America scrambles for antidotes and vaccines

War on terrorism: Bioterror

The Barometer of fear shot up several degrees in America with news that two postal workers in Washington DC had contracted the inhaled form of anthrax while two others had died from causes that were not known. It was not a time to worry anyone about the dangers of a different plague.

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Antibiotics could endanger potential anthrax victims

Infectious smallpox holds advantage as killer weapon

The Barometer of fear shot up several degrees in America with news that two postal workers in Washington DC had contracted the inhaled form of anthrax while two others had died from causes that were not known. It was not a time to worry anyone about the dangers of a different plague.

Even as the government is scrambling to respond to the anthrax scare and discover who is behind it, they are also moving with extraordinary speed to prepare for another, once unthinkable, threat: smallpox. Officials now admit that they are seeking to buy enough smallpox vaccines to inoculate all 260 million Americans.

The US Health Secretary, Tommy Thompson, is holding talks with several leading pharmaceutical companies about delivering 300 million doses of the vaccine within nine months. That would mean having a vaccine ready for everyone in the country.

There is still intense debate over whether so comprehensive an approach is necessary. The last naturally occurring case of smallpox was recorded in Somalia in 1977. The World Health Organisation declared the disease officially defeated three years later. And smallpox, a highly infectious illness that is fatal for three in 10 people who catch it, has not been seen in the US since 1949.

The White House is anxious not to spread panic about smallpox – for centuries it was one of the most potent of scourges to afflict the human species. Americans, after all, are already edgy about the anthrax scare that is still unfolding. Officials have said nothing about receiving any concrete intelligence to suggest that a terrorist attack involving smallpox may be imminent.

Politically, however, nobody wants to be unprepared in case someone does acquire the virus and unleashes it successfully in a major city. Possible ways this could happen would include releasing it in mist form in a crowded place, such as a stadium, or sending an infected suicide terrorist out into the general population.

"I think the American people will feel much more comfortable knowing they have their name on a vaccine shot in our inventory," Mr Thompson said in an interview with The New York Times yesterday. "It's the security of knowing you have enough for every American."

The US has about 15 million doses for civilian use. Plans to expand that supply were in fact already on the table long before 11 September, when terrorists targeted the World Trade Centre and the Pentagon. Last year, the US government awarded a contract to a little-known British firm, Acambis, to manufacture an additional 40 million doses at a cost of $343m (£241m) for delivery in 2002.

After 11 September attitudes changed quickly. Dick Cheney, the Vice-president, accepted the need to acquire doses for every US citizen after watching a research video made at Johns Hopkins University in Maryland. Called Dark Winter, it spelled out how devastating a smallpox outbreak would be. President George Bush signed up to the vaccine idea on 4 October, the day a man in Florida was diagnosed with anthrax.

One adviser to Mr Thompson is Dr Donald Henderson. Attached to Johns Hopkins and one of those who brought Dark Winter to the attention of the White House, he is one of only a few American doctors with first-hand knowledge of smallpox. "After Dark Winter there was a spate of briefings, so that a whole lot of people suddenly began to realise just how serious an epidemic this sort could be," he said.

Dr Henderson stresses that it is not at all easy to disperse smallpox. It could not, for example, be sent in powder form in envelopes as has been happening in America with anthrax. It would have to be puffed into the air rather like an aerosol. Nor he does take very seriously the idea of an infected terrorist wandering the streets of New York, because they would be too debilitated to go anywhere.

On other hand smallpox, while harder to handle than anthrax, poses a more frightening threat. It is relatively easy to isolate the cases of anthrax when they appear and victims can usually be helped with antibiotics. Smallpox is a virus and can very quickly be spread from person to person. People who catch it first notice severe flu-like symptoms, including a high temperature, a severe headache and an aching back. Later a flat rash develops, particularly on the face, arms and legs, that quickly erupts into scores of round pustules. Those who survive often live with horrible scarring.

"It is the lion king of infectious diseases," said Michael Osterholm of the Centre for Infectious Disease Research at the University of Minnesota. "Once it were to get into that population, it would not only take hold, but its ability to be transmitted on to additional generations with large increases in numbers of each of those generations is a very real possibility."

In theory, there should be no cause for worry. After the WHO declared that smallpox was no longer a threat, it was agreed that remaining research stocks would be sent to two repositories, one at the Centres for Disease Control in Atlanta and another in Russia. No one else was permitted to store it. There have always been suspicions, however, that smallpox might have since fallen into the wrong hands.

Those fears were first confirmed back in 1989 when a top Russian biologist, Vladimir Pasechnik, defected to Britain and described the extent to which Moscow had been secretly diverting smallpox for military use. The aim was to put the smallpox virus into warheads of cruise missiles.

It is now thought possible that disaffected scientists who were involved in those secret Russian programmes may have sold their knowledge and expertise to rogue governments, notably Iraq or North Korea. They might likewise have sold themselves to terrorist groups.

Like most industrialised countries, America ceased giving routine smallpox vaccinations to young children in the early Seventies. There is no scientific certainty whether the doses given to older generations of Americans will still be effective. Most experts fear the vaccines, which contain a virus similar to smallpox, will have worn off by now. Thus everyone would have to be vaccinated.

At the weekend, the WHO suggested other countries should also examine their state of readiness for a possible smallpox attack. So far, there is no sign that the US government is preparing to vaccinate the whole country preventatively. Instead, the vaccines would be made available from the stockpile, which would be held at a number of secret locations, only once cases of the disease have been detected.

This is partly because the vaccine itself is not risk-free. Roughly one in a thousand people can have serious adverse reactions to it. Emphysema is one recorded side-effect, for example. Moreover, the rates of those reacting badly may be much higher that in previous generations because of the existence of Aids. Giving the vaccine can be particularly risky for anyone suffering from a weakened immune system.

That consideration has created an additional problem: the medicine needed as an antidote in the event of anyone responding badly to the smallpox vaccine is also in extremely scarce supply. The US government is also contacting pharmaceutical companies about manufacturing that drug.