Deadly anthrax attacks in the United States, explosions in London subways and trains, and Japanese sarin gas attacks have kept the threat of bioterrorism at the forefront of public consciousness for the past decade.

In January, the US Department of Homeland Security announced its new national bioterrorism response plan, stating it "establishes a comprehensive, all-hazards approach to enhance the ability of the United States to manage domestic incidents." Administered by the Federal Emergency Management Agency, the National Response Plan describes a close working relationship between the US Departments of Health and Human Services and Homeland Security that will bring about a unified response to bioterrorism and other public health emergencies while supporting state and local efforts.

Neurologists would most certainly be at the forefront of treating injuries brought on by a bioterrorist attack. But are neurologists and others who will be drawn into disaster management prepared to respond locally and nationally should a large-scale bioterror attack occur?

"I think not," remarked Leon D. Prockup, MD, one of the country’s leading experts on the health care arena’s bioterrorism preparedness efforts and an international expert in neurotoxicology and occupational and environmental neurology. Dr. Prockup, Professor of Neurology and Director of the Neurotoxicology Program at the University of South Florida in Tampa, believes that America is far from prepared for an almost inevitable bioterror attack. "Physicians aren’t geared toward treating victims" of nerve- and brain-damaging agents that would come with a bioterror attack, he said. Dr. Prockup refers to the NBCEs—nuclear, biological, chemical, and explosive agents—as a broader term for describing terrorism involving nuclear, chemical, and biological weapons.

National leaders and policymakers have heightened the public’s awareness and fear over the possibility of attacks by terrorists using large-scale chemical or biological agents. But a public health response plan continues to lag, according to Trust for America’s Health (TFAH), a national nonprofit organization. The group recently gave the federal government a grade of D+ in public health emergency preparedness in a report funded by the Robert Wood Johnson Foundation.

"Accelerated, immediate action must be taken to bridge the gap in our nation’s preparedness, no matter the threat," said Shelley A. Hearne, DrPH, Executive Director of TFAH. "The health community has worked tirelessly since 9/11 to make improvements, but serious vulnerabilities still remain. While there is no way to be 100% prepared, there are still basic achievable levels of preparedness we have yet to meet. Americans deserve—and must demand—better."

NUCLEAR THREATS

Citizens and physicians cannot realistically counteract the effect of a nuclear attack, according to Dr. Prockup. "Nuclear attack is so catastrophic, it’s a matter of prayer," he said. Still, Hollis-Eden Pharmaceuticals Inc, a San Diego–based company, has thus far been awarded about $2.5 million from the US Department of Defense and the NIH to continue to develop an experimental antiradiation drug. The steroid 5-androstenediol, to be marketed as Neumune and packaged as a self-administered injectable, has been under experimentation at the Armed Forces Radiobiology Research Institute since 1997. Neumune is said to restore infection-fighting white blood cells and platelets, which would prevent hemorrhage. The drug has been tested on monkeys but has not yet undergone a large study to test whether it can improve survival after a lethal dose of radiation. The company hopes to win FDA approval under a federal rule that allows animal data to be used in lieu of dangerous or unethical human testing.

BIOLOGICAL HAZARDS

Treatment for anthrax, polio, plague, botulism, viruses and bacteria, and smallpox will require more sophisticated plans and better vaccines than are currently available, said Dr. Prockup.

ANTHRAX

The September 2001 anthrax attacks that occurred through use of the postal service resulted in five deaths. Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. Anthrax is diagnosed through isolation of B anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of people with suspected exposure. Treatment with antibiotics must be initiated early to be effective. "Most physicians have never seen anthrax, so we’re not trained in that," said Dr. Prockup. "Most physicians practicing today have not seen polio or smallpox. We’re not generally trained in these things either."

According to the CDC, the anthrax vaccine, manufactured and distributed by BioPort Corporation, is reported to be highly effective in protecting against anthrax. The vaccine is a cell-free filtrate vaccine, containing no dead or live bacteria.

The standard immunization against anthrax consists of three subcutaneous injections administered two weeks apart, followed by three additional subcutaneous injections given at six, 12, and 18 months. Annual booster injections of the vaccine are recommended thereafter.

The US Department of Defense has been testing the anthrax vaccine on military personnel since 1998, injecting 1.3 million troops per a mandatory program. The Defense Department program was temporarily halted by a federal ruling in December 2003, brought about by a lawsuit filed by military personnel and civilian contractors who had concerns about side effects. The Defense Department resumed immunizations last spring, but on a voluntary basis.

Initial symptoms of anthrax may resemble those of a common cold. After several days, the symptoms may progress to severe breathing problems and shock. Inhalation of anthrax is usually fatal.

SMALLPOX

The Bush administration announced its smallpox vaccination policy—the first nationwide measure to address the threat of bioterrorism—on December 13, 2002. An article in the Journal of Biolaw and Business in 2004 reported that the vaccination policy received "mixed reactions" as a result of partisan issues, tensions in public health policy and federal and state jurisdiction, conflicting scientific views, and different risk assessments. The difficulties of the program serve as a case study revealing current shortcomings in federal and state antiterrorist and public health policies.

An estimated 10% to 15% of the US population cannot tolerate the live Dryvax vaccine for smallpox. In 2004, the US government contracted with two companies—Acambis, based in Cambridge, UK, and Cambridge, Massachusetts, and Bavarian Nordic of Denmark—to produce a modified smallpox vaccine that will not replicate within cells like the current live one does, thus lessening the risk of adverse reactions.

RICIN

Ricin is a toxic protein made from castor beans. It enters the inside of cells and prevents them from producing proteins, resulting in cell death. Within hours of inhalation of significant amounts of ricin, symptoms would appear, including respiratory distress, fever, cough, nausea, and tightness in the chest. Pulmonary edema could cause heavy sweating. Excess fluid in the lungs would be present, and low blood pressure and respiratory failure may occur, leading to death. No antidote exists for ricin.

Human testing of an experimental vaccine against ricin began last year at the University of Texas Southwestern Medical Center in Dallas. In January, DOR BioPharma, licensor of RiVax, announced results of a Phase I clinical trial indicating that the vaccine is well tolerated and induces antibodies in humans that neutralize ricin toxin. An approved ricin vaccine could take four years or longer to develop, according to medical center officials in Dallas.

CHEMICAL WEAPONS

With one notable exception, hospitals are not equipped for combating chemical weapons such as sarin gas, which was used in the Tokyo subway attacks in 1994 that killed 19 and injured 6,000. Because chemical agents permeate clothing, victims of an attack must undergo decontamination before the victim can be admitted to a hospital.

"Hospitals are not equipped with decontamination rooms outside or away from the main hospital," said Dr. Prockup. "Each hospital should have a decontamination room. Treatment must be initiated within minutes, or else the patient dies. This isn’t known by the average person and by many physicians. Most people, including physicians, know very little about nerve gases or how to treat the victims."

One new facility in Nebraska gives a boost to response efforts. Using Homeland Security funding, the state spent nearly $1 million to build a novel 10-bed biocontainment facility administered by the University of Nebraska Medical Center in Omaha. The Center for Biosecurity includes a secure isolation area, with filters that kill airborne germs, and an automated mobile lab. A dozen medical experts affiliated with the center are studying transmission and diagnosis of biological and chemical agents and prevention of their effects. Omaha hospital staff recently participated with the university in holding a practice disaster drill in January to simulate response to bioterror attacks involving anthrax, smallpox, and the avian flu.

EXPLOSIVES

Inexpensive and easy to detonate, explosives are a commonly used terrorist weapon. Explosives were used in the Madrid bombings in March 2004 and the London subway and bus incidents last summer. An improvised explosive device (IED) can be made from explosives alone or in combination with toxic chemicals, biological toxins, or radiological material.

Package, vehicle, or suicide bombs are detonated on a daily basis in Iraq. Nearly 800 US soldiers serving in Iraq have been killed by IEDs, and tens of thousands have been injured by the homemade explosives.

Persons at the site of an explosion may have a limb blown off and/or experience pulmonary damage and extreme concussions to the brain. "If they survive, they may suffer brain damage, emotional damage, and physical damage to the nervous system, and concussion," said Dr. Prockup. "Sometimes it’s easy to detect physical damage from an explosion, but others suffer mental impairment. We’re seeing this is the case with lots of returning veterans. They may be walking and talking, but they’re mentally impaired. They can’t hold down a job, and suffer from depression."

PHARMACEUTICAL AND GOVERNMENT RESEARCH INITIATIVES

Hollis-Eden, along with dozens of other pharmaceutical companies, aims to tap into additional Project Bioshield funds and has used extensive lobbying and public relations strategies to bring its case before lawmakers and the general public. Since passage of Project Bioshield in 2004, the US government has distributed about $1 billion of the $5.6 billion it allocated for the stockpiling of drugs and vaccines for combating injuries sustained from terrorist attacks.

Competition for the Bioshield funds extends beyond industry to academia and to government research institutions. The Bush administration is also using the funds to develop its bioweapons program in at least three government and university labs—the Dugway Proving Ground in Utah has developed anthrax for use in testing biological defense systems; the CDC in Atlanta handles live smallpox, and research is ongoing at the US Army Medical Research Institute of Infectious Diseases at Fort Detrick, Maryland, and in Hamilton, Montana.

The federal government gave final approval in February to Boston University’s bid to build a high-security research laboratory that will work with some of the deadliest viruses and bacteria, such as Ebola, anthrax, and plague. The $128 million center is expected to be completed in 2008.

Kentucky and Tennessee are currently competing for a $451 million federal bioterrorism research lab project. Funded by the Department of Homeland Security, the lab would also be another highly secure site with a Biosafety Level 4 designation and be among a growing number of institutions researching bioterrorist threats, foreign animal diseases, and other emerging public health threats.

Physicians for Social Responsibility, the Council for Responsible Genetics, and the National Academy of Sciences are among the scientific groups that have expressed concerns about the United States’ research and development of weapons-grade germs. Some have warned that the initiative could be perceived as "development" of biological weapons, in violation of the Biological Weapons Convention. Others question the safety of such facilities and the impact on public safety, should any of the deadly toxins escape from laboratories.

The Council for Responsible Genetics lists 30 incidents involving environmental releases, containment and security breaches, missing samples, and exposure and infection of personnel occurring at bioresearch labs since 1985. The mistakes include the disappearance of anthrax and Ebola viruses from the US Army Medical Research Institute of Infectious Diseases in the 1990s. The 2001 anthrax attacks are believed by the FBI to have been caused by a scientist with access to a government laboratory.

PLANNING FOR ATTACK

Leaders in neurology are striving to make preparedness workshops and training widely available and easily accessible. For example, Johns Hopkins University offers an online bioterrorism training module, and the University of Oklahoma Health Sciences Center hosts Webcasts on current immunizations for smallpox and anthrax and on recognizing chemical exposure.

Considering the many threats from abroad and domestically, the risk of an NBCE attack or unintentional outbreak should be of grave concern. "It’s not a matter of if it will occur, it’s a matter of when and where," said Dr. Prockup.

—Kathy Stone

Suggested Reading
Beane J. A look behind the scenes: bioterrorism, smallpox, and public health policy. J Biolaw Bus. 2004;7:40-53.

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