Bioterrorism is a Real Threat Requiring Rational Response

Writing an article on bioterrorism for the popular press is as difficult as it is important. How to be factual, clinically sound and responsive to widespread anxiety and fear is the task. Events of Sept. 11 form the frame. Bioterrorism is real. We need to be informed, cautious and alert.

At the same time, we need to understand the range, risk and response to the threat and not be panicked into holing up at home, avoiding the mailbox or loading up on Cipro. Imagination is scarier than fact. "Biological warfare" can be worse than poison gas or conventional weaponry, but it is also easier for us to limit casualties.

Unfortunately, there are not a lot of things the average person should or could do. Don't buy a gas mask. The key to an appropriate, quick response is with the professionals.

What are the facts? There are four likely bioterrorist weapons; anthrax (Bacillus anthracis), plague (Yersinia pestis), botulism toxin (Clostridium botulinum) and smallpox (variola major). Most U.S. physicians have never seen a patient infected with any of these agents, yet our health facilities will clearly be our first line of defense. The rapid identification of the event and the pathogen could literally save thousands of lives.

In truth, we were not prepared for either the events of Sept. 11 or the subsequent anthrax letter attacks, but we are closing the gap quickly. In fact, given the potential, the public health response so far has been very effective and should be reassuring to the public.

Anthrax is the bioterrorism agent being used in the United States today. It has a colorful history, starting with its description as the fifth plague of Egypt in 1491 B.C. It was the first identified "infectious disease" and one of the first targets of an effective vaccine.

Anthrax has been used in warfare since World War I (by the Germans). Japan developed and used anthrax as a biological weapon in World War II, and the U.S., along with almost all major powers, developed anthrax bombs during World War II, but did not use them.

U.S. biological weapons were destroyed in the 1970s. The Soviet Union, unfortunately, continued the clandestine development of anthrax, best evidenced by the unfortunate accident in 1979 in Sverdlovsk where more than 60 workers and local residents died of inhalation anthrax after an explosion in a secret biological weapons plant.

More recently, Iraq used anthrax on Iran and had deployed anthrax-filled SCUD missiles during the Gulf War. Sophisticated anthrax and related technology is available today on the international black market.

Anthrax, when outside a living being, is generally in an inactive spore form. It can survive in the ground for decades. When anthrax is used as a bioweapon, it is generally designed to induce inhalation anthrax. To get the spores into the lungs, the organism needs to be aerosolized. Getting the spores into a powder fine enough to do this is technologically difficult, but once in the proper form, delivering the aerosol is straightforward using standard commercial dry spraying equipment.

The anthrax being used is very sophisticated and forms a fine aerosol when a letter containing it is opened. The inhaled organisms land in the air sacs of the lung and are transported to the lymph nodes in the center of the chest. There, the spores "germinate" and begin to multiply. These now active bacteria produce several toxins that are primarily responsible for the hemorrhage, edema, tissue necrosis and, ultimately, death of the victims. As a result of these toxins, patients often die even after appropriate antibiotics are given. This was true of all three of the recent anthrax deaths.

Inhalation anthrax is a two-stage disease. Symptoms first develop one to two days after inhalation. The initial illness is flu-like and can spontaneously resolve or improve. A chest X-ray may be normal or look like a mild pneumonia. A few days later, the patient returns extremely ill with high fever, sweating, short of breath and with chest pains. The chest X-ray at this time is unusual because the middle of the chest is often enlarged (very uncommon in other types of pneumonia). Half will have an unusual type of bloody meningitis. This is what tipped off doctors to the first case in Florida. Shock and death occur rapidly.

Unfortunately, death of an index case (the first case in any event) is likely, even if the diagnosis is made. In contrast to recent articles, Ciprofloxacin is not the only drug that can be used. The current anthrax organism could be effectively treated with amoxicillin or doxycycline. In addition, several other antibiotics in the family of fluorquinolones could be used.

Recognition that one may have inhaled spores is important since swift action is required. Treatment is continued for 60 days for suspected cases. There is a window of several days to weeks, as long as the individual stays well, to start treatment. If symptoms start, treatment must be started immediately.

Fortunately, individuals in the first symptomatic phase of this illness also do well with treatment. If a vaccine were available, it would not be used to treat exposures, but might be used among members of rapid response teams or people with occupational exposure (such as postal workers). Currently, there are technical problems with the vaccine, but I believe it will be available again soon.

Anthrax contracted through the skin is distinctive and easier to diagnose. The infected area turns black. In fact, the name anthrax comes from the Greek word for coal suggested by the characteristic skin color. Anthrax can also cause intestinal illness when eaten with food. Fortunately, both oral and skin anthrax are rarely fatal. It is also useful to remember that animals, especially cats, are also susceptible to anthrax. Indeed, rapidly dying cats might be the "canaries in the coal mine" alert that a clandestine attack has occurred.

The reason terrorists are using anthrax is easy to understand. It has a high fatality rate if untreated, a long incubation period and non-specific early symptoms. All of these facts induce panic. The terrorists have ample time to get out of town and a vaccine exists that can protect them. The sophisticated powder is easy to disguise or hide and the delivery system can be crude or sophisticated.

The good news is that anthrax is sensitive to antibiotics, person-to-person transmission doesn't occur and exposure can be readily addressed by a competent health care system and a responsive, vigilant public.

ACE Hardware announced it would begin selling home test kits for anthrax. This is a bad idea. First, these kits (similar to a home pregnancy kit) have both false positives and false negatives. Non-anthrax bacteria can turn these kits positive, causing unnecessary panic, while they may not detect very small numbers of anthrax spores that could still make people sick.

The most important reason not to use them is that any potential anthrax exposure is a potential criminal act. People who think they have been exposed to anthrax need to immediately call the authorities. Would anyone think it reasonable to have people use "home evidence collection kits" in a murder case, rather than calling the police? Recently, a report also circulated that suggested that all pneumonia cases in the U.S. should be treated for anthrax.

First, the initial illness from inhalation anthrax may not be pneumonia. One of the postal workers who recently died went to an emergency room with vague symptoms and was sent home. He did not have pneumonia. The failure of the system was not recognizing the exposure history. Second, Ciprofloxacin is not a very good antibiotic for community-acquired pneumonia. We should use antibiotics whenever there is a reasonable risk, but the key is identifying the exposure, not panicking into treating everyone with the flu or pneumonia.

Finally, for more than two weeks, people have asked me about having a supply of Cipro at home "just in case." This powerful antibiotic is not only very expensive, but potentially dangerous if not monitored by a physician. All antibiotics can cause medical problems when used incorrectly.

Hospitals and the health infrastructure have taken steps to assure adequate local and national supplies of drugs. They will be available should we need them. If we were worried about being invaded by Canada, I hope we wouldn't give every man, woman and child in the U.S. an assault rifle. We would let the army, police and National Guard organize a defense.

Bioterrorism is a reality and, as a society, we are having trouble dealing with it. The events of Sept. 11 will change our society forever. People in England have had to live with civilian terrorism for some time, as have most of Europe and virtually all developing countries.

It is useful to know the facts, but this particular threat is best handled by professionals. We need to keep this threat and any additional issues in perspective. We must stay alert, be prudent, and know what to do, but also continue to lead normal lives.

What is currently happening is exactly what the terrorists want. We need to stay rational, get the facts, look out for the profiteers, and, whatever we do, not panic.

This article appeared previously in the Milwaukee Journal Sentinel.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.