Jewish World Review Nov. 2, 2001 / 16 Mar-Cheshvan, 5762

Making sense of bio-warfare

By Robert A. Wascher, M.D., F.A.C.S. -- TWO MONTHS before our collective sense of security was shattered by the September 11th attacks, the Department of Defense (DOD) submitted a report, from a panel of independent experts, regarding the status of military preparedness for bio-warfare. Basically, the panel of experts concluded that the US military was not prepared to face unconventional threats such as anthrax, smallpox, botulinum, ricin toxin, tularemia, plague and other potential biological warfare agents. DOD-sponsored vaccine programs were found to be poorly organized and inadequately funded.

By 1980, smallpox had been declared "eradicated" from the world's population by the World Health Organization (WHO). The WHO subsequently recommended that all research stocks of the virus causing smallpox (variola) be destroyed. Most authorities at the time believed that this mandate was accomplished, except for stocks openly maintained, in Moscow and Atlanta, at two international reference laboratories. It is now known that the former Soviet Union stockpiled extensive cultures of the most virulent smallpox strains, and carried out elaborate "weaponization" studies using this material. There is also recent evidence that post-Soviet Russia may be continuing research in this area.

Sadly, it is unlikely that Russia is the only country conducting research into the military applications of the smallpox virus and other potential bio-warfare organisms. In the US, the routine vaccination of civilian populations against smallpox ended in 1972. However, even those adults who were immunized prior to 1972 are unlikely to have adequate residual immunity against smallpox today. Thus, virtually the entire US population is susceptible to the variola virus. Unlike anthrax, smallpox is highly infectious, and is easily passed from one person to another by respiratory secretions and by direct contact. Although the mortality due to smallpox is based upon data from the 1960s, it is estimated that at least 30% of cases would be fatal if this disease were to resurface today.

As with all viruses, there are no antibiotic medications capable of curing the disease, unlike most bacterial infections (including anthrax, if diagnosed early enough). At the present time, there are only 15 million vials of smallpox vaccine stored in the US, and the potency of these 1960s era vaccines is unclear. Fortunately, a new vaccine is in the works, with predictions that it will be available for testing by early 2002. It now seems very likely that vaccinations against smallpox will resume in this country, and for the first time in thirty years. The return to routine vaccination against this virus, if it occurs, will serve as yet another marker of the paradigm shift that occurred in this country on September 11th.

Botulinum toxin, produced by the bacterium Clostridium botulinum, has long been known as a potential bio-warfare agent. In a recent Science magazine review of bio-warfare issues, the authors note that less than one millionth of a gram of botulinum toxin can be fatal. Minute quantities of this toxin, once ingested, cause paralysis of the muscles, including the diaphragm. Death from suffocation is rapid if the diagnosis is not promptly made, and if the patient is not immediately placed on a ventilator.

During the brief period of UN-sponsored weapons inspections in Iraq in the 1990s, it was discovered that more than 4,000 gallons of botulinum toxin had been produced by Sadam Hussein's government. Some of this deadly material had actually been loaded onto ballistic missile warheads, which appeared deployable as offensive weapons. At the present time, a vaccine against Clostridium botulinum is not available, though some progress has been made in creating a genetically engineered prototype vaccine.

Almost certainly, the events of September 11th, and the subsequent outbreak of anthrax infections, will compel the US Government to expedite the testing and validation of this new vaccine, in addition to a new smallpox vaccine. Ironically, this toxin is currently in vogue among many cosmetic surgeons and their patients. Tiny amounts of diluted toxin are injected into the muscles that wrinkle the skin of the face. Following "botox" injections, these muscles of facial expression are temporarily paralyzed, causing a reduction in skin wrinkles, especially around the eyes and mouth....

Bacillus anthracis has been known to man for as long as food animals have been domesticated. Unlike smallpox, anthrax is not thought to easily pass from one person to another. Rather, this organism spreads itself to new victims through a peculiar form of the bacterium, called a spore. When the environmental conditions for growth are poor, the anthrax bacillus "sporulates," forming a hermetically sealed sphere that can withstand amazing extremes of temperature and the nearly complete absence of moisture. Such spores remain dormant in the environment, often for many years, awaiting reactivation after ingestion by an animal host.

The cutaneous-or skin-form of anthrax infection is the best known, as it is the most common form of the disease as it occurs in nature (it is most often seen in livestock handlers). Anthrax bacilli can gain access to the skin through even small cuts, and may result in a cutaneous infection characterized by redness, swelling and blistering, followed by ulceration and the formation of a black layer of necrotic tissue, or eschar. Fever, headache, fatigue and malaise are also common systemic symptoms.

A second form of disease, the so-called orogastric form, can occur when the spores are ingested into the mouth or throat. Throat swelling and pain may be quite severe, and ulceration of the lining of the mouth and throat are also common. If swallowed, severe nausea, vomiting, diarrhea, and abdominal pain may also occur. However, the most lethal form of the disease is the inhalational form. Although the initial symptoms of inhalational anthrax resemble those of the flu (e.g., fever, joint and muscle aches, headache, dry cough and malaise), they rapidly progress to chest pain, profound shortness of breath, and eventual death due to respiratory failure and the shutdown of other vital organs. For treatment to be effective, antibiotic therapy must be started within the first few days of the infection, and before severe damage to the lungs and other vital organs has occurred.

Even if appropriate treatment is initiated early, patients at either extreme of age, as well as patients with other causes of impaired immune systems (e.g., patients with cancer, transplanted organs, or HIV), may succumb to inhalational anthrax. Despite all of the hype over Cipro as the "treatment of choice" for anthrax, the organism is generally sensitive to a number of antibiotic drugs. Indeed, the Centers for Disease Control confirmed, this week, that the drug doxycycline appears to be effective against the strain of anthrax so far detected in recent attacks.

This drug is generally well tolerated by most people who do not have allergies to the tetracycline class of antibiotics, although it should not be taken by children or pregnant women. It is also a generic drug, the patent for it having expired, and it can be produced by almost any generic drug manufacturer for a fraction of the price of Cipro. Good old penicillin is also effective against most strains of anthrax, and costs pennies per dose to manufacture.

As with doxycycline, the patent for manufacture of penicillin expired long ago, thus allowing multiple manufacturers to synthesize this antibiotic. In non-allergic patients, both of these antibiotics are actually associated with fewer potentially severe side effects than is Cipro. Ironically, there has been an effective vaccine against anthrax for many years. Used by large animal veterinarians and livestock handlers, and by the US military since the Persian Gulf War, the vaccine is quite effective.

Ironically, nearly 400 US military personnel have been separated from military service, prior to September 11th, because of their refusal to undergo compulsory anthrax vaccination (the vaccine can cause pain and redness at the injection site, and malaise, in some people).

However, the currently approved vaccine is manufactured by only a single company, and all lots of the vaccine have been pre-purchased by the DOD. Moreover, that company is currently operating under FDA sanctions due to quality control issues, and its anthrax vaccine is still under quarantine. There is reason to be hopeful, though.

More than 95% of the genetic code for the anthrax bacillus has already been deciphered, and the mechanism whereby the organism's toxins destroy host cells is now well understood. Using genetic engineering, it is anticipated that an effective vaccine, with minimal side effects, will be available soon. Meanwhile, physicians throughout the country, including this author, have been dusting off old infectious disease textbooks and brushing up on the signs and symptoms of anthrax infection.

And fourth, our aim is not to kill a cartoon character foe. It's to wipe out an ideology that considers slaughter saintly, particularly if the victims are Americans. Remember?

JWR contributor Dr. Robert A. Wascher is a senior research fellow in molecular & surgical oncology at the John Wayne Cancer Institute in Santa Monica, CA. Comment by clicking here.


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© 2001, Dr. Robert A. Wascher