Headline: Bioterror threat tests front lines of medicine

Source: Gareth Cook and Beth Daley, Boston Globe, 1 October 2001, page A1

URL: http://www.boston.com/dailyglobe2/274/nation/Bioterror_threat_tests_front_lines_of_Medicine+.shtml

When the third exhausted student stumbled into his infirmary last March with a soaring fever and an inexplicably sore chest, Dr. Richard Pacropis thought one thing: outbreak.

Through dry, hacking coughs, the students told different stories with a few common elements: spring break, Acapulco, the Calinda Beach Hotel. Pacropis, a physician at Villanova University in Philadelphia, called a local hospital, the hospital contacted the state, and within four days the Centers for Disease Control in Atlanta had issued a nationwide alert.

As more sick students came forward across the country, doctors identified the culprit as histoplasmosis, a potentially life-threatening fungal infection. Word went out, and the sick students - 221 of them, from 37 colleges - were all saved.

With a worried public shaken by the threat of bioterrorism, specialists in biological warfare say people should be thinking about scenes like this: a few patients trickling in, with symptoms not so different from the flu. More than anything else, they say, it is the speed with which front-line doctors determine something unusual is happening that could make the difference between a treatable crisis and tragedy.

''If things worked this well in an actual attack, it would be great,'' said Dr. Andre Weltman, a physician with the Pennsylvania Department of Health, who quickly alerted the CDC about the student outbreak. ''They don't always.''

It would be very hard, say many scientists and engineers, for terrorists to construct a biological weapon capable of inflicting anywhere near the number of casualties seen on Sept. 11. Yet, public concern over bioterrorism is high. And just as the 1993 bombing of the World Trade Center might have provided hints of how the recent disaster may have been prevented, public health officials say the clues for stopping a biological attack are everywhere.

From this year's histoplasmosis scare to a 1994 plague outbreak in India to a bizarre string of Oregon salad bar poisonings in 1984, they say the secret to being prepared lies in seeing an attack as an extension, albeit an extreme one, of what doctors confront every day.

''We have to use the same principles we use to deal with all unusual diseases, whether they are from a bioterrorism attack or not,'' said Dr. Anita Barry, the director of communicable disease control at the Boston Public Health Commission.

Over the course of history, disease has been a far more lethal foe than any manmade weapon. The flu killed more than 20 million in 1918. The bubonic plague, or Black Death, took down a third of Europe in the 14th century. One estimate puts the total toll of smallpox at more than half a billion people.

From the early days of lobbing plague-infected bodies over ramparts, the technology of biological warfare has advanced a great deal. A bag of refined, powdered anthrax spores, such as the Soviet Union is known to have made, holds the potential to annihilate entire neighborhoods. And Osama bin Laden, thought to be the mastermind behind the Sept. 11 attack, has declared that killing Americans with weapons of mass destruction is not only justified, but noble.

While the United States may have been lax about its security before, however, there is now a danger of terrifying the public when change, not panic, is needed, says Amy Smithson, a biological weapons specialist with the Henry L. Stimson Center, a think tank in Washington, D.C.

''These formulas have been out there since World War I,'' said Smithson. ''What isn't written in the textbooks are the tricks of the trade for scaling these up into weapons.''

Anthrax is still very difficult to turn into a bioweapon, according to David R. Franz, the former director of the Army's infectious disease research institute.

One obstacle to would-be weapons developers, he said, is figuring out how to distribute the disease without killing it in the process. In the lab, anthrax grows as a bacterial mush that is very hard to disperse. The Soviets, with a massive research program and top scientists, figured out a way to create a smooth anthrax powder that could infect people who inhaled it, but the technique is very challenging.

To spread anthrax in its more common liquefied form, a terrorist would have to figure out how to spray it in droplets small enough to be breathed in by victims. A crop-duster plane is not equipped to spray poison this way.

''Then you have to deal with meteorology,'' said Franz. Wind can easily disperse an agent until it reaches concentrations too low to cause a health problem. And many contagions, such as plague, break down surprisingly quickly when exposed to heat and to ultraviolet sunlight, he said.

One of the most infamous terrorist attacks was the 1995 release of sarin gas in the Tokyo subway by the Japanese cult Aum Shinrikyo, which killed 12 people. But Smithson points out that the same cult, which was extremely well-funded and had access to highly trained Japanese scientists, never managed to hurt anyone with anthrax despite years of trying.

Anthrax is also treatable with strong antibiotics - though only if caught in time, usually meaning before the symptoms begin. Although a vaccine exists, the United States has a limited supply that is reserved for the military.

Smallpox remains a far more disturbing possibility, analysts said. Unlike anthrax, it spreads easily from person to person. And unlike other potential bioweapons, there is no cure. (There is a vaccine, but not enough to handle a major outbreak.)

The United States and Russia have the only remaining official supplies of smallpox, which was eradicated in 1977. Both stocks are heavily guarded. Many analysts suspect that other governments still have stocks, but would be unlikely to share them willingly with terrorists - if only because an outbreak could easily backfire and devastate their own populations.

For all the challenges, officials say it is only a matter of time before someone at least tries to spread a biological agent. And then a quick response becomes critical. With any outbreak of disease, whether natural or manmade, the great enemy is time.

''Noticing early can reduce the number of deaths, sometimes by an order of magnitude,'' said Michael Shannon, the associate chief of emergency medicine at Children's Hospital and a member of the Greater Boston Biodefense Collaborative.

But the front line of defense is scattered: It consists of busy ER doctors and the primary-care physicians, like Villanova's Pacropis, who would see the first patients.

''The hardest part is getting the primary-care physician to notice the first case,'' said Shannon, who is helping design an easy-to-use Web site to give doctors information on the symptoms of biological attack.

As of August, Boston had in place a surveillance system to help notice larger patterns doctors might miss. Every day, computer records of emergency room visits from 11 hospitals are downloaded to a system that notifies the city if there is an unexpected jump in volume.

The system looks for only a numerical surge in cases, but it could be expanded so that syndromes - such as a cluster of young people with fevers and breathing problems - would also generate an alarm, according to Jonathan Burstein, who helped design the system and is director of disaster medicine at Beth Israel Deaconess Medical Center. A similar national system could be designed, he said, although none yet exists.

In the event of an attack, another crucial delay could come in the time it takes to identify the contagion. With the plague, for example, identification can take a day or more, and a laboratory would want to be sure before sounding the alarm.

At MIT and other labs, engineers are working on systems that use DNA to identify a contagion in hours, or even faster. A prototype that quickly identifies Yersinia pestis, which causes plague, has already been built by the Lawrence Livermore National Laboratory. And a system that could constantly monitor the air for a wide range of pathogens - a biological ''smoke detector'' - is under development, according to Bert Weinstein, director of the lab's biology program.

Once the threat is identified, local hospitals would be able to swing into action. For years critics have been warning that competitive pressure has forced hospitals to focus on the most common emergencies, making them less able to meet rare, potentially devastating threats.

Anthrax and smallpox top the lists of biowarfare analysts, yet there is not enough vaccine of either available for the public. A draft study released last week by the General Accounting Office warned: ''Emergency rooms in major metropolitan areas such as Boston are routinely filled and unable to accept patients in need of urgent care.''

Help from the federal government, such as stockpiled antiobiotics and medical teams, would take between one and three days to reach a city, the GAO reported.

For now, if terrorists are bent on killing people in appreciable numbers, it is far easier to do what the Sept. 11 attackers did: Blow something up.

As for the bioterrorism threat, ''It is worth being a little bit worried and asking your government and doctor: Do you know how to deal with this stuff?'' said Beth Israel's Burstein. ''Certainly, I'm happier to be living here than anywhere else right now.''

Gareth Cook can be reached at cook@globe.com.

-- Andre Weltman (aweltman@state.pa.us), October 01, 2001

Answers

The article is fine, but it's a measure of how the media work that I spoke to Beth Daley for a full 30 minutes last Thursday...and the other reporter for several minutes the next day. This article isn't quite what I was expecting. But it's OK as far as it goes.

-- Andre Weltman (aweltman@state.pa.us), October 01, 2001.

Headline: Some See U.S. as Vulnerable in Germ Attack

Source: New York Times, 1 October 2001

URL: http://www.nytimes.com/2001/09/30/health/policy/30BIO.html

WASHINGTON, Sept. 29 — The United States is inadequately prepared to confront bioterrorist attacks, according to a broad range of health experts and officials. The nation must develop new vaccines and treatments, they say, but it must also fortify its fragile public health infrastructure, the first line of defense in detecting and containing biological threats.

Bioterrorism — the intentional release of potentially lethal viruses or bacteria into the air, food or water supply — poses daunting technical challenges, and experts say it would be difficult to carry out a successful attack. Still, many believe it is inevitable that someone will eventually try it in the United States.

In the weeks since the Sept. 11 attacks on the World Trade Center and the Pentagon, much of the discussion about bioterrorism has centered on a shortage of antibiotics and vaccines. But the bigger problem, officials agree, is a lack of basic public health infrastructure and preparedness that could thwart a terror attack or limit its effects.

Doctors are poorly trained to recognize symptoms of infection with possible biological weapons, like plague and anthrax, which can resemble the flu. Many of the nation's hospitals lack necessary equipment — in some cases even simple tools like fax machines — to receive or report information in an emergency. Though a number of federal agencies have established bioterrorism response teams and procedures, and there has been steady improvement in laboratory facilities around the country to test and identify biological agents, the result is a patchwork, set against a larger patchwork of cities, counties and states with their own reporting requirements and plans.

"For bioterrorism, the No. 1 inadequacy, if you had to rank them, is the inadequacy of our public health infrastructure," said Senator Bill Frist, Republican of Tennessee. "That is a product of about 15 years of neglect."

In a report issued last week, the General Accounting Office said the government's bioterrorism planning was so disjointed that the agencies involved could not even agree on which biological agents posed the biggest threat. Officials at the Centers for Disease Control and Prevention, for instance, consider smallpox a major risk. But the Federal Bureau of Investigation does not even put smallpox on its list.

At the same time, there are holes in the federal bureaucracy, where two important health positions remain unfilled: commissioner of food and drugs and director of the National Institutes of Health. The Food and Drug Administration will play a crucial role in the development of vaccines or treatments for use in the event of a biological attack, but President Bush and Congress — in particular Senator Edward M. Kennedy, Democrat of Massachusetts — have been unable to agree on an acceptable nominee.

Federal officials got a taste of how complicated, and chilling, a bioterrorist attack could be during a war game played at Andrews Air Force base, outside Washington, in June. The exercise, code-named Dark Winter, began with a report of a single case of smallpox in Oklahoma City. By the time it was over, the imaginary epidemic had spread to 25 states and killed several million people. As it unfolded, growing grimmer and grimmer, the government quickly ran out of vaccine, forcing officials to make life-and-death decisions about who would be protected — health workers? soldiers? — and whether the military would have to be brought in to quarantine patients.

"Dark Winter showed just how unprepared we are to deal with bioterrorism," said Jerome M. Hauer, the former head of emergency management in New York City and now a bioterrorism consultant to Tommy G. Thompson, the secretary of the Department of Health and Human Services. "It pointed out that there were significant challenges to all levels of government."

To meet those challenges, Senators Kennedy and Frist are urging President Bush to spend at least $1 billion on a range of measures that, they say, will improve the ability of health officials to combat bioterrorism. In an interview, Mr. Thompson agreed that improvements were needed, although he said the government was prepared to handle an attack right now.

"I would like to expand our pharmaceutical supplies," Mr. Thompson said. "I would like to strengthen the public health system. I would like to get some more inspectors for the food supply. I would like to expand security in our laboratories. I would like to purchase more vaccine."

For years, federal officials considered the threat of bioterrorism to be negligible. But concern began to mount in 1995, after a Japanese cult, Aum Shinrikyo, launched nerve gas attacks in the Tokyo subways. In the wake of the World Trade Center and Pentagon attacks, some members of the public have developed intense fears of germ warfare, and are trying to stock up on their own supplies.

"We have people buying gas masks and antibiotics when that is not going to provide real protection," said Stephen S. Morse, director of the Center for Public Health Preparedness at Columbia University.

Mr. Thompson said the administration was "very confident that we could act and react to any kind of bioterrorist breakout." But while Dr. Morse and other public health experts say the nation is better prepared than it was even three or four years ago, they do not share that confidence.

For instance, the United States has only 7 to 15 million doses of smallpox vaccine on hand — estimates vary — while experts estimate that at least 40 million would be needed to combat a serious epidemic. Under a government contract, a company in Cambridge, Mass., is testing a new vaccine, but it will not be available until 2004 at the earliest.

But perhaps the most pressing need, many health experts say, is improving the nation's ability to recognize when a biological attack is under way. "We are not going to have a bomb fly out of the sky and land on somebody so that we can say, `Look, there's a bomb, and we are all dying of anthrax,' " said Asha M. George, who studies biological warfare for the Nunn-Turner Initiative, a nonprofit foundation in Washington. "It is most likely going to be a covert release, and people will get sick and go to their hospitals, and the public health system will have to pick up on this."

In some ways, the Sept. 11 attack on the World Trade Center was a test of that system. Minutes after two jets slammed into the World Trade Center, the National Guard was mobilized. The Guard has created 29 teams around the nation to aid the response to chemical, biological and radiological attacks; on Sept. 11, a 22-member unit was ordered into Manhattan to test the air for deadly germs or chemical toxins. None were found.

Soon afterward, the Centers for Disease Control and Prevention, the branch of the health and human services agency that coordinates bioterrorism preparedness, alerted state and local health departments to look for signs of unusual illnesses that might be the result of a biological or chemical attack. That alert remains in effect; so far, nothing out of the ordinary has been reported.

At the same time, officers from the centers' Epidemic Intelligence Service were stationed at 15 sentinel, or warning, hospitals scattered in New York City's five boroughs, also looking for strange symptoms. And for the first time, drugs and other medical supplies were dispatched from the National Pharmaceutical Stockpile, which is maintained by the disease control centers to respond to a germ outbreak.

"You could see how orderly we are right now in responding to the terrorist attack on the 11th," Mr. Thompson said. "And we would do the same thing with a bioterrorist attack."

But in many respects, Sept. 11 was not a true test. There were no biological or chemical agents to detect. Because there were far fewer people injured than officials had originally expected, the epidemic intelligence officers were working in relatively calm hospital surroundings, as opposed to crowded emergency rooms. The drugs and medical supplies went largely unused.

So while Mr. Thompson insists the government "can handle any contingency right now," there is no way to know if the response would have been adequate during an actual bioterrorism attack, according to one expert closely involved in the government's antiterror planning who spoke on condition of anonymity.

For one thing, the expert said, in the New York City attacks doctors, nurses and other health care workers stayed at their jobs. But in the event of a biological attack, many might go home to their own families.

Moreover, with managed care's pressure to eliminate hospital beds and increase efficiency, hospitals have lost their so-called surge capacity — the ability to accommodate a sudden increase of patients. And doctors are not trained to recognize the symptoms of germ warfare.

"When you don't see very uncommon things, you don't think about very uncommon things," said Nicole Lurie, a former federal health official who worked on bioterrorism issues in the Clinton administration. "I saw three people in the morning yesterday with acute respiratory illness. They all had the same symptoms. Should I think this is bioterrorism?"

A big part of the government's formidable challenge is simply coordinating its response; across Washington, a range of bureaucracies, including the departments of energy, defense and justice and the health and human services agency, are busy planning for bioterrorist attacks. That job will soon fall to Tom Ridge, the governor of Pennsylvania, whom President Bush named to head a new Office of Homeland Security.

Some experts outside government say Secretary Thompson has already taken a step in the right direction by creating a position coordinating a departmentwide initiative against bioterrorism. In July, nearly two months before the World Trade Center attacks, Mr. Thompson named Scott Lillibridge, the disease control center's top expert in bioterrorism, to fill the job.

So, despite their worries, many experts agree that the groundwork has been laid for improvements.

"Are we prepared to prevent it? No," Dr. Lurie said. "Are we prepared to respond to it? It depends on what form it takes. I would say that we are a whole lot further along than we were three or four years ago."

Mr. Hauer agreed. "A lot of what we need to do is being done," he said. "The problem is, some of these steps take time."

-- Andre Weltman (aweltman@state.pa.us), October 01, 2001.

The second article, from today's NY Times, is much better than the first from the Boston Globe.

Of course, I wasn't interviewed for the Times (grin). The Boston Globe went to me only because they said they wanted to examine a "natural" outbreak -- they picked the Acapulco fungal infections -- as a model for how surveillance works. Didn't really do that, I thought, although I tried to give them useful quotes. Oh well.

FWIW, I was an EIS Officer 1993-1995 (assigned to NY State, doing TB and a mix of other, general communicable disease investigations). The EIS program is sort of a "fellowship" for applied epidemiology. The irony, not lost on anyone involved, is that the original justification 50 years ago for creating the program was to detect bioattack on the U.S. in the early days of the Cold War. That aspect of EIS withered over the decades, but has now come back with a vengeance. Interesting.

See http://www.cdc.gov/eis/index.htm.

-- Andre Weltman (aweltman@state.pa.us), October 01, 2001.