Against the backdrop of a growing number of anthrax-related deaths and illnesses in the US, nearly 300 people packed three auditoriums at HSPH last week for a symposium about bioterrorism on October 25 and 26. Others watched a live webcast now available at www.hsph.harvard.edu/bioterrorism. HSPH Dean Barry Bloom hosted both days of the symposium and moderated the October 26 discussion.

Day 1: "Bioterrorism: Public Health Perils"

Margaret Hamburg, vice president for biological programs, Nuclear Threat Initiative, and former assistant secretary for planning and evaluation, US Department of Health and Human Services

"The growing bioterrorism threat," said Margaret Hamburg, "challenges our traditional ways of thinking about prevention, deterrence, non-proliferation and response and really requires us to think anew about solutions and how to define and implement them so they are meaningful and enduring."

Opening the symposium with a theme that overarched both days, she observed that the US public health infrastructure needs strengthening at local, state and federal levels: "This includes trained personnel, updated labs and improved communication links so health agencies can communicate across levels of government as well as with critical other agencies and partners to have a coordinated and effective response."

The partnership between public health and the medical care community, which has eroded in recent years, is critical. The medical community, as the front line of defense, needs to be engaged, she said, and better trained to recognize and respond to bioterrorism-related illnesses. Quoting a saying she learned in medical school, "when you hear hoofbeats, think horse, not zebra," she said those days are gone, and physicians must now be prepared to "think outside of the box and at least rule out the zebra."

New tools of disease reporting must be developed, so that a sort of early-warning system can evolve. Monitoring of admissions to intensive care units, purchases of over-the-counter-medication, and other indices may help public health officials detect patterns of emerging diseases earlier.

One concern in a public health response to terrorism is that competitive economic pressures have downsized many aspects of the health care delivery system, creating a lack of "surge capacity" for events that might produce large numbers of sick or injured. Local assets and capabilities need to be surveyed, and a plan created for how they could "be augmented swiftly and smoothly when needed," she said.

Clear communication with the media–and through it, the public–is also a critical factor in a response to threats. As the recent experience with anthrax shows, said Hamburg, officials will not have the "luxury" of dealing only with health and science reporters but those recruited from all over. The media should quickly be given the background it needs and "have credible, trustworthy health officials from the very beginning with clear, consistent messages to the public about what’s going on and what they can do to protect themselves and also what they shouldn’t do."

As always with public health, prevention is key. Hamburg felt that prevention in the face of bioterrorism has been "underaddressed." Reducing access to dangerous pathogens by people who would do harm is important, and increased intelligence of the nature of weapons being developed by nations or groups is necessary and should engage the expertise of the larger scientific community, she said.

David Franz, former commander, US Army Medical Research Institute of Infectious Diseases and former deputy commander, US Medical Research and Materiel Command

David Franz, who has also led three UN weapons inspection teams in Iraq, followed Hamburg. He briefly reviewed the recent history of the development of biological weapons, with the US and USSR the biggest players. Both countries researched agents such as smallpox, cholera, plague and anthrax. Some of these agents were "weaponized," and, indeed, said Franz, the Soviets had loaded smallpox and plague onto missiles pointed at US cities. They had also mounted an enormous, secret biological weapons program, much larger than the US’s capacity, he said.

At one point, he estimated, the Soviets could have produced 100 to 1,000 tons of an agent per year as compared to the one ton the US could have produced. (In 1969, the US renounced the "first use" of lethal or incapacitating chemical agents and weapons and unconditionally renounced all methods of biological warfare.)

The two nations, however, were not alone in developing biological weapons. Iraq developed a biological weapons program that included anthrax and botulism. The UN has repeatedly called on Iraq to allow UN inspection of the country’s weapons facilities, but Iraq has countered with a demand that economic sanctions against the country be lifted before inspections are allowed to resume.

Franz differentiated between chemical and biological weapons. Chemical agents act more rapidly than biological agents and should be considered a hazardous material problem, he said. Biological agents are not as volatile as chemical ones, and their time of onset of symptoms differs. Biological terrorism clearly falls into the realm of public health, he said.

The implications for public health are numerous. Many of the diseases resulting from biological weapons tend to mimic the symptoms of flu, so that clinicians may not quickly recognize a different disease. Even after proper diagnosis, treatment may be too late, said Franz. These pathogens are rarely seen in the public, and therefore, therapies are not always ready or useful.

Vaccines are disease-specific and need time for development. Even when vaccines are available, they and other prophylaxis methods may not be socially acceptable, he said. A few years ago, for example, some military personnel protested when told they would be injected with the anthrax vaccine.

Franz said he worries about the use of highly contagious agents, such as smallpox, and genetically engineered agents. But he also said there are technical obstacles that make biological weapons development difficult. The agents must be aerosolized and easy to breathe. They also are generally dependent on the weather for their dispersal, and meteorology is never completely predictable; the agents may float to unwanted places. Of course, Franz pointed out, by coming through the mail, the recent anthrax attacks have not been weather-dependent, adding another dimension to biological weaponry.

Matthew Meselson, Thomas Dudley Cabot Professor of the Natural Sciences, Harvard University, co-director, Harvard Sussex Program on CBW Armament and Arms Limitation, and consultant on chemical and biological weapons defense and arms control

Matthew Meselson has traveled to Sverdlovsk in the former Soviet Union, where in 1979 anthrax spores were accidentally released into the air from a military microbiology facility. In 1994, Meselson and six co-authors published an article in Science describing the release and its effects.

More than 65 people died in the weeks following the release. They all lived or worked within a few miles of the facility. Additionally, farm animals further away also died. Interviews with survivors and families of the victims showed that exposures occurred within a narrow zone south of the facility and that the animals that died of anthrax were within the same zone. Meselson and his colleagues correlated the zone to a southerly, prevailing wind that blew two days before the first victim fell ill.

At the time, the USSR blamed the deaths on people eating anthrax-contaminated meat, but the work of Meselson’s team definitively disproved the Soviet explanation.

Meselson said there are several things people can do to shield themselves against certain forms of bioterrorism. Air filters in ventilation systems could be installed and would reduce harmful exposure to respirable particles in polluted air. In the case of some contagious outbreaks, simple masks worn over mouths and noses may help. Basic hygiene, such as hand-washing, could also help. (Postmaster General John Potter has said much the same, recommending that people wash their hands after handling mail.)

As for treatments after infection, Meselson suggested that researchers take a closer look at the use of immunoglobulins, which include all antibodies and form a key part of the immune system.

He said that a powerful norm for the species needs to be fostered, one that prohibits any exploitation of present or future biotechnology for hostile purposes.

Such a norm, he urged, should be backed up by the creation of an international criminal law that would apply to individuals, whether terrorists, government officials or others.

He also suggested the formation of a small group of scientists who could receive suggestions from the general scientific community for protective and forensic measures which, if judged worthwhile, could be passed on to government. He added that he and some colleagues already are discussing such issues.

Meselson offered some sobering observations: One-third of the human race is infected with tuberculosis (although the majority is not expressing the disease). Malaria kills large numbers of people every year. "This is getting a lot of attention right now and deservedly so, but we’re not very generous to all of the sick people in the world."

When asked if he thought the open exchange of information about biological research should be restrained because of the threat of bioterrorism, Meselson said not in a university setting. He said that secret research should be kept out of universities and reviewed by people who see the "whole picture."

"The real problem is that there are people who hate each other," Meselson concluded, stressing the importance of trying to minimize hatred in the world, something "we haven’t done a very good job at," he said.

Day 2: Bioterrorism: Public Health Response

Barry Bloom, dean, HSPH, and professor of immunology and infectious diseases

Barry Bloom moderated the second day of the symposium and observed that the use of biological weapons is not new, although the forms have changed over time.

As early as 1346, he described, Tatars practiced bioterrorism by throwing people infected with bubonic plague over the walls of Kaffa on the Black Sea to spread infection.

In 1763, Lord Jeffrey Amherst sent blankets infected with small pox to Native American tribes.

In World War II, a Japanese army unit stationed in China conducted experiments using biological agents, killing 10,000 prisoners. The unit’s leader escaped punishment from US forces after agreeing to share his knowledge with American officials.

In 1995, the Aum Shinrikyo cult released sarin gas in a Tokyo subway, killing 12 people and injuring thousands more.

Today, an unknown person or group is sending anthrax through the mail in the US.

Said Bloom, "We could spend vast amounts of money on bioterrorism that would not in fact benefit the vast majority of the public’s health, and may not even be useful. Stockpiling vaccines against 32 agents that are listed on the CDC web site as potential biological weapons may not be the best use of those resources. And then the question is, ‘What is the best use of those resources?’"

Furthermore, Bloom asked, how does public health prepare against biological weapons in the face of what the military calls "dual use" of equipment. For example, breweries, vaccine companies and recombinant enzyme companies may need fermenters to create bacteria. In the wrong hands, these fermenters may have the potential to become biological weapons factories.

But Bloom also described the potential for a positive connotation of dual use in public health–one that uses the current crisis to benefit the entire field.

"I believe that investment in public health will benefit us not just for terrorism [defense], but for improving the infrastructure of public health," said Bloom.

Later, in a question-and-answer period, Bloom said that public health academicians should not lose sight of their mission. On September 11th, he said, an estimated 5,000 people died in terrorist attacks on the US, but on the same day, approximately 8,000 people died of AIDS, 5,000 people died of tuberculosis, and 150 million children suffered from malnutrition. And, unlike the attacks that ended in hours, suffering from death and disease continued on September 12, 13 and 14.

He added that one of the goals of HSPH is to continue to train a well-educated, full-time public health workforce, as well as secondary workers who can deal with surges in the demands on public health in crises. He said there are 1/2 million public health workers in the US, but less than half of them have professional training and much fewer are certified.

"One of the first things we want of an infrastructure capable of responding to all kinds of emergencies and continuing health problems is a well-educated and responsive work force, and there has been very little, as some of you students know extremely well, support for that, and that is an absolute, it seems to me, high priority and desperate need."

Bloom also said that providing capacity for training and development in other countries remains vital.

Jonathan Burstein, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Research Scientist, Emergency and Disaster Public Health Sciences, Centers for Disease Control and Prevention; consultant, Weapons of Mass Destruction Defense Stockpile Task Force, CDC

Jonathan Burstein observed that the pace of public health has quickened since the September 11th attacks, as questions about real and envisioned perils mount, while epidemiological investigation continues to be the "heart and soul" of community-based public health, he said.

Burstein described the current plan of response to wide-scale emergencies in Boston, which includes a simple monitoring system. Every night, city hospitals transmit the number of emergency room cases dealt with that day to a computer server at the Boston Public Health Commission (BPHC). If an unusually high volume, when compared to historical trends, is detected, the hospital must explain the reason to the BPHC and city officials, perhaps revealing an emerging disease cluster.

Burstein added that system designers may one day include other data from places such as physician offices, HMO sites, pharmacies and health centers.

If a crisis grows beyond the means of local authorities, state and then federal agencies may step in.

More difficult than monitoring the caseload volume in emergency rooms, said Burstein, may be the education of health care workers about new threats. Thousands of medical care providers need to be retrained to detect diseases such as anthrax or other potential results of bioterrorism, such as smallpox. He said such material needs to be incorporated into the regular curricula of medical and other health-related schools.

Communication to colleagues and to the public is also a priority, said Burstein.

"One of the biggest roles of public health in an outbreak or attack is to get information out to the people so that they know how to protect themselves. They know when to worry and when not to worry. It’s coordination. It’s communication. It’s education and surveillance. This is something that we can meet the challenge of."

Howard Koh, Commissioner of Public Health, Commonwealth of Massachusetts

Howard Koh encapsulated the state’s response immediately following the September 11th attacks, when within hours Massachusetts made available 1,200 hospitals beds, hundreds of medical care practitioners, 150 ambulances and 500 units of blood, indicating a readiness in emergency.

Koh described the pressure on the State Laboratory Institute of the Massachusetts Department of Public Health since the anthrax scares began. In the past few weeks, the state lab–open 24 hours a day–has processed more than 1,000 samples of substances feared to be anthrax. All have been negative.

Koh said he has worked intensely with state officials during the anthrax scares, collaborating with fire marshals, hazardous materials experts, state police, postal service representatives, Attorney General Tom Reilly and Acting Governor Jane Swift. He has also been communicating with other public health practitioners, including US Health and Human Services Secretary Tommy Thompson, CDC Director and HSPH alumnus Jeffrey Koplan, HSPH Dean Barry Bloom, and other deans.

The crisis has become an opportunity for public health awareness, said Koh. In the last six weeks, Americans have learned what public health is, and the media has used the term "public health infrastructure" more than ever before.

Education of Americans continues to be key. Risk communication has become Koh’s major responsibility, he said.

He referenced two documents as good sources for guidelines in conveying risks to the public: "Anthrax Offers Lessons in How to Handle Bad News" in the October 23 issue of The New York Times and "Risk Communication: The West Nile Virus Epidemic and Bioterrorism–Responding to the Communication Challenges of Intentional or Unintentional Release of Pathogens in an Urban Setting" in the June 2001 issue of the Journal of Urban Health.

Relying on the facts, and not on speculation, is important, said Koh. The facts in Massachusetts so far amount to no deaths from anthrax, no cases, no infections and no documented exposures, he said.

He concluded, "We need public health now more than ever before. Everybody now knows what public health is. Everybody now understands that a strong public health infrastructure is very critical to our society. It can’t be taken for granted."

Information about bioterrorism may be found on the Massachusetts Department of Public Health’s web site at www.state.ma.us/dph or at 866-627-7968.