Experts are still learning lessons about anthrax

Key discovery: Attacks can defy preparation

War On Terrorism


It is nearly a month since the U.S. government announced that a Florida man had come down with inhalation anthrax, a disease that almost no doctor in the United States had ever seen and few had thought about.

"It is an isolated case," Tommy G. Thompson, secretary of health and human services, said at a White House briefing Oct. 4. "There is no terrorism."

Soon, it became clear that the patient - 63-year-old Robert Stevens - was the victim of a terrorist attack. And now, with seven cases of the deadly inhalation anthrax confirmed in addition to seven of the easily curable cutaneous, or skin, type, scientists and government officials must rethink everything they thought they knew about anthrax, and they candidly admit that much of what they thought was wrong.

The biggest lesson, some say, is that despite years of discussing and imagining how a bioterrorism attack might occur, and how it might be recognized, the actual attack took everyone by surprise. Experts say that is the very nature of terrorism. "The more you prepare for one kind of surprise, the more they are likely to come in an area you're not prepared for," said a senior government official with knowledge of the situation.

Anthrax was on everyone's list of possible agents for a terrorist attack, but the situations imagined tended to involve large-scale attacks, with clouds of spores dropped on a city and with hundreds or thousands of people getting sick at once.

Such attacks are considered hard to pull off. The spores have to be finely ground so they can get into people's lungs and treated so they will not clump together, but they can easily be dispersed by the wind and killed by the sun.

No one expected that terrorists would send expertly processed anthrax spores through the mail. Neither did experts anticipate that the spores would burst out of letters and infect postal workers. "The full scale of this has emerged gradually, over a period of weeks," said Dr. Jonathan B. Tucker, a bioterrorism expert at the Washington office of the Monterey Institute of International Studies.

Even when a letter with highly lethal spores arrived at the office of Senate Majority Leader Tom Daschle, said Dr. Jeffrey Koplan, the director of the Centers for Disease Control and Prevention, "we were still operating on the assumption that in order for a letter to convey this - the anthrax - it had to be either opened by someone who was opening mail, or in some way torn or disrupted in the sorting process, because the concept of powder in a sealed letter was one that suggested it would stay with that letter."

Calvin Chue, a scientist at the Center for Civilian Biodefense Studies at the Johns Hopkins University, said the idea mailed spores could give postal workers inhalation anthrax was not considered.

Though the cases in Florida, New York, New Jersey and Washington are being intensely studied, they have not yielded data to answer some of the most basic questions about anthrax.

Of particular concern is inhalation anthrax, the most dangerous form of the disease. Much of what is known about how it progresses was learned from 1993 research on an outbreak in the Soviet Union that occurred in 1979. Anthrax spores were accidentally released from a germ warfare laboratory in Sverdlovsk, infecting at least 96 people and killing at least 68, but the number of people who suffered symptoms and many other details remain mysteries. And as the recent cases show, the survival rate is unknown, whether or not the disease is aggressively treated with antibiotics. In seven confirmed cases of inhalation anthrax, three people have died.

The recent attacks also raise questions about how many spores are inhaled by those who become ill. Textbooks say 8,000 to 10,000 spores. But, said Dr. Marguerite A. Neill, an infectious disease expert at Brown University, those estimates are based on studies decades ago of workers who handled animal hides. It might be that fewer spores are required, especially if they are treated to float in the air and penetrate the lungs.

Also, the patients might have significant characteristics, such as whether they smoke. On the other hand, it is impossible to know how many spores people inhaled and how many other people might have inhaled spores and not become ill.

The anthrax cases also show there is no early warning system that such a bioterrorism attack is under way, Neill said. The first sign is that someone, like Stevens in Florida, becomes gravely ill.

The recent case of Joseph P. Curseen Jr., a 47-year-old Washington postal worker who died of anthrax, provided another lesson.

Curseen, who worked at the Brentwood Road sorting center, went to the emergency room of the Southern Maryland Hospital Center the night of Oct. 20 but was sent home with medications for nausea and diarrhea. Two days later, after he returned to the hospital in an ambulance, attempts to save his life failed.

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