Q&A: What anthrax has taught us about public health preparedness

The 2001 anthrax attacks in the United States marked the first time public health was deemed central to emergency response and national security, and has since served as a catalyst for national, state, and local efforts to ensure public health preparedness efforts are in place. The attack was the first case of intentional, deliberate release of anthrax in the United States. Thought to be devised by a mentally ill, lone scientist, the threat spawned from only a few grams of Anthrax, but infected 22 individuals and resulted in five deaths causing wide-spread public fear, significant government disruptions and a direct economic cost over a billion dollars.

So what would happen if a terrorist group got their hands on several hundred grams of anthrax? Consequences could be catastrophic, with casualties potentially in the thousands with untold economic, social and political consequences, underscoring the need for collaborative public health preparedness and response efforts between health departments, emergency management, law enforcement and private entities from local to national levels. Gerald Parker, D.V.M., Ph.D., associate vice president for public health preparedness and response at Texas A&M Health Science Center, offers information on the realities of a bioterrorist attack and what is currently being done to prepare for the next unknown threat.

Q:  How dangerous is anthrax from a national security standpoint?

A:  Attempts to use biological warfare agents date back to antiquity, but biological warfare increased in sophistication during the 20th and into the 21^st century.  For example, the German Army developed anthrax as a strategic weapon in World War I to undermine allied cavalry operations and logistics. The United States initiated a biological weapons program in World War II in response to the fact that our enemies had biological weapons.  By the time the United States terminated its biological weapons program in 1969, the feasibility of manufacturing biological weapons had been demonstrated and civilian population vulnerabilities were established through simulations.

The Soviet Union began a biological weapons program in the 1920’s, but when the United States terminated its weapons program in 1969, the Soviet Union took that opportunity to greatly expand their offensive program even though the Soviets were a signatory to the Biological and Toxins Weapons convention of 1972.  Through the end of the Cold War, the Soviets maintained an immense, clandestine and sophisticated offensive biological weapons enterprise employing thousands of scientists, engineers and technicians. The Soviet program went largely undetected by the west until 1991, when two defectors made their way to the United Kingdom and the United States. We learned that anthrax spores and other pathogens, including smallpox, were produced in ton quantities and coupled to strategic weapon delivery systems. After becoming aware of the extent of the former Soviet enterprise after the end of the Cold War, the threat of proliferation of scientific expertise and biological weapons materials from Russia to other state and non-state actors was real. Although much of the Russian enterprise has since been redirected through cooperative threat reduction programs to peaceful purposes, Russia has not allowed western inspectors and scientist to visit a few key Russian military facilities thought to have been involved in illicit biological weapons production activities to this day. In addition to Russia, there continues to be concern that China, North Korea, Iran and Syria may still harbor clandestine biological weapons capabilities. For this reason, in addition to the growing bioterror threat from non-state actors, the Department of Defense, Department of State, Department of Justice and Director of National Intelligence maintain biological weapon counter-proliferation and non-proliferation programs in partnership with our strategic allies to prevent, mitigate and interdict illicit use of pathogens as biological weapons.

Since the anthrax attacks in 2001, dozens of policy, intelligence, technical reports and other open source publications have affirmed that terrorist groups and violent extremists, to include the Islamic State, intend to acquire and use biological pathogens to cause death, suffering, and socio-economic disruption on a catastrophic scale. Today, anthrax is near, or at the top of most bioterror threat lists.

Anthrax spores are easily found in nature, can last for a long time in the environment, and are maintained in research and diagnostic laboratories around the world. Many of these laboratories are in the developing world within a terrorist nexus, and most lack biosecurity, biosafety and personnel reliability controls.

The knowledge and tools needed to acquire and disseminate anthrax as a bioterror threat are accessible and easily concealed.  Anthrax can be released on a civilian population quietly and covertly, without anyone knowing, making it a prime bioterror agent.  The consequences of an anthrax attack can range from a few casualties to thousands; and environmental contamination that may require months or years to remediate.

An anthrax attack on a city in the United States could be catastrophic, yet several bi-partisan commissions and reports have consistently reported major gaps in our bioterror preparedness.  The most recent was the bi-partisan report from the blue ribbon panel on biodefense:  A National Blueprint for Biodefense (October 2015).  For these reasons, public health emergency preparedness planning and action have become a national security imperative.

Q:  How would an anthrax attack be detected?

A:  It is challenging to recognize early indications of an anthrax attack because its release is invisible, but early detection is key to effective management, response, prophylaxis and treatment of the affected population. Unfortunately, since early symptoms appear flu-like, anthrax disease may first go unnoticed until physicians begin to see unusual patterns of illness among patients in emergency rooms and order samples to be tested for anthrax.
Laboratory identification will be achieved through the Center for Disease Control and Prevention’s (CDC) Lab Response Network, a nationwide response network enacted in 1999 to mount an effective laboratory response to bioterrorism. This laboratory network is able to confirm or rule out whether a patient has anthrax or whether or not the environment is contaminated with Bacillus anthracis. These labs are vital to the early identification of anthrax, especially in the case of a bioterrorism attack.

Additionally, the Department of Homeland Security oversees the BioWatch program, a detection system deployed in 30 U.S. cities that is intended to detect the intentional aerosol release of the most catastrophic biological pathogens, including anthrax. The BioWatch system consists of units that collect air samples coupled to a network of local, state, and national laboratories—many in the LRN network—with a goal of providing a warning that an attack may have occurred within 12-36 hours after intentional anthrax release.

It could take days for labs to confirm anthrax in those early clinical, environmental or air samples. But with enough evidence, public health and other authorities would not need to wait for lab confirmation before they took action.

Q:  Is the threat of bioterrorism real?

A:  Some question whether the threat of bioterrorism is real, particularly since the 2001 anthrax letter attacks may have been perpetrated by a lone U.S. scientist and other attacks have not occurred since. I do not want to overstate, nor underestimate the threat and risk, but there is little doubt that Al Qaeda and the Islamic State intend to acquire weapons of mass destruction, including dangerous pathogens, to use in mass casualty bioterror attacks. We ignore the threat at our peril.

Q:  Is there any way we can prepare for such a threat?

A:  We have to prepare for high consequence infectious diseases whether naturally occurring or from an attack. Federal agencies have provided preparedness grants to local and state health departments and emergency management agencies across the country to plan and prepare for an anthrax attack. If such an emergency were to occur in the U.S., CDC and other federal agencies would work closely with, and support, local and state partners to mount a coordinated response. Unfortunately, funding for bioterror preparedness for state and local public health preparedness has decreased in recent years.

Q:  What medical countermeasures are available for anthrax?

A:  Antibiotics represent the first line of defense to protect the nation following an anthrax attack, and the CDC has millions of courses of antibiotics in the Strategic National Stockpile (SNS) ready for distribution, but local authorities are responsible for rapidly dispensing these life saving medications in their jurisdiction. Anthrax vaccines are also an essential element of preparedness, and the CDC maintains a limited stockpile of vaccine in the SNS for pre-exposure and for use as a post-exposure prophylaxis in combination with antibiotics. In addition, antitoxins are necessary to treat individuals in advanced stages of disease, and may contribute to a more successful therapeutic outcome.

Government funded research efforts continue to explore the development of novel and more cost-effective vaccine and medical countermeasure candidates to enhance protection from, and treatment of, anthrax disease.

Following the 2001 anthrax attack, plans are now in place to distribute countermeasures from the SNS to state and local authorities should the need arise, but challenges remain in dispensing antibiotics to a potentially exposed large population rapidly in an urban area, and anthrax vaccine remains in limited supply.

Public health authorities have also forged new partnerships, and have a much closer relationship with law enforcement and emergency response agencies to effectively communicate life-saving information to the general public. Ultimately, important lessons were learned from the 2001 attack, with the most important being the vital role public health preparedness and response plays in responding to acts of bioterrorism—one of the most insidious forms of a weapon of mass destruction.

For basics on the infectious disease, visit our Anthrax 101.

Dr. Gerald Parker, associate vice president for public health preparedness and response at the Texas A&M Health Science Center and principal investigator at the Texas A&M Center for Innovation in Advanced Development and Manufacturing. Dr. Parker previously served as deputy assistant secretary of defense for chemical and biological defense at DOD; principal deputy assistant secretary for preparedness and response at HHS, and he is a former commander of the United States Army Medical Research Institute for Infectious Diseases.