Bioterrorism: Clear and present danger

The horrific attacks of Sept. 11 and the subsequent campaign against bioterrorism have undermined our feeling of safety and security. Bioterrorism, in particular, is a difficult issue to deal with because of the uncertain nature of this new threat. In addition, there is little experience to draw upon. In the U S, for example, government agencies and medical facilities practically learned how to handle bioterrorism as the situation unfolded.

Here are the lessons learned so far:

• Keep the risk in perspective. If you wanted to kill a lot of people with anthrax, you wouldnít do it by sending it through the mail. But if you wanted to scare a lot of people and be certain everybody knew about it, you would send your tainted letters to prominent politicians and news organizations. Keep in mind that much of terrorism is about attracting an audience. It feeds on a large multiplier effect from intense media coverage.

• Learn to accept uncertainty. When it comes to our health, we want accurate information immediately. But tests often take time, and results are not infallible. Indeed, some of the early anthrax tests done in the US turned out to be false positives: The first results suggested the presence of bacteria, but retesting showed there was none. People also may have unrealistic expectations about the unanimity of experts when, more often than not, they disagree. Add to that CNN, BBC, and CNBC, and the drumbeat of their continued news updates, and you almost guarantee the circulation of a certain amount of incomplete, and sometimes contradictory information, about almost any health scare. Here’s definitely one lesson we have learned: No one can protect us from the noise of the Information Age when it comes to bioterrorism, but you can apply some filters: commonsense, skepticism, and attention to facts rather than conjecture.

• Don’t get surprised if they get it wrong sometimes. After postal workers died of inhalation anthrax, US Surgeon General David Satcher admitted that government officials were wrong to have underestimated the dangers posed by a sealed envelope. Part of the problem was the mixed message about the quality of the anthrax sent to Senator Tom Daschle’s office. Some downplayed it as "garden-variety" anthrax. Others said, no, it was weapons-grade, whatever that vague term means. Only later was it revealed that the anthrax had, indeed, been especially processed so the spores wouldn’t cling together, an indication that it probably originated from a sophisticated lab. In that non-stick form, anthrax spores are especially dangerous because they float in the air and can easily be inhaled deep into the lungs.

Everyone is learning on the job in these circumstances. Only with hindsight can anyone steer flawlessly between prudent precaution and overreaction. This doesn’t mean to say we should happily tolerate bungling or, worse, moral blindness. It does mean we can anticipate that some mistakes will be made.

• Take comfort in how much is known. Bacillus anthracis is a germ with which we are very familiar. I remember attending an excellent lecture on anthrax many years ago when I was still a medical student under the eminent microbiologist and parasitologist, Dr. Pedro P. Chanco, Jr.

Inhalation anthrax used to be known as "woolhandler’s disease" because people got it from sheep. It’s long been attractive as a weapon because anthrax bacteria hole up in spores that are hardy and can be made so lightweight that they float in the air like some kind of poisonous vapor.

But if an anthrax infection is caught early, it’s quite treatable. Moreover, it’s treatable with antibiotics. They are plentiful and easily available. So, we’re not exactly sitting ducks when it comes to anthrax.

Bioterrorism experts say variola major, the virus that causes smallpox, is another possible weapon. Unlike anthrax, smallpox is a contagious disease. Most of us in this country are vulnerable to it because routine vaccination stopped 20 years ago. Even vaccinated people are probably no longer protected because immunity wears off. What’s more, the virus spreads easily through the air within buildings and on contaminated clothing. Some experts fear one infected person in a crowded city might be capable of igniting an awful epidemic.

Antibiotics don’t work against viruses. But even after exposure, the smallpox vaccine is an effective treatment. And if it’s given to people who have been exposed to the infected individual, the vaccine works to isolate the virus and keep it from spreading.

The problem is there is not enough smallpox vaccine available at this time although manufacturers are rushing their supplies and keeping them in reserve, just in case. That’s good news, and it shouldn’t be discounted.

Theoretically though, someone could bioengineer a version of Bacillus anthracis that would slough off a specific medication or our entire antibiotic arsenal. It is also possible that immune systems primed by the current smallpox vaccine might be blind to a form of variola major that has been radically altered. But there are reasons to doubt that these could happen soon. For one thing, engineered organisms tend to be pretty fragile creatures that lab scientists have a hard time keeping alive even in the best of conditions. And in time, we may have treatments or vaccines for such hypothetical "superbugs."

• Be assured that assurances will change. Before US postal workers died, much of the commentary about the anthrax letters was about Americans overreacting. Public health officials downplayed the dangers. In an Oct. 18, 2001 interview, the director of the US Centers for Disease Control and Prevention (CDC), Jeffrey Kaplan, described the risk of contracting anthrax as "infinitesimal." A week later, US Postmaster General John Potter suggested that people should wash their hands after opening their mail, although he did say the risk of infection was very small. As events unfolded, so did the advice. News you can use had a short half-life.

• Beware of bottom-feeders. As the fear of anthrax grew, so did other opportunities for making money off it. Internet-based companies started to hawk the antibiotic ciprofloxacin (Cipro) of doubtful quality. Other firms started to push anthrax detectors of dubious worth. Not every business that jumped into the fray should be tarred. There’s a line between filling a need and exploiting a crisis. Nothing is more certain than this: If and when another threat becomes real, some will get a gleam in their eye and see it as a business opportunity.

• Don’t be selfish. The likelihood of Cipro shortages may have been exaggerated. Its patent rights were under attack. Bayer ramped up production and dropped its price. The CDC tested other antibiotics and found that they also worked against the anthrax bacteria. All along, some experts were saying that the clamor for Cipro was misguided and that other antibiotics would be just as effective. Still, after Sept. 11 and as the first reports of anthrax letters came in, the possibility of a Cipro supply problem seemed real enough as doctors were inundated with requests for prescriptions. Understandably, people want to protect themselves and their families. The me-and-mine impulse has to be tempered by a public health version of civic responsibility. Also, have some faith that you don’t need to hoard. Chances are, if you need medicine, it will be there for you.

• Worry about antibiotic resistance. By the end of Oct. 2001, over 10,000 Americans were taking Cipro, a powerful, broad-spectrum antibiotic. For years, doctors and public health officials have always warned that overuse of antibiotics could lead to a microbial survival of the fittest, with only antibiotic-resistant organisms left standing. Terrorists may not need to bioengineer superbugs. Liberal use of antibiotics may do it for them.

• And finally, think low-tech. If there’s any lesson to be learned from the box cutter hijackings of Sept. 11 and the use of the humble envelope as a delivery system for a biological weapon, it should be the recognition of the low-tech approach. So while washing your hands may seem like a silly way to fight bioterrorism, it is one of the best ways to prevent infection, regardless of the source. Expensive gas masks are a waste of money. If you’re worried and want to be prepared, go to your drugstore and buy a box of paper face masks. It’s difficult not to get swept along by such events but chances are, more Filipinos will die from smoking cigarettes – than from malevolent encounters with exotic germs!