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

Antibiotics, Bioterrorism, and Vaccines

John G. Bartlett, MD


March 30, 2017

Countries Involved in Bioterrorism

The following countries have the suspected, but not necessarily established, capacity for bioterrorism.

Russia. The Russian capacity for bioterrorism became evident when anthrax was accidentally released from a large storage facility in Sverdlovsk,[19] and when Ken Alibek, who had once been in charge of the Soviet bioterrorism program, defected to the United States. In a book and other publications[20] he authored, he reported that the program he previously directed had more than 20 metric tons of weaponized smallpox.

Iraq. Documents from 1995 indicate that Iraq had stores of biologic warfare agents, including anthrax, botulinum toxin, aflatoxin, and ricin. More recent inspections suggest that these stores no longer exist, although some doubt the validity of this observation.[21]

North Korea. Evidence of bioweapon storage was revealed in 2015, when a defector delivered extensive reports of human testing data,[18] which included anthrax[22] from a pesticide storage facility.

This summary is disturbing, although the designated countries have denied bioterrorism stores and intent has not been consistently established.

There are two obvious questions. First, with no current credible threats and no relevant incidents in the past 15 years, why should we worry about bioterrorism? This might well have been asked in 2001, but our somewhat scrambled initial response in the face of public panic and the lack of precedent was a great disadvantage. Contemporary society seems increasingly divided on this issue, with substantial anger on one side and seemingly unlimited ethical barriers on the other. We might not need this planning now, but if we do need it, we really need it. It's good to have guidance based on this previous experience.

The second question is, why do we need to worry about smallpox when it has been eliminated? The reason is simple: we know that smallpox is clinically gone, but we also know it is an ideal bioweapon. Most people are immunologically naïve and lack the highly characteristic and unique immunologic marker of previous smallpox immunization—multiple encircled punctate scars in the upper shoulder.

The biologic properties of this pathogen make it an ideal bioweapon. For this reason, the Centers for Disease Control and Prevention (CDC) recently published guidelines on the management of smallpox,[23] new antiviral agents for treatment are in development,[24] and new vaccines for prevention are being developed.[25] That's a substantial use of resources for a pathogen that is no longer relevant.


A CDC review indicates poor compliance with nearly all vaccine recommendations. The 60% compliance with pneumococcal vaccination in people older than 65 years presumably reflects Medicare coverage. For tetanus, zoster, and human papillomavirus (HPV), vaccination rates for the target populations range from 17% to 37%.[26]

The 2017 vaccine recommendations for adults cover potentially important changes in influenza, HPV, HBV, and meningococcal vaccines.[27]

Influenza. The live-attenuated influenza vaccine should not be used in patients with egg allergy. Patients with adverse reactions other than hives can receive age-appropriate inactivated influenza vaccine or recombinant influenza vaccine. In such cases, the vaccine should be administered in a medical setting by a provider who is skilled in the management of severe allergic reactions.

HPV vaccine. [28] Healthy adolescents who start the HPV series before the age of 15 years should receive two doses. For those who start the series later, three doses are recommended. For previously unvaccinated women up to 26 years of age and men up to 21 years, the standard three-dose series should be administered at 1, 2, and 6 months. Men 22 to 26 years should receive the standard three-dose series at 0, 1–2, and 6 months. Women up to 26 years and men up to 21 years who initiated the series before the age of 15 and who received two doses at least 5 months apart are considered adequately vaccinated.

Meningococcal vaccine. [29] The FDA has now licensed two serogroup B vaccines: the MenB two-dose series and the MenB-Hbp three-dose series. Both are approved for people 10 to 25 years of age. Adults with HIV infection should receive the two-dose primary series for serogroups A, C, W, and Y. Adults with asplenia or complement deficiencies should receive the two-dose primary series of the A, C, W, Y; C; W; and Y meningococcal vaccine.

Meningococcal vaccination for men who have sex with men (MSM). Outbreaks of infections involving type B meningococcus in MSM have been reported in Chicago, Los Angeles, New York, and possibly other cities.[30] This has occurred primarily in men who meet anonymous sex partners while visiting gay bars in the designated cities. This has prompted the recommendation for preventive meningococcal type B vaccination for MSM before anticipated travel to designated cities. Other outbreaks have occurred on college campuses and in homeless people.[31]


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