By Justin Hurt
Moderator: Gigi Gronvall, PhD
Julie Gerberding, PhD, former CDC Director
Jeffrey Smith, Partner, Arnold and Porter
Imagine a never-before-seen virus emerging simultaneous in multiple places on Earth with no warning, no current countermeasures, and no idea as to the origin. Think about the difficulties that leaders could encounter if one of the outbreaks was in a nation with which we had less than desirable relations, but was close enough that it was likely to spread to our shores quickly. What could that mean for effective response or humanitarian assistance and how would we broach that with our own leaders and diplomatically with our international partners? What if the virus was found to have been engineered and intentionally released? Finally, how do we determine the most effective distribution of any countermeasures we might develop?
On January 30th, 2019, The American Society for Microbiology’s Biothreats Conference in Arlington, VA presented a discussion panel on John’s Hopkin’s University’s 2018 Clade X Exercise centered around just these types of questions. A pandemic tabletop exercise hosted by JHU’s Center for Health Security on 15 May 2018, Clade X sought to identify important national policy issues and preparedness challenges that could be solved with sufficient political will and attention. Built on a fictional scenario based on epidemiological principles and challenges identified and unresolved in response to past outbreaks, key takeaways from Clade X were intended to inform senior leaders and decision makers at high levels in the government on how to deal with the potential for future pandemic events.
Clade X was designed to simulate external events in a realistic way, incorporating what could happen if an infectious disease emergency occurred. It simulated a series of NSC-convened meetings of high level officials to advise the president. Conducted in front of a live audience and live streamed on Facebook, exercise players were mostly high level current and former government officials including former congresspersons and senior cabinet staff.
The exercise simulated media inputs, including news videos and live briefings to stimulate discussion and debate. There were 10 major policy challenges identified across several dimensions – none were straightforward, intended to be challenging and requiring comprehensive analysis and thoughtful recommendations to be made to the executive. The panel displayed examples of the simulated news stories broadcast to the players during the exercise, which detailed how the simulated infection began in Frankfurt and Caracas and the initial reports of infection clusters, and how the incident progressed over several months.
Dr. Gigi Gronvall, of the JHU Center for Health Security introduced the exercise parameters: The virus, a novel variant of parainfluenza, cause fatality in about 10% of infected cases. There was no known countermeasures, but the CDC had developed a PCR test by the time the NSC staff began deliberations within the scenario. One initial challenge was whether to limit travel to the US from the countries of origin. Dr. Julie Gerberding, former Director of the Centers for Disease Control and Prevention, elaborated on how complete closure of the borders was a really difficult and unrealistic measure to take, especially this early and with limited information. Force protection was also a challenge for discussion – could this have been an intentional incident, especially with Soldiers in Germany affected? Mr. Jeffrey Smith, a retired partner and national security attorney from Arnold and Smith, related how the lack of information early presents a significant challenge of its own, especially in terms of the possible attribution or origin of the infection, since many initial reports are erroneous.
Some of the issues brought up with a travel ban included how suspending travel not only violates international agreements, but could represent a significant economic and political problems, even if there was public will for a travel restriction. In the exercise, Venezuela was badly affected by the outbreak, and included a notional request for US assistance – the question arose if the US should provide civilian and DOD medial teams to help in light of the political situation with the country, already in turmoil. Having US personnel assist allows for better information gathering, control of the disease spread, and humanitarian goodwill, but potential security threats to the personnel became a challenge. One of the major insights from this discussion was how the different agencies that would be involved have differing views of the world that can influence their recommendations. Of additional concern was the commitment of personnel in depth to a crisis in a tenuous environment when these same personnel might be required elsewhere in short order. An interesting corollary was the situation in the Democratic Republic of the Congo, where the US has had to make difficult decisions on sending large numbers of personnel to assist in containing the ebola outbreak occurring there.
The next topic up for debate happened when a case happened inside the United States, at a college with a student who returned from Germany. A discussion of federalizing a state-mandated quarantine (using the National Guard) at the affected college ensued. Some major points included how the world would view the quarantine. Mr. Smith noted the complexity of the problem, offering how opinions can evolve as more information comes to light or more experts weigh in on the issues. The decision was ultimately made not to federalize the quarantine, but it left lingering concerns about the potential for spread from the campus. Next, about a dozen military service members in Afghanistan became ill, not only raising concerns about the potential that the outbreak was other than natural in origin, but also how it could overwhelm in-country medical capabilities and affect military readiness. The question arose whether or not to bring home potentially affected military personnel and to what extent that repatriation would involve a few, some, or all personnel that are or could be possibly affected. This concern also reinforced the need for a rapid diagnostic test to separate out those infected from the healthy.
Further information came to light during the exercise that an extremist organization had taken credit for creating and disseminating the virus to cull the human population. At the next notional NSC conference, it was briefed how the virus had significantly affected the US health care apparatus and many hospitals were now failing to deal with the infected. CDC had encouraged social distancing and telework. Globally, millions had been affected by the six month mark, with high transmission in megacities, and many hospitals turning away patients. A vaccine under development was still 6-9 months away from distribution. One major question here was what method would be used to determine the distribution of limited amounts of the vaccine to the populace, with options based on value to others, age, the most affected, or lottery – this sparked an in-depth debate of how to determine the most effective method to inoculate the public. One gap identified was the issue of continuity of government and how the business of the nation could continue under the scenario conditions – something that had not really been exercised in a large-scale way in the past.
The epilogue of the epidemic at 20 months later, with no effective vaccine until that point, resulted in 150 million deaths, with 15 million fatalities in the US alone, the crash of the stock market, and the collapse of the healthcare system which had to be forcefully nationalized.
What the exercise best represented was a discussion of the major challenges that the nation could face in the event of a major biological event, natural or intentional. What the participants and the larger community of interest gleans from such an exercise is that we have significant gaps that require solutions and that preparedness is critical to early detection and mitigation of a pandemic incident. Senior leaders have tough discussions ahead and even harder decisions and recommendations to make when it comes to biothreats. Having exercises like Clade X are useful in identifying and discussing these challenges. However, the true benefit will only be realized if such engagements result in better structures for addressing a real incident and if the recommendations of these exercises are instituted in a meaningful way throughout the potential players in a future pandemic event.