Faculty Bibliography

Mr. [Tommy G. Thompson] oversees the Centers for Disease Control and Prevention in Atlanta, which has acknowledged its failure to prepare adequately to communicate during the anthrax outbreak. In the first days of the outbreak, C.D.C. did not take the leadership in providing vital medical and epidemiologic facts to state health departments, practicing physicians and the public. Spokesmen for the centers said the information was supposed to come from Mr. Thompson's office. Much of Friday's briefing centered on clarifying the options and what officials had recommended to Mr. Thompson and President Bush. But before reporters could question Dr. [Julie L. Gerberding] about this unexpected news development, she suddenly left the stage, leaving two participants, Jerome M. Hauer, an assistant secretary of health and human services and director of the department's Office of Public Health Preparedness, and Dr. Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Diseases, to field the questions. Also, reporters entering the auditorium at Mr. Thompson's headquarters on Friday afternoon passed packets about smallpox stacked on a table. The reporters were not allowed to take them until they were distributed after the news briefing began. So reporters were deprived of an opportunity to inform themselves before asking questions. But, as it turned out, the packets contained little new information and no summary of the messages the top officials were trying to make in the briefing

The question arose over the weekend after President Bush announced a plan to vaccinate about 10 million health care and emergency workers with smallpox vaccine, which contains a live virus that is closely related to the one that causes smallpox. Smallpox vaccination differs from other immunizations because recipients can accidentally transmit vaccinia, the virus in the vaccine, to others, in effect involuntarily vaccinating them and putting some at risk of life-threatening complications. General recommendations are that people who have recently been vaccinated stay out of close contact with others or cover the vaccine site with a bandage, because the virus can be shed from the site for several weeks after inoculation. Some hospital officials say that newly vaccinated workers who take care of patients will be required to wear special semipermeable bandages at work, because they are better than gauze at containing the virus. If secretions from a smallpox vaccination soak into clothing or blankets, the vaccinia virus may survive in the fabric for a day or two and could theoretically infect someone else who comes into contact with the item, said Dr. Donald A. Henderson, the epidemiologist who led the global smallpox eradication program and who now is a senior science adviser to Mr. [Tommy G. Thompson]

Since then, the vaccine has been given only to a few thousand qualified scientists who work with the smallpox virus and the vaccine, which is made from a closely related live virus, under top security precautions in approved laboratories. After eradication, the former Soviet Union and the United States were allowed to keep stores of the smallpox virus for research, one in Russia and one at the disease control agency in Atlanta. Original plans called for destroying the stores of the virus, but they have been deferred, largely because of disclosures that the former Soviet Union secretly weaponized smallpox virus. Smallpox vaccine is the most dangerous human immunization. Before the United States stopped routine smallpox vaccinations, life-threatening complications occurred at a rate of 15 per million among those who received their first smallpox vaccination, and the number included about one to two deaths

Under one possible scenario, the vaccine could simply be kept from the public until it is licensed, which is expected in 2004. Under another, people could apply for the vaccine under the 'investigational new drug' rules of the Food and Drug Administration. Under the new drug, or IND, rules, people who make a compelling case that they need experimental medicines can be given permission to take them by the FDA. But the process is cumbersome, and it is unclear how easily smallpox vaccine could be obtained if the president chose to make it available this way. Existing stockpiles of the vaccine, which are decades old and are not currently licensed by the government for use, will be kept for use only if there were an attack before the new vaccine was available. There is enough of the old vaccine on hand to inoculate all Americans, administration officials said. Smallpox vaccine is the most dangerous human immunization. Before the United States stopped routine smallpox vaccinations, life- threatening complications occurred at a rate of 15 per million among those who received their first smallpox vaccination, and the number included about one to two deaths

There were no heart attacks or deaths among the 200 participants in the study, because they had implanted defibrillators, which monitor heart rhythms and deliver electric shocks to restore normal heartbeat when they detect life-threatening abnormalities. Two of the authors -- Dr. Jonathan S. Steinberg, chief of cardiology at St. Luke's-Roosevelt Hospital in Manhattan, and Dr. Marcin Kowalski, a resident at St. Luke's -- said the findings documented persistence of increased psychological stress after Sept. 11 and showed compelling evidence of its effects on the heart. The researchers scrutinized the electrocardiograms stored in the device for evidence of two life-threatening abnormal rhythms -- ventricular tachycardia and ventricular fibrillation. The device is programmed to deliver a shock when either of these rhythms develops. (The researchers did not study the rate of arrhythmias that were not life threatening.)

Cangene, by contrast, has a bigger contract but a less urgent time frame. It is to produce up to 100,000 doses for the United States civilian population over five years. Lacking a pool of frozen plasma, it is seeking about 10,000 volunteers like Mr. [Michael Kuring] to be inoculated for smallpox and then bled twice a week for two months. Plasma is spun off their blood and their red cells are returned to them. Each is paid $100 a week, but four donors interviewed in Marietta said money was not a factor. Mr. Kuring, Ralph McKinstry, Albert Casanova, all veterans, and Kathy Eagye, who has a master's degree in public health, said they wanted to help protect others. Ms. Eagye, however, did confess that she so feared a smallpox attack that she volunteered partly to get revaccinated. Ralph McKinstry, recently immunized for smallpox, gives blood to help create a treatment for people who have serious reactions to the vaccine. (Photographs by Erik S. Lesser for The New York Times)(pg. F1); Jacke Grayson, left, gives a smallpox vaccine to Karl Fivecoat, who has provided blood to help create an antidote to the vaccine's side effects. (Erik S. Lesser for The New York Times)(pg. F2)

Federal health officials had recommended a 60-day course of an antibiotic for more than 9,300 workers who were exposed to anthrax spores in four states and the District of Columbia in 2001. In making their recommendation, officials had to weigh the benefit of preventing cases of anthrax and the risks of side effects from the drugs themselves. [Colin W. Shepard] said that his team was confident that antibiotic prophylaxis had prevented some cases of anthrax among those exposed to the letter sent to Sen. Tom Daschle, the majority leader, because of the heavy exposure of spores in the Senate and the Brentwood postal processing center in Washington. The antibiotics available to the exposed workers were Ciprofloxacin, Doxycycline and Amoxicillin, licensed drugs that the government distributed free of charge to workers. Ciprofloxacin was the drug used most often in the initial days of the anthrax attacks. It can cause convulsions as well as other adverse effects on the brain and central nervous system

Federal health officials had recommended a 60-day course of an antibiotic for more than 9,300 workers who were exposed to anthrax spores in four states and the District of Columbia in 2001. In making their recommendation, officials had to weigh the benefit of preventing cases of anthrax and the risks of side effects from the drugs themselves. Dr. [Colin W. Shepard] said that his team was confident that antibiotic prophylaxis had prevented some cases of anthrax among those exposed to the letter sent to Senator Tom Daschle, the majority leader, because of the heavy exposure of spores in the Senate and the Brentwood postal processing center in Washington. The antibiotics available to the exposed workers were Ciprofloxacin, Doxycycline and Amoxicillin, licensed drugs that the government distributed free of charge to workers. Ciprofloxacin was the drug used most often in the initial days of the anthrax attacks. It can cause convulsions as well as other adverse effects on the brain and central nervous system, and also lead to rupturing of the Achilles tendon and others

''We'd have no difficulty recognizing'' the chemical and providing the appropriate care, Dr. [Lewis R. Goldfrank] said. But the Moscow disaster and a theoretical attack on this country differ in crucial ways. If the agent is a narcotic like fentanyl or heroin, victims will probably be calm, their pupils pinpoint size, their breathing and heart rates slow and their blood pressures low. Other types of drugs could produce opposite symptoms. If it is scopolamine, an anti-motion sickness drug that robbers have used to incapacitate victims, people may be delirious. While treatment progresses, toxicologists will use laboratory tests to try to quickly identify the chemical used in the attack. All major cities have equipment to identify or rule out certain classes of chemicals. Many hazardous materials teams carry mass spectrometers and other analytical tools that can screen a large number of chemicals and provide specific identification of an agent, said Jerome M. Hauer, who directs the Office of Public Health Preparedness in the Department of Health and Human Services

The network will also be used to determine who will get the scarce and dangerous drugs needed to treat complications of the smallpox vaccine, and when, said Dr. Gina Mootrey, another official at the centers, in announcing the monitoring plan to a panel advising the government on smallpox vaccinations. The panel also recommended not giving smallpox vaccine to anyone who has a family or household member with either skin condition because the virus in the vaccine could be transmitted to them. The other is cidofovir, a drug that experts hope might be effective against vaccinia, the virus in the vaccine that protects against smallpox. Cidofovir must be injected, is dangerous and its only approved use is for a different virus