John Bartlett's Take on Critical Infectious Disease Topics: Part 2

Antibiotics, Bioterrorism, and Vaccines

John G. Bartlett, MD


March 30, 2017


Historic event. On October 2, 2001, a 63-year-old journalist presented to a Florida emergency department with headache, fever, and confusion. A lumbar puncture, reviewed by Dr Larry Bush, who is trained in infectious disease, showed Gram-positive boxcar-like bacilli. His immediate impression, quite remarkably, was that this was anthrax and was an instance of bioterrorism. The patient died the following day.[8] This was the first case of inhalational anthrax during the bioterrorism attack that terrified the country in 2001. The putative agent, Bacillus anthracis, is a spore-forming Gram-positive bacillus.

During this bioterrorism incident, anthrax was used to contaminate mail, and the pathogen proved remarkably efficient for targeted and widespread distribution. The journalist in this case was the first of several recipients of contaminated mail directed at journalists and politicians. There is no easy way to confirm the agent on contaminated mail; it requires laboratory culture. However, small white flecks can sometimes be visually detected, and the public soon learned that any unidentified white fleck could be anthrax. The aggressive response involved extensive training, hotlines, massive use of ciprofloxacin prophylaxis, and formal guidelines on management. By November 20, 2001, there were 22 cases of anthrax (11 inhalational, 11 cutaneous) and five deaths.[9]

Bioterrorism is defined as the intentional release or dissemination of biologic agents intended to cause harm. In the 40 years before the anthrax attack, there were two major bioterrorism incidents.

Rajneeshee attack, 1984. This attack was an attempt to manipulate an election by disabling voters. Salad bars in restaurants, grocery stores, and other public places were infected with Salmonella typhimurium in a city in Oregon. The resulting food poisoning affected 751 people. This was the first, and largest, bioterrorism attack in the United States in the twentieth century.[10]

Aum Shinrikyo attack, 1993. The perpetrators of this attack—members of a religious sect—attempted to carry out an anthrax attack in Tokyo. However, because they used a vaccine strain that had been rendered nontoxic so it could be used in healthy people, the result was a total failure.[11]

The Center for Bioterrorism

In response to the 2001 anthrax experience, the Center for Bioterrorism was established at Johns Hopkins University in Baltimore, under the leadership of Dr D.A. Henderson, the man credited with the eradication of smallpox, the only human microbial pathogen successfully eliminated from the planet. Dr Henderson subsequently became dean of the Johns Hopkins University School of Public Health and Hygiene. With his former student, Dr Thomas Inglesby, he developed a think tank for bioterrorism and other major public-health threats.

During its highly productive history, meetings were held and documents from authoritative sources were developed on many topics, including guidance for the management of major bioterrorism, or category A, pathogens. To be included in this category, the pathogen must meet the following criteria:

  • Easy transmission or dissemination

  • A capacity to lead to severe illness, including morbidity and mortality

  • A capacity to have a significant public-health impact

  • A capacity to cause public panic and/or to require special action for public-health preparedness

Category A agents:

  • Anthrax[12,13]

  • Tularemia[14]

  • Smallpox[15]

  • Viral hemorrhagic fever viruses (Ebola, Marburg virus, Lassa fever virus)[16]

  • Botulism toxin[17]

  • Plague[18]

Regulatory Issues. The United Nations (UN) considers bioterrorism illegal and immoral. Security Council Resolution 687 authorizes the UN Special Commission and the International Atomic Energy Agency to perform on-site inspections of facilities thought to be intended for bioterrorism activities.


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