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Thursday, November 15, 2001



“The question isn’t whether we will face a terrorist attack with a deadly viral or bacterial weapon, but when,” was written in a book (Michael T. Osterholm, John Schwartz, Living Terrors: What America Needs to Know to Survive the Coming Bioterrorism Catastrophe) on bioterrorism last year. This prediction has become reality with the recent incidents concerning anthrax in the United States.

Since October 3, 2001, the Centers for Disease Control (CDC) and public-health authorities have been investigating causes of possibly bioterrorist-related anthrax in the US. As of November 15, investigations in Florida, New Jersey, New York, Washington, DC, Maryland, Pennsylvania, and Virginia have identified 15 (11 confirmed cases and four suspected) cases of anthrax. Seven of them were inhalational anthrax and eight were cutaneous (skin) anthrax. Of the seven cases of inhalational anthrax, five occurred in postal workers in New Jersey and Washington, DC, and in one person who sorted mail at a media company in Florida. Two letters mailed to two different recipients in New York are known to have contained anthrax bacteria. Six cases were identified in employees of media companies; one was a seven-month-old infant who happened to be on the premises of a media company; and eight cases were consistent with the route of letters known to contain anthrax spores. The bacteria from all the cases are indistinguishable, suggesting a common origin.

Bacillus anthracis, the scientific name for the bacterium that causes anthrax, derives from the Greek word for coal, anthrakas, because the disease causes black, coal-like lesions on the skin. The anthrax bacterium has the capability to form spores that survive harsh conditions for years. For centuries, anthrax has caused disease in animals and, uncommonly, serious illness in humans. There are three types of anthrax disease in humans.

Skin (cutaneous) anthrax is the most common type, and is usually not fatal unless left untreated. Skin anthrax occurs most commonly in agricultural and industrial workers who come in contact with infected animals or animal products. Most recently, cases of skin anthrax have resulted from exposure to spores sent through the mail. The earliest symptom is a small sore on the skin, which blisters and then within one to two days becomes an ulcer with a black scab.

  Lung (inhalation) anthrax was rare prior to last month. It results from breathing in anthrax spores. Inhalation anthrax is usually fatal unless treated early. Early symptoms are similar to the flu, remembering that the flu and other viral infections are much more common than anthrax. Gastrointestinal anthrax is also rare, and usually occurs after eating contaminated, undercooked meat. It is important to note that anthrax is not transmitted from person to person.

Many persons have received or stockpiled antibiotics in the face of recent incidents. Current recommendations are that persons do not obtain or take antibiotics such as ciprofloxacin or doxycycline for anthrax, either through prescription or other means, unless public-health authorities inform us to do so in the face of documented exposure. Taking antibiotics without being examined by a physician can do more harm than good, since it can mask symptoms of other serious diseases. In addition, widespread use of antibiotics leads to drug-resistant bacteria that can make medicines ineffective for those who truly need them. If an outbreak occurs, the CDC and other appropriate healthcare organizations will dispense antibiotics through a coordinated effort. Anthrax vaccine is not recommended for people younger than 18 years of age, and is currently administered only to military personnel. In light of recent events, an accelerated anthrax vaccine program is needed.

Research on anthrax as a biological weapon began more than 80 years ago. Today, at least 17 nations are believed to have offensive biological weapons; it is uncertain how many people are working with anthrax, but Iraq has acknowledged producing and “weaponizing” the disease.

Most experts agree that the manufacture of an anthrax aerosol is beyond the capability of groups or individuals without access to advanced technology. However, autonomous groups with substantial funding and contacts may be able to acquire materials for a successful attack. One terrorist group, Aum Shinrikyo, responsible for the release of sarin, a nerve gas, in a Tokyo subway station in 1995, dispersed aerosols of anthrax and botulism throughout Tokyo on at least eight occasions. For reasons that are unclear, the attacks failed to produce illness.

The accidental release of anthrax spores from a military microbiology laboratory in Sverdlovsk, in the former Soviet Union, in 1979 resulted in at least 79 cases and 68 deaths, and demonstrated the deadly potential of anthrax aerosols. An anthrax aerosol would be odorless and invisible following release and would have the potential to travel many kilometers. Evidence suggests that following an outdoor aerosol release, people indoors could be exposed to the same threat as that outdoors.

In 1970, a World Health Organization expert committee estimated that casualties following the theoretical aircraft release of 50 kilograms of anthrax over a developed urban population of five million would be 250,000, 100,000 of whom would be expected to die without treatment. A 1993 report by the US Congressional Office of Technology Assessment estimated that between 130,000 and three million deaths could follow the aerosolized release of 100 kilograms of anthrax spores upwind of the Washington, DC, area – lethality matching or exceeding that of a hydrogen bomb. An economic model by the CDC suggested a cost of $26.2 billion per 100,000 persons exposed.

This has been a wake-up call regarding a new threat for the United States and the developed nations of the world. The ramifications of this attack and other possible attacks with different biological weapons continue to evolve. The terms smallpox, plague, tularemia, and botulism have all entered our daily vocabulary and are likely to stay there for awhile. For the moment, it seems that the current anthrax outbreak has been controlled. Nevertheless, as the character of Dr. Rieux in Albert Camus’s The Plague understands, it is always premature to celebrate the end of an outbreak of plague: “And, indeed, as he listened to the cries of joy rising from the town, Rieux remembered that such joy is always imperiled. He knew what those jubilant crowds did not know that the plague bacillus never dies or disappears for good; that it can lie dormant for years and years in furniture and linen-chests; that it bides its time in bedrooms, cellars, trunks, and bookshelves; and that perhaps the day would come when, for the bane and the enlightening of men; it would rouse up its rats again and send them forth to die in a happy city.”

Theoklis Zaoutis is attending physician in special immunology (pediatric HIV) at the Children’s Hospital of Philadelphia and an investigator for the Pediatric AIDS Clinical Trials Group (PACTG). He is also a fellow in pediatric infectious diseases at the Children’s Hospital of Philadelphia and an instructor in the department of pediatrics at the University of Pennsylvania School of Medicine.
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