.

5. Principle of Honesty: Bhola Island. Respect of Robert Stevens’ body after death evaluations. Inspection of monkeys during research studies by Jahrling and Geisbert (done carefully and respectfully). Reporting of findings from all cases, needed to be reported honestly, regardless of outcomes. Russians did not remain honest about what they were doing with their small pox strands.



ETHICS GUIDELINES FOR EPIDEMIOLOGISTS AND HEALTH EDUCATION PROFESSIONALS [Refer to Part II of the Ethics Guidelines as well as the Code of Ethics for Health Professionals, note examples/evidence of either adherence to these guidelines/code or where the actions were in conflict with them] [Use bulleted format, not all elements of the guidelines and code need to be addressed]

Referred to code on attached: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/

-Monkeys in Jahrling’s smallpox study were given standardized dosages, to create a uniform study that maintained its integrity.

-Field tests respected the rights of all patients used for research by performing tests according to proper codes of ethics.

-Public health professionals and epidemiologists in the book provided all information for public use by the CDC and FBI as necessary.

-Public health institutions used for anthrax studies were safe and secure in a way that maintained safety and health of workers.



-Public health institutions should act in a timely manner. This code was definitely maintained, as the epidemiologists in the book gave their entire lives to the studies explained. Jahrling’s wife and family rarely saw him, and Hensley had a hard time maintaining her relationship; all because of their dedication to the studies they were a part of.

-Public health institutions should maintain a safe environment for patients and employees. This was not maintained at the hospital Peter Los was put in isolation when he became sick with smallpox. The virus spread to many patients unnecessarily because of lack of a controlled environment.


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