So You Want to Write an Outbreak Story...
Guess who took Epidemiology (not this version, unfortunately) this summer?
Admittedly, the majority of the class was interesting but not particularly exciting. It had a lot to do with incident reporting and using statistics to craft public health interventions. Generally speaking statistics and I are not friends, but overall it really didnāt suck, and that was about all I could say.
But then we got to a unit titled āField Epidemiology and Outbreak Investigationā and I thought Iād do a post celebrating outbreak fiction and the coming zombie apocalypse. Look at me branching out into Public Health.
Have you ever seen the movie Contagion? As far as fictional pandemics go, that one is probably my favorite (I mean, it doesnāt quite pack the whump punch that World War Z does- I love it for other reasons). Mostly because it addresses the US public health and incident management system that would typically be in play with a pandemic on that scale, as well as how the general public reacts to the threat.
For those of you who havenāt seen it, Contagion presents a fictional pandemic (MEV-1) that ultimately causes about 26 million deaths worldwide within two years. We havenāt had a pandemic reach that scale irl in a really, really long time (since the 1918 flu pandemic), but the likelihood of a similar pandemic striking again is pretty high, and when and where it will originate are largely unknown (though weāre pretty sure its going to be some kind of influenza again, so get your flu shots).
Which makes it a highly relevant topic to write fiction about. Ā
If you decide to write a fictional account of widespread disease (or incorporate it into the setting of your story), the first thing to think about is how far you want your illness to spread. Here are some choices to help get you started:
Epidemic: When there is more than the typical number of cases of a particular illness.
Outbreak: An epidemic that occurs in a limited geographic area, like one state, island or town. This is useful in quarantine stories, where the main drama comes from characters feeling trapped/needing to escape/risking spread of the disease.
Pandemic: An epidemic that occurs across several countries or continents. This is useful for stories where the main drama is a āno safe place leftā feeling.
The next thing youāll need to consider is what kind of pathogen is causing the epidemic. The most likely culprits are:
Ā Virus: A strain of influenza is currently voted āmost likely to cause a pandemic,ā but other viruses such as smallpox and polio have caused devastating epidemics in the past. Viruses also have much less effective treatment options than bacteria.
Bacteria: Most of the time itās going to be difficult to find a bacterial outbreak that canāt be treated with antibiotics. But if the outbreak occurs in a remote area, or where antibiotics are very expensive or difficult to obtain, this is a good choice. Also consider bacteria such as anthrax that are very well suited to biological terror attacks, and are more difficult to treat.
Drug-resistant bacteria: after the invention of effective antibiotics, it became tough to find a bacterial organism that could effectively spread and kill fast enough to cause significant infections. With the emergence of drug resistance, however, public health professionals are starting to worry that a drug resistant strain of diphtheria or other former major bacterial threat may return.
After youāve figured out what you want the scope of the epidemic to be and whether a virus or bacteria goes better with your story, think about the stages of infection:
(Aron, JL (2004). Infectious disease epidemiology: Theory and practice. Nelson, KE (Ed.). Jones & Bartlett Learning: Burlington, MA)
If you are picking an existing pathogen for your story, you can look up ālatent period of ______ā and āincubation period of ______ā to determine when infected characters might become contagious or begin to experience symptoms. If you are creating your own pathogen, you can base latent and incubation periods on similar infections, or generate them based on the needs of your story.
If you want a pandemic, choose or create a disease with a longer communicable portion of the incubation period. This allows characters time when they do not know they are sick to spread the disease to others. If youāre looking at it from a whump aspect, it also allows for a lot of worrying about whether they have the disease or not, or whether they are spreading it to others.
If you are looking at an outbreak-type story in a confined area, having a long communicable period isnāt necessarily essential- the disease will spread anyway in close quarters, especially if it is established that the pathogen can live on inanimate objects or other surfaces. Diseases with harsher symptoms or faster progression rates may create a better atmosphere for a ātrapped in quarantineā story.
If your main character(s) are responsible for investigating an outbreak, hereās a potential framework they will be following:
Outbreak investigation has the goals of determining the cause of infection, controlling and preventing further spread of the disease, and learning from the disease in order to be more prepared in the future.
Conveniently, there is a step-by-step framework for field investigation of an outbreak (note, some steps have been omitted due to overlap or redundancy).
Prepare for field work- Investigators determine what the outbreak is supposedly of, and what information is already available on the disease and past outbreaks. A full team of investigators and specialists are gathered.Ā
Establish the existence of an outbreak- Investigators figure out if the cases of disease are related, and if they occur in sufficient numbers to launch an investigation.
Verify the diagnosis- Investigators collect specimens and carry out testing to determine the diseases are the same and/or match an existing disease. Done at the same time as step 2.Ā
Construct a working case definition- Investigators figure out what criteria need to be met to determine a case of illness, including general setting, clinical manifestations and time frame.Ā
Find cases systematically and record information- Investigators look for other cases of the disease, either by contacting those in the healthcare settings or by alerting the public directly and asking for specific information from parties who may have been infected.Ā
Perform descriptive epidemiology- Investigators summarize the data obtained above and determine what types of people were infected and where the infection might have originated. Create graphs of the data.Ā
Develop hypotheses- Through the information available, investigators come up with a hypothesis as to what is causing the outbreak (note: this happens through all levels of investigation).Ā
Evaluate hypotheses epidemiologically- Investigators determine whether the hypothesis fits the evidence and whether or not the epidemiology seems natural or if there may be an intentional origin to investigate further.Ā
Implement control and prevention measures- This should be done immediately if disease and means are known and available, including:Ā
quarantine
vaccination campaigns
preventative medicationĀ
Instructing the public to avoid certain areas or wear long sleeves to avoid insect bites (for outbreaks involving mosquitos, such as West Nile Virus or Malaria)
Initiate or maintain surveillance- Investigators should begin or review current reporting and analysis protocols.Ā
Communicate findings- Communicate findings to the public and government agencies throughout investigation, and assemble a complete written report summarizing the findings after epidemic has ended. [example].
For more information on each specific step, click hereĀ
If your character is not an investigator, they may only see investigators for an interview, hear a few things on the news about investigation results, and may be ordered/advised to participate in a few of the control/prevention measures above.
Hereās a good resource if you want to write something about a bioterrorism attack.
Hereās information on the National Incident Management System and Incident Command System that might go into effect during a widespread epidemic or pandemic (in the USA).Ā
Hereās the WHO checklist for influenza pandemicĀ preparedness (international).
Hereās more general information about emergency response by the WHO
Hereās some information on epidemic and pandemic diseases (click onĀ ādiseasesā underĀ āscope of workā)
Bioterrorism event (anthrax, smallpox, plague) on a plane/in a train (quarantineĀ story)Ā
FourĀ seemingly random people in different parts of the world develop the same new infectious disease
Fake outbreak sold to the public to seed fear, but some people get symptoms via the placebo effect
CourierĀ sent to deliver the last known vials of smallpox/all-but-extinct illness mysteriously disappearsĀ
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