- The Washington Times - Friday, November 23, 2001

Lost in the pervasive coverage of anthrax bioterrorism is the fact that this disease is neither new nor novel. Lest we forget the Unabomber, even the mode of attack a weapon delivered by mail is old hat. Moreover, anthrax has striking parallels to Legionnaire's disease so that the extensive scientific knowledge we have of the latter should can help us in strategic thinking about anthrax.
Anthrax and Legionnaire's disease both:
m Terrify, because in the absence of rapid diagnosis and treatment they kill.
m Produce pneumonia which, though severe, can be treated with available antibiotics
m Are caused by organisms that live in nature, but are encountered by humans as a result of man-made circumstances.
m Are occupational diseases: the exposure that causes infection usually occurs in a workplace.
m While purely environmental in origin, both are acquired by exposure to an agent in the environment not by person-to-person transmission.
m Their most efficient method of control is prevention of exposure to the organism, not treatment afterwards.
In 1976, when Legionnaire's disease appeared in Pennsylvania as a "mystery epidemic," the nation panicked similar to the current anxiety about anthrax, chemical and microbiological bioterrorism as well as the long-expected epidemic of "swine flu" were initial hypotheses to explain the phenomenon. These and other theories were systematically ruled out by one of the most intensive investigations in history. Ultimately, the bacteria that causes Legionnaires' disease was isolated, named Legionella, and thoroughly defined.
To be sure, the diseases differ in important aspects: Legionella, the cause of Legionnaire's disease, is a water-borne organism; Bacillus anthracis, which causes anthrax, is airborne. Bacillus anthracis forms spores, which are long-lasting and resistant to destruction; Legionella does not form spores, but hides itself in other single-celled organisms, and thus is long-lasting and resistant to destruction.
Another big difference between the two that is relevant is our current situation. Anthrax, though ancient, is not nearly so well-studied as Legionaires' disease. The latter appeared late in the 20th century when medical, epidemiologic, microbiologic, and biochemical sciences were far advanced. We probably know more about Legionnaire's disease and Legionella than any other infectious disease.
Part of what we know about Legionella is what to expect when we test various environments for it. Once Dr. George Morris of the CDC figured out in 1978 how to recover Legionella from the environment, extensive surveys were done of numerous environmental sources. The results left us with a clear understanding of what to expect under normal conditions when we test such settings as office buildings, hospitals, homes, prisons, and even congressional offices. The baseline information enables us to soundly interpret tests done in the crisis of outbreaks.
We have no such understanding of expected findings when we test for the anthrax spore. For example, we have no sound scientific basis on which to interpret a finding of one spore in a sample from an office building, clinic, hospital, or mail sorting operation. Given this lack of understanding of the background, every finding of an anthrax spore fuels the public terror.
We lack such critically needed information because we have not done the necessary peacetime preparation in the form of environmental surveys of various potential exposure settings that would provide the baseline. Because anthrax has been on everybody's top ten list of potential bio-terrorist weapons for years, one may legitimately ask, "Why were these studies not done by those we pay to protect us?" The answer is not insufficient funding of the CDC, as seems to be the recurring theme of Department of Health and Human Services Secretary Thompson. No, this is not a funding issue; plenty of money was available for far less important issues. The explanation for failure in preparedness more likely lies in the preoccupation of the Public Health Service's agencies with what I call the "medical model." This phrase describes a way of thinking about disease prevention that focuses attention on the disease rather than on the agent or hazard that causes the disease and the likely circumstances of exposure. In the "medical model," one watches and waits for cases of the disease to come to light ("disease surveillance") and then works backwards to find the hazard and exposures caused of the cases so as to control the hazard and prevent future cases. Operating in the "medical model" tends to produce retroactive thinking and inadequate preparedness for the potential attack.
An alternative model, the "industrial hygiene/engineering model" focuses attention on the causative agent, the hazard ("hazard surveillance"), and the types of exposures necessary for transmission. By controlling the hazard and exposures necessary for transmission, this model hopes to prevent even the first case of disease. Thinking in this mode leads to such proactive measures as environmental surveys to learn the existence and habits of the particular hazard under ordinary circumstances; doing so enables an understanding of the results of our crisis-driven investigations. It appears such proactive surveys were not done for anthrax. Hence, we found ourselves ill-prepared to interpret the environmental investigations done in the crisis; at least temporarily, this enhanced the public's terror.
Weeks, Wagner and Levy in their book, "Preventing Occupational Disease and Injury" explain that the ideal prevention strategy for an environmental problem is an "integrated strategy" combining the strengths of both the "medical" and "industrial hygiene/engineering" models. There is little indication there was ever an "integrated strategy" for anthrax.
As can easily happen with the "medical model," the absence for several years of detected anthrax not the same as absence of anthrax seems to have lulled us into ignoring the hazard and disdaining any systematic efforts to define the expected background distribution of anthrax. Now, we must play "catch-up" with little scientific basis for interpreting our testing during the crisis. The fact that anthrax, like Legionnaire's disease, is purely environmental should be good news. Being purely environmental means that anthrax has similarities to any other occupational and environmental disease such as those caused by chemical agents. Many such problems were successfully controlled by application of tried-and-true methods of industrial hygiene and engineering: anticipation, detection, analysis and control. These can as readily be applied to anthrax. However and this is a big however doing so will require that our public health leaders think less like doctors and more like industrial hygienists.
A good first step would be to add an outstanding industrial hygienist there are many to the staff of the newly created Office of Public Health Preparedness. Moreover, with regard to diseases caused by bioterrorism, our national objective should be to apply integrated prevention strategies capable of preventing the first case as well as those occurring after discovery of the attack.

J. Donald Millar served as director of the National Institute of Occupational Safety and Health from 1981 to 1993.


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