Bioterrorism cannot be ignored

November 2003

---Philip A. Brunell, MD

If a patient called and told you they had heard on TV that the CDC had confirmed several cases of smallpox in a community, or if a patient you were seeing had a suspicious looking illness that you suspected might by caused by a biologic or chemical weapon, would you know what to do? There have been two excellent documents in Pediatrics during the past few years dealing with chemical-biological or with bioterrorism (2002;109[6]:685-692). My consciousness was aroused by a book I had just finished called Biohazard by Ken Alibek. The book is an easy read, although not particularly great literature. It describes Dr. Alibek’s experience during the time he was involved in the Soviet Union’s bioterrorism program.

Bioterrorism is a very attractive alternative to nuclear weapons for terrorists. It is much cheaper, can be delivered relatively easily and can be prepared surreptitiously. Our country had a bioterrorism program as did several other countries (as attested to by the occurrence of clusters of unusual illnesses in rather suspect locations). Bioterrorism has been in use for some time. We were aware of the successful sarin gas attack in a Tokyo subway by the Aum Shinrikyo, a terrorist group in 1995, which killed 12 people and resulted in 5,500 injuries. However, in the subsequent trial it was revealed that they had tried nine times to spread anthrax and botulism toxin in the streets of Tokyo and Yokahama between 1990 and 1995.

But bioterrorism has a longer history than this. One of the most notorious gifts of all time was blankets containing smallpox given by the British to Native Americans during the French and Indian War. In the recent past, anthrax spores arrived in the mail. Since October 2001, 17 confirmed and five suspected cases have been reported.

As pediatricians we must assume our traditional role of child advocacy. In the first Pediatrics report (2000;105 [3 pt 1]:662-670), their increased vulnerability to chemical or biological weapons was delineated. We have a special role to assure that systems that are put in place take cognizance of the needs of children. The Academy in its traditional role as child advocate has prompted Congress to include measures in legislation, which would assure this. In fact, Health and Human Services secretary Tommy G. Thompson has established an Advisory Committee on Children and Terrorism.

What are our special responsibilities? We are told in the first Pediatrics (2000;105[3pt1]:662-670) publication that we should work within our communities to assure things are geared to the needs of children. One should assure that if an attack occurs while children are in school or other child care provisions have been made for them. It may also be necessary to be certain that the community has child appropriate resources. Psychological support for children should be available. One of the most important roles is to identify suspicious cases. Be alert! Once having done this, local health or police departments should be called. Offices should have a plan for isolation, decontamination and transport of patients in the event of an attack.

In the first-responders handbook published in 1998 it is stated that “an unusual number of sick or dead people or animals within an area or location” should arouse concern of bioterrorism. Because of the prevalence of syndromes similar to those caused by chemical or biologic weapons in a pediatric population, it may be particularly difficult to appreciate an increase in categories of illness that might be due to these agents. In the second Pediatrics (2002;109[6]:685-692) article, the symptom categories are respiratory, influenza-like illnesses, acute rash with fever, neurologic symptoms and blistering syndromes. Thirty-three agents are listed as possible biological weapons and any one or several of these agents may cause a single syndrome. Q fever, smallpox, tularemia, Rocky Mountain spotted fever, Ebola or Lassa fever, for instance, can cause a “flu-like illness.” We are unfamiliar with most of these illnesses. What is more, Dr. Alibek tells us that efforts to clone myelotoxin or botulism toxin into Yersinia pestis was avidly pursued in Russia. Thus, we may be dealing with a totally undescribed syndrome. In most cases we may be unable to make a specific diagnosis but we should get help when we are suspicious and take proper precautions. The second article (2002;109[6]:685-692) has detailed information on the clinical features resulting from many of these agents, along with the diagnostic tests and treatment for children. Laboratories are organized with increasing sophistication with CDC being the end of the line. Ordinarily, the local health department would be called first.

The Institute of Medicine (IOM) report this past August on smallpox was quite illuminating. One of the conclusions, a very important message, is that we cannot focus on a single agent. Systems must be in place to deal with an attack with any agent. The second message was to take stock of what is out there and then to organize. Communication between agencies, the medical community and with the general population is important. Awareness that there is a system of dealing with a smallpox attack may dissuade people from insisting on being vaccinated now. Much has been done, but more still needs to happen. The levels of preparedness vary in different parts of the country.

The final part of the IOM report deals with vaccination of the general population. In December 2002, the president indicated the need to immunize the military and first responders now. Approximately 440,000 service men and women and 40,000 first responders have been vaccinated. This has not produced many surprises except for the myopericarditis observed following immunization. President Bush also noted that many civilians wanted to be vaccinated now. He did not recommend this but left it to the CDC to handle. The IOM report indicated that if this was done, it should be done in the context of a clinical trial.

Bioterrorism is easily forgotten among other more pressing problems, but it cannot be ignored. We need to periodically perform an inventory of our preparedness as well as be sure our communities have the capability of caring for children in such an eventuality.

I am sorry to announce the deaths of Jim Seidel, MD, PhD, and G. Scott Giebink, MD, both members of our editorial board.

Jim was a good friend. He will be missed by the pediatric community. He was not only an outstanding clinician but he also was outspoken in his support of children. He was past president of the Ambulatory Pediatric Association and a long time member of the UCLA faculty working at Harbor General Hospital in Torrance, Calif.

Scott was the “complete pediatrician” in its true sense. In addition to his contributions as an investigator, he was a strong advocate for children. I first met Scott when Stan Plotkin met with a group of us at a meeting in Miami to suggest that we needed a pediatric infectious disease club (later to become PIDS). I was so impressed with him that as chair of the Red Book committee, I recommended his appointment, and he served as associate editor during my tenure as chair. We again interacted when we both were active in the Academy. He contributed to the early efforts to define the health needs of children in day care. We have all lost a good friend.