Bioterrorism-Related Anthrax: International Response by the Centers for Disease Control and Prevention

Christina S. Polyak, Jonathan T. Macy, Margarita Irizarry-De La Cruz, James E. Lai, Jay F. McAuliffe, Tanja Popovic, Segaran P. Pillai, Eric D. Mintz, and the Emergency Operations Center International Team


Emerging Infectious Diseases. 2002;8(10) 

In This Article


Any suspected bioterrorism event has immediate global implications, no matter who the intended target or where the event occurs. This global impact is particularly true for communicable diseases such as smallpox. However, because of international trade, travel, and social connectedness, the same principle applies to less easily transmitted communicable diseases such as anthrax. More than 4,000 threat letters were tested in public health laboratories in Europe in the month after the first report of intentionally contaminated mail in the United States, and all surveyed national public health institutions took extraordinary measures to improve bioterrorism preparedness.[3]

In countries throughout the world, threat letters caused a shift in resources from traditional public health concerns to national security concerns. This shift represents a particular challenge for developing countries with chronically scarce resources for public health. Therefore, additional resources, particularly for the health sector of developing countries, are needed to address future threats. In many countries, strengthening the public health surveillance and response capacity for naturally occurring emerging infectious diseases is the most efficient means to provide a critical early warning system for intentionally released biologic agents and a defense against their further spread.

Public health agencies need to be able to exchange information rapidly across international borders to keep pace with events and make critical medical and public health decisions. Public health agencies must also keep pace with worldwide media coverage to minimize the potential for misguided public reaction. In the United States and other countries, many persons who were exposed to suspected anthrax-containing materials were told to not start or to discontinue antibiotic chemoprophylaxis after anthrax exposure was ruled out by testing at public health reference laboratories and by further epidemiologic investigations.[4] Information and technical support provided by the international team helped allay fears, prevent unnecessary antibiotic treatment, and enhance laboratory-based surveillance for bioterrorism events worldwide.

The operations of the international team were not without difficulty. Responding rapidly in different languages to countries in different time zones proved to be a challenge. In addition, the team was not always able to provide rapid technical assistance because of the need for review and clearance of documents containing new scientific information. Despite strict adherence to regulations governing the transport of infectious agents, shipment of suspected isolates of B. anthracis from laboratories in one country to reference laboratories in the United States was complicated by hesitance from shipping companies, air carriers, and national authorities. In some cases, the laboratory investigation of suspected exposures was delayed for several days while consent was sought from higher authorities and willing shipping companies and air carriers were identified.

The largest percentage of requests received by the international team were from persons or agencies affiliated with ministries of health, reflecting concern about bioterrorism issues at the national government level. On request, the team also provided specific information about the events occurring in the United States, often through referrals to publications and other materials regularly posted on the CDC website. Information provided to field epidemiology training programs through TEPHINET addressed some of these issues proactively and reduced the overall number of requests.[5] Given the essential role of the public health laboratory in bioterrorism preparedness and response,[6] information provided proactively to laboratories through the WHO Global Salm-Surv listserv may also have reduced the number of requests.

Rapid, reliable access to the Internet is an extremely useful tool for connecting public health agencies and laboratories and should be universally promoted. Digital cameras are an economical means of capturing clinical and laboratory images for Internet transmission and can greatly enhance communication about suspected cases or specific etiologic agents of infectious diseases. Nonclassified commercial laboratory reagents and protocols for isolating and identifying B. anthracis and other bioterrorism agents should be widely available to national public health reference laboratories. Through its collaborating centers, WHO has already begun to establish a worldwide network of reference laboratories capable of isolating, identifying, and confirming bioterrorism agents; WHO will continue to play a critical role in global coordination of outbreak surveillance and response. In addition, during the World Health Assembly of May 2002, the 191 member states agreed to a resolution recognizing that a deliberate release of biological agents could have serious public health implications and jeopardize public health achievements of the past decades.[7]

In the long term, strengthening the capabilities of national public health agencies and laboratories to recognize and respond to potential bioterrorist events and agents will also build capacity for recognition and response to naturally occurring outbreaks. Ensuring connectivity between these national public health agencies and reference laboratories worldwide is critical to improving global preparedness for emerging infectious diseases, whether or not they result from the deliberate release of a bioterrorism agent.


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