Answer 1:

Generally, no. An anthrax attack can occur very quietly without any bombs going off or any observable "clouds" being present. Our abilities to detect anthrax rapidly are very limited at present, so the first sign that an attack occurred could be thousands of people rushing to the hospital after a few days of exposure. Most states rate biological attacks as one of their weakest preparedness areas. On a national scale, the US government does stockpile antibiotics for use in the case of an anthrax attack, but these supplies may not arrive in the attack area until 12 hours after a federal decision to send them and may take days to disseminate to large segments of the population. In the case of a large-scale attack (where greater than 2 million people were affected), the U.S. would likely run short of antibiotics very rapidly. Unfortunately, in a medium to large-scale attack, thousands to millions could die.

Question 2: Why worry about anthrax attacks?

Answer 2:

The tragic death of Bob Stevens (5 Oct 2001) due to inhalation anthrax (even with heroic medical intervention) and the subsequent finding that others who worked with him in Florida's Palm Beach County (in the American Media Headquarters building) were contaminated with anthrax has caused considerable national fear. The FBI has not determined the exact source of the anthrax, but is certain that it was not a natural outbreak, but rather a deliberate vicious criminal act on the part of one or more individuals. It is not known whether terrorists associated with Iraq or Osama bin Laden spread the fatal anthrax in Florida. What is known is that at least 6 of the World Trade Center terrorists lived close to where the Florida anthrax attack occurred (in nearby Delray and Boynton Beach). Many US citizens are concerned that USA-based terrorists with ties to Iraq or Osama bin Laden might try to unleash a major biological attack against the U.S. population in response to the U.S. anti-terrorism activities worldwide, especially the military actions in Afghanistan. U.S. citizens are also extremely concerned by the fact that several suspected terrorists (and one known World Trade Center terrorist, Mohammed Atta) made inquiries about crop dusting aircraft (suitable as a crude means to spread anthrax over a large region) within the same general area (Belle Glade, FL) as where the Florida anthrax attack occurred.

Question 3: Is anthrax a credible threat?

Answer 3:

Yes. Given what recently happened with the fatal case of anthrax inhalation in Florida and the known capabilities of countries that are hostile to the U.S., like Iraq, this is a very real threat. We know that Iraq has hidden and lied about much of its biological warfare program in the past and that several other countries hostile to the U.S. are likely to have anthrax biological weapons capabilities. We know, for example, that Iraq has claimed to have produced, and subsequently destroyed (so it says), roughly 9,000 liters of anthrax.

In addition, Iraq has admitted testing anthrax and other agents as part of its biowarfare program. As a result of this and other perceived threats, former Secretary of Defense Cohen decided to vaccinate all active duty and reserve personnel against anthrax.

He shifted $500 million to new chemical and biological preparedness programs. Former President Clinton also added roughly $10 billion to the budget (in January 1999) into preparing for weapons of mass destruction terrorism – largely to help mitigate biowarfare attacks.

The bottom line is that at least Iraq, and possibly several other hostile countries, have the technical expertise and demonstrated capability to support anthrax terrorism. Whether Iraq or other terrorist organizations have successfully placed (or attempted to place) terrorists in the U.S. with anthrax is unknown – or at least unknown to the American public.

Many other countries have known or suspected biological warfare programs. Information and expertise (and possibly biological warfare agents) from Russia's extensive biowarfare programs are likely to have leaked out to several other nations and terrorist groups.

Question 4: How big a problem is anthrax?

Answer 4:

Anthrax weapons can be produced that can have the same killing capability as nuclear weapons for a fraction of the cost and expertise. For example, the Oak Ridge National Laboratory did a comparison of costs of various threats and came up with the following:

Weapon Lethality Versus Cost
From the late Dr. Conrad Chester
Oak Ridge National Laboratory

Question 5: How deadly is anthrax?

Answer 5:

According to the late Dr. Chester of Oak Ridge National Laboratory, cultured anthrax has roughly 2 x 10 5th lethal doses per gram. Anthrax in a slurry has roughly 10 7th lethal doses per gram. Powdered Anthrax has roughly 10 8th lethal doses per gram.

Former Secretary of Defense Cohen illustrated this point on TV by saying that a five-pound bag of anthrax, if properly dispersed, could kill perhaps half of the population of Washington, D.C.

Dr. Harold Strunk, who retired from the U.S. military and has extensive experience with anthrax, stated that a sugar cube quantity of anthrax could theoretically kill 100 million people. He pointed out that in reality, the number of people potentially killed by this amount of anthrax is much less because of the problems of dispersal within a population.

Question 6: How would an anthrax attack occur?

Answer 6:

According to the late Dr. Chester, the best method of spreading lethal anthrax is through spraying the spores into the wind, where it is subsequently inhaled and begins to multiply. Dr. Chester, while at Oak Ridge National Labs, looked at many anthrax attack scenarios, which resulted, in part, with the following estimations:

Scenario 1: A single-operator terrorist with a truck-mounted 55-gallon drum of anthrax and sprayer could cause tens of thousands of deaths within a city.

Scenario 2: A sophisticated and well-trained technical terrorist group with four medium-sized planes (DC-3 size) were shown to potentially kill 35 percent of the U.S. population with one night flight spraying anthrax over key population centers.

Question 7: Some experts say anthrax is difficult to disperse through air and sunlight. Is this true?

Answer 7:

The difficulties of an attack are mainly related to producing and dispersing a proper sized aerosol, rather than weather related issues. Presumably the terrorists would be trained on what the best weather conditions are for dispersing anthrax spores and how to effectively produce an aerosol laden with anthrax spores. According to some experts, this would typically be done at night or on an overcast day with a gentle breeze so that the sun would not kill off the spores before they are inhaled. Other experts have indicated that anthrax spores are hardy enough that an attack on a sunny day is also quite feasible. Terrorists can certainly wait for the right weather conditions to exist. According to studies performed by the Oak Ridge Labs and the U.S. Congressional Office of Technology Assessment, a well-executed attack can kill thousands to many millions. The Defense Department has formally stated that a large portion of a city could be killed in a well-executed anthrax attack (see http://www.anthrax.osd.mil/Flash_interface/default.html).

Question 8: How vulnerable is the food supply to anthrax?

Answer 8:

Anthrax spores can fall upon food in either a dedicated attack on the food supply or as a secondary effect of an airborne release. If ingested in a sufficient dose, then an intestinal form of anthrax can occur that can be lethal for somewhere between 25 percent and 60 percent of those infected - if it is conventional anthrax for which we have clinical data resulting from the few cases where people ate infected meat. However, if the antibiotic supplies are limited, or a more drug-resistant strain is used, then a higher percentage of deaths would likely be expected.

Question 9: What should be done at the governmental level?

Answer 9:

Educate the public on the threat and how to counter it. This should include candid (but sanitized) information on any known attempted threats that have occurred in the past. The public deserves to know what is fact and what is fiction with the many rumors that have spread. (For example, USA Today and other news outlets reported a few years ago that there were several attempts by terrorists with biological warfare agents from Iraq who were successfully thwarted as they tried to enter our country – and some news sources said that some actually did enter.)

Public education should also include how to prepare in advance to limit your exposure during any future biowarfare attack, as well as instructing medical personnel on how to treat this disease (see the USPDI website for some practical recommendations).

Learn more about the Russian and other strains of anthrax and develop new vaccines and antibiotics as required. Research on new non-drug-based antibiotics, such as the ASAP Solution® being studied at BYU, should be accelerated. Expand the current vaccination program for people who live in high-threat areas or in high-risk professions. For example, a vaccination program similar to what is required of the military could be offered on a voluntary basis to medical personnel and first responders to blast/chem/bio/radiation scenes.

Encourage Congress to increase the vaccine production capabilities in the U.S. (currently only one company in the U.S. produces the vaccine) so that concerned citizens can be vaccinated, not just U.S. military personnel, and to allow for rapid mass immunizations should a large terrorist biowarfare attack occur.

Continue research on rapid detection devices for anthrax and other biological weapons and distribute these for real-time, 24-hour monitoring of major urban areas.

Increase the quantity of stockpiled antibiotics as well as the number of dispersal locations to respond to anthrax and other biowarfare attacks. Hours of delay in receiving antibiotics can translate to thousands or millions of additional deaths. Antibiotic stockpiles should be readily available to the medical community without having to wait 12 or more hours. Low-cost disposable respirator masks and latex gloves should also be stockpiled, as the current supplies (especially of respirators) could be quickly depleted and lead to many unnecessary deaths and prolonged social disruption.

Train and immunize emergency services personnel on how to identify/treat/triage biowarfare victims and how to limit the further spread of anthrax and other biological agents.

Upgrade intelligence, customs and law enforcement capabilities to thwart potential biological terrorists without infringing on citizens' rights.

Question 10: What can the average American do to be prepared?

Answer 10:

Here are some practical steps to consider:

There is an extremely low risk of biological attack if you live far outside a major urban area. Hence, if you live tens of miles outside a major city, you probably do not need to do much to be prepared other than have food, water, power, and medical supplies, etc., stored up in case of long infrastructure outages due to biological attacks. Some low-cost medical supplies, such as disposable HEPA or N95 respirators (which can be bought for somewhere between $1 and $10) and some latex gloves, would be needed if a highly infectious bio-warfare agent was used.

Consider obtaining at least of few days supply of antibiotics, based on your doctor's recommendations (but do not take these unless you know there has been an attack). Both the U.S. military and a public health consensus panel recommend prophylaxis (preventive dosing) with ciprofloxacin (500 mg orally, one every 12 hours) as the first-line medication in a situation with anthrax as the presumptive agent. Part of the rationale for this is that the Russians are known to have engineered strains of anthrax that are resistant to tetracycline and penicillin classes of antibiotics, which would include doxycycline and amoxicillin (it is possible that the Russians have also engineered a strain resistant to Ciprofloxacin, but this is not known). Hence, Ciprofloxacin (Cipro) recently became the first medication approved by the FDA for prophylaxis after exposure to a biological weapon (anthrax). You can obtain Cipro at websites like: www.2-buy-cipro.com where you can by 60 tablets for $399 after filling out an on-line questionnaire and then getting a prescription. Alternatives are levofloxacin at 500 mg by mouth once per day or ofloxacin by mouth at 400 mg every 12 hours (from JCD: May - Jun 99, p. 7). Other alternatives are doxycycline (doxy) (100 mg orally, twice per day) {or tetracycline may be substituted if doxy is not available at a dose of 500 mg every 6 hours} or amoxicillin (500 mg orally, every 8 hours), if the strain is found to be susceptible to these drugs. Doxy is the tetracycline-class antibiotic of choice, but resistant strains are likely to exist. Should an attack be confirmed as anthrax, antibiotics should be continued for at least 60 days (or for 4 weeks if the person exposed has received the 3 anthrax vaccinations). The above represents recommendations from the CDC and/or the DoD on preventative dosing (the DoD source is from the 2001 edition of the USAMRIID’s Medical Management of Biological Casualties -- see http://www.vnh.org/BIOCASU/6.html for a copy). Another excellent information resource recommended by the military, based on a consensus panel of 21 experts can be found in the Journal of the American Medical Association (JAMA Vol. 281 No. 18, May 12, 1999, 1735-1745) article titled: Anthrax as a Biological Weapon, which can be found at www.anthrax.osd.mil/Flash_interface/default.html (this site provides much additional background on guidance for using various antibiotics for both adults and children). Others would suggest somewhat different dosing guidelines than those listed above (see http://medicalcorps.org ). Some antibiotics, such as trimethoprim, sulfamethoxazole, cefotaxime sodium, cefuroxime, aztreonam, and ceftazidime are not recommended as anthrax is normally resistant to them. Although untested (for example, in monkeys), it is thought that other antibiotics such as erythromycin, chloramphenicol, clindamycin, extended-spectrum penicillins, aminoglycosides, macrolides, vancomycin hydrochloride, other first-generation cephalosporins, and cefazolin may be effective against anthrax (see JAMA article). See the Preparing for Terrorism article for more information for children's dosing and for many precautions.

If you live in or near a large urban area, you should learn how to make bio-safe rooms at your home and place of business (see www.usdpi.org for details). If you learn of an attack that is imminent or has occurred in your area:

• Go inside your home or business and close your windows. Prepare a bio-safe room and don a HEPA or N95-style respirator mask, if available.
  
  
• Monitor the radio or TV and seek medical advice immediately. The USDPI website provides information resources on what the military and others recommend for anthrax and other biowarfare agents. If there is a known attack and you have previously been recommended to do so by your doctor, begin taking a safe dose of antibiotics. Be careful, because there is some wrong information out there produced by popular so-called biowarfare experts. This literature can be dangerous when it comes to dosages, especially as it pertains to mapping vet dosages of animals to humans.
  If you really believe you've been exposed, you need to seek professional advice and antibiotic treatments immediately. If you wait until clear symptoms appear (normally after one to six days after exposure), in the case of anthrax, it will probably be too late to save yourself (20% or less are expected to survive after clear symptoms appear). However, be careful not to overreact to false warnings or rumors of attacks. See the Preparing for Terrorism article for more details on how to obtain antibiotics legally as well as for a discussion of one non-drug "mineral supplement" option for consideration, called the ASAP Solution ®.
  
  Dead animals or people who have died from anthrax should not be cut into but buried quickly and deeply or cremated to reduce spore spread, which occurs with exposure to air. Those treating suspected anthrax patients should wash their hands frequently and take preventive antibiotics [though sick human to well human transmission is unlikely].
  
  
• Try to obtain vaccinations for anthrax if really concerned. (Note: These are not currently available to the general public, only the military and certain other fields, like veterinarians). You can write to your congressman to see if Congress can work to make this an option to the average American. There are a lot of issues surrounding the effectiveness of the vaccination program. One argument is that if an attack occurs with a genetically engineered special strain of anthrax (as with the Russian versions), the vaccine will not help much. The counter argument is that in many scenarios, especially one with a less sophisticated adversary, the vaccine may prove helpful in reducing your risk.

© USDPI, 2001. Note: This article may be reproduced without permission as long as it is not altered (to include the disclaimer), it is not sold, and a reference to USDPI website at www.usdpi.org is provided.

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