Contagion: Lessons Learned

By Keanu Bellamy
Biosecurity and Bioterrorism Response (PUBLPOL122)

Table of Contents
(Quick) Overview of Movie
Medical Concepts in Movie
Accuracies and Inaccuracies of Movie
Lessons Learned from Movie
Contagion in Popular Culture Today

Overview of Movie

Contagion: Synopsis

Contagion documents the

genesis, spread, and
mutation of the MEV-1 virus,
as well as attempts by
leading medical researchers,
and public health officials to
understand the virus origins,
structure, and capabilities in
order to facilitate the creation
of a vaccine against it, in the
midst of national and global
pandemonium.

Medical Concepts
1. Overview of Medical Concepts
2. Definition of Introduced Medical Terms

Contagion: Medical Concepts

Many real medical terms are used to help imbue the movie with a
sense of realness in the discussion of the MEV-1 virus pandemic and
search for a vaccine.

The movie shows how strains of a virus from different animals can
combine to create a new strain that has never been seen before

The movie helps explain virus transmission, and necessary procedure

to understand and combat the virus

The movie explores the difficulties in trying to obtain a vaccine, as well

as deciding who can get vaccinated, given that the supply is limited.

Explores different levels of biocontainment

Med. Terminology: Fomite

Any object or substance
capable of carrying
infectious organisms, such
as germs or parasites, and
hence transferring them
from one individual to
another.

Example
fomites

Med. Terminology: R0 (R nought)

Basic reproduction number
of an infection can be
thought of as the number
of cases one case
generates on average over
the course of its infectious
period, in an otherwise
uninfected population.
The larger the value of R0,
the harder it is to control
the epidemic

Disease

Transmissio R0
n

Measles

Airborne

12-18

Smallpox

Airborne
Droplet

5-7

SARS

Airborne
Droplet

2-5

Influenza

Airborne
Droplet

2-3

MEV-1
Fomites
Premutatio
n

MEV-1
Fomites
Postmutati
on

Med. Terminology: R0 (R nought)

Factors influencing R0 include:
Incubation period (time between exposure to pathogen
and symptoms)
How long someone is contagious for
Are they contagious without symptoms
How big population of people susceptible to virus

Med. Terminology: Ground Zero, Index

Patient
Ground Zero: location of
origin of the
virus/pathogen

Index patient: Original

victim of infection
(Source)
On right: sample web of
infection of AIDS starting
from index case

Index patient highlighted in red

Med. Terminology: Biosafety Levels

A biosafety level is a level of the biocontainment precautions required
to isolate dangerous biological agents in an enclosed laboratory
facility. The levels of containment range from the lowest biosafety level
1 (BSL-1) to the highest at level 4 (BSL-4).
At the lowest level of biocontainment, the containment zone may only
be a chemical fume hood. At the highest level the containment
involves isolation of an organism by means of building systems, sealed
rooms, sealed containers, positive pressure personnel suits
(sometimes referred to as "space suits") and elaborate procedures for
entering the room, and decontamination procedures for leaving the
room. In most cases this also includes high levels of security for access
to the facility, ensuring that only authorized personnel may be
admitted to any area that may have some effect on the quality of the
containment zone. This is considered a hot zone.

Med. Terminology: Biosafety Level 1

This level is suitable for work involving well-characterized agents not known
to consistently cause disease in healthy adult humans, and of minimal
potential hazard to laboratory personnel and the environment (CDC,1997).
At this level, precautions against the biohazardous materials in question are
minimal and most likely involve gloves and some sort of facial protection.
The laboratory is not necessarily separated from the general traffic patterns
in the building.
Work is generally conducted on open bench tops using standard
microbiological practices.
Usually, contaminated materials are left in open (but separately indicated)
waste receptacles.
Decontamination procedures for this level are similar in most respects to
modern precautions against everyday microorganisms (i.e., washing one's
hands with anti-bacterial soap, washing all exposed surfaces of the lab with
disinfectants, etc.).

Med. Terminology: Biosafety Level 2

This level is similar to Biosafety Level 1 and is suitable for work
involving agents of moderate potential hazard to personnel and the
environment.
It includes various bacteria and viruses that cause only mild disease
to humans, or are difficult to contract via aerosol in a lab setting
BSL-2 differs from BSL-1 in that:
laboratory personnel have specific training in handling pathogenic
agents and are directed by scientists with advanced training;
access to the laboratory is limited when work is being conducted;
extreme precautions are taken with contaminated sharp items; and
certain procedures in which infectious aerosols or splashes may be
created are conducted in

Med. Terminology: Biosafety Level 3

This level is applicable to clinical, diagnostic, teaching, research, or
production facilities in which work is done with indigenous or exotic
agents which may cause serious or potentially lethal disease after
inhalation.
It includes various bacteria, parasites and viruses that can cause severe
to fatal disease in humans but for which treatments exist
Laboratory personnel have specific training in handling pathogenic and
potentially lethal agents, and are supervised by competent scientists
who are experienced in working with these agents. This is considered a
neutral or warm zone.
All procedures involving the manipulation of infectious materials are
conducted within biological safety cabinets, specially designed hoods,
or other physical containment devices, or by personnel wearing
appropriate personal protective clothing and equipment. The laboratory
has special engineering and design features.

Med. Terminology: Biosafety Level 3

(cont)
It is recognized, however, that some existing facilities may not have all
the facility features recommended for Biosafety Level 3 (i.e., doubledoor access zone and sealed penetrations). In this circumstance, an
acceptable level of safety for the conduct of routine procedures, (e.g.,
diagnostic procedures involving the propagation of an agent for
identification, typing, susceptibility testing, etc.), may be achieved in a
biosafety level 2 (P2) facility, providing
The filtered exhaust air from the laboratory room is discharged to the
outdoors,
The ventilation to the laboratory is balanced to provide directional
airflow into the room,
Access to the laboratory is restricted when work is in progress, and
The recommended Standard Microbiological Practices, Special Practices,
and Safety Equipment for Biosafety Level 3 are rigorously followed.

Med. Terminology: Biosafety Level 3

(cont)

Top left: A researcher for the CDC working with the influenza virus
under biosafety level 3 conditions, with a respirator inside a biosafety
cabinet
Top right: Inside a Class III biological safety cabinet with an aerosol
control platform

Med. Terminology: Biosafety Level 4

This level is required for work with dangerous and exotic agents that pose a high
individual risk of aerosol-transmitted laboratory infections, agents which cause
severe to fatal disease in humans for which vaccines or other treatments
arenotavailable
This level is also used for work with agents such assmallpox that are considered
contagious enough to require the additional safety measures, regardless of
vaccination availability
When dealing with biological hazards at this level the use of a positive pressure
personnel suit, with a segregated air supply is mandatory.
The entrance and exit of a level four biolab will contain multiple showers, a
vacuum room, an ultraviolet light room, and other safety precautions designed to
destroy all traces of the biohazard.
Multiple airlocks are employed and are electronically secured to prevent both
doors from opening at the same time.
All air and water service going to and coming from a biosafety level 4 lab will
undergo similar decontamination procedures to eliminate the possibility of an
accidental release.

Med. Terminology: Biosafety Level 4

(cont)
Agents with a close or identical antigenic relationship to biosafety level 4 agents are
handled at this level until sufficient data are obtained either to confirm continued
work at this level, or to work with them at a lower level.
Members of the laboratory staff have specific and thorough training in handling
extremely hazardous infectious agents and they understand the primary and
secondary containment functions of the standard and special practices, the
containment equipment, and the laboratory design characteristics. They are
supervised by qualified scientists who are trained and experienced in working with
these agents. Access to the laboratory is strictly controlled by the laboratory director.
The facility is either in a separate building or in a controlled area within a building,
which is completely isolated from all other areas of the building. A specific facility
operations manual is prepared or adopted. Building protocols for preventing
contamination often use negatively pressurized facilities, which, even if
compromised, would severely inhibit an outbreak of aerosol pathogens.
Within work areas of the facility, all activities are confined to Class III biological safety
cabinets, or Class II biological safety cabinets used with one-piece positive pressure
personnel suits ventilated by a life support system.

Med. Terminology: Biosafety Level 4 (cont)

Top left: The circular containment tube separates the patient table in
the "hot" zone from the "cold" zone around
Top right: Inspection of positive pressure suits to locate any leaks

Med. Terminology: Human Subject

Research
Human subject research is systematic, scientific investigation
that can be either interventional (a trial) or observational (no
test article) and involves human beings as research subjects.
Despite not being explicitly named, in order to test a sample of
the attenuated MEV-1 virus, Dr. Ally Hextall uses herself in
human subject research.
Dr. Hextall inoculates herself with the experimental vaccine and
immediately visits her gravely ill father, who has been infected
with MEV-1
She does not contract the MEV-1 virus, and is able to declare
the vaccine a success.

Accuracies and Inaccuracies

1.
2.
3.
4.

Inaccuracies
Comparisons with Real Viruses
How Real Outbreak is Controlled
Unanswered Questions

Accuracies and Inaccuracies

To preserve the realism of the movie, many epidemiologists, including

those from the Centers for Disease Control and Prevention served as
advisors for the movie and helped to create an accurate perception of a
pandemic event.
In addition, the 2009 flu pandemic was also highly beneficial to the
conception and writing of the movie because it provided a glimpse of the
social disarray following the onset stages of a pandemic
The 2009 flu pandemic brought up questions that were also raised in the
film:
How does society handle the situation?
Do we keep schools open?
If we close schools who stays home with the kids?
How does the internet handle the pandemic?
What homeopathic and anti-viral treatment protocols will be
falsely published
This helped with the creation of the character Alan Krumwiede, a
conspiracy theorist who helps create fear and panic through the millions
of people he reaches on his blog with his homeopathic remedy forsythia
The movie was also good in depicting the hesitance of the government to
publicize details surrounding the pandemic for fear of causing
pandemonium as seen by the Chinese and US government officials

General Inaccuracies in the Movie

Doesnt teach much about how epidemiologists work

1.
2.
3.
4.

This is tough to include fully because of the lack of excitement in the

routine processes of epidemiological studies. It would not make for a
thrilling movie.

The process of an epidemiologicial study is as follows:

Establish that a problem exists
Confirm the homogeneity of the events
Collect all the events
Characterize the events as to epidemiological factors
1.
2.
3.
4.

5.
6.
7.
8.

Predisposing Factors
Enabling/Disabling Factors
Precipitation Factors
Reinforcing Factors

Look for patterns and trends

Formulate a hypothesis
Test the hypothesis
Publish Results

General Inaccuracies in the Movie (cont)

One of the vital points of the epidemiologist is to ask
the right questions

Doesnt always ask the right questions

The doomsday scenario is unlikely to occur

A virus that mutates to be easily transmissible between

humans is likely to become far less lethal
Evolution favor survival, and a virus that kills off too many
hosts will not survive long

Inaccuracies in the Movie:

Spread of Virus

The speed at which MEV-1 spreads is highly implausible

With SARS, it took three months before the epidemic was

reported to the WHO

More recently with H1N1 (swine flu), from March 18, 2009
(the first diagnosed case), to May 1, 2009, only an estimated
331 cases were diagnosed

Compare that to a death toll of 2.5 million in the US and 26

million worldwide for the MEV-1 virus

Inaccuracies in the Movie:

Portrayal of Public Health Officials
Contagion is also flawed in its portrayal of how public
health officials operate during an international
catastrophe
During a real pandemic, the CDC would interact with
other federal agencies, local and state health
departments, and with national and intergovernmental
agencies
The scale of response would also be larger. Contagion
only highlighted a few key health officials doing the
brunt of the work for the CDC, WHO, etc

Inaccuracies in the Movie:

Creation of Vaccine
The research and development leading to the MEV-1
vaccine is highly laconic, taking just twenty three days to
go from growth of the virus in the lab to the discovery of
a vaccine that works on a monkey
The research and development of this vaccine is achieved
by the help of three researchers
The vaccine that works on a single monkey is pronounced
usable in humans without further study and research.

Monkey and human immune response while similar are not

exactly alike. Therefore it is unknown whether a vaccine that
works in primates would immediately work in humans

Inaccuracies in the Movie:

Creation of Vaccine (cont)
It takes time for a vaccine to stimulate the
immunological defense system to produce an
adequate level of antibody to defend against a
pathogen
However in the movie Dr. Hextell, who identified the
possible vaccine, inoculate herself with the vaccine
and immediately visited her sick father to test the
vaccine, without giving it the required time to
stimulate creation of antibodies

Inaccuracies in the Movie:

Allocation of Vaccine
Contagions method for allocation of the MEV-1 vaccine
is very different from actual practices
In Contagion, the MEV-1 vaccine was allocated by a
random lottery
In comparison, the limited supply H1N1 vaccine was
given first to those most susceptible to infection and
those who might suffer grave consequences from
infection, and second to first responders, nurses, and
doctors, etc

Comparisons with Real Viruses: Nipah

Virus
1. Background
2. Similarities to MEV-1 Virus

Background on Nipah Virus

The MEV-1 virus was based partly on the Nipah Virus
The Nipah virus endemic began in 1998 in Malaysia with pigs. The
pigs began to twitch, cough, bite at the bars of their cage.
Eventually they exhibited bloody urine and collapsed and died.
Farmers developed fevers. Some would go into a coma and die.
Some farmers advertised and sold sick pigs to other farms and
farmers, spreading the disease.
The transmission of Nipah virus from flying foxes to pigs is thought to
be due to an increasing overlap between bat habitats and piggeries
in peninsular Malaysia. At the index farm, fruit orchards were in close
proximity to the piggery, allowing the spillage of urine, faeces and
partially eaten fruit onto the pigs.

Background on Nipah Virus (cont)

The outbreak was finally brought under control at the
end of May 1999.
By this time over a million pigs had been sacrificed and
almost half of the 280 identified human cases had
died.
Direct contact with sick pigs was determined to be the
primary risk factor
It was suspected and later corroborated that Malaysian
bats might help serve as a reservoir for Nipah virus.

Background on Nipah Virus (cont)

In the years following the initial outbreak, Nipah virus
jumped to Bangladesh and parts of India
It often had a very high mortality rate, nearing 60-75
percent of its victims
However there was no evidence of person to person
contact ---- it always required contact with a pig

Background on Nipah Virus (cont)

Symptoms of infection from the Malaysian outbreak were
primarily encephalitic in humans and respiratory in pigs.
Later outbreaks have caused respiratory illness in humans,
increasing the likelihood of human-to-human transmission
and indicating the existence of more dangerous strains of the
virus.
In humans, the infection presents as fever, headache and
drowsiness. Cough, abdominal pain, nausea, vomiting,
weakness, problems with swallowing and blurred vision are
relatively common. About a quarter of the patients have
seizures and about 60% become comatose and might need
mechanical ventilation.

Similarities and Differences with MEV-1

Virus
Similarities:

Genetic Recombination of viruses from bats and pigs

leading to a virulent human-affecting pathogen

High mortality rate of those infected

Differences:

Symptoms of infection

Transmission of disease (Pig to person, not person to

person

Comparisons with Real Viruses: SARS

1. Background
2. Similarities to MEV-1
3. Differences from MEV-1

Background on SARS
Severe acute respiratory syndrome is a viral respiratory
disease caused by the SARS coronavirus.
The SARS epidemic started in the Guangdong Province of
China between late 2002 and early 2003.
Within a few months populations throughout the world
were affected.
Chinese government officials did not inform the World
Health Organization of the outbreak until February 2003.
This lack of openness caused delays in efforts to control
the epidemic

Background on SARS (cont)

The SARS epidemic was first picked up in November 2002 when
Canadas Global Public Health Intelligence Network found
reports of a flu outbreak in China through monitoring of internet
media.
The epidemic reached greater heights in February 2003 when
an American businessman traveling from China became afflicted
with flu-like symptoms
The businessman died in Vietnam, but not before passing on
SARS to medical staff who treated him
This threat was later communicated to the WHO by a doctor
who later succumbed to the disease.

Background on SARS (cont)

The severity of symptoms alarmed global health
authorities
In March 2003, the WHO issued a global alert, due to
its high contagion level which was rapidly spread by
travelers sharing international flights
The alert contained precautionary measures,
preventative measures to be taken by individuals, and
hygiene information to help mitigate the spread of
SARS

Background on SARS (cont)

Symptoms of SARS: Initial symptoms are flu-like

Fever above 100 F (38 C)

Myalgia

Lethargy

Cough

Sore Throat

Shortness of breath

Occasionally leads to pneumonia

Similarities to MEV-1
Both SARS and the MEV-1 virus emerged in remote
locations in China
Both were carried to Hong Kong by infected people
Both were carried worldwide by air travellers
Both are transmitted by airborne droplets as well as by
fomites

Differences from MEV-1

SARS and MEV-1 have differing symptoms
SARS symptoms:

Fever above 100F, Myalgia, Lethargy, Cough, Sore Throat,

Shortness of Breath

MEV-1 symptoms:

Cough, Headache, Fever, and as a prelude to death,

foaming at the mouth

Differences from MEV-1

Both SARS and MEV-1 generated problems for health
delivery and public health systems
Both disrupted air travel and international trade
However only MEV-1 had a military response to the
disease and collapse of civil society in most affected
areas

Differences from MEV-1

SARS and MEV-1 have differing mortality rates

SARS Mortality Rate: ~10%

MEV-1 Mortality Rate: ~25%

SARS and MEV-1 have differences in scale:

SARS is estimated to have sickened 8100, killing 775 by

the end of 2003.

MEV-1 killed millions worldwide

Unanswered Questions from Movie

Being a movie, Contagion does at times lack realism in the
feasibility of events that occurred
How do Mitch and Jory Emhoff survive in quarantine for four
months when food supply quickly runs out?
The quarantine and isolation of big cities in the US are enforced
by the military because contemporary social order falls apart.

How does the military effective do this?

Why do they not also get sick in the same numbers as the rest of
the world?

Why is there not large scale defection from the military, same as
the 25% reduction in capacity that the police encountered?

Unanswered Questions from Movie (cont)

The movie also leaves questions unanswered in the resulting
effects of the epidemic on the rest of the world.
How does the rest of the world fareswith their vaccinations?

What happens with the strain of the virus that mutated in

Africa to have an R0 of 4 (vs the original strain with an R0 of
2)?
Is the vaccine also effective against this strain?

Does the virus mutate more given the massive condensation

of timeline regarding virus spread, infection, and study?

How Real Outbreak is Controlled

If a pandemic should occur, the CDC would conduct an
investigation and provide technical assistance to the
locations dealing with outbreak
Assistance includes:

Consultation

Lab Testing and Analysis

Patient Management and Patient Care

Tracking of contacts

Infection Control

How Real Outbreak is Controlled (cont)

Primary goals of CDC:

Determine the Cause of the Illness

Determine the source of the infection

Learn how the pathogen is transmitted and how readily it

is spread

Learn how to break the cycle of transmission and prevent

further cases

Learn effective treatment methods

How Real Outbreak is Controlled (cont)

Scientists would be working to identify the cause and
cure of outbreak
The CDC and other federal and international agencies
would send medical teams and first responders to help
those in affected areas
Scientists would also work to develop a vaccine to
combat the virus, distribute the vaccine and
administer the vaccine to the public

Lessons Learned
1. Social Commentary
2. Power of Internet and Social Media
3. Epidemic Preparedness (General & Movie Takeaways)

Lessons Learned:
Social Commentary
A large part of the overarching commentary regarding
reaction to the pandemic in Contagion is social
There is mass hysteria and panic, riots, disorder
This raises many personal questions

How are people likely react to hearing that a new highly

contagious, highly potent virus has been found and is propagating
around the world?

How are people going to react when insufficient drugs to

counteract these new pathogens are available?

How will we decide how and to whom the drugs are distributed

Will there be similar violent reactions and looting as in the movie?

Lessons Learned:
Social Commentary
An overarching theme of the movie is the reluctance of
government officials to inform the public about the
epidemic for fear of inducing panic
Both the US and Chinese governments exhibit this
behavior, citing the reaction to other epidemics as
examples (H1N1)
Similar reactions can be found in real life to Ebola,
Swine Flu, etc

Lessons Learned:
Social Commentary
Contagion helps show that we are unprepared for such
panic driven behavior.
Yes, the movie does show use of the military as an effective
tool to counteract this rowdy social behavior.

However what happens when the people revolt against the

military as well?

What happens when the military gets sick, or people desert

from the military due to unsafe conditions?

Contagion helps show us that when pervasive, panic is a

very strong tool for destabilizing society and driving public
action

Lessons Learned:
Power of Internet and Social Media
Social Media and the Internet often propagate the
hysteria and panic surrounding epidemics
They help drive this by the large amounts of
misinformation and false-truths that are readily
available and accessible by billions of people
Fear spreads faster then the disease itself

Lessons Learned:
Power of Internet and Social Media
In Contagion, the blogger and freelance writer Alan
Krumwiede, convinces his 12 million followers that the
government is lying and their vaccine is useless
Instead he pitches his own homeopathic remedy,
forsythia
He pretends to have contracted the virus and to have
cured himself through use of forsythia, going so far as
to team up with hedge funds and other corporations to
get rich off sales of the drug much like Vicks VapoRub
did after the flu epidemic of 1918.

Lessons Learned:
Power of Internet and Social Media
Krumwiedes actions lead to mass hysteria of people seeking forsythia.
They overwhelm pharmacies causing violent riots and increasing the
spread of infection
His claims attract national attention from where he is able to discredit
the CDC and their lead doctor, Dr. Cheever, further adding fuel to the
fires of fear
Despite later being arrested for conspiracy and securities fraud, and
blood work proving that he never actually contracted the virus,
Krumwiede is released on bail through donations from his fans
His arrest would have been inconsequential, having already stoked
societys fears

Lessons Learned:
Power of Internet and Social Media
Krumwiede helps reflect the growing influence of the
internet and social media through blogs and other
websites on public opinion
Not only do they disseminate information rapidly, they
hold such a large audience of easily swayed people,
without many checks on the factuality of information
displayed

Lessons Learned:
General Epidemic Preparedness
There are weak links and blind spots around the world that lack the
health systems needed to detect an outbreak before it becomes a
crisis.
Less than 20% of countries have reported meeting WHO
requirements showing they are adequately prepared to respond to
emerging infectious threats
There needs to be increased local disease prevention and
monitoring systems, improved laboratory facilities and
strengthening of emergency response to outbreaks
The ripple effect that one unprepared country can have
Learning to tackle one disease can pay off against each other

Lessons Learned:
General Epidemic Preparedness
The importance of preparedness at the hospital level
The expected volume of patients in a pandemic
highlights the need for plans that incorporate
measures to provide quality care to affected patients,
protect health care personnel from from health care
associated infection, and maintain continuity of core
operations in the face of an epidemic

Lessons Learned:
General Epidemic Preparedness
Comprehensive EPRI plans must address the following:

Screening, surveillance, and tracking of exposed individuals

Controlled hospital access
Prevention strategies
Isolation and cohorting
Personal protective equipment use
Vaccination
Antiviral prophylaxis
Modification of environmental controls

Disease-specific admission criteria, treatment, and triage

algorithms
Continuity of limited clinical operations

Lessons Learned:
Epidemic Preparedness
We are badly prepared for future outbreaks

A study examining the initial response of health care

institutions to H1N1 found that more than half of hospitals
neglected important infection prevention measures

One month after the release of the release of the H1N1

vaccine, only seven percent of high priority adults were
vaccinated

Lessons Learned:
Epidemic Preparedness
Better coordination is necessary
Many agencies are responsible for responding to a
pandemic emergency and it is complex to ensure that
the communication and coordination between
agencies leads to effective responses to emergency
situations

Contagion in Popular Culture

Today: Plague Inc
1. Overview of Plague Inc
2. Lessons Learned from Plague Inc

Plague Inc

Overview of Plague Inc

Plague Inc is a $.99 app for the Iphone and Android
phone systems
Within the game, players select a pathogen and
strategize how to evolve the disease to successfully
wipe out humanity by evolving symptoms,
transmission of the disease and countering actions
taken by world governments and scientists

Overview of Plague Inc

The critical stage in the game is the Infection Cycle
that dictates how people become infected with a
disease and how they infect others.
The core design of this stage is based on the concept
of R0, the basic reproduction rate

Lessons Learned from Plague

Inc
In March 2013, James Vaughan, the developer of Plague Inc was
invited to talk at the CDC about Plague Inc.
He spoke about how he had modeled the spread of infectious
disease in the game and how the game can be used to inform
and educate the public
The CDC is interested in Plague Inc because it creates a
compelling world that engages the public on serious public
health topics
It is a tool that can be used to teach the public about outbreaks
and disease transmission using a non traditional route to raise
public awareness on epidemiology, and disease transmission