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EDITORIALS: Nigel Lightfoot, Martin Wale, Robert Spencer, and Angus Nicoll Appropriate responses to bioterrorist threats BMJ 2001; 323: 877-878 [Full text]

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Information at last

Iain Bonavia   (19 October 2001)

Abuse of antibiotics.

Stuart Berry   (22 October 2001)

(IN)appropriate responses to bioterrorist threats

Ian Spencer   (23 October 2001)

Which Antibiotic

Jody Aberdein   (24 October 2001)

Re: (IN)appropriate responses to bioterrorist threats

Tim Kerruish   (24 October 2001)

Cipro in anthrax

C Madhu   (1 November 2001)

Health protection structures are good - for now

Lorraine Lighton, David Irwin, Peter English, Roy Fey   (2 November 2001)

Stop all bioterrorist attacks!

Alfredo D Espinosa-Brito, Frank C Alvarez-Li, Alfredo A Espinosa-Roca   (27 November 2001)

Information at last 19 October 2001
Iain Bonavia, General Practitioner Tennant Street Medical Practice, Stockton-on-Tees, TS18 2AT Send response to journal: Re: Information at last	Thank goodness for the BMJ. A week ago (Friday 12 October) Mr Milburn was informing the press that all Health Care Professionals were receiving detailed information on the treatment and early recognition of anthrax. Like many GPs and other Primary Health Care Professionals I am still waiting. I found some details myself on the PHLS site (excellent I must say) but am pleased that at least through the BMJ there has been some dissemination of information across the profession. Clearly the Government has a lot on its plate at the moment and also needs to put across the impression that everything is under control. However I'm sure I'm not alone in having had some queries from patients who expect that I will have the relevant information at my fingertips as they were told on the TV last week.
Abuse of antibiotics. 22 October 2001
Stuart Berry, G P registrar Crosshills Health Centre Send response to journal: Re: Abuse of antibiotics.	Americans appear to be having little success in controling the purchase of ciprofloxacin by the american public. The potential effect on drug resistance by the use of this antibiotic as prophylaxis against a largely psychological threat should be recognised. the fear of anthrax will fade as the widespread outbreaks fail to materialise, but the effect of inreased drug resistance will remain much longer. Does the USA have a duty to conserve the effectiveness of this antibiotic by limiting its availability ?
(IN)appropriate responses to bioterrorist threats 23 October 2001
Ian Spencer, Consultant in Anaesthetics University Hospital of North Durham Send response to journal: Re: (IN)appropriate responses to bioterrorist threats	The authors of this editorial, all peace-time epidemiologists and laborarory-based clinicians, appear not to have grasped the dangers posed by the threat of biological warfare and, in particular, the need for early recognition and treatment of an attack. The first warning of this should be made, not by finding 'severe sepsis with Gram positive rods or a bacillus species identified in the blood or cerebrospinal fluid' but by the prompt detection of abnormal patterns of symptoms within the community Some years ago, when I was a Royal Air Force Medical Officer, I thought that the MoD's ability to detect, early, a biological attack, was impaired by its disease notification system since this required a diagnosis to be made by the reporting medical centres and this was unlikely to be quickly made. I considered that more emphasis should be placed on the reporting of symptoms and signs and wrote a computer program that would suggest a diagnosis, using probability analysis, based on this more readily available data. (See articles in BMJ on Logic in Medicine published Oct-Nov 1987 and A Mathematical Approach to Medical Diagnosis Warner et al JAMA Vol 177 (3)177-183). Although the program was written in QLbasic (for the Sinclair QL), it could readily be adapted for incorporation within the NHS Direct scheme as this is likely to be the earliest source of enquiry about signs and symptoms from patients who might,to take a pessimistic view, be affected by a biological agent. The program also incorporates a 'best question'algorithm that suggests which piece of missing information (in this case a symptom) would best produce a more accurate prediction - again something that could be used by NHS Direct staff who answer queries from patients. If anyone would like a copy, please let me know (a similar offer has been made to the Department of Health but not responded to). Dr Ian Spencer Consultant in Anaesthetics Durham
Which Antibiotic 24 October 2001
Jody Aberdein, PRHO in General Practice Plumstead Health Centre, London Send response to journal: Re: Which Antibiotic	I was looking at the WHO website and the guidelines there for anthrax treatment. These say that ciprofloxacin is effective, but that penicillin is the first treatment they recommend. Several other antibiotics are also mentioned as being useful such as streptomycin, tetracyclines, gentamycin and chloramphenicol. Cna anyone explain the basis for the ciprofloxacin recommendation in particular?
Re: (IN)appropriate responses to bioterrorist threats 24 October 2001
Tim Kerruish, Consultant , Emergency Medicine Dunedin Hospital , Dunedin , NZ Send response to journal: Re: Re: (IN)appropriate responses to bioterrorist threats	One of the aspects that I find most interesting about the current anthrax releases in the United States, is the apparently disproportionate fear that it has produced amongst the population, fuelled I think, by the media coverage it has been given. I note that in the CDC report of September the 25th 2001, in the year 1999, a total of 28,874 persons died from firearms injuries, 19,102 died from drug related causes , and 19,171 from alcohol related causes. Neither the drug nor alcohol related statistics include accidents , homicides or other causes indirectly related to their use. Given that the media is able to wield such massive influence, perhaps in the hoped for 'New World Order' they can do so in more useful ways.
Cipro in anthrax 1 November 2001
C Madhu, Cosultant Physician Hyderabad India Send response to journal: Re: Cipro in anthrax	The fear of anthrax seems overrated to us from a distance but we do no know the military implications of this .Highly concentrated spores inhaled directly are definitely more dangerous than the usually familiar infection transmitted from sheep animal hides etc.The military of US should know better as it has been a well known biological agent developed for warfare.Old textbooks mention the same.The use of Ciprofloxacin was approved by FDA and is safe and effective.Currently Cipro is indicated in 14 indications and anthrax is the latest one.Certainly it is more effective than penicillin.Here in India we have used it in Typhoiid and other infections and found it very safe and effective.The recommended dose for post inhalation Anthrax is 500 mg twice a day for adult and 15mg/kg wt twice a day for children.FDA okayed it basing on animal experiments. The iv dose is 400mg twice a day for adult and should be started as soon aspossible after inhalation.The drug must be given atleast for 60 days.Common adverse reactions are nausea diarrhoea vomitting and rash but these are minor.
Health protection structures are good - for now 2 November 2001
Lorraine Lighton, Consultants in Communicable Disease Control , David Irwin, Peter English, Roy Fey Send response to journal: Re: Health protection structures are good - for now	In their editorial Nigel Lightfoot et al commend the excellent public health systems and infrastructure in the United Kingdom which will help to ensure a swift and appropriate response to deliberate releases of chemical or biological agents. In England the health protection infrastructure is generally based within Health Authorities and particularly with Consultants in Communicable Disease Control (CCDCs) and their support staff. In May 2001 the Government announced the abolition of Health Authorities with effect from April 2002. Although many of the public health functions of Health Authorities will be taken over by Primary Care Trusts (PCTs) and the new Strategic Health Authorities, the only guidance so far on the future of health protection is that accountability for this function will lie with the Regional Director of Public Health. Further guidance was promised for mid-September 2001 but none has been forthcoming. The delay in guidance on the future structure of the service is already causing problems. While other Health Authority staff are preparing for posts in PCTs or elsewhere, those working in health protection, including communicable disease control, have an uncertain future, not knowing who they will be working for or where they will be based. Although some Health Authorities have nominally moved their health protection staff to PCTs there is no guarantee that the guidance will advocate this, nor is this necessarily the best model for the service. In the meantime, support staff are seeking more secure jobs elsewhere, resources and accommodation are being snapped up by others and the remaining workforce is increasingly demoralised. Recent world events have highlighted the importance of a robust and well-resourced health protection function. To ensure the continuation of “our excellent public health systems” we need clear guidance on future structures and responsibilities now. Any further delay may lead to a significant deterioration in the ability of the service to protect the health of the public. Yours sincerely DR LORRAINE LIGHTON CONSULTANT IN COMMUNICABLE DISEASE CONTROL WEST PENNINE HEALTH AUTHORITY DR DAVID IRWIN CONSULTANT IN COMMUNICABLE DISEASE CONTROL NORTH ESSEX HEALTH AUTHORITY DR PETER ENGLISH CONSULTANT IN COMMUNICABLE DISEASE CONTROL EAST AND WEST SURREY HEALTH AUTHORITY DR ROY FEY CONSULTANT IN COMMUNICABLE DISEASE CONTROL SOUTH DERBYSHIRE HEALTH AUTHORITY Contact address:- Dr L Lighton Consultant in Communicable Disease Control West Pennine Health Authority Westhulme Avenue Oldham OL1 2PL
Stop all bioterrorist attacks! 27 November 2001
Alfredo D Espinosa-Brito, Internal Medicine Department Hospital Dr. Gustavo Aldereguía Lima, Ave. 5 de Septiembre and Calle 51 A, Cienfuegos 55 100, CUBA, Frank C Alvarez-Li, Alfredo A Espinosa-Roca Send response to journal: Re: Stop all bioterrorist attacks!	Dear Sir: We read carefully the very interesting editorial "Appropriate responses to bioterrorist threats" appeared in the BMJ recently.(1) We agree that there are limited experiences with deliberate release of a "weaponised" biological agents, but we want you to emphasized that Cuba suffered a very large and ominous attack of bioterrorism in 1981. At that time, a new Dengue type 2 virus epidemic (before unknown in the Americas) was intentionally introduced in our country from abroad (you can imagine from where). The evidences for this assumption were published in a landmark article: "One nucleotide change was observed between the first strain isolated during the epidemic and the rest of the Cuban strains. This mutation induced a nonconserved amino acid change from phenylalanine to leucine at position 43 that was not observed in any of the other strains with which it was compared".(2) Near 400 000 cases were reported in the whole nation, more than 10 000 with severe complications (Dengue Hemorrhagic Fever and/or Dengue Shock Syndrome). In spite of the exemplary public health response to that Dengue epidemic, 156 deaths occurred, including 101 children.(3) For all of us, medical doctors, who we are fighting every day against death, it is incredible that these things happenned.(4) As health professionals we have to join together and to call now, and always, for non-violent and just solutions rather than vengeful acts, to help to promote tolerance and understanding at a time of social tension, and to contribute to an understanding of the psychosocial causes of violence. Sincerely, Prof. Alfredo D. Espinosa-Brito, MD, PhD Frank C. Alvarez-Li, MD Alfredo A. Espinosa-Roca, MD REFERENCES. 1.Lightfoot N, Wale M, Spencer R, Nicoll A. Appropriate responses to bioterrorist threats (editorial). BMJ 2001;323:877-878. 2. Guzman MG, Deubel V, Pelegrino JL, Rosario D, Marrero M, Sariol C, Kouri G. Partial nucleotide and amino acid sequences of the envelope and the envelope/nonstructural protein-1 gene junction of four dengue-2 virus strains isolated during the 1981 Cuban epidemic. Am J Trop Med Hyg 1995; 52(3):241-6. 3. Kouri GP, Guzman MG, Bravo JR, Triana C. Dengue haemorrhagic fever/dengue shock syndrome: lessons from the Cuban epidemic, 1981. Bull World Health Organ 1989;67(4):375-80. 4. Davis R. Medicine responds to terrorism in the US. BMJ 2001; 323:700.