Appropriate responses to bioterrorist threats
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7318.877 (Published 20 October 2001) Cite this as: BMJ 2001;323:877
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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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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?
Competing interests: No competing interests
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
Competing interests: No competing interests
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 ?
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests