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March 2001
Volume 65 |
Number 3
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VENTILATIONS
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| Death
in a Droplet
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Mark J. Lema, M.D., Ph.D. Editor
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It is a hot, oppressive
morning in an arid, third-world country. The last bags are loaded
into the cargo bay. A service truck makes some final adjustments
to the air-handling system. Soon, the 747 jet is bound for Washington,
D.C. The pleasant afternoon breeze on this perfect spring day
is in direct contrast to the antiquated world left behind. The
passengers deplane; some to meet family in the D.C. area, others
to make connections with flights departing to all points across
the United States.
A few days later in
Chicago, a middle-aged businessman complains of abdominal cramping,
asthenia, congestion and headache. His watery diarrhea is rapidly
dehydrating him, and faint red lesions begin to appear on his
body. If it were not for his hardy condition, he would have sought
medical attention a day earlier; but now it is time to be healed
by American medical care.
The disease advances
into large black eschers, and he becomes extremely edematous.
Rales, widened mediastinum, hypotension, meningitis, mechanical
ventilation and death complete his hospital course. The doctors
are baffled, but more puzzling are the reports of similar cases
in Washington, D.C., New York and Los Angeles. The Centers for
Disease Control and Prevention (CDC) has made the diagnosis of
inhalational anthrax emanating from the airplane, reaching Washington
D.C., from somewhere east. Quarantines are now posted in the affected
metropolitan areas. Transportation into and out of these cities
is restricted. Houston, Des Moines and Portland also report cases
of anthrax to the CDC. The first case of a hospital employee being
afflicted is seen in Chicago. Americans are in a panic, staying
in their homes, wearing surgical masks. Drug stores are being
raided for any available penicillin, tetracycline, erythromycin
or chloramphenicol. The comfortable life that we take for granted
in this country has been transformed into a quarantined state
with martial law being imposed.
This little vignette
of medical horror is unfortunately only a terrorist's thought
away from possibly occurring somewhere in the world in the next
few decades. The threat of bioterrorism grows as the government,
medicine and pharmaceutical companies struggle to address the
possibility of its occurrence. With respect to the relatively
slow progress being made, there is cause for hope yet concern
about preparedness.
We, as anesthesiologists,
have a negligible (if any) presence in developing strategies for
preventing or administering to the catastrophe. Certainly, this
topic is never considered by annual meeting organizers, and if
it were, few would be expected to attend the session. Depending
on the inoculum, however, our specialty, along with surgery and
emergency medicine and nursing, would probably be in the first
wave of medical casualties. Perhaps it is appropriate for the
ASA leadership and meeting organizers to begin introducing the
topic at future meetings.
It is important to
appreciate why I, as an anesthesiologist, continue my tirade about
bioterrorism. Consider the following cases and statistics that
strengthen my paranoia:
• Nearly 1,000
people died in Denver after a terrorist sprayed airborne plague
in a concert theater. Confusion reigned as hospitals became progressively
overwhelmed with victims. This three-day, $3 million exercise
by the Department of Justice concluded that the systems and resources
now in place would be hard-pressed to successfully manage a bioweapons
attack. 1
• A van inconspicuously
parks outside of a packed ballpark in Washington, D.C., and releases
a cloud of anthrax spores. Within two days symptoms begin; in
five days a diagnosis is made. Of the 20,000 people in the park,
4,000 died. This fictional scenario is based on reliable biological
data and is used by the Johns Hopkins Center for Civilian Biodefense
Studies. 2
• Anthrax spores
introduced in sufficient quantities into the Washington, D.C.,
water supply would likely produce 250,000 illnesses in seven days
in an area that contains 3,000 hospital beds. 3
• In 1347, Tartars
catapulted dead plague victims over the walls of Kaffa, gateway
to the silk trade routes. The effects produced the Black Plague
(or Black Death) that killed one-third of Western Europe’s inhabitants.
4
• In 1942, the
Russians are thought to have deliberately infected German troops
with tularemia during the Battle of Stalingrad. The outbreak spread
to both sides causing 100,000 deaths. 4
• In 1979, the
Biopreparet program (the Soviets' bioterrorism section) caused
the Sverdlovsk Incident. More than 100 people and countless livestock
died suddenly along a narrow band directly downwind from the microbiology
facility. Inhalation anthrax was released inadvertently when a
shift worker removed a clogged biofilter, releasing spores over
several hours before the error was discovered. In 1992, Boris
Yeltsin acknowledged the event as a flagrant violation of the
Bioweapons Containment Treaty. 4
• In 1995, the
Japanese apocalyptic cult Aum Shinrikyo released sarin gas in
a Tokyo subway station, killing 13 people and hospitalizing more
than 5,000. Few people know, however, that their experiments with
aerosolized botulinum toxin and anthrax failed. They also failed
to obtain samples of Ebola virus and rickettsia (Q fever). In
all cases, real experiments near U.S. air bases and the Imperial
Palace failed because of either their selection of bacterial strains
or inadequate spraying mechanisms. 4
Anthrax is the best
biological agent, but smallpox and Yersinia (plague) are also
suitable agents. When one evaluates anthrax, it emerges as the
first-choice death germ. It is convenient and ubiquitous; great
quantities of hardy spores can be grown; it is well-suited for
aerosolization, long-term storage and widespread dispersal; it
is not communicable, and the spores die with sunlight exposure
(self-terminating); it is effective (80 percent mortality); and
there is an effective vaccine to prevent disease in the aggressor.
Smallpox is more insidious. Although it kills only 30 percent
who contract it, it is the disease that keeps on giving because
it is highly communicable. Vaccination is the only prevention.
The plague is similar in infectivity with smallpox, but it is
readily treatable with penicillin if detected early.
The time for action
is now. This situation, unlike nuclear war threats, is real, practical
and devastating. The cumulative worldwide risks must make the
inhabitants of the global village reconsider the low probability,
high consequence scenario of bioterrorism once thought to be the
reality. We, as physicians first, should play an active role in
addressing these threats. As anesthesiologists, we may suddenly
become a dying breed but not because of politics.
–
M.J.L.
References:
1.
Biodense Quarterly. 2000; 2(2):1-10
2.
Marwick C. JAMA. 1999; 281(12). [www.JAMA.com]
3.
Vertag B. JAMA. 2001; 285(1).
4.
Block SM. American Scientist. 2001; 89:28-37. [www.americanscientist.org]
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