May 10, 2006 (CIDRAP News) The creators of the fictional ABC-TV movie "Fatal Contact: Bird Flu in America" blended medical facts from the 1918 influenza pandemic with current predictions from flu experts to portray a contemporary flu pandemic, but they added a liberal dash of sensationalism.
The disease shown in the film, aired May 9, bore a strong resemblance to the illness that killed an estimated 675,000 Americans in 1918 and 1919. And a good many of the issues raised came straight out of the US government's pandemic preparedness plans and recent news stories about possible pandemic scenarios. But some scenes and details went well beyond what happened in 1918 or what is plausible today. And along the way, important medical details were left out.
In the drama, H5N1 avian flu begins to spread from person to person in China, signaling the start of a pandemic. An American businessman contracts the virus and brings it back to his home in Virginia, where he spreads it to others before falling desperately ill. Soon, cases are spreading across the United States. As panic spreads, the governor of Virginia quarantines neighborhoods where cases have cropped up, and federal officials confess they have no vaccine and scant supplies of antiviral drugs. Major socioeconomic disruption sets in, with shortages of food and medical supplies, power outages, and riots in the streets of New York. Eventually (after countless numbing commercials), the pandemic begins to subside. But in the final scene, the discovery that the entire population of an Angolan village has died heralds a new mutation of the virus and a second wave of cases.
The illness in the American businessman who has the first US case in the film clearly resembles the illness that struck many in 1918. After fits of violent coughing, he suddenly collapses on the job, blood streaming from his nose. He later dies of acute respiratory distress. At his autopsy, a CDC doctor says, "He coughed so violently he tore apart his abdominal muscles. He basically drowned in his own blood."
The 1918 pandemic produced similar reports: people collapsing suddenly, coughing up blood, and autopsies revealing lungs clogged with fluid, the imprint of the "cytokine storm," or immune system overreaction. The businessman's copious nosebleed might have seemed sensational, but it had a basis in fact. "The nosebleed was described in 1918," said Michael T. Osterholm, PhD, MPH, director of CIDRAP. "They made it fairly extreme."
The 200-plus human cases of H5N1 that have occurred over the past 3 years have been severe as well, of course, but just how closely the movie portrayal resembles them is not clear from our perspective. In any case, in depicting a 1918-like illness, the producers deliberately chose a worst-case scenario. While disease experts agree that a flu pandemic is inevitable sooner or later, they don't believe it will inevitably be as severe as in 1918. Even if the H5N1 virus is the pathogen, in acquiring the ability to spread from person to person, it could become less virulent. The other two 20th century pandemics, in 1957-58 and 1968-69, were far milder than 1918. The fact is that no one knows how severe the next pandemic will be.
"Fatal Contact" portrayed a number of difficulties and dilemmas that public health planners are envisioning now as they prepare for a pandemic. Some examples include the necessity of rationing vaccine and ventilators, overwhelmed hospitals, the use of overflow hospitals, shortages of healthcare workers as staff members stay home to care for their families, shortages of ordinary drugs and medical supplies, such as insulin, and food shortages caused by disrupted transportation systems.
On the vaccine front, the movie made a bad situation look even worse. It depicted the government as having no vaccine at all at the outset of the pandemic. In reality, the government is stockpiling a "pre-pandemic" vaccine based on the H5N1 virus. The supply is small, and studies have shown it takes two large doses to generate an adequate immune response, which occurs in only about half of those vaccinated. But this vaccine would probably be better than nothing if a pandemic began today.
In some scenes, the movie clearly went over the top. One was the governor's decision to quarantine some neighborhoods behind chain link and barbed wire, an obviously futile measure with the pandemic well under way. "I can't imagine any elected official doing that," said Osterholm. "I think pressure would be brought to bear by other government leaders" to prevent it.
Another example was the film's grimmest scene, in which dump trucks back up to a large pit and dump mounds of shrouded human bodies into it. This too may have been inspired by the 1918 experience. In that pandemic, the city of Philadelphia was overwhelmed by the number of corpses, and mass graves were used for a time. But there is no record of bodies being unceremoniously dumped, and such a scenario seems inconceivable today.
"Corpse management will be a real concern [in a pandemic], but I can't imagine under any condition we would put bodies in the back of a truck and dump them in," said Osterholm.
The end of the film, in which an entire Angolan village appears to have been wiped out, is another example of sensationalism. Osterholm, who previewed the film but was not involved in it, commented in a news conference this week that the scene "looks like the Jonestown massacre, not something caused by infectious disease." A 100% fatality rate would be highly unlikely with any virus. In fairness, the producers told the New York Times that the scene was meant to show a village that was emptied by a combination of evacuation and disease.
Another scene in the film has armed men trying to seize a van carrying a supply of vaccine, only to be shot by soldiers. That looked extreme, but Osterholm found it conceivable. "I don't think that one was necessarily unreal," he says.
For those interested in medical and epidemiologic details, the film left some major questions unanswered. There was no indication of the case-fatality rate, for one thing. It appeared that only two characters who had the disease survived (the son of the businessman, and a soldier who got sick while in Iraq), which implied a very high fatality rate. But no clear information was given. Nor was there any indication of the age distribution of cases. Was it the typical pattern, with the very young and very old most affected? Or did the illness hit young adults the hardest, as occurred in 1918? It wasn't clear.
The production also gave birders and conservationists reason to complain. It began and ended with scenes of wild geese in flight, implying that wild birds are the main carriers of the H5N1 virus around the world. This question is hotly debated, but most experts would probably say that both wild birds and poultry handling practices play a role in spreading the pathogen.
This commentary was written by the CIDRAP Editorial Staff.
US Department of Health and Human Services information about "Fatal Contact"