Infections: Public Health and Bioterrorism: Learning the Lessons of the Anthrax Attacks

July 31, 2010

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Public Health and Bioterrorism: Learning the Lessons of the Anthrax Attacks

Richard E. Dixon, M.D., and David J. Sencer, M.D., M.P.H.

Dr. Sencer is Director Emeritus of the Federal Centers for Disease Control and Prevention (CDC) and Dr. Dixon is the former head of CDC's Hospital Infections Branch. Neither is currently affiliated with CDC.

Disclaimer: Drs. Dixon and Sencer have not consulted with the Centers for Disease Control and Prevention in the preparation of this article and the opinions expressed and actions proposed are those of the authors.

Before October 2001 there was a lively debate in the medical world about whether the U.S. public health system should put significant amounts of its limited resources into preparations for a possible bioterrorist attack. The issues are well summarized by two articles published on TheDoctorWillSeeYouNow. In the first, entitled "Bioterrorism — Are we Prepared?", Dr. Martin Carey argues that the U.S. faces "a real threat" of terrorist attack using smallpox, anthrax, or some other biological agent. In the second ("Scare Stories Can Be Dangerous to Your Health") Drs. Cohen, Seidel and Gould disagree, asking instead: "Is it hype?"

Now the debate is not whether or not but how — how to prepare for and respond to the next attack.

All this has changed since the September 11 terrorism and the anthrax attacks that occurred shortly afterward. Now the debate is not whether or not but how — how to prepare for and respond to the next attack.

The anthrax attacks and their aftermath continue to rewrite what is known about the clinical and public health approaches to epidemics caused by anthrax and bioterrorism in general. Four points are already clear:

Doctors, ER staff and other front line medical professionals should now routinely consider whether patients have been the victims of an attack by biological agents. In the recent series of anthrax attacks, several people died primarily because those treating them, quite understandably, never considered anthrax infection as a possible diagnosis.
Other specialists may be the first to encounter a bioterrorist victim. It was a pediatric dermatologist who determined, early in the anthrax epidemic, that the infant daughter of a television network employee had the characteristic lesion of cutaneous (skin) anthrax.
In any bioterrorist attack or new epidemic, the first cases may be hard to recognize. Many unusual infections produce initial symptoms and signs that resemble those of more common conditions. Bioterrorism agents will not necessarily have tell-tale signs that can be counted on to raise an alarm.
Illnesses caused by naturally occurring, emerging infections are likely to present the same kinds of treatment and management problems as those caused by bioterrorism. Public health policies and medical treatments that are aimed at one group of infections will also be generally effective against another.

There is no easy answer to all of the problems presented by bioterrorist attack. A good first step for both professionals and patients would be, we believe, for every doctors' office, clinic and hospital to adopt a new screening protocol for every patient:

identify patients who may have been exposed to dangerous pathogens,
order infection control precautions that will prevent spread to others,
collect clinical information and laboratory specimens,
immediately notify public health authorities, and
arrange appropriate treatment and follow-up care.

These simple actions are the critical first steps toward protecting all of us against bioterrorism and other dangerous infections. Once they have been taken, appropriate investigations and actions can proceed. Without them, important epidemics may not be recognized promptly and many people could be put at risk.

Infectious Agents To Watch

There are hundreds, if not thousands, of microorganisms or their toxic products that could be used as agents for bioterrorism (BT) or biowarfare (BW). Many of these are already available from commercial or natural sources.

For example, Bacillus anthracis, the microorganism causing anthrax, was relatively easy to obtain from commercial, academic and government laboratories until recently. And not only from labs — naturally occurring anthrax is still present in many parts of the world. Viable anthrax spores contaminate sites in the United States and occasional outbreaks of anthrax may occur because of exposure to these sites or imported animal products.

Many of the agents that can be used in BT and BW attacks can also be produced in large quantities and more cheaply than, for example, nuclear or chemical agents. Microbiologic agents have the added advantage that they can affect very large populations, and in such small quantities that they can be easily hidden and transported.

Only a few of the many potential agents are believed, however, to represent a real threat. This is because most potential agents cannot cause the kinds of diseases or disabilities that will incapacitate an enemy or terrorize a population. And many cannot be converted into a form that allows them to be delivered efficiently or to cause high infection rates (i.e., they are difficult to "weaponize"). Immunizations are available for other potential BT and BW agents, while preventive or early treatments can blunt the effects of others.

As a result, at the present time, only about 25 types of biologic agents have been identified as likely threats. Of those, seven have been given the highest priority ("Category A" agents) by the Federal Centers for Disease Control and Prevention (CDC):

Variola major (smallpox)
Bacillus anthracis (anthrax)
Yersinia pestis (plague)
Clostridium botulinum toxin (botulism)
Francisella tularensis (tularemia)
Viral hemorrhagic fever agents, which include the Filoviruses, which produce illnesses such as Ebola and Marburg hemorrhagic fevers
Arenaviruses, causing illnesses such as Lassa (Lassa fever), Junin (Argentine hemorrhagic fever) and related illnesses

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