TY - JOUR
AU - Voelker, Rebecca
AB - Like many Americans, D. A. Henderson, MD, MPH, sat mesmerized in front of his television on the morning of September 11, 2001. The noted epidemiologist was working at home that day, writing an article on smallpox, the deadly nemesis he was instrumental in defeating some two decades earlier. Had it not been for the article, Henderson would have been working that day at "the center," more formally known as the Johns Hopkins Bloomberg School of Public Health's Center for Civilian Biodefense Studies, where he was director. View LargeDownload D. A. Henderson, MD, MPH (Photo credit: Office of Public Health Preparedness) Henderson and his wife watched the horror unfold as a second terrorist-piloted aircraft slammed head-on into the World Trade Center. "I couldn't believe what we were seeing," he recalled. Even for one of the world's most renowned experts on bioterrorism, it took several days for the full magnitude of the attacks to set in. "Here were some people who obviously had done a lot of planning to bring this off, who were intent on doing the maximum amount of damage, and who had absolutely no moral scruples whatsoever," he said. "It wasn't until a couple of days later that I began thinking about it—what could be next?" Planning for potential threats now is a full-time job for Henderson. On November 1, 2001, Health and Human Services Secretary Tommy Thompson appointed Henderson to head the new Office of Public Health Preparedness, which is charged with coordinating the government's response to biological attacks and other public health emergencies. As a tragic, tumultuous year passed into history, Henderson offered some perspectives on his new post and the current state of emergency preparedness. JAMA: Your new position covers some broad territory. What are your initial priorities? Dr Henderson: There are a couple. As we looked over the list of possible agents that might be used, smallpox and anthrax are right at the top. There had been a contract let for 40 million doses of smallpox vaccine in September 2000. So immediately the decision was made to order more vaccine, to try to get that contract increased. The second piece was the anthrax vaccine. We've asked the question, is it possible to get the recombinant, second-generation anthrax vaccine produced and developed on a fast track? That is under way, with a very active program involving the National Institutes of Health, the US Food and Drug Administration, and the US Army. It is being very tightly run. We do not want to do each separate experiment or development sequentially. There should be some overlap to move faster. Thirdly, we need to increase the stockpile of antibiotics, primarily doxycycline and ciprofloxacin. JAMA: A recent study in the Annals of Emergency Medicine indicated that up to three fourths of hospitals studied weren't fully prepared for treating casualties from weapons of mass destruction. What steps can improve their preparedness? Dr Henderson: One is that the hospitals have been exercising some emergency planning to identify who's in charge, who should go where, how to discharge patients in an orderly manner when they can be discharged, and securing the hospitals so that you don't have floods of people coming in. Then you move on to specific items like decontamination. Most hospitals are not equipped to decontaminate anybody in case of a chemical [incident]. In case of biological agents, you've got people who are potentially contagious. And many hospitals do not have a separate isolation room so they do not infect others. We've had huge outbreaks of measles from children coming to an emergency room where other children are there for measles. That is fairly simple. Then you have to consider, as we did at Hopkins, what to do about beds. We have a multistory tower that is on a single ventilation system. If we need that space, we can evacuate the patients to other floors or other places and turn the whole section over to contagious disease cases. We need to do this communitywide. Right now, what's important is planning at the state and local levels, and the development of contacts between emergency departments and health departments. JAMA: The United States could spend billions to defend against bioweapons. How can experts accurately estimate the threat and allocate resources accordingly, given the current economic recession? Dr Henderson: Our health care system has had a real problem in dealing with infectious disease outbreaks. Hospitals simply are not well prepared. Irrespective of concerns about bioterrorism, we have a problem that should be addressed. We need to build into a hospital's costing system provisions for some sort of flexible space that they can use for surge capacity. We have new and emerging infections at a pace we have not seen before, and we really need to be better equipped to deal with early diagnosis and early [treatment]. A stronger public health system with a responsive communications system that can move quickly and a laboratory network that is in a position to make the diagnoses—these would seem to be good investments, irrespective of the bioterrorism area. When we come down to it, the only investments that we are making in bioterrorism are for smallpox vaccine, anthrax vaccine, and antibiotics. And with smallpox vaccine, once it's produced you have it forever. It does not expire. JAMA: Recently, much criticism has been leveled at the federal government for not properly warning postal employees who were exposed to anthrax, and then for offering vaccine a couple of months after exposure when there were recommendations on earlier administration of vaccine published in 1999. Do you think the criticism was warranted considering the way these events were handled? Dr Henderson: The criticism, I think, is unduly harsh. The fact is, we had a large number of hoaxes. Powders were delivered to all sorts of places, particularly Planned Parenthood sites. A good deal of thought went into [estimating] how big this risk would be. The data we had to work on were developed in the 1950s and 1960s when we still had a biological weapons program. The impression we had was that first of all, there would not be a large dose of material expelled into the environment simply because of the characteristics of this powder—how it adheres to surfaces and so forth. So, we did not anticipate that this would be a major cause of a lot of infections. Then we had the [Sen Tom] Daschle office experience. Then we saw the last thing in the world anyone thought of, which was the post office. The letters were sealed. Surely you're not going to have much [powder] come out of a letter. It really wasn't until we got data from Canada—they did some work in which they opened a letter not with anthrax but with an anthrax-like substance, with a letter opener in an enclosed room. This was done in a special building they were going to tear down. They had all kinds of sensors [and found that the letters] released a huge amount of material—much, much more than we would ever have imagined. At that point we began to see the cases in the post office. So, could we have anticipated this? It's perfectly obvious that no one expected this. We tried to point out that we had very little experience with inhalation anthrax—18 cases in the 20th century, and none since about 1975. We had one outbreak in Russia in connection with a manufacturing plant that was producing aerosolizable anthrax. Information from that was garnered primarily during a visit made 13 years after the epidemic occurred. There were no clinical records, they were confiscated by the KGB. Everything had to be assembled from interviews with friends or family of those who died, and from interviews with physicians who were trying to remember what was done 13 years before. That's all we had to go on, plus whatever work had been done on monkeys. When we closed down our biological weapons program in the early 1970s, research on a lot of these things came to a halt or markedly slowed. There were only a couple of people doing any work on anthrax and that was experimental, to get an idea if the vaccine worked or didn't work. JAMA: The government's Joint Vaccine Acquisition Program, in which outside contractors handle production of biodefense vaccines, has been described as poorly coordinated and counterproductive. Do you think it will be scrapped anytime soon, and if so, would the federal government sponsor a major biodefense vaccine production effort? Dr Henderson: There is some discussion going on about just how we are going to handle procurement of vaccines in the future. How that's going to come out, I don't know. There are questions of how you handle production of vaccines for which there is little demand but real need, and the question of how you develop all the specialized vaccines with military need. Should one think about a special vaccine facility to do what manufacturers are not keen to do? For example, we have an adenovirus vaccine that the military developed and the manufacturer stopped producing, so adenovirus vaccine is not available. There's been a lot of illness in military training centers from adenovirus because [the personnel are] not vaccinated. That's a problem and we're going to have other problems. At the moment, tetanus toxoid is in desperately short supply; we're out of it in many areas. There have been regular shortages of many other vaccines. I don't know that a national vaccine acquisition program is the answer, but it's clear that we're not adequately served by the mechanisms we now have. JAMA: Are there lessons from the work you did in the eradication of smallpox years ago that can be applied to the potential eradication of the threat of bioterrorism? Dr Henderson: I think there are some real lessons here. We controlled smallpox during the epidemic by focusing vaccination very heavily among contacts of patients and their families. Even when we had widespread outbreaks we continued to do that. It's like being a fireman, you put the water at the point of the fire or around it rather than spraying the whole building. That piece is very important. From the experiences we had, we'd be pretty optimistic that with enough vaccine we would do very well. But [bioterrorism] is a very nasty disease. It's going to be tough one. JAMA: Can we ever truly eradicate the threat of bioterrorism? Dr Henderson: I'm afraid not. It's now possible for many people to do many things [with biological agents] in many different parts of the world. They may do it deliberately or they may do it accidentally. We're in a new era. Twenty-first-century biology is a different world than the one we had before.
TI - Bioweapons Preparedness Chief Discusses Priorities in World of 21st-Century Biology
JO - JAMA
DO - 10.1001/jama.287.5.573
DA - 2002-02-06
UR - https://www.deepdyve.com/lp/american-medical-association/bioweapons-preparedness-chief-discusses-priorities-in-world-of-21st-MQaW8CKdfm
SP - 573
EP - 575
VL - 287
IS - 5
DP - DeepDyve
ER -