“The anthrax attacks were a harbinger of public health challenges to come.”
- Maryn McKenna, senior writer, WIRED
“The failure to sustain public health readiness has had tragic consequences for the ongoing COVID-19 response.”
- Lawrence Gostin, JD, law professor, O’Neill Institute for National and Global Health Law, Georgetown University Law Center
During the course of my 45-year career as an infectious diseases physician, I’ve seen many infections emerge that were alarming, not the least of which is the ongoing COVID-19 pandemic. But the only infectious disease that struck me with terror was an act of bioterrorism—the anthrax attacks of October 2001. These attacks precipitated an unprecedented public health response, rivaled only by the present effort to stop the COVID-19 pandemic. In this Germ Gems post, I put anthrax in historical perspective—it ushered in the “germ theory of disease.” But sadly, the unlearning of the key lesson of the anthrax attacks—to prioritize public health preparedness—contributed to faulty preparedness in preventing the COVID-19 pandemic.
Synopsis of anthrax. Anthrax is an acute infectious disease that affects both humans and other animals that is caused by the bacterium Bacillus anthracis. It occupies a unique place in the history of microbiology and immunology. The German country doctor Robert Koch’s discovery of B. anthracis in 1876 launched the concept of the “germ theory of disease” and the field of medical bacteriology. And in 1881, the French scientist Louis Pasteur developed the first effective vaccine for anthrax. Pasteur’s research was foundational to the field of immunology.
Most forms of anthrax are lethal—its high mortality is one of the reasons that the disease captures so much attention. While it is now considered a rare disease, before the 20th century, anthrax infections killed hundreds of thousands of animals and people worldwide.
Key in the pathogenesis of B. anthracis is its production of endospores (called “spores” for short) that can survive harsh environments, such as frozen habitats in Antarctica. There they can linger for many decades, even centuries. When spores are inhaled, ingested, or come in contact with a skin lesion, they may reactivate and multiply rapidly. Dissemination of the bacilli throughout the body can involve the lungs, brain, and bloodstream. Soil-borne spores can infect wild and domesticated animals. Anthrax spores can also be produced in a laboratory for use as a biological weapon as happened in the anthrax attacks of 2001.
In addition to the 2001 bioterrorism anthrax attacks, there have been other notable anthrax outbreaks. These include: April 1979, Sverdlovsk, USSR where anthrax spores were accidently released from the Cold-war-era secret military facility (about 105 victims); October 2014, Simdega district, India, where people affected had contact with a dead, infected cow (7 deaths); July 2016, nomadic communities in Siberia, Russia where people encountered a thawing infected reindeer carcass (1 human death, 2,300 animal deaths).
Anthrax terrorist attacks of 2001. Memories of the fall of 2001 are indelibly imprinted in the brains of all adult Americans who witnessed the September 11 terrorist attacks on the World Trade Center and Pentagon by the extremist Islamic network al-Queda. Just seven days after these harrowing attacks, anonymous letters laced with B. anthracis spores began showing up at postal facilities, media companies, and congressional offices. The first death occurred on October 5, 2001 with an additional 4 deaths and 17 infections over the ensuing two months.
At first, it was thought that the perpetrators of these anthrax attacks were foreign terrorists. Then in 2008 the Federal Bureau of Investigation (FBI) linked the attacks to a scientist, Bruce Ivins, working at the U.S. Army Medical Research Institute of Infectious Diseases. Ivins committed suicide while the FBI was investigating him.
Having lived and worked during the immediate post-anthrax attack years, I can attest not only to the palpable terror but also to the improved coordinating and communication functions of public health, both at the state and federal levels. I agree, however, with the assessment of Dr. Ali Khan, dean of the College of Public Health at the University of Nebraska, who was quoted in an article in WIRED magazine last year titled, “20 Years After the Anthrax Attacks, We’re Still Unprepared.” “We’re much better prepared for a bioterror attack now,” Dr Khan states, “But we still remain woefully unprepared. We don’t have the public health practitioners and the information systems that we need.”
A similar assessment of the failed attempts to learn from the 2001 anthrax attacks can be found in an October 2021 article in the Journal of the American Medical Association by Georgetown University professor Lawrence Gostin, JD and Jennifer Nuzzo, Ph.D., Director of the Center for Pandemic Preparedness and Response at the Brown University School of Public Health, “Twenty Years After the Anthrax Terrorist Attacks: Lessons Learned and Unlearned for the COVID-19 Response.” They conclude, “It will be essential to understand why the US allowed its health capabilities to deteriorate and to identify a comprehensive strategy to end the vicious circle of panic to neglect.”
Anthrax treatment and control. The armamentarium to control anthrax contains antibiotics, such as ciprofloxacin, for treatment, and also a vaccine licensed for use in the U.S. by the Food and Drug Administration. The vaccine is given to people 18 through 65 years old at increased risk of exposure.
According to the Center for Disease Control and Prevention (CDC), the anthrax vaccine is effective at protecting most people from anthrax, including the most deadly form that can happen when someone breathes the bacterial spores into their lungs. To build up protection against anthrax, people need 5 doses of vaccine over a period of 18 months.
The CDC recommends anthrax vaccination to three key groups aged 18 to 65 years: laboratory workers who deal with anthrax; individuals working with animal products (veterinarians); and certain U.S. military or government personnel.
Can experience with the anthrax vaccine inform our understanding of long Covid? The routine vaccination of U.S. combat personnel with anthrax vaccine has been a highly contentious issue. Research carried out by University of Minnesota neuroscientist Apostolos Georgopoulos and his colleagues heightens concern about its use. These researchers found a robust association between a debilitating illness called Gulf War Illness (GWI) that afflicts approximately 200,000 Gulf War veterans, and exposure to PA63, an anthrax antigen that is in the vaccine. (See their article “Anthrax and Gulf War Illness (GWI): Evidence for the Presence of Harmful Anthrax Antigen PA63 in the Serum of Veterans with GWI,” in the November 25, 2019 issue of the Journal of Neurology & Neuromedicine.)
The clinical characteristics of patients with GWI are very similar, if not indistinguishable, from those suffering from “long Covid,” a debilitating illness that occurs in about 20% of those infected by SARS-CoV-2, the virus that causes COVID-19. As I’ve described in previous Germ Gems posts, including most recently on February 9, 2022, “Long Covid: Is the Fog Lifting?,” the pathophysiology of long Covid is unknown. The Georgopoulos research group hypothesizes that a component of SARS-CoV-2 behaves in a similar way to anthrax antigen PA63 in causing the disabling illness long Covid.
Because of my long-term research interest in the neuroimmunology of brain infections, I’m especially intrigued with the work of this research group. I’m sure we’ll be learning more from them and hope that if they’re hypothesis is supported by others, that this is one lesson of anthrax we don’t forget.
