By Mike Field
the influenza pandemic of 1918, health officials believed that wearing
gauze face masks could interrupt the transmission of the disease.
Many localities passed legislation requiring public masking, but
ultimately, the exercise was of doubtful benefit. Gauze alone cannot
filter viruses. Largely unchecked, the disease ran its course. More
than 600,000 Americans died. Globally, up to 20 million perished.
Almost 90 years later, the prospect of such widescale death and
suffering seems remote. "But you have to keep in mind that
the flu virus of 1918 was fatal in only about 2 to 3 percent of
all cases," says Gigi Kwik, PhD, a fellow with the Johns Hopkins
Center for Civilian Biodefense Strategies. "Smallpox, by contrast,
is typically fatal about 25 to 35 percent of the time." The
United States stopped vaccinating for smallpox in 1972; currently,
it has about 15 million doses of the smallpox vaccine on hand to
safeguard a population of almost 300 million. Since the World Health
Organization declared smallpox eradicated in 1980, the doses of
vaccine on hand seemed, until recently, more than adequate. But
with the revelation in the 1990s that the Soviet Union had produced
tons of smallpox for an illegal bioweapons program and the
uncertainty of whether any of those materials were eventually acquired
by terrorists those 15 million doses of vaccine have lately
begun to seem like just so many gauze masks.
Yet the outlook is not entirely bleak. For each of the biological
weapons considered by experts to be the most serious threats to
America anthrax, botulinum toxin, plague, smallpox, or tularemia
modern medicine has some effective means of responding, be
it by vaccination, antibiotic, or antitoxin. And despite years of
neglect of the nation's public health infrastructure, and an ongoing
crisis in the delivery of health care, the U.S. still has one of
the world's most comprehensive and sophisticated systems of medical
care. "I'd say [in the event of a smallpox outbreak] we'd be
OK in the long run," says Kwik. "A lot of other countries,
by contrast, would do quite poorly."
In recent years, the government has established national pharmaceutical
stockpiles in hidden, secure locations as part of a coordinated
effort to prepare for the possibility of a biological warfare attack.
The sites contain antibiotics, medical and surgical equipment, gloves,
masks, and other supplies useful in a widescale medical crisis.
The system had its first test on Sept. 11, and authorities report
medical supplies were delivered to Ground Zero in New York within
seven hours of the attacks.
The Latest Vaccines and Antibiotics
Anthrax The anthrax bacterium can be stopped
by the prompt administration of antibiotics, including ciprofloxacin
and doxycycline. An anthrax vaccine requiring a series of
six shots over a period of weeks has been licensed since
1970 but is currently in limited supply in the U.S.
Botulism Licensed botulinum antitoxin is
available only from the CDC via state and local health departments.
An investigational botulinum toxoid has been used to provide
immunity against botulinum toxin over the past 30 years,
but widescale immunizations are currently considered impractical.
Plague A U.S. licensed vaccine exists and
in a pre-exposure setting appears to have some efficacy
in preventing or ameliorating bubonic disease, but not against
inhalationally acquired pneumonic plague. Immediate administration
of antibiotics such as streptomycin or doxycycline as treatment
or prophylaxis would significantly reduce the mortality
of the disease.
Smallpox There is no known treatment to fight
the disease once it begins; and essentially no one in the
U.S. has been vaccinated during the past 29 years. Immunity
acquired decades ago wanes substantially with time. Infected
individuals can be inoculated with the vaccine as long as
3 or 4 days after their smallpox exposure and still receive
protection against death from smallpox. Currently, there
are about 15 million doses of the vaccine available in the
U.S., and another 60 million worldwide.
Tularemia With prompt antibiotic treatment,
the most recent mortality rates in the U.S. have been 2
percent. A live-attenuated tularemia vaccine has been used
to protect laboratory personnel, but given the short incubation
period of the disease, and incomplete protection of current
vaccines against inhalational tularemia, vaccination is
not recommended for post-exposure prophylaxis.
Source: Johns Hopkins Center for Civilian Biodefense Strategies
Even so, there is some concern that the amount of supplies and
system organization are inadequate to respond to a biological attack
of any magnitude. "Antibiotics and vaccines alone are not enough,"
says Thomas Inglesby, MD, deputy director of the School's Center
for Civilian Biodefense Strategies. An infectious disease specialist
who holds an assistant professorship in the School of Medicine's
Division of Infectious Diseases, Inglesby cites the need to beef
up state, city, and local health departments, increase national
disease surveillance capacity, address the lack of "surge capacity"
in U.S. hospitals, improve community response plans, and more thoroughly
plan for sudden, widespread medical catastrophes.
"A national biomedical research and development program to
address the nation's greatest infectious disease vulnerabilities
is also an imperative," says Inglesby. "We want to have
the diagnostic tools to be able to say if a person is sick or not
sick, and a public health system of tracking disease as it evolves
and containing the spread of disease."
An analysis by the Office of Technology Assessment of the U.S. Congress
estimated that as many as 3 million deaths could occur following
the release of 100 kilograms of aerosolized anthrax over Washington,
D.C., making such an attack as lethal as a hydrogen bomb. Prompt
detection and immediate administration of the proper antibiotics
could save many or even most of those lives. But the logistics of
such an effort, including the delivery and distribution of 5 or
6 million doses of antibiotics, remain daunting. Says Inglesby:
"If we don't have rapid systems of distribution, people won't
get the antibiotics they need. We need a medical care system capable
of handling sick people in greater numbers than we've ever seen
A problem already apparent to many is simply the shortage of necessary
medicines. The anthrax mail attacks have prodded the government
to significantly increase the scale and scope of its pharmaceutical
stockpiles. But even that effort faces huge challenges. "You
can't go from zero to 60 in five seconds," is how Don Burke,
MD, director of the School's Center for Immunization Research, describes
the government's recent decision to increase its stockpile of smallpox
vaccines from 15 million to 300 million doses. "The current
model in treating an outbreak of smallpox is to try to create a
ring of immunizations around anyone known to be infected,"
says Burke, in explaining how smallpox was eventually quarantined
But a model that works for only a handful of infections in remote
areas of developing countries may prove inadequate to the challenge
of many hundreds, or even thousands, of infections in a highly mobile
society. In that situation, it could rapidly become necessary to
vaccinate many millions perhaps even the entire nation. "We
don't have any experience in large-scale immunizations of that nature,"
says Burke, a professor of International Health. "One of the
basic questions is just who are we going to get to give all these
shots? We'd probably have to very quickly start to look outside
the classic health care delivery system for answers."
Researchers are quick to point out that none of the problems associated
with the sudden and unexpected widescale infection of populations
are insurmountable. What is needed, they say, is planning and the
political will to prepare adequately for a future most people would
rather not consider. "There are many things to do," Inglesby
says. "This is not insoluble, it's not a lost cause, but [the
answers] are not necessarily easy or cheap. The problem will not
go away when the anthrax mailings are over or when the war in Afghanistan
All agree that a significant change is in order for American health
policy. "We spend remarkably little of our public health dollars
on vaccination in particular and prevention in general," says
Burke of the situation prior to Sept. 11. "The total global
annual market for all vaccines is about $3 billion. But every year,
we spend $5 billion on Viagra. That should tell us something."