- The Washington Times - Sunday, June 8, 2003

First of two parts

Doctors, scientists and public health officials across the nation went into overdrive within hours of the World Health Organization’s first global alert on SARS, the deadly new virus from Asia. The word went out over phone trees, blast faxes, BlackBerry alerts, e-mail. And inside 24 hours, the U.S. public health system stood ready to tackle SARS — severe acute respiratory syndrome — as it became the world’s latest “emerging disease.”

The speed of the response illustrates how much has changed since the September 11 attacks and the anthrax-in-the-mail mystery that followed.

“The relevant U.S. agencies must be given credit. The United States is much better prepared today than we were two years ago to respond to a full-blown terrorist attack,” says Richard Fischer, senior fellow at the Jamestown Foundation think tank in Washington, who writes extensively on China and published a paper, asking “what if SARS were a bioweapon?”

Sixty-eight persons in the United States have been identified as “probable” cases of the disease, which is characterized by high fever, coughing and contact with someone who recently visited Asia.

Worldwide, more than 8,400 cases of SARS have been diagnosed. Of 779 reported deaths, all but 55 were in China or Hong Kong. No U.S. deaths from SARS have been reported; 31 have died in Canada.

No authority has suggested that SARS is in any way connected to bioterrorism.

However, the outbreak proved to be an ideal test for the ability to cope with a fast-moving, communicable disease — the kind of pathogen that terrorists would love to weaponize.

“From a response perspective, there is not much difference between what we have to do if Mother Nature or a terrorist” introduces a disease, says David Heyman, biological terrorism specialist at the Washington-based Center for Strategic and International Studies.

The letters containing anthrax infected 23 and killed five, including two postal workers from Prince George’s County. It took several weeks for doctors to understand the bacterial infection they faced.

‘A long way to go’

With SARS, the pieces were in place to meet a new disease head-on.

“SARS shows that we now have a heightened level of awareness and a much more robust communications system,” Mr. Heyman says. “Things are better today than they were at 9/11, but we have a long way to go.”

Dr. John Huggins, chief of viral therapeutics at the Army Medical Research Institute of Infectious Diseases at Fort Detrick, Md., agrees.

“I think the SARS outbreak has pointed out a new way of doing business. With SARS, everyone has gotten into the mobilization effort,” says Dr. Huggins, who is in charge of a team testing thousands of potential anti-SARS drugs.

On April 14, a month after the WHO announced the new disease, Canadian scientists said they had “sequenced” a portion of the cellular structure of the SARS virus. This allowed other scientists to begin working on an “assay,” or diagnostic test, to differentiate between SARS and more common aliments with similar symptoms.

“It is amazing that the medical community identified the cause of the disease, sequenced it and we have come up with a test this fast,” says Heinard Dreismann, director of Roche Molecular Diagnostics in Alameda, Calif., which plans to make a computer-designed test for SARS available to hospitals by the end of this month.

It took years to identify and genetically sequence hepatitis C and HIV, Mr. Dreismann says, but SARS was on the “fast-track approach” in part because today’s technology — including diagnostic computer chips that contain the genetic sequencing on hundreds of viral identifiers — is far more advanced than it was just a few years ago.

In early May, the Santa Clara, Calif.-based biotechnology firm Affymetrix Inc. announced it had placed the genome sequence of SARS — 300,000 strands of DNA — on a gene chip. This made it easier for scientists to compare and contrast it with other viruses, opening a way for analyzing mutations, new tests, and vaccine and drug research.

Price of preparedness

In the years before September 11, public health officials went to Capitol Hill to testify that a bioweapons attack on the United States was inevitable.

Although most experts considered a high-casualty attack a low probability, the doomsday testimony helped pry money out of Congress for the real problem: The public health system was not prepared for either the catastrophic consequences of a deliberate bioweapons attack, such as with anthrax, or an emerging disease such as HIV/AIDS, West Nile virus or SARS.

After September 11 and the anthrax letters, Congress was far more willing to contemplate — and fund — preparation for the horror of a disease outbreak or bioweapon attack.

In 1999, the lawmakers had authorized $121 million for bioweapons preparedness. At the time, 20 percent of public health offices had no Internet access.

The Atlanta-based Centers for Disease Control and Prevention (CDC) did not have an office with a telephone dedicated to bioterrorism. And funding was not expected to increase.

Congress has allocated $1.1 billion for bioweapons preparedness since September 11, and that figure is expected to increase tenfold in the next two years.

Halfway through last year, the CDC had doled out $908 million to upgrade public health care infrastructure, local public health centers, research facilities and laboratories in preparation for a naturally or deliberately spread infectious disease.

The Health Alert Network, a secure Internet system linking health departments around the country, is coming on line. The Laboratory Response Network has grown to more than 100 labs, able to handle a surge of samples for emergency testing.

On April 1, just in time for SARS, the CDC opened its $7.1 million Emergency Operations Center in Atlanta to act as a traffic-control base for any “disease event.”

Improving communication

The CDC has gotten a workout with SARS. By most accounts the agency has done its job, helping to identify and sequence SARS, coordinating the day-to-day response and longer-term action, and overseeing research into diagnostic tests, vaccines and cures.

The CDC also has monitored and coordinated exercises and simulations contemplating use of bioweapons.

Mr. Heyman, who studies U.S. preparedness in case of bioweapons, chemical or nuclear attack, says a key change since September 2001 is that communication is better.

Cities and states have networks that talk with each other, and they all talk with the federal government’s disease specialists at the CDC.

“The Greater New York Hospital Association has about 70 hospitals in its association,” Mr. Heyman says. “They can get in touch with every doctor in their community within one hour, if they need to.”

The major weakness in the system today, the bioterrorism specialist says, is that the public remains uneducated about what to do in case of attack.

“Are you prepared? What would you do in case of attack? If you can’t answer that question, you are not prepared,” he says, fiddling with the duct tape and plastic sheeting he keeps on a shelf in his downtown Washington office.

“What if there were a radiological attack on Capitol Hill or a biological attack on the White House right now? The only way I’d know is if CNN sent an alert to my BlackBerry. And then what would I do, shelter in place or evacuate? … We need an alert system, sirens or something.

“We are operating in an entirely new security environment,” Mr. Heyman adds. “Our first line of defense has moved from the battlefields abroad to our streets and cities at home, where we must rely on citizens, police, doctors and firefighters to protect us.”

Tell-tale signs

Michael Powers, senior fellow at the Washington-based Chemical and Biological Arms Council, says that despite improved communication among health and police agencies, there is a need for increased surveillance at hospitals, clinics and general practitioners’ offices to catch a disease before infection blossoms throughout a population.

Most diseases initially present common symptoms, including headache, fever, chill, cough or respiratory difficulty. So-called “syndromic surveillance” could alert health authorities to anomalies.

For example, a run on Kaopectate at pharmacies in a particular area should tell health specialists that something is amiss. A spike in absences from work and school, or visits to the doctor could indicate release of a biological agent.

“Tracking the symptoms of people entering clinics, emergency rooms, etcetera, would provide a quick snapshot of disease prevalence within a population,” Mr. Powers says. “With anthrax we were slow to recognize the severity of the situation. In the case of SARS, it was very rapid, quick mobilization.”

The down side is that this kind of monitoring raises privacy issues.

Mr. Powers says a “clash of cultures” seems to have been overcome: Prior to September 11, standard procedure for police, fire and rescue and emergency medical services was to rush in and solve a problem.

But health care providers “cautiously assess and analyze,” he says. “There are now greater connections between the two communities and they are better able to operate together in a crisis mode.”

Research and resources

The government held simulation exercises in mid-May to test local, state and federal ability to respond to a nuclear “dirty bomb” in Seattle and a chemical release in Chicago.

The exercises were called Topoff 2 and cost $16 million. Critics said the money could have been better spent on computers, radios and other communications upgrades.

But Mr. Powers, who has written extensively on U.S. preparedness for terror attacks, disagrees.

“Preparation is not just technical. It is also social. Having the chance to talk with each other is very important,” he says, adding that while the nation is better prepared, “more people and more technology” are required.

“We need the ability to deal with infectious diseases across the board,” Mr. Powers says.

He argues for several more years of intensive investment, “maybe $5 billion a year,” for vaccine research and production as well as research and development in medicine.

“Looking at the progress made in the last 18 months, I’d give it a B-plus or an A-minus. SARS indicates that we have made a lot of progress.”

Dr. Huggins, of USAMRIID, argues for more pure research, and that means more funding. Many specialists were surprised that SARS is a coronavirus, he notes. Named for crownlike surface projections, this type of virus usually is not deemed deadly and is one of more than 100 viruses linked to the common cold.

“The coronavirus wasn’t considered medically relevant,” Dr. Huggins says. “It shows the need for more sequencing and genomic research. I wish we’d invested more in the science of virology.”

Mr. Heyman adds: “We need to do a tremendous amount of research into antivirals, antibiotics, vaccines and antidotes — $1 billion a year in research money to study the pathology of disease.”

‘A great test’

Despite progress, many gaps in planning remain. The CDC convened a meeting of child care specialists in Alexandria on May 21 to discuss recommendations for addressing the needs of children during a bioterror event.

Children pose different medical needs and psychological reactions, especially if separated from parents. Most participants in the meeting were concerned that these needs have been overlooked in government planning. A total of 53 million children attend 117,000 public schools in the United States.

“In Topoff, schools were not part of the conversation as far as planning,” says Brenda Greene, director of school health programs for the National School Boards Association in Alexandria. “Schools are to be used for medical dispensation, but the schools themselves and the students were not part of the planning.”

Much more preparation is required, says Col. Theodore Cieslak, chief of pediatrics at Brooks Army Medical Center in San Antonio, who attended the CDC conference on children and terrorism.

“I don’t think we’ll ever be perfect, but we are way ahead of where we were a few years ago,” he says. “New diseases will continue to present themselves and continue to fool us, whether natural or sinister.”

Dr. Cieslak, a veteran of the Army Medical Research Institute of Infectious Diseases, says there is a high probability of an attack with low consequences: Some “nut case,” he explains, “will contaminate a salad bar or release a small amount of chemical or biological agent,” but few will be infected or die.

“I think a successful, large-scale bioterror attack with anthrax or smallpox is a low probability, but the consequences of something like that are so great, we have to be prepared,” he says.

Dr. Peter Rumm, Wisconsin’s chief medical officer, says that in addressing the threat of bioterrorism, the states are becoming more ready for a public health crisis.

“We are dramatically more prepared than we were a few years ago. SARS has been a success story,” Dr. Rumm says. “In Wisconsin, our Health Alert Network put out instant messages to hospitals, doctors, laboratories and public health officers with specific instructions, and every state in the union is building a similar network.

“Public health principles are the same, whether it is West Nile virus, SARS or anthrax. SARS is a good test,” he says. “We don’t have a cure, but it was a great test. And SARS shows we’ve made great progress.”

Tomorrow: Bioterrorism scares breathe new life into obscure scientific projects.

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