August 1, 2000

Bioterrorism — Are We Prepared?

For most of us, bioterrorism seems out there with alien invaders as something likely to occur on television but not in real life. Or perhaps if we do think about it more in terms of the here and now, a sort of panicky sense of "It's too scary, " sets in and we push it out of our minds as quickly as we can.

Hospital emergency rooms, however, don't have this luxury. Many of them have begun to develop procedures for dealing with various bioterrorist events because, in the past twenty years, there have been a number of bioterrorist attacks around the world:

1979 An accidental release of anthrax spores from a Russian military base in Sverdlovsk kills between 40 and 1,000 people. The number remains unknown because of a massive Soviet cover-up.
1984 Attempting to disrupt a local election, members of a religious cult poison 751 residents of The Dalles, Oregon, by contaminating restaurant salad bars with salmonella.
1995 A dozen commuters are killed when members of Aum Shinrikyo, another religious sect, intentionally release Sarin, a type of nerve gas, on a Tokyo subway.
1996 An unknown person leaves muffins contaminated with a rare and dangerous bacteria in a Texas hospital.
1998 FBI agents seize small amounts of a substance reported to be anthrax from two men in Las Vegas.
2000 A Texas man is indicted for causing an anthrax scare, becoming the first person in the nation to face such charges. He left a vial of what was alleged to be anthrax , but which actually contained water, in a bin at the U.S. Postal Service mail center.
2000 Anthrax contamination threats are made against numerous Planned Parenthood clinics across the U.S. So far, none has been carried out.

Bioterrorism is not a paranoid fantasy. It did not die with the end of the Cold War. It does not happen only in obscure Third World conflicts. Ironically, the threat of a massive chemical or biological attack, especially with certain infectious agents such as smallpox and anthrax, exists because of the achievements of modern medicine that have eradicated these scourges.

Together with recent advances in biotechnology, that have made it very easy to mass-produce microorganisms, we now face a real threat from these biological agents. What do we know about smallpox and anthrax? Is there anything we can do to protect ourselves and our communities from such agents?

Smallpox is an extremely contagious viral disease. Capable of killing up to 40% of those it infects, smallpox has afflicted mankind since prehistory in successive waves of great epidemics. Imported by European explorers and settlers to the New World, it killed more Native Americans than all the settlers' bullets and swords.

Smallpox can be contracted through breathing or by contact with the skin of an infected person. After an incubation period lasting approximately two weeks, sufferers come down with fever and aches. A few days later, blisters spread over the body. These blisters fill with pus, then open and crust over, causing painful itching. Those who survive the disease are left with terrible pockmark scars.

In the 20th century, the worldwide vaccination campaign against smallpox achieved amazing results."

While there is no actual treatment for smallpox, Englishman Edward Jenner, in 1796, used the related cowpox virus to create immunity to smallpox. The word vaccination derives from "vacca," the Latin word for cow. Modern versions of Jenner's vaccine gave complete immunity from smallpox, as long as periodic booster shots were taken. But if the booster shots are not continued, the degree of immunity provided by the vaccine gradually declines, over several years, to zero.

In the 20th century, the worldwide vaccination campaign against smallpox achieved amazing results. By the 1960s, the disease was eliminated in the U.S. and vaccinations ceased in 1971. In 1980, the World Health Organization (WHO) declared that smallpox had been eliminated worldwide.

Today, smallpox virus is known to exist in only two places: in stores maintained by the U.S. Centers for Disease Control and Prevention (CDC) and by the Russian government. However, fears that other nations or organizations may have secret stockpiles of the disease prompted WHO to postpone, until at least 2002, its controversial plan to destroy all remaining stocks of the smallpox virus. Critics of the plan had argued that samples of smallpox might be needed for research purposes in the event of an attack or outbreak.

In 1998, Dr. Donald A. Henderson, the scientist who directed WHO's smallpox eradication program from 1966 to 1977, warned that smallpox still presents a formidable danger to mankind. Speaking of the former bioweapons center at Novosibirsk in Russia, he recalled that through the early 1990s, the 30-building facility had been surrounded by electric fences and patrolled by an elite guard. Recently, however, the facility stood decrepit, half-empty and poorly guarded. "There's no way of knowing for sure where all the scientists have gone," he said. "Nor is there confidence that this is the only storage site for smallpox virus outside CDC." Some Russian scientists from Novosibirsk are rumored to have traveled to Iran to participate in bioweapons research there.

Henderson and other experts worry that smallpox would make an effective weapon against the United States. One reason is that almost no American has been vaccinated or received an immunization booster for 30 years. This means that; only an estimated 15% of the U.S. population currently has immunity from the disease. Furthermore, since smallpox has been unknown in the United States for decades, doctors would not immediately recognize its symptoms. And even if they did, they would have few weapons against the disease. The United States currently has enough smallpox vaccine for about seven million doses. Another problem would occur when doctors and hospital staff began to contract the disease. "Who would care for the patients?" Henderson asked. "Few hospital staff have any smallpox immunity."

Recently, fear of terrorism led the U.S. government to fund a St. Louis University study to examine the possibility of stretching existing stocks of the vaccine, which has not been manufactured since the early 1970s, by using them in a diluted form. Another possibility being investigated is the development of a weakened strain of related virus, modified vaccinia Ankara ((MVA).

Can You Get Vaccinated?
Smallpox vaccinations were once a routine part of growing up. Look at the upper arm of anyone over 35 and you will probably see the telltale circular scar that the vaccination produces.

Suppose you wanted to get a smallpox vaccination, or a booster shot, in the year 2000. Could you?

An editor at TheDoctor asked his pediatrician, New York-based Dr. David Horwitz who practices at a university medical center, whether he could have his two children, 9 and 11, vaccinated and whether he could arrange for a booster shot for himself.

The answer was a definite no.

"No one has ever asked me for a smallpox vaccination and I wouldn't know where to go to get some," Dr. Horwitz said. "I am sure that there is none available."

Dr. Horwitz went on to explain that this is a public health issue, not something that individual patients can — or should — be able to decide for themselves. "Every vaccine carries with it the risk of a negative, even serious, reaction and there is always a trade off between the risk from vaccination and the risk from contracting the disease itself;" he added, "in the case of smallpox it is an easy call because there is virtually zero risk of anyone becoming infected with the disease."

But what if a terrorist released smallpox into the environment, what would be the risk then? There is no gentle way to say this — smallpox is extremely contagious and deadly. Everyone would have to be vaccinated to stop its spread. Unfortunately, as of 1999, only seven million doses of the vaccine were available in the entire United States. How much vaccine is this? Consider that in1947, six million New Yorkers were vaccinated in one week in response to a smallpox outbreak that affected eight people.

The good news about anthrax is that, unlike smallpox, it can be successfully treated with antibiotics. The bad news is that those infected may not know that they have been exposed, a serious problem because anthrax needs to be treated quickly.

The airborne form of the disease is far more dangerous, causing lesions in the lungs and brain.

Although its use is banned by international convention, anthrax has long been the most popular subject of study for bioweapons research. While it is not contagious from human to human, very small quantities of anthrax spores released into the air could kill or sicken large numbers of people. Anthrax is an especially dangerous biological weapon because it can survive for long periods in the environment. According to WHO estimates, if 50 kilograms of anthrax spores were released along a two-kilometer line upwind of a city of 500,000 people, 125,000 would become infected within three days, of whom 95,000 would die.

When spread by contact with infected sheep, horses, hogs, cattle or goats, anthrax rarely kills humans, though it is almost always fatal to the animals. The airborne form of the disease is far more dangerous, causing lesions in the lungs and brain. Because the anthrax spores are odorless and colorless, by the time an infected person seeks treatment, it may already be too late to help — the death rate from inhaled anthrax is close to 100% if not treated within 24 to 36 hours of onset of symptoms.

In the 19th century, Louis Pasteur developed a method of vaccinating sheep and cattle against the disease. As a result of widespread animal vaccination, anthrax is rare in the United States, though quite common around the world. Because a dried form of anthrax spores can be loaded into artillery shells, bombs and missiles or sprayed from airplanes, the U.S. Armed Forces began, in 1998, a program, now 85% complete, to vaccinate all 2.4 million active-duty and reserve members against anthrax. But what about the rest of us?

A lesson from the military experience serves as a warning. So far, the military has had a tough time convincing all of its troops that the vaccination is safe. Numerous servicemen and women have refused to be vaccinated, even in the face of court-martial. Will vaccination of the public be any easier?

What Are the Symptoms?
Anthrax symptoms look like a virus infection or a cold — fever, cough, complaints of chest pain, muscle aches and fatigue. A doctor might suspect bronchitis or sinusitis. But, unlike your average cold, respiratory anthrax doesn't get better with rest and fluids. The fever goes higher, blood pressure drops and some patients can become delirious. Sometimes, it's only because other patients show up in the E.R. with the same story that the medical staff will begin to suspect they're dealing with an illness more dangerous than the common cold.

Is There a Treatment?
Intravenous doses of the antibiotics ciprofloxacin or doxycycline are effective against anthrax if given soon enough. Although there have been no reported cases of human-to-human transmission of inhaled anthrax, those who have been in close contact with an infected person should be treated with the above antibiotics, plus anthrax vaccine, for at least four weeks. The reason for this is that cases of anthrax have been known to occur, suddenly, many weeks after exposure.

Is There Anything You Can Do?
Start by contacting your local hospital and civil defense unit. Ask whether they have a plan to deal with bioterrorism. If they don't, suggest to them and to other members of your community that it might be a good idea to have a plan. Ask your doctor, emergency medical workers and other health care providers to become involved. Sensitivity to the possibility of bioterrorism, as well as information about the signs and symptoms of these diseases, are important first steps that may, one day, help to prevent their epidemic spread.

A community will need a disease reporting system. Insist that your local health department have one. Raise the issue of prophylactic immunization. It deserves debate and consideration but, remember, that the issue is not one-sided. In the smallpox outbreaks in the United Kingdom in 1961-62, 5.5 million people were vaccinated and at least 18 deaths were attributable to the vaccinations.2 Today, with many people immunocompromised (from diseases like HIV, or after cancer therapy or transplantation) more people can be expected to have adverse, sometimes fatal reactions to the administration of live vaccine.

The mastery that modern medicine achieved over these once-common organisms has caused us to let our guard down against these virtually extinct diseases. Without adequate amounts of vaccine or knowledgeable medical staff, we may now be as vulnerable to smallpox and anthrax as our pre-scientific ancestors living before the discoveries of Edward Jenner and Louis Pasteur.
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