Is nation prepared for germ attack?

Posted: Thursday, September 27, 2001

Stashed in secure government warehouses around the country are 400 tons of antibiotics and other medical supplies ready for what seemed until two weeks ago to be an unimaginable catastrophe -- a terrorist germ attack.

The stockpile is already packed in hundreds of air freight containers, which can be shipped on 12 hours notice. There are enough pills, IV solution and other supplies to fill eight 747s, enough to treat thousands of victims of an intentional release of anthrax or plague or other germ.

The medicines are the most tangible centerpiece of federal preparations for a bioterrorist attack on the United States. But reassuring as they are, many health experts fear the country has hardly begun to get ready for such a disaster.

''How prepared are we? We are more prepared than we were two years ago. A lot of efforts are under way. But we are woefully unprepared,'' says Bruce Clements, associate director of St. Louis University's Center for the Study of Bioterrorism and Emerging Infections.

The possibility -- or probability -- of a bioterrorist attack was already near the top of some experts' worry lists long before Sept. 11. The Centers for Disease Control and Prevention published its strategic plan for dealing with one last year.

''Many experts believe that it is no longer a matter of 'if' but 'when' such an attack will occur,'' said Dr. James M. Hughes, the CDC's chief of infectious diseases, in congressional testimony seven weeks before the attacks in New York and Washington.

After those attacks, however, many say the risk is being taken much more seriously. The government has twice grounded crop dusters because of fear they could be used to spray germs or chemicals over large areas. While some experts maintain that relatively advanced technology would be needed to make and release large batches of germs, others say resourceful terrorists can almost certainly find ways to do it on a shoestring.

Dr. Michael Osterholm of the University of Minnesota, author of ''Living Terrors,'' argues that launching a smallpox epidemic, for instance, could be as easy as leveling the World Trade Center using planes hijacked with box cutters: Intentionally give the virus to 40 or 50 suicidal terrorists, wait a few days until they are highly infectious and then send them out to walk through airports, ride subways or go to ballgames.

Thousands of people would catch it and pass it on. Scientists say the protection many people had from their childhood smallpox vaccine has largely worn off.

Osterholm doubts the country could competently deal with a medical disaster of that scope or even one less catastrophic. ''We are just not ready for even a moderate-size event,'' he says.

The CDC leads government planning for the medical effects of such terrorism. Over the past two years, besides stockpiling drugs, it has underwritten state and local bioterrorism planning and education, strengthened communications among health officials and improved labs' ability to identify unusual bugs.

However, many experts say that on the local level, preparation has been scattershot, and doctors, nurses and hospitals are simply untrained and unprepared to deal with tens of thousands of patients with a deadly infection.

First, how long would it take to realize an attack occurred? Who would get the first limited doses of antibiotics? Who would count out and distribute the pills? And where would all the sick be hospitalized?

Many involved in local planning say such questions have no answers yet. ''Until now, we haven't even looked at the fact there are weaknesses, let alone how we might fix them,'' says Dr. Kathy Rinnert of the University of Texas Southwestern Medical Center, medical director of Dallas' metropolitan medical response system.

The first problem will be recognizing that a germ attack has even taken place. Bugs could be sprayed, invisible and odorless, through buildings, into train stations and across entire cities, but they cannot be detected with any monitoring equipment.

The first hint of disaster might come days later, when unusual numbers of otherwise healthy people turn up at emergency rooms with aches and fever.

Most doctors have never seen a case of anthrax, smallpox or plague. The early signs of many bioterror infections could easily be mistaken for the flu.

Bioterrorism training programs, aimed especially at emergency room doctors, encourage them to report odd clusters of common ills. ''We need a system where a physician who sees a flu-like illness doesn't just say, 'Go home and rest. It's the flu,''' says Dr. Ronald Atlas of the University of Louisville, president-elect of the American Society for Microbiology.

Identifying an attack quickly is critical. Once symptoms start, the outlook is grim, even with plenty of medicine. But prompt doses of antibiotics can keep outwardly well but infected people from falling ill. Most of the bacterial threats, such as anthrax and plague, can be treated with ordinary antibiotics like Cipro and doxycycline.

But who will get treated first when demand will far outstrip hospital supplies? Probably hospital personnel, since they need to stay healthy for everyone's sake, as well as police, firefighters and ambulance crews. Many will demand it for their families, too. City officials will argue they also deserve protection.

''Where will it end?'' ask Rinnert. ''Are there enough doses to even take care of the responders?''

Stockpiled drugs could arrive a day or two later, depending on how long it takes the CDC to acknowledge the crisis and get moving. But distributing them will be a herculean job.

The medicines are divided around the country into eight lots, called push packages. One or more would be sent, depending on the situation. Each weighs 50 tons and takes up more than 100 air cargo containers. They include more than 900 cases of pills and 2,500 cases of intravenous medicines, as well as catheters, breathing equipment, intravenous fluid and bandages.

Most of the antibiotics -- 432,000 Cipro tablets and 5 million doxycycline -- would be in bulk bottles. Somehow they would have to be sorted into handfuls of individual doses in plastic bags. And these would somehow have to be distributed to hundreds of thousands of people frantic that they are infected.

Osterholm says the stockpile is useless without the manpower and plans to distribute the drugs quickly, and ''those plans are not in place throughout most of the country.''

There are fears of shortages.

''The concern is there won't be enough ventilators and enough antibiotics, so we will have to decide who gets treated and who doesn't,'' says emergency physician Nicki Pesik of Emory University in Atlanta.

And after a decade of downsizing, hospitals wouldn't have room for all the patients, nor would they have enough nurses.

What if the infection is highly contagious, like smallpox? In the entire Washington-Baltimore area, by one count, there are just 100 beds in rooms equipped with air flow systems that keep germs from escaping.

And finally, those who think about the unthinkable ponder this: What if the strain of anthrax or plague released by terrorists has been genetically altered? What if it is resistant to common antibiotics? Then those 400 tons of government medicines could be worthless.

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