Americans are feeling unduly anxious and vulnerable. Recent cases of anthrax and false alarms of terrorist attacks, combined with a waning U.S. economy and spiraling unemployment rates have disrupted the tranquility of our lives and have made us feel vulnerable to outside forces. In the midst of such, we are being sent ambiguous messages by U.S. leaders to "be vigilant, but return to [our] routines (1)."

Many who have either directly or indirectly experienced the terrorist attacks of September 11 are suffering from nightmares and experiencing difficulty concentrating. Many are also merely feeling uneasy when entering tall buildings, shopping, traveling, or opening mail and have resorted to taking antianxiety drugs. As compared to the previous year, the number of new prescriptions for alprazolam, the generic version of Xanax, rose 22 percent in the Washington DC area alone and 12 percent in New York during after September 11 (2).

President Bush has promised $11 billion in addressing bioterrorism over the next two years (3). While the government must undertake various measures to prevent, prepare, and respond to possible cases of bioterrorism, we, as individuals, can also do our part through reducing our anxiety levels while remaining appropriately cautious.

What is bioterrorism?

According to the American Heritage Dictionary, bioterrorism is the use of chemical and biological weapons for terrorist purposes (4). Biological weapons include biological agents such as bacteria, protozoa, rickettsia, viruses, and fungi, as well as toxins, such as poison gas. These weapons are extremely pathogenic and may cause paralysis, organ failures, or sometimes, death (5).

While bacteria and other microorganisms can prove fatal, the potential of biological weapons to cause epidemics has been exaggerated by the media. In order to be better acquainted with the true dangers of bioterrorism, anthrax and smallpox, two infectious diseases, will be reviewed here.

Anthrax - a recent threat

Historically, workers involved with animals and animal products were at the highest risk of contracting anthrax, since cattle and sheep carry the bacteria endemically. While a fatal infection can occur after inhalation of anthrax spores, most reported cases are of the benign cutaneous type of infection. Only eighteen cases of inhalational anthrax were reported in the United States from 1900 to 1978. Human-to-human transmission of anthrax has never been reported. Thus, anthrax is not as contagious as other highly infectious diseases such as influenza and tuberculosis (6).

Dr. Swailem Hennein, an International Health specialist at the UIC School of Public Health, responds, "Anthrax is more readily available. Anyone who knows anything about laboratory technology can reproduce it. [But] it is difficult to imagine [that] anyone will do this on a very large scale."

Smallpox - less likely but more deadly
Considered from the medical and epidemiological point of view, smallpox is the most feared and devastating of all biological weapons. Smallpox can spread from person-to-person through inhalation of droplets of saliva or aerosols expelled from the throat, physical contact, and contaminated clothing and bed linens.

However, the likelihood of the smallpox virus being utilized by terrorists is considered very slim. First, smallpox virus no longer exists in nature, but only in laboratory cultures of two legitimate repositories in the U.S. and Russia (7). It is, therefore, very difficult to obtain, as well as to cultivate and disseminate.

Second, smallpox becomes contagious only after an incubation period characterized by a rash. By the time the rash appears, the victim is usually prostrated, bedridden, and most likely, hospitalized (8). Therefore, it is not realistic to believe that the disease would spread throughout a large population by the physical contact of an infected terrorist.

Lastly, even if such an event were to occur, existing stockpiled vaccine could be made available to the public to prevent an epidemic.

Is the U.S. taking measures for protection against smallpox?
In the U.S., the administration of smallpox vaccination ended in 1972. Individuals who were vaccinated prior to that time, however, still retain significant immunity (9). Moreover, early detection, quarantine of infected individuals, surveillance of contacts, and focused, aggressive vaccination can contain and control possible smallpox outbreaks.

Since the attack, interest in receiving smallpox vaccines has increased. Recently, Bavarian Nordica, a Danish biotechnology firm, announced that the U.S. government is sponsoring clinical trials of the firm's small pox vaccines. The U.S. National Institute of Allergies and Infectious Diseases has begun research to formulate a "third generation" smallpox vaccine that would cause fewer side-effects. The U.S. has ordered 200 million doses of the current vaccine to add to its existing 15 million stock (10).

What can health agencies do to prevent and prepare?
Health care facilities must have in place emergency plans for the sudden arrival of large numbers of infected individuals. These plans must be designed to recognize the incident, protect staff and facility, maintain patient decontamination and triage, offer treatment, and institute coordination with external agencies. Practicing physicians and other health care workers must also receive training, since very few have seen a single case of anthrax, smallpox, or plague. In addition to physicians, local police and paramedics should be trained to handle bioterrorist situations.

Laboratories must familiarize themselves with the Center for Disease Control (CDC) protocols, which indicate that any suspected specimen should be shipped to the state public health laboratory. Laboratories are also required to contact the healthcare provider and local law enforcement department (11). A microbiologist from Rush Presbyterian Lutheran Hospital comments, "CDC is not completely ready yet. Only after September 11 have we started getting new procedures to handle bioterrorism. We're still not 100 percent ready for it. We are in the process of improving." For the CDC Guidelines for State Departments, visit American Society of Microbiology's website at www.asmusa.org.

"The CDC sent reports and the State Health Director sent a letter to every single physician in Illinois," testifies Amy Szyszko, MD, Department of Emergency Medicine at UIC Hospital. Since September, a number of panels and lectures have been organized between the School of Public Health and UIC Medical Center. The hospital has also developed a bioterrorism subcommittee. Szyszko adds, "The information has been passive but has increased awareness." However, doubts still remain as to how prepared UIC really is. "The School of Public Health is not doing much. The hospitals have been prepared but the general population still needs education. The doctors at Cook County have never even seen a single case of malaria, let alone anthrax," protests Job Ngwe, a public health student.

As civilians, we must control our fears
Government planners, intelligence operatives, law enforcement officers and health professionals cannot do the job by themselves. Civilians are an important part of the solution. Perhaps we will never solve the problem of terrorism. However, we must prepare and learn to live with it. Indeed many of us have already put the terrible incident of the September 11 attacks in the past. As we try to cope with and define what Vice-President Dick Cheney called the "new normalcy," we need to find ways to manage our sense of anxiety and vulnerability (12).

Franklin D. Roosevelt said, "We have nothing to fear but fear itself." Feelings of anxiety and vulnerability are normal in such times, but they cannot deteriorate our lives. We need to stay well informed, but remain cautious. Hennein adds, "All this country need to do today is to take precaution, [in other words] keep your eyes open."

Justin is a third-year pre-med student double majoring in biological sciences and history. He plans to pursue an M.D./M.P.H. Rena is a third-year history major and plans to pursue M.D./M.P.H. in international and community health.