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Smallpox: United Kingdom Prepares Vaccination PlanThe United Kingdom is developing a smallpox vaccination plan that might involve inoculating a large portion of the population if the virus were to spread, the London Independent reported today (see GSN, Sept. 23). The plan — announced by Britain’s chief medical officer, Liam Donaldson — calls for precautionary vaccinations of vital emergency health workers and for those workers to “search and contain” the virus in the event of an outbreak. “A proper counterplan to a smallpox attack would involve having a group of essential workers who were immune to the disease through vaccination,” Donaldson said. Donaldson called a mass vaccination a “last resort,” saying there is no new risk of a smallpox attack. He added, however, that the United Kingdom should nonetheless be prepared for numerous outbreaks of the disease. “We should have in place enough vaccine to vaccinate on a mass population basis if necessary,” he said. In April British officials decided to buy enough smallpox vaccine to inoculate 20 million people (see GSN, April 15; Pippa Crerar, Independent, Oct. 9).
From October 8, 2002 issue.Smallpox: U.S. Medical Groups Urge Caution on Mass VaccinationSeveral U.S. medical groups have said the United States should be cautious in providing smallpox vaccine to the public, especially before an outbreak has occurred, the New York Times reported today (see GSN, Oct. 7). The American Medical Association said yesterday that it supports the smallpox guidelines that the United States released in June (see GSN, Dec. 5, 2001). The guidelines call for the vaccination of health care workers and the use of the “ring vaccination” strategy — vaccinating those who came into contact with an infected person — in the event of an outbreak. “The need for further voluntary vaccination beyond front-line health care workers is a very complex issue,” the association said in a press statement. Policy-makers must compare the potential health risks of a smallpox outbreak with the side effects of the vaccine, the association said, noting concerns about who would be responsible for deaths or injuries in a mass vaccination campaign. The American Academy of Family Physicians has taken a similar position, according to the Times. The American Academy of Allergy, Asthma and Immunology has also called for caution, said spokesman James Baker. The group is concerned about potential risks that the vaccine poses to people with the skin conditions such as atopic dermatitis and eczema, he said. In their calls for caution, the medical groups have not criticized U.S. smallpox vaccination plans, according to the Times. They also have said that mass vaccination would probably be appropriate in the event of an actual outbreak. The groups’ concerns are based on the potential risks of the smallpox vaccine, which is more likely to cause serious side effects than other vaccines, the Times reported. The rates of complications caused by mass vaccination are expected to be higher now than during vaccination campaigns of the 1960s and 1970s because the number of people at risk from the vaccine’s side effects has increased. People at increased risk from the vaccine include immuno-compromised patients, those on chemotherapy and pregnant women. People who are vaccinated can also endanger those who are especially vulnerable to the vaccine’s side effects, according to the Times (see GSN, Nov. 21, 2001). The vaccine, which uses a live version of the virus, can be shed for up to several weeks from the vaccination site and poses an infection risk to others (Denise Grady, New York Times, Oct. 8). For further information, see: Journal of the American Medical Association Background on Smallpox
From October 7, 2002 issue.Smallpox: U.S. Health Officials Support Public Access to VaccineThe United States should conduct a voluntary smallpox vaccination campaign to first vaccinate 500,000 health care workers and 10 million first responders and then make the vaccine publicly available as early as 2004, U.S. public health officials said Friday (see GSN, Sept. 27). “We live in a society that values individual choice,” said Julie Gerberding, director of the U.S. Centers for Disease Control and Prevention. “If we have vaccine and we have data to accurately assess the safety, one school of thought is that informed people may want to have the choice of getting vaccine or not.” White House biological terrorism advisers have recommended giving the public “ever-expanding access to vaccine” as more doses pass Food and Drug Administration requirements. The agency will probably approve the first batches of vaccine by next month, according to the Washington Post. To apply the ever-expanding access approach, officials would first vaccinate those considered to be at the greatest risk in the event of a smallpox outbreak, for example, public health investigators, emergency room personnel and hospital support staff, the Post reported. The goal is “is to maximize our ability to respond to an attack should one occur,” Gerberding said. In the second stage, officials would offer vaccine to 7.5 million health care workers and 3 million first responders, said Jerome Hauer, assistant Health and Human Services secretary for emergency preparedness. Bush could also choose to combine both stages and vaccinate the bulk of U.S first responders at one time, the Post reported. After these two stages, the vaccine could be made available to U.S. residents as early as 2004, according to officials. “Right now, our thinking is in favor of making vaccine available to the general public,” Gerberding said. Bush has yet to decide who should be vaccinated and when vaccinations should begin, according to the Post. Vice President Dick Cheney has advocated a broad U.S. vaccination plan, sources said. The policy is “under review,” said White House spokesman Scott McClellan (Washington Post, Oct. 5). Senator Urges Public Vaccination Senator Judd Gregg (R-N.H.), ranking member on the Senate Health, Education Labor and Pensions Committee, argued in a commentary in yesterday’s Washington Post that U.S. residents should be given access to smallpox vaccine and should be allowed to choose to be vaccinated. The panic and confusion likely to result from a smallpox outbreak would make it difficult for the U.S. Centers for Disease Control and Prevention to implement a policy to begin mass vaccinations within 10 days, Gregg wrote (see GSN, Sept. 23). The vaccine must also be administered within four days to be effective, and the flulike symptoms of smallpox could mean it could take weeks to detect an outbreak, he wrote (Judd Gregg, Washington Post, Oct. 6). Pediatricians Advocate Limited Vaccination The American Academy of Pediatrics said today that the U.S. smallpox vaccination plan should involve only limited vaccinations in the event of an outbreak. The potential side effects of the vaccine are too serious, and it has not been tested on children, the academy said in a policy statement (see GSN, Sept. 25). Instead, the academy supports a “ring vaccination” strategy — vaccinating those who came into contact with an infected person. “We’re talking about a disease that hasn’t existed in the world since the 1970s and a vaccine that we know can cause death,” said Julia McMillan, a Johns Hopkins medical school pediatrics professor and coauthor of the policy (Lindsey Tanner, Associated Press/Boston Globe, Oct. 7). Risks The smallpox vaccine poses several potential health risks, including complications for as many as 50 million U.S. residents at special risk, according to the Washington Post (see GSN, Sept. 24). U.S. Department of Health and Human Services experts have estimated that for every 1 million people who are vaccinated, 15 would suffer life-threatening side effects such as encephalitis, and one or two might die. More people could experience other serious side effects such as blindness, but most of them could probably recover, the Post reported. If 200 million U.S. residents were to take the vaccine, 200 to 400 would probably die, as many as 3,000 would probably suffer life-threatening side effects and 160,000 would probably suffer other serious side effects, according to the Post. A large number of vaccine recipients would be expected to suffer mild side effects such as fever, and 15 to 20 percent of vaccinated children would probably be sick enough to miss school for several days (Washington Post, Oct. 5). Israelis Hospitalized Meanwhile, two Israeli health care workers have been hospitalized due to complications from the smallpox vaccine, Ha’aretz reported today (see GSN, Aug. 21). An employee at a public health office in Jerusalem was hospitalized after contracting a rash but was released two days later. An employee at a public health office in Safed was hospitalized after experiencing headaches and fever. Doctors initially suspected meningitis, but the symptoms were later diagnosed as the flu, according to Ha’aretz. About 6,000 Israeli first responders and health care workers have so far undergone voluntary vaccinations. The Israeli Fire Department is expected to begin vaccinations next week, according to a department spokesman (see GSN, Sept. 18). Most Israeli ambulance crews have also agreed to be vaccinated, said a spokesman for Magen David Adom, Israel’s emergency response service. The majority of employees at hospitals and health maintenance organizations, however, have refused to be vaccinated, Ha’aretz reported. Israeli Environmental Ministry staff members have said they would be vaccinated, but only if they receive extra pay (Haim Shadmi, Ha’aretz, Oct. 7). For further information, see: Journal of the American Medical Association Background on Smallpox
From October 7, 2002 issue.Anthrax I: Hatfill Prepares Defamation LawsuitsSteven Hatfill, the former U.S. Army biologist who has become the public focus of the FBI’s investigation into last fall’s anthrax attacks, said Saturday that he plans to file several lawsuits for defamation (see GSN, Oct. 3). During a press conference held by Accuracy in Media, a nonprofit media watchdog group, Hatfill’s spokesman Patrick Clawson said the scientist plans to file lawsuits against individuals and organizations. “He is planning to file several defamation suits in the upcoming months against several individuals and organizations, but he did not specify against whom the suits would be filed,” Clawson said. Hatfill’s attorney Victor Glasberg asked Attorney General John Ashcroft last month to apologize for publicly calling Hatfill a “person of interest” in the FBI’s “Amerithrax” investigation. Glasberg also asked Ashcroft to help Hatfill find work after the Justice Department prompted Louisiana State University to dismiss him (see GSN, Sept. 19). In August, Hatfill said his lawyers planned to file an ethics complaint against Ashcroft (Reuters/Yahoo.com, Oct. 5). For further information, see: GSN Anthrax Attack Chronology (Dec. 12, 2001)
From October 7, 2002 issue.Anthrax II: Third Brentwood Test Successful, Officials SayThe U.S. Postal Service has conducted a third successful test of equipment to clean the anthrax-contaminated Brentwood Road postal facility in Washington, officials said Saturday (see GSN, Sept. 30). The Postal Service conducted a 24-hour test of the “scrubbing” equipment that neutralizes the chlorine dioxide gas used to decontaminate the Brentwood facility. Air sensors detected no leaks during the scrubbing process, officials said. A bus equipped to detect trace amounts of chlorine dioxide gas reported some gas, but at safe levels, the officials said, adding that they hoped the latest test would clear the way for them to treat the entire building (Washington Post, Oct. 6). For further information, see: GSN Anthrax Attack Chronology (Dec. 12, 2001) Journal of the American Medical Association Background on Anthrax CDC Frequently Asked Questions About Anthrax
From October 4, 2002 issue.Anthrax: Vaccine Makers Hope to Begin Production Next YearThe United States has contracted two pharmaceutical companies to produce 25 million doses of a new anthrax vaccine, health officials said yesterday. Under a fast-track proposal, production is scheduled to begin by late next year (see GSN, Aug. 8). “There is an urgent need to devise more effective measures to protect U.S. citizens from the harmful effects of anthrax spores used as instruments of terror,” Health and Human Services Secretary Tommy Thompson said. British company Avecia and U.S. company VaxGen received the contracts to produce the vaccine, worth a combined $22.5 million. The contracts call for a vaccine that can be used as a post-exposure treatment and can be administered in three or fewer doses. The current vaccine, in use by the Pentagon, requires six doses administered over 18 months. The new anthrax vaccine is also to be produced through more modern techniques than the current vaccine, according to the Washington Post. Developers plan to use “recombinant” technology to use genetically engineered bacteria and leave out extraneous substances that could cause side effects, according to the Washington Post (Washington Post, Oct. 4). For further information, see: CDC Frequently Asked Questions About Anthrax Journal of the American Medical Association Background on Anthrax
From October 3, 2002 issue.Anthrax — One Year Later: Attack Culprit Remains at Large, But Preparedness Spending IncreasesBy Mike Nartker Now, on the first anniversary of the anthrax attacks, the FBI’s “Amerithrax” investigation has yet to determine who is responsible. The incidents have, however, galvanized U.S. biological defense researchers and public health officials to better prepare responses to any future incidents. The first reports of the anthrax attacks came Oct. 3, 2001, when Robert Stevens, a photo editor for American Media Inc. in Florida was diagnosed with the inhalational form of the disease. When Stevens died two days later, he became the first U.S. fatality from anthrax since 1976 (see GSN, Oct. 5, 2001). Ultimately, a second AMI employee, Ernesto Blanco, became infected, and six other AMI employees tested positive for exposure (see GSN, April 23). The source of the anthrax in the AMI building has not yet been found. FBI agents armed with new investigative techniques re-entered AMI headquarters Sept. 3 to try to recover the source — probably a letter or package mailed to the building — but they have released no details about what they found (see GSN, Sept. 11). The first anthrax victim outside of Florida — an NBC News employee who contracted anthrax on her skin — was reported Oct. 12, 2001 (see GSN, Oct. 12, 2001). That day, investigators tested a suspicious letter sent to NBC Nightly News anchor Tom Brokaw that was later linked to the attacks. Two employees at other New York media organizations and a 7-month-old boy who visited the offices of ABC News contracted skin anthrax as a result of the attacks. In New Jersey, five postal workers contracted anthrax — two inhalation cases and three skin infections. Investigators have speculated that tainted letters processed in New Jersey mail-handling centers caused these cases. Anthrax arrived in Washington Oct. 15 with the opening of a tainted letter sent to Senate Majority Leader Tom Daschle (D-S.D.). The “Daschle letter” ultimately caused officials to close the Hart Senate Office building, where Daschle’s offices are located, until Jan. 23, 2002 (see GSN, Oct. 16, 2001). While no member of Congress or congressional staff member became infected, four Washington postal workers contracted inhalation anthrax and two died — Thomas Morris and Joseph Curseen (see GSN, Oct. 23). An employee at a U.S. State Department mail center also contracted inhalation anthrax. On Oct. 31, New York City hospital worker Kathy Nguyen died from inhalation anthrax (see GSN, Oct. 31, 2001). Investigators have been unable to find anthrax spores in any locations, such as her home or where she worked, that Nguyen was known to frequent. Analysts have speculated that she might have contracted the disease through cross-contaminated mail — mail that passed through the same sorting machines as the tainted letters. The anthrax attacks continued into November, with the discovery Nov. 17 of an unopened tainted letter mailed to Senator Patrick Leahy (D-Vt.). On Nov. 21, the fifth and final death related to the anthrax attacks occurred — the death of Ottilie Lundgren of Oxford, Conn. (see GSN, Nov. 21, 2001). Investigators have speculated that Lundgren also died through contact with cross-contaminated mail (see GSN, March 27). CDC Analysis The U.S. Centers for Disease Control and Prevention has divided the anthrax cases into two clusters based on exposure to two different sets of tainted mailings, according to a CDC report released this month. One cluster originated from two letters mailed Sept. 18 to NBC Nightly News and the New York Post. The other cluster surrounds two letters mailed Oct. 9 to Daschle and Leahy. All four of those letters were mailed from Trenton, N.J. Patients in the first cluster of cases were more likely to have developed skin anthrax and to have been exposed at media organizations rather than postal facilities, according to the report. Patients in the second cluster were more likely to have developed inhalation anthrax and to have been exposed at postal facilities that handled the tainted letters mailed to Daschle and Leahy, the report says. According to the report, a difference in the consistency of the anthrax spores in the Sept. 18 mailings versus the Oct. 9 mailings might account for the increased number of inhalation cases in the second cluster. The media employees generally suffered fewer effects than did the postal employees who worked along the paths of the Daschle and Leahy letters, it says. The report also says that “substantial” death and illness might have resulted among Senate staff members exposed to the Daschle letter if health officials had not distributed preventive antibiotics such as ciprofloxacin (see GSN, Oct. 18, 2001). “Amerithrax” Investigation The FBI’s investigation into the anthrax attacks has not yet revealed the person, or people, behind them. It is difficult to gather evidence in this kind of case, Barbara Hatch Rosenberg, a biologist at State University of New York who has often publicized her views on the anthrax investigation, told Global Security Newswire last week. She added that she is unsure whether the FBI would move to arrest someone in the absence of final, conclusive evidence. In January, Rosenberg released a possible profile of the person responsible for the attacks. According to the profile, the person behind the attacks is probably a middle-aged U.S. resident who worked at the U.S. Army Medical Research Institute of Infectious Diseases at Fort Detrick, Md., has experience in working with dangerous pathogens such as anthrax and has been questioned by the FBI, among other characteristics (see GSN, Jan. 25). Throughout the Amerithrax investigation, the FBI has questioned and administered polygraph tests to several U.S. biological defense researchers (see GSN, May 21). The investigation seems to have focused on many of the traits listed in Rosenberg’s profile. Some observers have speculated that the anthrax incidents were linked to the Sept. 11 attacks, which were perpetrated by non-U.S. citizens. Newsweek reported in July, however, that several FBI agents had begun to believe a U.S. scientist is responsible (see GSN, July 8). Genetic testing has determined that the anthrax spores included in the Daschle and Leahy letters are the same strain as samples at USAMRIID (see GSN, June 13). Even though the FBI has gathered a large amount of information during its investigation, the longer the case goes on, the less likely the person responsible will be found, said Charles Pena, a senior defense policy analyst at the Cato Institute, a Washington think tank. The Strange Case of Steven Hatfill In the course of the FBI’s investigation, only one name has been publicized: Steven Hatfill, a former U.S. Army biologist who has become a “person of interest” in the case. Newspapers reported June 25 that the FBI had conducted what became the first search of Hatfill’s Frederick, Md., apartment (see GSN, June 26). The FBI later searched the apartment two more times and searched the apartment of Hatfill’s girlfriend and a storage unit he rented. It was later reported that Hatfill had commissioned a study in 1999 examining a possible anthrax attack similar to those carried out last fall (see GSN, June 27). Suspicions were also raised when it was learned that Hatfill had apparently listed several false qualifications in his resume, including his educational history and military service. During an Aug. 11 press conference, Hatfill publicly declared his innocence, saying he had nothing to do with the anthrax attacks (see GSN, Aug. 12). “I am a loyal American and I love my country. I had nothing to do with the anthrax letters, and it is terribly wrong for anyone to contend or think otherwise,” Hatfill said. Analysts are unsure what role, if any, Hatfill might have played in the anthrax attacks. Rosenberg, whose profile Hatfill matches in many respects, said the FBI must have had something they were looking for by the time of the third search of Hatfill’s apartment. She has never publicly named Hatfill, however, and last week she said it is “unfortunate” that his name was made public. It would be fair to label the FBI’s interest in Hatfill as “overzealous,” Pena said. Investigators might have concentrated on Hatfill because he was an easy lead, but not necessarily a good one, he added. The fact that the FBI continues to publicly focus its investigation on Hatfill might be an indication that it is under pressure itself to find someone responsible, Pena said. Unless investigators have solid evidence on Hatfill, however, he is probably going to go the way of Richard Jewell, Pena added, referring to a man once suspected, but later exonerated, of being responsible for a bombing at the 1996 Olympics in Atlanta. If it turns out that Hatfill had no role in the anthrax attacks, the FBI has “essentially ruined someone’s life, and no one seems to care,” Pena said. Preparations for (A Possible) Next Time While the investigation into the anthrax attacks has so far had little success, the United States has begun an intensive effort to be better prepared for a future possible attack. In January, three months after the attack, U.S. officials increased efforts to develop the National Pharmaceutical Stockpile — supplies of treatments and vaccines stored throughout the country to counter biological agents (see GSN, Jan. 29). Funding for the stockpile jumped this year to $644 million, up from the $50 million spent annually since it was created in 1999. In June, President George W. Bush signed into a law a bioterrorism bill to provide $4.6 billion for improvements to U.S. defenses (see GSN, June 12). The bill included $640 million to develop a stockpile of smallpox vaccine and $1.6 billion to help states improve hospital systems. Last month, the CDC began distributing more than $900 million in grants to state and local public health departments to help improve readiness for a biological attack. “That money is helping to build better laboratories and better systems for detecting a potential terrorist attack as well as expanded communications systems to get information to public health workers and clinicians quickly,” CDC Director Julie Gerberding said in a Sept. 4 press release. “These investments will not only pay off in terms of terrorism preparedness, but public health in general will also benefit.” The increased funding in biological defense research and public health preparedness probably would not have occurred without the anthrax attacks, according to experts. The attacks were “quite a wake up call,” said Mohammad Akhter, executive director of the American Public Health Association. The anthrax incidents and the Sept. 11 attacks have demonstrated that terrorists are interested in causing mass casualties and in using weapons of mass destruction — which has led to the increased spending, said Mike Powers, a research associate at the Chemical and Biological Arms Control Institute. The attacks have led to “unprecedented” biotechnology research including new detection devices and safer vaccines, Akhter said. The increased biological defense spending has been well focused, addressing areas of concern as well as potential new threats, he added. Rosenberg has claimed, however, that the United States has rushed to increase funding into research on potential biological weapons agents that might be ineffective and lead to security problems (see GSN, Jan. 22). “Because of the rush to ‘do something,’ large amounts of government money are being thrown, without sufficient forethought, at research involving potential biological weapons agents,” she wrote in a Sept. 22 commentary for the Los Angeles Times. “Scientists go where the money is, and we’re now seeing a crowd of biologists lacking in relevant experience trooping to the trough.” Increased research on biological agents could make it even more difficult to impose regulations and oversight, Rosenberg wrote. Some have speculated that the anthrax used in the attacks originated from a U.S. research facility (see GSN, Dec. 17, 2001). Instead of increasing funds for biological defense, the United States should fund improvements in the U.S. public health system to be able to respond to a wide range of naturally occurring diseases, Rosenberg wrote. “Natural outbreaks of disease, including rapidly emerging new diseases for which we are unprepared, are a far more likely hazard for most people,” she wrote. “Improving the public health system’s ability to respond would help combat these diseases as well as biological attacks.” The increased biological defense funding has not appeared to take away from public health spending, according to Akhter and Powers. Even with the small number of casualties caused by the anthrax attacks, the increased funding is justified, Powers said. Terrorism has both a physical and psychological effect, he said, noting that the disruptive effect of the attacks has been “quite substantial.” The appearance of preparedness, through the increased funding and research, can help to reduce the psychological effects of a future attack, Powers said. Powers did agree that the United States still has “a long way to go” in developing a basic public health capacity. There is a tendency to focus research efforts on improving response capabilities such as developing a new smallpox vaccine, he said. The “front-end” public health system, however, provides detection and assessment capabilities in the event of a biological attack, without which it would be hard to determine how to allocate response capabilities, he said (see GSN, Feb. 20). There is also still a tendency to focus planning and research on high end attacks — ones that could cause mass casualties such as the use of smallpox, Powers said. While it is important to be prepared for such attacks, an exclusive focus on them could leave the United States unprepared to combat other biological weapons agents, he said. There are two U.S. public health areas that still need to be improved, according to Akhter. One is better public preparedness, such as the distribution of treatments and vaccines to the public in the event of an attack. For example, more research needs to be done on new vaccine delivery methods, he said. The recently released U.S. smallpox vaccination plan calls for the vaccine to be administered in the same way as it was 30 years ago, Akhter said (see GSN, Sept. 23). “We don’t do anything the way we did 30 years ago,” he said. Vaccines and treatments to be distributed to other countries also need more development, Akhter said. “People over there are basically sitting ducks.” A global strategy is needed to combat biological terrorism, he said. “We’ve asked out allies about a war on Iraq” but have not sought their help in combating biological terrorism, he said. Could It Happen Again? The possibility of another attack is based largely on the supply of anthrax still in the hands of those responsible for last fall’s attacks, Pena said. If a non-U.S. terrorist group is behind last fall’s attacks, the chances for a future attack are lower because “real terrorists” tend to alter their methods to retain an element of surprise, he said. If the person responsible fits the mold of a “Unabomber”-type terrorist, however, the chances of future attacks increases, according to Pena. These types of terrorists tend to repeat attack methods to taunt authorities — a “catch me if you can” mentality, he said. Whether or not the anthrax culprit is found, the CDC has said it is now better prepared to respond to any future acts of biological terrorism in the United States. “The process of preparing for a terrorist attack is a continual one with no real endpoint, but even today CDC’s level of preparedness is very high,” Gerberding said in a Sept. 9 press release. “We have the plans, the policies, the people, the products, and now we have the practice to make sure we are ready to respond.” For further information, see: CDC Frequently Asked Questions About Anthrax Journal of the American Medical Association Background on Anthrax GSN Anthrax Attack Chronology (Dec. 12, 2001)
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