Tracking Hepatitis C: Health Project Demos Worldwide Early-Warning System For Disease Outbreaks; Sandia Tests Disease-Tracking Approach

The Centers for Disease Control estimates that 3.9 million Americans arechronically infected with hepatitis C. New Mexico health officials believe up to2 percent of the state's population has the disease.

Yet very little is known about hepatitis C risk factors--behaviors thatincrease the probability that a person will contract the disease. The hope isthat by sharing information about who gets the virus and how it is transmitted,physicians can better understand how to prevent its spread.

The primary goal of the international project, though, is to show how monitoringunusual outbreaks of disease can serve as a worldwide early-warning system forcovert biological weapons development.

Sandia scientists have proposed setting up an online health information exchangethat would rely on thousands of doctors worldwide sharing disease informationabout their patients. By keeping an eye on unusual outbreaks, and by askingnations that censor the sharing of health information to explain themselves, thescientists believe an effective "transparency regime" can be created forinternational treaties such as the Biological Weapons Convention (BWC), whichforbids experimentation or acquisition of biological agents or toxins formilitary purposes.

"We think investigating unusual outbreaks of disease may be the best way tocatch a cheater," says Al Zelicoff of Sandia's Nonproliferation InitiativesDepartment.

The hepatitis C project is the first step in demonstrating how such a systemmight work.

Called the Cooperative Disease Monitoring Project, the effort is beingcoordinated by Sandia with funding from the Department of Energy's Chemical andBiological Weapons Nonproliferation Program. Also participating are the NewMexico Department of Public Health, the University of New Mexico School ofMedicine, Los Alamos National Laboratory, and the former Soviet nuclear weaponslab Chelyabinsk-70.

Outbreaks can be reason for suspicion

When an outbreak of a rodent-borne disease now known as the hantavirus killedmore than a dozen people in the southwestern United States in spring 1993, theU.S. had some explaining to do, says Zelicoff. The outbreak was sudden, it wasoften fatal, and it was confined to a region where military research takesplace. To some, it looked like the U.S. might have been experimenting withbiological agents forbidden under current treaties, and that the bug somehow hadgotten out among the populace.

A similar outbreak in 1979 in the Russian province of Sverdlovsk, nearChelyabinsk-70, turned out not to be so innocent. Foreign physicians attending aconference there became disturbed by local doctors' accounts of a pulmonaryillness that caused 64 deaths in a two-week period. On further study,pathologists found the victims had been infected with several strains ofanthrax. The Soviet government first blamed the outbreak on contaminated meat,but a 1994 study published in Science suggested that a release of windborneanthrax from a Sverdlovsk biological weapons factory probably caused theinfections.

More than 150 nations have agreed to an outright ban on biological weaponsresearch as part of the BWC, ratified by most participants by the mid 1970s. Butafter more than 20 years, the world community still hasn't agreed on the bestways to verify that all party nations are complying with the treaty.

Epidemiology may strengthen the BWC

Developing a practical compliance regime for the BWC has been difficult, partlybecause all biological agents have peaceful uses. Even botulism, which wasdiscovered in the early 1980s to be effective in treating an eye-muscle disordercalled blepharospasm, now has more than 50 FDA-approved uses.

"There isn't one bioagent you can name that doesn't have a legitimate use," saysZelicoff.

In the early 1990s a multinational BWC Verification Experts Group (VEREX forshort) considered a set of 21 confidence-building "transparency" measures forthe BWC, including on-site inspections, remote sensing, and voluntary dataexchanges between participating countries.

Now the BWC nations are considering including the disease-tracking approach as away to strengthen the final verification regime, says Zelicoff, who was a memberof the U.S. VEREX delegation.

"The primary goal of any treaty is to build trust among participating nations,"he says. "Finger pointing detracts from that, so you want to avoid falseaccusations but still catch the occasional cheater."

A combination of vigilant disease monitoring and follow-up pathological studieswould help accomplish that, Zelicoff says. Once a mysterious outbreak isidentified, the tools of modern epidemiology would be sufficient to determineits origin, he says. In the hantavirus case, it took pathologists only a fewweeks to isolate the virus and determine it was transmitted through theexcrement of field mice.

"If epidemiologists isolate four strains of anthrax, then you might startpointing fingers," he says.

What about rogue nations that might interfere with doctors' abilities to shareepidemiological information over the Internet? Nations that agree to terms of atreaty are entering into a cooperative agreement. If a participant nation beginscensoring doctors, you know something's amiss, he says.

Sandia initially is cooperating with Chelyabinsk-70 partly because hepatitis Cis a potentially serious worldwide problem, and partly because the virus isclearly not related to military applications--"it's an apolitical disease,"Zelicoff says. Also, both New Mexico and the region surrounding Chelyabinsk-70have unusually high incidences of hepatitis C.

Info gathering began Monday in New Mexico, Russia

On June 1, hospitals in Snezhinsk, Russia, began taking 1cc blood samples fromrandomly selected emergency room visitors who agree to the tests. Meanwhile themain hospitals in three small New Mexico cities--Los Alamos, Silver City, andAlamagordo, selected for their demographic similarities with Snezhinsk--arecollecting samples from randomly selected volunteers. Each volunteer is asked tofill out a 150-item questionnaire intended to isolate behaviors that could berisk factors for contracting the disease.

In all 2,000 patients in Snezhinsk and 2,000 in New Mexico will be tested forhepatitis C over the next four or five months. Statistically about 2 percent, or40 to 50 people at each site, are expected to be infected. Genotyping, it ishoped, may isolate new variants of the virus as well.

Sandia provided additional emergency room equipment as well as the videoconference and computer hardware necessary for the hospitals involved tocoordinate their work over the Internet. Sandia also helped design the patientquestionnaire and postulate its questions along with hepatitus C experts at theNew Mexico Department of Public Health and the UNM School of Medicine.

In the end, Zelicoff hopes, doctors will know a lot more about hepatitis C thanbefore and will be more equipped to stem its spread. Hepatitis C is four toeight times more prevalent than HIV and AIDS in the U.S., and at least half ofhepatitis C sufferers develop cirrhosis or liver cancer, he says.

Some 30 percent of those who contract hepatitis C have no identifiable historyof exposure to the virus, according to the Hepatitis Foundation International.One in five people infected develops acute liver failure. Currently there is nohepatitis C vaccine.

Results of the study will be submitted for publication in an internationallyrecognized journal.

Disease monitoring benefits world health community

In the long term, Zelicoff hopes, BWC signatories will set up and maintain anInternet-based information-sharing network based on the hepatitis C model andprovide investigative support when new disease outbreaks are identified. Aworldwide community of physicians would report the outbreaks, obtain informationabout new viruses, and make the information available to all BWC parties.Many disease outbreaks have occurred during the last 30 years, Zelicoff pointsout. Since January 1998, in fact, the World Health Organization has monitoredsome 20 separate outbreaks worldwide.

"Setting up a system not only would contribute to BWC verification but wouldhelp the world health community continually watch for new outbreaks," he says.

Zelicoff first proposed the hepatitis C project to DOE in 1996. Sen. PeteDomenici, R-N.M., initially supported the project in Congress and announced itscreation during a May 6, 1997, news conference at Sandia's CooperativeMonitoring Center, which assists political and technical experts from around theworld in evaluating and acquiring technology that can help ease tensions amongcombatants in regional conflicts and keep weapons and weapons materials secure.

"The surveillance of infectious diseases, because of their destructivepotential, is an important national security concern," Domenici said. "I believeprojects like this help to reaffirm the spirit of openness and trust that is soimportant between the United States and Russia in this post-Cold War era."

Sandia is a multiprogram Department of Energy laboratory operated by LockheedMartin Corporation. With main facilities in Albuquerque, N.M., and Livermore,Calif., Sandia has R&D programs contributing to national defense, energy andenvironmental technologies, and economic competitivene