Plague fears

A bioterrorism expert talks about the wicked ways of anthrax and the even deadlier potential scourge of smallpox.


Suzy Hansen
October 9, 2001 8:15PM (UTC)

With at least two mysterious anthrax cases in Florida, Americans are wondering if the next wave of terrorist attacks has begun. Anthrax and smallpox have long been considered the ideal bioterrorist weapons; in fact, smallpox may have been used as long ago as the French and Indian War. President Richard Nixon officially renounced biological warfare in 1969, but other countries, significantly Russia, continued their development programs. Jonathan B. Tucker, an expert on chemical and biological weapons in the Washington office of the Monterey Institute of International Studies, is the editor of "Toxic Terror: Assessing Terrorist Use of Chemical and Biological Weapons" and, more recently, "Scourge: The Once and Future Threat of Smallpox." Salon spoke to Tucker from his office in Washington.

What are the first signs of anthrax?

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Nonspecific flu-like symptoms followed by fever, difficulty breathing and death. There are treatments -- Cipro and other antibiotics -- but they're only helpful if administered before the development of acute symptoms like difficulty breathing.

What do you think about what's going on in Florida right now with the two anthrax cases?

From the evidence that has been made available thus far, it is highly suspicious, but not conclusive that this is a bioterrorist incident. It is puzzling that only two people appeared to have been exposed. One would have expected that if in fact aerosolized anthrax was disseminated through the ventilation system, more people would have been exposed. Why only two? Unless they are particularly susceptible to the disease depending on the state of their immune system.

There's the suggestion that this could have arrived by mail. Is anthrax effective in a powder form?

It definitely could arrive in a powder form. It could survive indefinitely if it wasn't exposed to light. It would be killed if exposed to ultraviolet rays. If it was a fine powder then it could easily be suspended in the air. It takes 8,000 to 10,000 spores to cause an infection -- that's a speck of dust. But the spores have to be small enough that they could be inhaled deep into the lungs and be retained. If they're too big, they'll get caught in the nose or throat.

This could be a low-tech terrorist attack, some local deranged individual or domestic terrorist group. There have been literally hundreds of anthrax hoaxes over the years. But the timing is extraordinary. If we weren't in a state of high-vigilance, we might not have diagnosed this case. It does show that the system worked.

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How fast do symptoms show?

It really depends on the dose and the immunological competence of the host. Anywhere from two to three days up to more than a month, depending on how well the body can fight off the infection. Also, it depends on the amount of spores that are inhaled.

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But in contrast to smallpox, people do not spread this to others.

Anthrax is not contagious. Only those directly exposed would be at risk of developing the disease.

Exactly what does it do to you?

There are different types, but the most lethal form is pulmonary anthrax, which results from the inhalation of spores. Spores are a form of bacterium that's in a kind of suspended animation -- the bacterium forms a tough outer coating so that it can survive under harsh conditions for long periods. Once inhaled into the lungs -- roughly 8,000 to 10,000 spores are sufficient to cause infection -- they will germinate, multiply in the bloodstream and release toxins that cause damage to vital organs and cause a lethal outcome. It's a highly virulent disease. If the strain of the bacterium is a virulent strain, it can cause an upwards of 85 to 90 percent fatality rate.

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Typically, how fast can this happen?

In the case of the individual in Florida, it was within a week or two.

Could this man have gotten it from an animal?

Back when there was a serious problem with natural anthrax, most people contracted it by coming in contact with contaminated wool or animal hides. In the 19th century it was called "wool-sorters disease" because people who dealt with contaminated wool or yarn or worked in tanneries could inhale spores from the contaminated hides.

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Do you think that they're taking the necessary precautions down there?

The Centers for Disease Control is investigating this. They are testing everyone. They are administering antibiotics to everyone in that building in Florida. They are obviously treating everyone in the Sun building with antibiotics because of the possibility that they might have been exposed to anthrax, and that is the prudent thing to do. If antibiotics are administered before the appearance of acute symptoms of anthrax, it is possible to prevent or cure the disease.

You used the term "aerosolized anthrax" before. Do smallpox and anthrax make good weapons?

Smallpox and anthrax are considered the ideal bioterrorist weapons because they are inherently rugged. Most bacteria and viruses are quite fragile in the environment and they will die off once released into the air. But anthrax -- because it can be induced to form a spore, a tough outer coating -- will survive for hours, particularly at night when it's not exposed to ultraviolet radiation. The same is true for the smallpox virus, which is normally transmitted through the air. That's its natural means of transmission. Smallpox virus will survive longer under cool, dry conditions than under hot, humid conditions.

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How would they release them into the air?

Either with some kind of fogger or spray device that can produce a very, very fine mist of particles that would be microscopic in size and could be inhaled and retained in the lungs.

Could crop-dusters have spread these diseases?

No, that was extremely unlikely unless the crop-duster was extensively modified. A crop-duster is designed to spray relatively large particles that will drop out of the air onto crops; they want to minimize drift. They tend to fly very low. It's not suited to a biological agent. You want to release particles that are small enough so that they remain suspended in the air, will drift downwind for long distances and can be inhaled and lodge in the lungs. If the particles are too large, they will get caught in the nose and throat and will not make their way into the lungs to cause infection.

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Should we worry about our water supply?

It's possible but an unlikely means of delivery, particularly for an urban reservoir, for a number of reasons. First, the dilution factor. We're talking about very large volumes of water that would tend to dilute all but a massive quantity of a chemical or biological agent. We have filtration and chlorination systems that are designed to kill natural biological contaminants such as e. coli. These are highly effective at removing dangerous pathogens from our water supply. So unless the contamination was downstream of a treatment plant, which would be difficult to do, I don't think that this would pose a threat. Still, we don't want people pouring nasty things into our water supply so it does make sense to improve security at our reservoirs.

Smallpox is contagious. Could we see the scenario of a smallpox-infected suicide bomber?

One could conceivably infect a number of individuals with this disease. After the two-week incubation period with a first appearance of the rash, they would become infectious and spread the disease.

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Now, there are certain limits on that scenario. Initially, smallpox looks like chickenpox -- flat, red spots on the skin -- which then fill with fluid to form blisters that then fill with pressurized pus to form pustules or boils all over the skin including the face. There would be a limited window of a week before the rash would be so obvious that people couldn't conceal it with makeup. That would be a constraint. Also, during that first week of the rash, people feel horrible. They have severe fatigue to the point of prostration so it would not be easy for people to do it -- of course, you'd have to be pretty fanatical to do this in the first place. Finally, it might be one thing for suicide bombers to go out in a blaze of glory but whether they would want to suffer the horrors, the disfiguration and the agony of smallpox including this pustular rash all over their skin, is another matter. They would have to be extremely fanatical to undergo that level of suffering to spread the disease. We're talking about possibilities but not likely events.

What would be the first unusual symptoms of smallpox?

High fever and prostration followed by the appearance of the rash. Unfortunately, by that time, the first wave of cases probably cannot be saved because we don't have a treatment for smallpox yet, though there are efforts underway at the CDC to develop drugs that could be used to treat smallpox. The only way to deal with it is to vaccinate people who might be exposed or have been exposed before they develop the acute symptoms. What you would want to do is isolate that first wave of cases and then vaccinate around the outbreak and it will burn itself out.

Do you think that smallpox is a threat?

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It's one of those threats that, while unlikely, is potentially catastrophic. We have to err on the side of caution in terms of preparation. But it shouldn't be something that the average person is extremely concerned about.

What about Sept. 11 makes you more concerned about bioterror?

We have to take the potential threat of bioterrorism very seriously. Osama bin Laden has stated that it's his religious duty to acquire weapons of mass destruction, including biological weapons, so obviously the motivation is there. Whether they could obtain access to the smallpox virus is uncertain because the disease was eradicated more than 20 years ago and the virus only exists in a few laboratories.

Which ones?

There are two official repositories of the virus; one, in the United States, in the Centers for Disease Control in Atlanta, and the other, in Russia, in a laboratory near Novosibirsk. These official repositories, which are overseen by the World Health Organization, are highly secure.

How vulnerable is the CDC facility? At one point in the book, you write that the CDC's labs were built to "withstand an earthquake, a tornado or an airplane impact." Obviously, that means something else to us now.

The smallpox repository is quite secure. The virus is deep frozen in liquid nitrogen. Of course, if there was any threat, they would stop working with the live virus and put all of the samples in liquid nitrogen in these stainless steel freezers. It's in a secure location that I'm told is capable of withstanding even a direct impact by an aircraft.

Really?

But, obviously, the CDC did shut down on Sept. 11. That was a concern. They do work with dangerous pathogens in a metropolitan area.

Have there been any reports or rumors that bin Laden or other terrorist groups have tried to get biological weapons?

There are some reports that bin Laden has tried to obtain chemical weapons. I have not seen any published reports about acquisition of biological agents. But clearly this is an area of concern.

Have terrorists tried biological attacks before?

There have been a number of attempts by terrorists to use biological weapons, including anthrax, and they have generally failed. The reason is that it's not easy to do. There are a number of fairly difficult technical hurdles that would have to be overcome. One example was in March 1995. The Aum Shinrikyo cult released sarin [gas], a chemical nerve agent, on a Tokyo subway. That is widely known. What is less well-known is that in 1990 and 1993, they tried on 10 occasions to release biological agents, both anthrax and botulinum toxin, and failed in all 10 attempts.

Why?

It appears that they obtained avirulent strains of both bacteria -- forms of the bacteria that were incapable of causing disease. They obtained them from natural sources and apparently they were just not effective. Also, they apparently had trouble disseminating the bacteria in the right form.

You say at one point that you see smallpox as an unlikely weapon for small terrorist organizations but maybe not for a state-sponsored terrorist group. Why the distinction?

The distinction is that the biggest hurdle for a terrorist organization would be to obtain access to this virus because it no longer exists in nature, unlike anthrax, which can be cultured from a stockyard or from soil. Smallpox has ceased to exist as a disease for more than 20 years and the last human case was in 1978. It's not readily available. The primary concern is that there may be some laboratory specimens that still exist that are not declared, that are clandestine.

What exactly do we know about Iraq and North Korea and smallpox?

The concern is the possible existence of undeclared stocks of the virus, including in countries such as Iraq and North Korea. There are rumors supported by circumstantial evidence that undeclared stocks may exist. We don't have any evidence that Iraq or North Korea have provided samples of the virus to terrorists, but this, of course, is a possibility. We know that Iraq and North Korea have biological weapons programs. Whether they have the smallpox virus is uncertain. There are rumors to this effect and some circumstantial evidence. For example, both countries continue to vaccinate their troops against smallpox. Iraq was working with camelpox which is a closely related virus to smallpox. It is much more benign and hence can be used as a surrogate to develop production and dissemination techniques that could then be applied to the smallpox virus if, in fact, Iraq has stocks of that virus. There hasn't been a good explanation yet for why Iraq was experimenting with camelpox.

What about missiles that can disseminate biological warfare?

They're highly specialized for that purpose. A terrorist would have to have so-called proximity-fused warheads that release bomblets at the appropriate altitude. The bomblets, which would each be filled with an agent, would spread over a large area and each disseminate a cloud of the biological agent as they fall to earth. To develop a biological warhead for a ballistic missile is extremely challenging. Only a state would be capable of that.

So who has done it?

We know that the Soviet Union did develop biological warheads to disseminate anthrax, smallpox and other biological agents, but a terrorist would not be capable of that level of technology.

What's the controversy about Iraq's missiles?

Iraq did develop Scud missile warheads that they filled with a slurry of anthrax, but they were impact-fused, which means that the warhead would slam into the Earth, explode and then form a cloud that travels a limited distance. It would cause a localized area of contamination, but it is not an effective delivery system. We know that Iraq was trying to develop more sophisticated missile warheads but had not done so by the end of the Gulf War.

What about Russia's laboratories? Are they secure?

There are two concerns about Russia. One, there may be undeclared stocks of smallpox in Russia that are not at the official repository. There are still some suspicions about that given the fact that Russia did do military work with smallpox back in the '80s and maybe up until the early '90s. One of the facilities where this work reportedly occurred, the Center of Virology in Zagorsk, remains a top secret facility, and no Westerners have been given access to that research center. There's still quite a bit of suspicion about the possibility that offensive biowarfare research may be continuing in Russia. I would hope that the Russians would be more open about their biodefense program to assuage some of these suspicions, but that has not happened so far.

The other concern is about the security, of not only the smallpox stocks, but of other culture collections that contain dangerous pathogens in Russia, Kazakhstan and Uzbekistan. The U.S. has provided funds to improve the security of these culture collections, but more needs to be done to make sure that these pathogens do not fall into the hands of terrorists.

What's in Uzbekistan?

The Soviet biological weapons program was not only in Russia but in some of the other Soviet republics. There was a facility in Uzbekistan called the Institute of Genetics that did some work related to the biological weapons program.

One reason why there's such concern about the potential of this virus is because of this Soviet weaponization of smallpox. That didn't come out until 1998, right?

The defection of Ken Alibek, the former chief scientist and deputy director of Russia's Biopreparat complex, was in 1992, so U.S. national security was aware of the allegations. It was not until 1998 that he went public in the New York Times and the New Yorker and elsewhere. The general public was not aware but, for six years, this had been a top secret piece of information that the government was aware of.

Did they destroy those weapons?

It's believed that the Soviets destroyed their 20 tons of smallpox suspension, but the concern is that with that quantity having been produced, how can you account for every last gram? You only need a very small seed culture to produce significant quantities of the virus by growing it in cells or even in eggs.

Where are the scientists who worked on the program?

The concern is the possibility that some of these weapon scientists that worked in the Soviet program may have emigrated to other countries and smuggled out seed cultures. Nobody has a good sense of what's become of the few thousand scientists with this deadly know-how to produce smallpox, anthrax and other deadly pathogens as weapons. A number of them have emigrated to Western countries, including the United States, England and Israel, but there's a concern that a number of them are unaccounted for, perhaps even hundreds.

They could have gone to Iraq or Iran.

The New York Times reported that they managed to find five former Soviet biowarfare experts working in Iran. That's the only public piece of data that I've seen.

Are we investigating this now?

I would hope that the intelligence community is trying to track these former weapons scientists but I'm sure it's difficult. The U.S. tries to provide peaceful research grants to these former scientists to try to keep them out of the hands of rogue states, but it's limited.

There's a close relationship between biological weapons proliferation at the state level and the potential that terrorists could get hold of these weapons. Technology is sufficiently sophisticated that terrorists would probably need the assistance of a state sponsor to stage at least a large-scale biological weapons attack capable of inflicting casualties on the level of the Sept. 11 events. On the one hand that is reassuring; on the other, it means it's a much broader problem.

Why did we stop vaccinating for smallpox?

When smallpox was eradicated, the World Health Organization decided in 1980 to halt vaccination against the disease because the vaccine had significant risk in terms of complications. It was judged that the likelihood that it would return was infinitesimal and that it would save money and lives to stop vaccinating.

I still think that that was a wise decision. In view of these new concerns about the possible existence of undeclared stocks, it does make sense to acquire more vaccine and have it on the shelf in the event that the virus is used as a bioterrorist weapon. The U.S. government is in the process of acquiring 40 million additional doses. Just last week, the Secretary of Health and Human Services, Tommy Thompson, announced that he was accelerating the acquisition. Instead of having a delivery date of 2005, he was moving it up to next year, 2002.

Will that be enough doses? How much do we have?

Nominally, we have 15 million doses, but people believe that because of deterioration and the way it would be administered in an emergency, it's closer to 7.5 million doses, which is far from sufficient for a country of this size. Forty million would be enough for a reasonably large outbreak.

And in the meantime?

The idea would be to acquire the 40 million but also maintain a warm production line so that additional vaccine could be produced on demand.

And other countries -- what are they doing?

That's unclear. I believe that European countries are going to produce more. South Africa has a fairly large stockpile of the vaccine. Russia has some. India has a small stockpile. But other countries will probably acquire additional vaccine as well.

Ideally, how much would we want to have?

I think 40 million is a reasonable amount unless there is a worst-case scenario; for example, if terrorists release aerosols of smallpox in multiple cities.

How would we handle that?

We would deal with an outbreak in a similar way to how we did in the eradication campaign. We didn't rely on mass vaccination; instead, the strategy was called surveillance and containment. Whenever there was an outbreak, it would be rapidly identified, the people with active smallpox were isolated and everyone with whom they had come in contact or could have come in contact was vaccinated. The idea was to vaccinate around an outbreak and prevent the flame of contagion from spreading. This technique was highly effective in eradicating the disease without the need to vaccinate the entire population.

Presumably if there was a localized release, if the public health system could detect it at an early stage -- and that's a big if -- it would be possible to contain it with this method. The fear is that by the time this disease is diagnosed -- there's a two-week lag between infection and the appearance of symptoms -- the initial group of people could have dispersed widely and spread the disease. Unlike anthrax, smallpox is a contagious disease and once someone develops the first appearance of the rash, they become contagious and can spread it to others.

Can you give an example of how fast this could spread?

In 1972, there was an outbreak of smallpox in Yugoslavia. An Albanian Muslim from Kosovo went on pilgrimage to Saudi Arabia, came back through Baghdad, where smallpox was present, traveled back to his village in Kosovo and spread the disease, triggered an outbreak that then spread throughout the country. That shows the potential of the disease from a single case. That was a fairly unusual situation for a number of reasons, but it does show the potential. Yugoslavia ended up vaccinating almost the entire population -- more than 18 million out of a total 20 million.

But you don't think that it makes sense for us to try to vaccinate against anthrax or smallpox?

For one thing, the vaccine isn't available for anthrax or smallpox -- we don't have enough. There are other reasons for not vaccinating and that's because this vaccine is a live-virus vaccine. It has a certain risk of complications associated with it. Back when we routinely vaccinated schoolchildren until 1972, there was one serious complication for every 300,000 children who were vaccinated, including death or permanent brain damage. This is not a vaccine that should be administered lightly. We have to balance the probability that people will be exposed to this disease against the risks of vaccination.

We hear about people going out and getting gas masks and things? Will anything help?

For one thing, a gas mask has to be fitted to your face to be effective. Just going to an army surplus store and picking up a mask off the shelf is probably not going to work. The filter is probably not in very good shape. You have to know how to use it.

Also, a biological attack would probably come without warning and one would probably not know that they're inhaling bacterium or virus. The first indication that an attack had occurred would be days or weeks later when people started getting sick. So unless you were wearing the mask at all times, it would not protect you.

This is not a problem that individuals can solve on their own. It's something that we as a society have to deal with by strengthening our public health systems so that we can recognize an unusual outbreak of a disease very early when it is still treatable or, in the case of a contagious agent like smallpox, when it is containable.

What should someone do if they think they have smallpox or anthrax?

My concern is that people, when they come down with a common cold, will jump to conclusions and think they have anthrax. People need to put this threat in perspective. It remains an unlikely threat. It's something obviously we have to be prepared for. We need to improve our public health systems to detect unusual outbreaks of disease in which dozens to hundreds to thousands of people all come down with unusual symptoms at the same time. That would be indicative of an unusual outbreak of disease that could be the result of a bioterrorist attack but short of that, people should not panic about this threat.

We live in frightening times and we have to be vigilant. If we observe suspicious behavior, if we see someone spraying something in a subway station, we should obviously report it immediately to the authorities. On the other hand, I don't think it makes sense to stockpile antibiotics or to medicate oneself. If you come down with a viral infection, antibiotics are not only useless -- because antibiotics are only good against bacterial infections -- but you could actually do yourself some harm from the side effects.

So individuals really can't do anything?

What the average person should do is put pressure on Congress to provide resources to strengthen our public health system because this is something that we have to deal with as a nation, not as individuals. The only way we can get our hands around this problem is by giving our local, state and federal public health officials the resources they need to detect an outbreak early and ultimately respond with the appropriate medications and vaccines.

Do you feel confident that our doctors are able to recognize these diseases?

No. A lot more has to be done in terms of physician education, not only emergency room physicians, but nurse practitioners and general practitioners. The first indication of a bioterrorist attack is likely to be when people start showing up at emergency rooms and doctors' offices in large numbers with nonspecific symptoms. Very few physicians practicing in this country have ever seen an active case of anthrax let alone smallpox so they do have to be able to distinguish influenza from pulmonary anthrax and smallpox from chickenpox. They look very similar at the early stages. Physicians need continuing education courses and eventually these courses might be made a requirement for medical licensing or board certification.

But we have to go beyond that. We need to improve the number of clinical labs that are capable of diagnosing these unusual infections. They also need to know who to call at the local health department if they detect something suspicious and we have to staff and equip our health departments so there are people there 24 hours a day to respond when the doctors call. Then epidemiologists at the health department can put the data together and do an epidemiological analysis that indicates there is something unusual going on. Then, they can consult with state and federal health officials at the CDC and elsewhere to come to some kind of conclusion.

The challenge for the public health system with bioterrorism is one of time. In the past, the public health system had the luxury of time; there was no great sense of urgency. But because it's imperative to identify an outbreak during its early stage, while it's still treatable, that means we have to improve the responsiveness of our public health system.

Can you give me an idea of the time we'd need to recognize an outbreak? Within hours?

Not hours, but days. As soon as possible.

Are you satisfied with the steps we've taken so far?

As Senator Bill Frist, R-Tenn., said last week at a hearing, "We are not unprepared, we are underprepared." That was an appropriate description. We do have effective capabilities at the federal level. The main gaps are at the state and local levels. Most of our cities and states have neglected their public health infrastructure over the past several years -- they're understaffed, underfunded and underequipped. More needs to be done. In terms of detection, it has to be done at the local level.

I testified at a hearing last Wednesday before a subcommittee of the Senate Appropriations Committee that deals with the Health and Human Services budget. There was a very strong consensus of everyone who testified including four senators -- Senators Frist, Edward Kennedy, D-Mass., Chuck Hagel, R-Neb., and John Edwards, D-N.C. -- that it's imperative to strengthen the public health system to deal with this kind of bioterrorism. This is a window of opportunity in terms of political will to do something about this problem. Senators Kennedy and Frist introduced legislation last year to do this that was passed but never funded. Now is the time.


Suzy Hansen

Suzy Hansen, a former editor at Salon, is an editor at the New York Observer.

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