Anthrax response: Guidance and Questions

How should we cope with a massive anthrax attack, and how can we prepare now so that our coping is optimal? The Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism predicted that a biological attack is likely within five years, and the intelligence community identifies anthrax as the most likely biological agent capable of causing mass casualties to be used in the near-term.  Thus, security communities should welcome the Department of Homeland Security’s recentProposed Guidance for Protecting Responders Following a Wide-Area Anthrax Attack.

By clarifying best response practices and thereby taking some of the worst sting out of anthrax, the Proposed Guidance actually reduces the risks that a terrorist will use anthrax to truly catastrophic effect. It is impossible, of course, to wholly neutralize the anthrax threat; a scientifically talented terrorist can still cause death and inspire fear, yetimplementing this Proposed Guidance will curtail anthrax’s capacity for killing Americans in numbers that exceed what could be done with an explosive device.  That noteworthy accomplishment, however, opens important questions about global preparedness and our international responsibilities.

Requirements and Domestic Capabilities

An outdoor aerosol anthrax could potentially encompasshundreds of square miles and potentially expose hundreds of thousands to spores.  Inhalation of these spores would be nearly 100% fatal if untreated. No one can be sure where or when an anthrax attack might occur.  What is certain is that post-exposure application of medical countermeasures (MCMS:  antibiotics and vaccines) is essential within 48 hours of exposure, often before symptoms are manifest.

To meet this goal effectively, responders must be able to rapidly distribute MCMs to every affected person, and civil order must be maintained.  Manifesting a true talent for understatement, the Proposed Guidance suggests “the logistical challenges to an effective response in the wake of a wide-area anthrax attack are significant.”

The good news for Americans is that there are sufficiently stockpiled MCMs.  The bad news is that DHS estimates a 12 – 36 hour lag between agent release and recognition of the attack, leaving only 12 hours for timely response.  To meet this cramped timeframe, the government plans to use postal carriers to dispense MCMs and to engage security forces to protect those carriers.  These personnel and other first responders must themselves be protected with antibiotics and vaccine because their exposure will likely be longest.  If first responders are not protected, some mightrefuse to serve precisely when their service is most urgently needed.

The Proposed Guidance reiterates the medical approach to treating anthrax that has long been the foundation of domestic preparedness.  Inhaled spores that germinate in the lung should be treated immediately with antibiotic infusions.  However, some inhaled spores can remain dormant in the lungs for up to three months, and antibiotics are ineffective against such dormant spores.  Antibiotic treatment is usually of much shorter duration; the antibiotics themselves can be harmful if taken for months.  

Accordingly, the CDC recommends post-exposure vaccination in addition to antibiotic treatment.  In brief, while the antibiotics destroy the germinated spores, the vaccine accelerates the body’s own immune response so that, when antibiotics are no longer administered, newly germinating spores can be effectively defeated.  According to the Proposed Guidance:

[A]nthrax exposure followed by administration of antibiotics post exposure generates no significant protective immune response, leaving no residual protection. … [T]he optimal means to prevent illness after suspected or confirmed inhalation exposure to aerosolized B. anthracis spores associated with a biological attack is post-exposure prophylaxis comprising a 60-day course of antibiotics in conjunction with anthrax vaccination in a three-dose regimen.

The Proposed Guidance takes this recommended practice – thoroughly supported by scientific research – an additional significant and perhaps controversial step.  Following a thorough discussion of how long it will take to recognize an anthrax attack, the Proposed Guidanceconsiders the efficacy of post-exposure vaccination for first responders.  First responders whose activities bring them intoextended close proximity with contaminated areas or personswill likely have the highest potential exposure levels to anthrax.  

Moreover, because of the need for immediate response, there will not be time to protect these first responders with personnel protective equipment.  Accordingly, the Proposed Guidance recommends offering pre-event vaccination to first responder organizations on a voluntary basis.

Meeting International Response Challenges

Altogether, the DHS Proposed Guidance more than adequately serves its domestic purpose.  That it is focused exclusively on domestic preparedness is wholly understandable and appropriate – homeland is the Department’s middle name.  Yet, from a broader security perspective, Americans would be well-advised to consider the global implications of potential anthrax attacks and, accordingly, to ask how our sophisticated understanding ofbest practices for coping with anthrax attacks can usefully reduce anthrax threats to our foreign allies.  More bluntly phrased:  Can the DHS Proposed Guidance contribute to America’s global leadership by advancing best practices for responding to anthrax attacks that happen elsewhere?

With only slight imagination, it may be realized that anthrax is not a uniquely American threat.  Strains of anthrax and the equipment necessary for weaponization are available worldwide.  Anyone with sufficient malevolence and technical skill to inflict catastrophic harm can choose any location to make as much agent as needed to commit multiple attacks.  Because of the time lag between release of anthrax and detection of that release, a terrorist could attack a city and before anyone knows of the attack be on a plane to another distant city and so on.

Envision the dreadful consequences of a well-designedseries of attacks in allied nations’ capitals -- consequencesnot only for the direct victims but for global stability.  Envision a series of attacks from Abu Dhabi to Barcelona to Calcutta, each attack potentially infecting hundreds of thousands (as the DHS Proposed Guidance suggests).  In each target city, lacking sufficient stockpiled antibiotics, absent plans for their effective distribution, and having no appreciable quantities of vaccine whatsoever – the death toll would mount with every passing day.  Worse, whoever is perpetrating the attacks is still on the loose.  

Panic levels begin to rise as there is no reason whatsoever to feel secure from future attacks regardless of where one resides.

In this context, it is absurd to assert that the United States is unaffected simply because the attacks have occurred on foreign soil and no Americans are among the casualties.  If only for the impact that such attacks would have on global commerce and the political stability that are fundamental toour national security, we would be profoundly harmed by such attacks.  Moreover, consider the implications of this choice:  our allies are pleading for antibiotics, vaccines and other protective measures, but the prospect of tomorrow’s attack against possibly an American city weigh heavily on the President as he decides whether to release our stockpiled MCMs for non-domestic use.  At that moment, theshortcomings of global preparedness against anthrax attacks will clearly suggest that, for American leadership, preparedness is just for our benefit.  Even if we want to begenerous, the situation is essentially unsolvable in the requisite timeframe that will be measured in mere hours.

Thinking Globally

Applying the lessons of the DHS Proposed Guidancemay be easier said than done.  Initially, there is a blatant contradiction between the DHS Proposed Guidance and the World Health Organization (WHO) guidance on treatment of anthrax inhalation.  WHO guidance recommends that anthrax should be treated exclusively with antibiotics, not in conjunction with vaccines; antibiotics administered in time can be wholly effective.  As the DHS Proposed Guidanceemphasizes, that assertion is untrue. The overwhelming weight of scientific evidence is that WHO guidance is wrong – out of date by as much as a decade.  Moreover, the WHO claims that vaccine is unavailable.  There is some credence to this point unfortunately, due to a remarkable circularity of policy debility – because of WHO guidance, production and stockpiling of anthrax vaccine is not considered a priority in the vast majority of nations.

This is not an academic question:  WHO’s misleading guidance is thwarting anthrax preparedness.  Right now, the Global Health Security Action Group (GHSAG, includingministerial level participation of the U.S., U.K., Canada, France, Germany, Italy, Japan, Mexico) is proposing to build a global infrastructure for medical countermeasure preparedness.  This global infrastructure would include stockpiling of MCMs and delivery capacities to get those MCMs to wherever they are need as quickly as possible.  The importance of this initiative – which has far broader concerns than just anthrax – cannot be overstated.  In a world where pandemic disease ranks among the top security threats, having a capacity to stockpile and quickly deliver medicine is critical.

Global anthrax preparedness would be well served by stockpiling of antibiotics and vaccines, combined with delivery capabilities to get these medical countermeasures to where they are needed. The GHSAG global infrastructure should be based on the principles elaborated in the DHSProposed Guidance. However, there will be both legal and policy objections to stockpiling anthrax vaccine if WHO guidance remains inconsistent with DHS guidance and withthe more recent scientific consensus.

A useful first step would be for CDC, citing the DHSProposed Guidance to call on WHO to bring its guidance up to date with relevant science.  Ironically, WHO officials have long known that their guidance for anthrax is wrong but have not yet corrected the misinformation.

The DHS already has policies that reflect science, and the steps to improve global security are straightforward.  All that remains is for the United States to exercise its influenceto promote global security from a looming threat.