Having identified 120 cities as the first-line potential targets for terrorist weapons of mass destruction, the U.S. federal government has dispatched a team of experts to "train the trainers." During the week of October 5, Tucson was the scene of various 8-hour programs, including the "Domestic Preparedness, Technician-Hospital Provider" course held at Tucson Medical Center. Three Tucson physicians and a few dozen emergency responders and hospital staff members attended.

The National Defense Authorization Act for 1997 includes Title XIV: Defense Against Weapons of Mass Destruction (WMD), Subtitle A: Domestic Preparedness. A plan to provide immediate response capability by the year 2000 is in progress. In the meantime, the Department of Defense does have a program for loaning chemical and biological defense equipment to civilian agencies. However, "personal protective equipment such as the mask or protective suit, if adapted for civilian use, would require National Institute for Occupational Safety and Health or National Fire Protection Association approval." Commercial protective equipment is in use at many locations. A testing program for such equipment was to begin in the last quarter of fiscal year 1997.

Biological agents of greatest threat to military personnel, according to the U.S. Army Medical Research Institute of Infectious Disease (USAMRIID) include the following: bacterial (anthrax, plague, tularemia, Q fever); viruses (smallpox, Venezuelan equine encephalitis, viral hemorrhagic fever); and toxins (botulinum toxin, staphylococcal enterotoxin B, ricin, and tricothecene mycotoxins).

Anthrax spores are easily disseminated in an aerosol. If 110 pounds of anthrax spores were sprayed along a 1.5 mile tract upwind from a city with population 500,000, about 24,000 persons would die. Iraq has tested this agent in various delivery systems, including rockets, aerial bombs, and spray tanks in aircraft. Inhaled anthrax causes a mediastinitis with sudden onset after an incubation period of one to six days and death in 24 to 36 hours. About half the patients also develop a hemorrhagic meningitis. Infection can also occur through the skin or gastrointestinal tract. Inhalational anthrax is not transmitted person to person, but the cutaneous form may be.

Treatment of severe mediastinitis is usually futile, but consists of intravenous ciprofloxacin (400 mg q 8 to 12 h) or doxycycline (100 mg IV q 12 h for 4 wks). Vaccine should be started simultaneously. (An FDA-licensed vaccine said to be available from the Michigan Dept. of Health.) For exposure, oral prophylaxis should begin immediately with ciprofloxacin (500 mg p.o. for 4 weeks) or doxycycline (100 mg p.o. q 12 hr for 4 weeks), until 3 doses of vaccine have been received. For children, penicillin or amoxicillin (20 to 40 mg/kg/day in divided doses tid to qid), although a genetically engineered strain might be resistant to penicillin.

Doxycycline is reasonably inexpensive and also effective in plague, tularemia, and Q fever, unless resistant strains are used.

Smallpox virus is said to be Russia's number one biologic weapon, and some Russian missiles may be carrying warheads loaded with it. Nearly the entire U.S. population is currently susceptible. The military discontinued vaccinating troops in 1983. In the past, smallpox had a 20 to 40% mortality rate in unvaccinated persons. Its contagiousness is one of its advantages as a BW agent.

There is no licensed antiviral against smallpox. The World Health Organization warehouses 20 million doses of vaccine. "It's kind of old, but we think it will work," stated course instructors. "They were going to get rid of it, but I think that's off now." Instructors were unable to answer the question of whether vaccine could be obtained to administer to hospital personnel at the present time. (Vaccine was formerly used to treat Herpes simplex by periodically boosting interferon levels, but has long been unavailable for such purposes.)

Russia has also allegedly weaponized the Ebola virus, the Marburg virus, or other viruses causing hemorrhagic fever, and may even have a genetically engineered combination virus called Ebolapox.

Noninfectious biological agents include botulinum toxin, ricin, and staphylococcal enterotoxin B. Such agents are up to 1,000 times more potent than standard chemical agents but may be more difficult to deploy as they are not volatile and generally not absorbed through the skin.

The U.S. military is testing an experimental Biological Integrated Detection System, which can be mounted on a vehicle and used to test air samples for biologic agents. There is also a Short-Range and Long-Range Standoff Detection System that uses lasers to detect aerosol clouds. The manual states that "the best way to minimize or prevent injury is to have a detection device available to the first responders at the scene to quickly identify the causative [biologic] agent." However, this technology "is not commercially available." Chemical detectors are also limited. Clinical observation is critical for both types of attack.

Clearly, in a CBW attack, local response teams, enhanced awareness, and self-protection by the population would be critical. Unless the nature of an incident is recognized and adequate protective gear is used, first responders are at grave risk of becoming casualties themselves.

The possibility of a nuclear incident is also recognized by the government. A presentation was given by one of four health physicists on constant call for the REACTS team, which has the ability to call on about 100 more. This instructor was apparently unaware that state and local authorities have no emergency radiation monitoring equipment. "Get them back," was his advice about the Geiger counters returned to FEMA. In the meantime, hospital nuclear medicine or radiation oncology departments would be the only resource for expertise and monitoring instruments.

The Domestic Preparedness kit has simplified, basic information on signs and symptoms caused by various radiation, chemical, or biologic exposures, along with an outline of suggested antidotes and antibiotics: your hospital should have a number of copies. However, it is evident that the federal government at the present time has no adequate stockpile of equipment or supplies for response and no obvious method of anticipating an attack before casualties arrive at the emergency room. The degree of denial as to the seriousness of the threat is the emphasis on controlling the media, abiding by OSHA regulations, and preventing lawsuits.

Members of the Pima County Medical Society who attended the training sessions have been asked to prepare shorter presentations for other physicians in Tucson. Plans are under development.

The 17th annual meeting will be held in Seattle on June 5-6 at the Marriott Hotel, Sea-Tac Airport. An optional tour of Boeing or a nuclear submarine base may be available on June 4 or June 7. Mark your calendar now!