Anthrax attacks could have killed thousands

A powerful bullet in an ineffective gun

The incredibly potent anthrax powder used in the bioterrorist attacks of 2001 could have killed thousands of people if the terrorist had simply placed an open container of the finely ground powder near the air intake system of a large building or skyscraper, a top federal advisor on bioterrorism said recently.

"That would have been an odorless, colorless, gaslike material that would have potentially infected thousands and thousands of people," said Michael Osterholm, PhD, director of the Center of Infectious Disease Research & Policy at the University of Minnesota in Minneapolis.

A key advisor to the U.S. Secretary of Health Tommy Thompson, Osterholm recently delivered a grim update on bioterrorism in Chicago at an infection control conference sponsored by the Joint Commission on Accreditation of Healthcare Organizations. Analysis has revealed that the anthrax used in the 2001 attacks was staggeringly powerful, he said.

"We still don’t know who did it, and I’m not sure we ever will," Osterholm said. "Whoever made that material made one hell of a powerful bullet. That stuff was incredible. There were up to 250 million infectious doses in each envelope that was sent. Why did it not do more? Because it was fired by a very ineffective gun — the U.S. Postal Service. The only thing that made it work at all was the energy of the sorting machines that the envelopes went through."

The attacks resulted in 22 anthrax infections and five deaths, and virtually shut down Congress. But the bioterrorism attacks could have much worse if the anthrax mailer made a strategy adjustment requiring little more than "box-cutter" technology, he said.

"The last 50 years, we have been building buildings around the world with HVAC systems that have this basic intake open for easy maintenance and ongoing service," he warned. "We never thought about the fact that those might serve as very efficient disseminators of such material. In this country, we have done almost nothing to protect our building air intakes since 9/11. Yet we know that the bad guys know [about this vulnerability]."

Indeed, a government investigation conducted after the anthrax attacks found that one of the prime vulnerabilities of institutional buildings — including hospitals — is access to the air intake, giving bioterrorists a possible mode to introduce an agent into the building ventilation system.1 The report stated that "publicly accessible outdoor air intakes located at or below ground level are most at risk. Securing the outdoor air intakes is a critical line of defense."

An amateur with $5,000?

In addition, Osterholm’s talk included the sobering revelation that the anthrax used in the 2001 attacks — as powerful as it was — apparently was not the work of some sophisticated bioweapons laboratorian. The FBI has "reverse engineered" the anthrax powder used in the attacks, looking at its ingredients and biological components, he explained.

"They can now tell you how that was made," he said. "And their basic bottom line conclusion — which, by the way, I concur with — is that, in fact, that material was made by somebody who had probably no more than a college education and spent less than $5,000 using off-the-shelf . . . technology processes to make it work. Will it happen again? I have no idea. Do I think it could happen again? Absolutely, I do."

Despite the homeland security and bioterrorism preparations made in the wake of 9/11, the nation remains target-rich and vulnerable, he emphasized. "I have no doubt that smallpox is still out there," Osterholm said. "There is no doubt in my mind. None. I worry about the very last KGB report — that was issued in 1990 before they imploded the former Soviet Union — in which they detailed at great length the North Korea smallpox weapons program that was active at that time."

With the national smallpox immunization effort in something of a hiatus, many have taken the position that just being ready to vaccinate people is sufficient preparation. Osterholm drew a sharp contrast to that scenario, saying the health care system will be beset by chaos if smallpox reappears anywhere on the globe.

"I will submit to you that if smallpox occurs anywhere in the world — one case, two cases — it will be utter chaos everywhere," he said. The recent monkey pox cases, for example, demonstrated that people will show up with rash illnesses once reports are in the news. Smallpox would dwarf that experience.

"I will guarantee right now if two cases of smallpox occur in the Philippines, tens of thousands of Americans will rush to emergency rooms with their rash illnesses wanting to be seen right now because they are convinced they are part of a smallpox attack," Osterholm said.

The health care system will be overwhelmed and the lack of immunizations nationally will result in a depleted work force.

"I will tell you that with the level of immunizations that is out there now, [some] emergency room people will walk, some will run, and some will never come into work," he said. "Don’t think we are going to get vaccine to you because I have been on the front lines of that issue. Public health will be [frantically] investigating these cases and trying to figure out what is going on. That first 48 hours there isn’t going to be an organized way of getting vaccine to 5,000 hospitals in this country."

Though saying he was nonpartisan and a "fan" of Thompson, Osterholm’s role as a bioterrorism advisor to the government gave his blunt comments a chilling weight.

Public health has been systemically eviscerated from lack of funding, while the health care system operates day to day on a "razor-thin margin" for equipment such as mechanical ventilators, he said. As a result, a bioterrorism attack that caused widespread botulism food poisoning would create "hard choices" about the distribution of ventilators.

"I worry desperately about botulism in this country," he said. "I am not going into how it could happen, because anyone out there that even has had high-school microbiology could perpetuate such an event. Today, we have about 82,000 mechanical ventilators in this country. On any one given day, 65,000 of them are in use. The point is, if we had a botulism attack, the only way is to [save some patients would be to] put them on mechanical ventilators to try to get them through."

In the face of such widespread system problems and overwhelming scenarios, infection control professionals and epidemiologists can do little more than "gnaw at the edges" of the preparedness problems. Osterholm’s assessment of the federal government’s efforts was no more encouraging.

"Much of what we do is cosmetic, when it comes to national policy and planning — at least out of the federal government," he said. "It is the world of politics. Who can get elected in the next election for what reason. We have very few leaders who are willing to get up and tell the people what they should hear, not what they want to hear."


1. Centers for Disease Control and Prevention. Notice to readers: Protecting building environments from airborne chemical, biologic, or radiologic attacks. MMWR 2002; 51:789.