Letters

Response to bioterrorism

Terror weapons are regarded as weapons of mass destruction

US anthrax incidents led to scares in Scotland

Screening for agents of bioterrorism increases terror

Countermeasures against weapons of mass destruction must be assessed now

Anthrax issue underlines need for infection specialists trained at bedside

Terror weapons are regarded as weapons of mass destruction

EDITORWessely et al speculate that a major reason why "armies have generally acquiesced in international treaties to contain" biological and chemical agents is these agents are "particularly ineffective as military weapons [and] have only limited uses."¹ This piece of reasoning does not do justice to the intelligence and serious intent of the drafters and signatories of the 1925 Geneva Protocol, the 1972 Convention on Biological and Toxin Weapons, and the 1993 Chemical Weapons Convention, nor does it explain why spears and stones are not similarly prohibited.

Terror weapons (biological, chemical, and nuclear) are so called not because they are capable of wreaking psychological destruction far in excess of their actual destructive capacity but because their use is considered inherently abhorrent. Somehow, in the collective psyche of our civilised world, killing and maiming with conventional weapons has always been considered more acceptable and less inhumane. Why should that be so?

Unthinkable or not, the events of 11 September 2001 and the subsequent spread of deadly anthrax by civilian post in the United States have upset our mental equilibrium and jolted our complacency. We suddenly realise that international treaties do not bind terrorist bandsthey apply only to sovereign statesand international opprobrium will not constrain the individual with a bent mind. Numbed by new talk of a "different" war, and stalked by ominous microbes and suspicious canisters lurking in every shadow, the entire civilised world feels nauseous not because of mass sociogenic illness but because the resort to these weapons proves that, despite all the signs pointing to the progress of the species, man's inhumanity to man has not diminished.

Why do biological, chemical, and nuclear weapons have such an unspeakable quality? Far from being ineffective and limited in use, they invoke feelings of revulsion and strike terror in our minds precisely because we recognise their true potential as weapons of mass destruction. Unlike conventional weapons, they do not leave the victor a hospitable earth to inherit. Weight for weight, and aided by technologically enhanced dispersal mechanisms, deadly pathogens and poisonous gases have the power to wreak as much havoc as nuclear bombs and annihilate the human species. Their use raises questions as to whether the human condition can be helped at all.

Meng-Kin Lim, associate professor. 
Department of Community, Occupational and Family Medicine, National University of Singapore, 117597 Singapore coflimmk{at}nus.edu.sg

US anthrax incidents led to scares in Scotland

EDITORNicoll et al commented on the effect the terrorist attacks in the United States on 11 September 2001 and afterwards have had on public health resources.¹ We examined the effect of the events on the population of Edinburgh and the Lothians.

In total, 27 incidents involving suspicious packages were notified to public health agencies. Assessments were made in all of these, but only three patients started taking prophylactic antibiotics. These were incidents in which a specific authenticated threat had been received or in which an individual was thought to have been in the United States at a known site of potential exposure.

The figure shows the epidemic curve of incidents involving suspicious packages in Lothian with the dates of fatalities from inhaled anthrax in the United States marked by arrows.² Many of the incidents we dealt with related to postal sorting offices, and the incidents were most frequent in the period surrounding the deaths of two postal workers in Washington, DC, on 21 and 22 October 2001. None of the packages was found to contain any biological agent; most turned out to be false alarms and some were deliberate hoaxes. The episodes showed, however, their ability to produce fear and alarm among ordinary people, which is the ultimate aim of terrorism. ^{3 4}

View larger version (10K): [in this window] [in a new window]   Incidence of suspicious packages in Lothian. Arrows show dates when people died of anthrax in United States

Liaison with the police, laboratory services, and the general public involved in such incidents is a large part of the role of health protection teams in such incidents. We estimate the total number of working hours spent on these incidents over a four week period at 480. The manpower demands created by them (when added to the existing functions of health protection teams) can threaten to overwhelm public health departments. Collaboration between national agencies and local services is vital to management of the crisis.

Margaret Bree, specialist registrar in public health medicine. 
Margaret.Bree{at}lhb.scot.nhs.uk

Janet Stevenson, consultant in public health medicine. 
Department of Public Health, Lothian NHS Board, Edinburgh EH8 9RS Janet.Stevenson{at}lhb.scot.nhs.uk

1.	Nicoll A, Wilson D, Calvert N, Borriello P. Managing major public health crises. BMJ 2001; 323: 1321-1322[Free Full Text]. (8 December.)
2.	Centers for Disease Control and Prevention. Update: Investigation of bioterrorism related anthraxConnecticut, 2001. Morb Mortal Wkly Rec MMWR 2001; 50: 1077-1079.
3.	Wessely S, Hyams C, Bartholomew R. Psychological implications of chemical and biological weapons. BMJ 2001; 323: 878-879. (20 October.)
4.	Kerruish T. Media could be used to better effect than inducing fear. BMJ 2002; 324: 115[Free Full Text]. (12 January.)

Screening for agents of bioterrorism increases terror

EDITORSince 11 September anthrax detection kits for use at home have become available to the general public, trumpeted as offering peace of mind. Extreme care should be taken in promoting these products. They are likely to serve as adjuvants to bioterrorism through identifying falsely positive signals, thus increasing, rather than decreasing, the associated terror and psychogenic illness.

As shown by the events after the postal delivery of anthrax spores in the United States, "the real `force multiplier' in [biological weapons] is the panic, misinformation, and paranoia."¹ For example, the number of investigations related to anthrax was high, despite the exceedingly low prevalence of disease related to bioterrorism.² Wessely et al advised caution about inadvertently amplifying the psychological response to biological and chemical terrorism.³ Interventions aimed at decreasing the panic and misinformation by providing accurate information to populations at risk through public dialogue may be a means of mitigating the psychological response.⁴

Few data are available on the performance characteristics of the anthrax detection kits that can be bought over the counter. They are not medical diagnostic tests and are exempt from the approval processes of the United States Food and Drug Administration. The only information available indicates false positive and false negative rates of at least 5% (sensitivity <0.95, specificity <0.95).⁵ The combination of less than perfect tests and an extremely low prevalence, however, produces some mathematical certainties. Screening for agents of biological terrorism with imprecise tools will yield high ratios of false to true positive results.

Positive results are likely, at least initially, to stimulate investigations of cases or outbreaks, which are not trivial in terms of time, expense, and population anxiety in an already overly extended public health system. Additionally, direct notification of the media about a "positive" anthrax identification by an affected person has the potential for rapid dissemination of mass misinformation with ensuing fear and panic.

Screening for agents of bioterrorism may be impossible with any screening test. Because these agents are rare and profoundly affect the public health, detection must be highly sensitive and timely. To avoid a high rate of false positive results, however, specificity must be high. Screening for anthrax at home is conducted without the benefit of context, which is harmful for rare exposures. Accordingly, there is little place for consumer tests for agents of bioterrorism.

Jonathan L Temte, associate professor. 
Department of Family Medicine, University of Wisconsin, 777 South Mills Street, Madison, WI 53715, USA

Countermeasures against weapons of mass destruction must be assessed now

EDITORHospitals and healthcare professionals have long planned for disasters and chemical spills, fires and hurricanes, but the terrorist attacks of recent months have led them to re-evaluate their preparedness for disaster and the safety of their countermeasures. Have experiences made people better prepared for chemical and biological weapons of mass destruction? Have the harmful effects of the countermeasures that might be adopted in response to such attacks been examined?

The Gulf war showed that "public health problems not adequately dealt with in the predisaster period are apt to emerge with greater severity during a crisis."¹ Israeli emergency planners preparing for the Gulf war failed to anticipate the complications from wide distribution of protective measures and misuse of masks. ^{2 3} Steady improvements in the quality and safety of gas masks and respirators have helped to reduce the complications arising from civil preparedness, especially among those at most risk.⁴ Widespread education initiatives in Israel helped to inculcate not only the dangers of weapons of mass destruction but also the hazards of protective equipment.

Are countries better prepared organisationally today to deal with such weapons? The evidence suggests that they are not. Little has been done to educate the public in the United States or Europe. The recent anthrax crisis in the United States shows how little was known.⁵ Some of the unanswered questions on countermeasures include:

• When should vaccines be given?
• Are vaccines safe for children?
• Which antibiotic should be given and when?
• Should protective masks be distributed and how?
• Is the technology safe?

During the Gulf war 119 deaths in Israel were directly attributed to incorrect use of masks in sealed rooms, especially in vulnerable populations.¹ Several years were needed to train a population of around 5 million to avoid the life threatening malfunctions of these masks. How long would it take to educate the United Kingdom's 55 million people or the United States' 284 million about using a mask properly?

The threat of states and terrorists using weapons of mass destruction has received increased attention in recent years. Resources need to be dedicated to increase knowledge about these agents and ascertain the effectiveness of countermeasures. Much work is needed to get public health systems ready, and now is the time. Fortunately, the widespread tendency to think that defence against weapons of mass destruction is unnecessary and too difficult is rapidly receding.

Paul Barach, assistant professor. 
Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA pbarach{at}airway.uchicago.edu

Anthrax issue underlines need for infection specialists trained at bedside

EDITORAs inconceivable as it might have seemed before 11 September 2001, the public in the United States now shows unprecedented interest in bioterrorism.^1-3 British press reports make it clear that healthcare services in the United Kingdom must retain the public's confidence in their ability to respond to such crises.²

Hart and Beeching's editorial is therefore timely, covering not only the management but also the clinical presentation and diagnosis of anthrax.⁴ This point is crucial. With not only anthrax but also the numerous other candidate weapons of warsuch as smallpox, tularaemia, plague, and viral haemorrhagic feversshould doctors not interpret the history, symptoms, and signs of such unfamiliar infections correctly, the consequences could be dire for the patient, and an opportunity to limit the spread of a contagious disease, such as smallpox, could be lost.⁴ Diagnosis will depend on acumen and the quality of the interface between clinicians and microbiologists.

The answer lies in access to appropriate expertise. Given the magnitude of the diagnostic challenge, expertise limited to the end of a telephone may not be the optimal way to conduct business, and accurate recognition and assessment of victims of bioterrorism by physicians with appropriate knowledge acting synergistically with microbiologists would be preferable. Patients could, however, conceivably present at a district general hospital, yet at present physicians with bedside training and accumulated experience in the recognition and management of infectious diseases are rare or absent in many parts of the United Kingdom, even in some teaching centres and medical schools, including many of the newly created ones.

Every specialty claims that its consultant numbers are too low. But there is a way forward. In North America infectious diseases is a large and thriving specialty, combining laboratory microbiology and bedside clinical work. In the United Kingdom, progress towards creating a similar entity has been slow, with specialist registrar training leading towards a certificate of completion of specialist training encompassing both infectious diseases and microbiology or virology.⁵

The current heightened awareness of the potential for a bioterrorism based Armageddon (a possibility that might not recede for a very long time, if ever) is yet another compelling reason to add to the othersfor example, increasing long haul tourism, movement of refugees and asylum seekers, multidrug resistant tuberculosis, and new and re-emerging infectious diseasesto accelerate and reinforce the trend towards more doctors being trained in the bedside aspects of infection diseases.

Stephen T Green, consultant physician in infectious diseases and tropical medicine. 
Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF steve.green{at}sth.nhs.uk