Astute Clinicians: The Best Defense against Bioterrorism

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In medicine, clinical developments are always occurring, and the treatment of a disease can radically change from year-to-year.  Bioterrorism-related diseases are no different. In the 13 years since the anthrax attacks, many important developments have occurred in the treatment of these diseases, and my colleagues and I sought to encapsulate them in an article aimed at clinicians.

That article, to our delight, was published by the most prestigious medical journal in the world, The New England Journal of Medicine.  Our article discusses the new knowledge that has accumulated in the treatment of anthrax, botulism, plague, tularemia, and smallpox over the last 13 years.  For some pathogens, the treatment is essentially the same, but for others new treatments, prognostic information and vaccines are available. For example, a monoclonal antibody is available for the treatment of anthrax, a hepatavalent anti-toxin is available for the treatment of botulism, and experimental antivirals have been developed for use in the treatment of smallpox.

Busy clinicians are understandably unable to follow every development with these diseases, as they are rare and not part of their day-to-day practice. However, in the event of another bioattack (or a natural occurrence), these clinicians will be the front-line of defense, and the degree of their astuteness will be directly related to the degree of our vulnerability. As the world unfortunately learned during the Ebola outbreak, arming our front line clinicians with the most up-to-date information about potentially serious infectious diseases protects us all. 

Revisiting the Anthrax Attacks 13 years later

It’s been over 13 years since the anthrax attacks of 2001 during which 22 people were infected with the anthrax bacilli (Bacillus anthracis) via mailed letters with 5 succumbing to their illness. This attack was instrumental in fostering government and hospital preparedness for bioterrorist attacks. After a massive investigative effort that basically created the field of microbial forensics, the FBI declared their case to be closed after they identified anthrax expert Dr. Bruce Ivins as the perpetrator. This conclusion was supported by the findings of specific genetic mutations in the anthrax bacilli found in the letters and also in a flask (RMR-1029) managed by Dr. Ivins. However, no charges, trial, or conviction occurred because Dr. Ivins committed suicide.

The FBI’s case against Dr. Ivins, because it relied heavily on sophisticated science, was the subject of a National Academy of Sciences (NAS) review. That review cast doubt on some of the FBI’s scientific findings that formed one of the pillars of their conclusion regarding Dr. Ivins. Aspects of the NAS report which I found particularly compelling include the following finding: “the scientific link between the letter material and flask number RMR-1029 is not as conclusive as stated” and their overarching conclusion that “it is not possible to reach a definitive conclusion about the origins of the B.anthracis in the mailings based on the available scientific evidence alone.”

Now, a new GAO report shares the concerns of the NAS.  Specifically the GAO found that “the FBI's research did not provide a full understanding of the methods and conditions that give rise to genetic mutations used to differentiate between samples of B. anthracis,” “did not institute rigorous controls over the sampling procedures it used to build the repository of B. anthracis samples,” and  “did not include measures of uncertainty to strengthen the interpretation of the scientific evidence.”

The issuance of the GAO report will hopefully provide impetus to implement the final recommendations of the NAS that “a review should be conducted of the classified materials that are relevant…including the material pertaining to the overseas environmental sample collections, “ that “other tools, methods, and approaches available” be used in microbial forensic investigations, and that emphasis be placed on communicating “the goals of forensic science and realistic expectations and limitations regarding its use in the investigation of a biological attack.”