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Health Officials Study Next Steps in Guarding Against Bioterror

WASHINGTON (AP) - In warehouses hidden across the nation are tons of pills for anthrax and radiation and vaccine for smallpox - but the nation's anti-terrorism stockpile is far from complete.

Next month, in a closed-door meeting in Atlanta, FBI and other intelligence agents will meet with physician experts on germ and chemical warfare and radiation to figure out what therapies should be bought next.

On the table are experimental treatments for hemorrhagic fevers and smallpox, the proper supply of antitoxin for botulism, and a new cyanide antidote that may replace one some experts call antiquated.

And while the stockpile has lots of antibiotics that prevent anthrax infection, it doesn't include some drugs that may be key to treating an already sick person.

"Everything is up for grabs," said Steven Bice, who runs the National Pharmaceutical Stockpile. "We'll review our entire formulary."

Most Americans had never heard of the federal stockpile until the fall anthrax attacks. The Centers for Disease Control and Prevention started it in 1999, spending $150 million over the next three years quietly purchasing antidotes - fortunately, starting with antibiotics that can fend off anthrax. Those drugs were a good buy: Many also can treat plague and tularemia, other potential bioterror agents.

When anthrax struck, the government swiftly spent more than half a billion dollars pumping up the stockpile, adding 100 million more doses of anthrax-fighting Cipro and enough smallpox vaccine for every American. The latest buy: millions of potassium iodide tablets, used to prevent thyroid cancer after release of radioactive iodine.

Now the big question is what to buy next.

CDC won't release an entire list of the stockpile's contents, citing security. Likewise, next month's meeting between intelligence officials and CDC-picked physicians on which pathogens top the threat list is closed to the public.

But some options will generate serious debate.

Take anthrax. The stockpile has lots of the Cipro and doxycycline pills that were taken by thousands of people who were exposed during the attacks-by-mail. But treatment once someone is sick requires additional drugs, to fight anthrax-caused meningitis and the protein synthesis crucial to the germ's lethality. While the stockpile contains stronger intravenous Cipro, CDC isn't sure which other drugs are best to prescribe with it and need to be stockpiled. Candidates include clindamycin, Rifampin and vancomycin.

"I'd like to see a little more definitive research" before choosing, said CDC anthrax expert Dr. Bradley Perkins.

Also on tap for February's meeting:

-How to handle hemorrhagic diseases like the terrifying Ebola virus or Lassa fever. There are no proven treatments, although the hepatitis drug ribavirin is sometimes tried.

"But you need an intravenous drug, which is not yet licensed in the U.S. and is available only in short supply," said Dr. C.J. Peters of the University of Texas, Galveston, a former top CDC official pushing to stockpile IV ribavirin.

-How much botulism antitoxin is needed? The CDC has a contract with Aventis Pasteur to make several hundred doses, not just for bioterrorism but for the nation's rare cases of natural - usually food-borne - botulism. The military also has a small antitoxin supply.

France houses the world's biggest antitoxin cache and some experts favor negotiating for overseas shipments, Bice said. But "we're working not to be dependent upon that."

-Should CDC add to the stockpile's small amount of cidofovir, a treatment for a common AIDS complication, which some research suggests might help smallpox?

Bioterrorism isn't the stockpile's only target. Experts are at odds over how to resupply local repositories of anti-radiation and chemical therapies.

Take the cyanide antidotes amyl and sodium nitrite. These old drugs can cause bad side effects, says Emory University emergency medicine professor Brent Morgan, who will urge stockpiling instead a B-vitamin substance used in Europe. Hydroxycobalamine isn't yet government-approved here because too few cyanide poisoning cases occur to study its effectiveness, but "it looks good in animal studies" and could be more easily used by paramedics, he said.

Still, what's in the stockpile may make no difference if CDC doesn't prepare local authorities to distribute the antidotes before disaster strikes, added Morgan, who plans to stress logistics at the February meeting.

For example, the antidotes likely would be shipped in huge air-freight containers that require counting out and labeling drug doses from bins of pills - and 100 cities are vying to practice with the government's one training container.

"If we've got tons of antidotes sitting at airports, how long it takes ... to get to patients who are poisoned and need treatment - that's really going to be the problem," Morgan said.

-- Anonymous, January 14, 2002

Answers

It was a great relief when it was determined that not only Cipro, but also tetracycline, penicillin, doxycillin were all effective against the particular strain of anthrax that made the rounds last fall. One of the reasons there has never been a large stockpile of drugs or vaccine is the near impossibility of determining whether the strain "they" are concocting can be countered by known medicines. That will continue to be an issue.

-- Anonymous, January 14, 2002