Editorial: The rise and fall of bioterrorism research

The Lancet Infectious Disease
Jun 2012  Volume 12  Number 6  p423 – 496

The rise and fall of bioterrorism research
The Lancet Infectious Diseases

In the months after the September 11, 2001, attacks in New York, USA, the world was on heightened awareness for terrorist attacks of all kind. The anthrax scares in the USA in the final months of that year led to a focus on bioterrorism. A decade ago this threat was viewed as one of the key areas for infectious disease research: the topic dominated the agendas at academic and clinical conferences at the time, and governments devised plans to address the threat of bioterrorism, often involving substantial investments in research. But a decade on, are we any more prepared for bioterrorist attacks, and what have we gained from the huge resources invested in the research?

Bioterrorism is defined by the US Centers for Diseases Control and Prevention as “the deliberate release of viruses, bacteria, toxins or other harmful agents used to cause illness or death in people, animals, or plants”; although this clearly leads to a murky distinction from biological warfare, and research into both goes hand in hand. Attempts in the early 20th century to weaponise biological agents quickly led to the realisation of the potency of such tactics as terrorist devices. And an arms race developed with governments simultaneously aiming to produce weapons with these agents and the countermeasures to use when faced with their deployment.

Despite a long history of research, the use of biological weapons in warfare and terrorism has been uncommon: the major downsides to their use are their lack of specificity and an inability to contain an infection within a target population. An infectious agent used against one group will almost inevitably infect unintended victims, even those who originally deployed the weapon.

However, in the late 20th century the face of terrorism changed, from one of targeted attacks to the use of indiscriminate tactics, in which the collateral damage of deaths on the aggressor’s side was accepted. In the late 1990s, the threat of bioterrorism was generating serious interest. The topic was a key theme at the 1998 International Conference on Emerging Infectious Diseases, at which experts warned that the growing interest in and proliferation of biological weapons was not being matched by investment in research to counter the effects of such attacks. But the watershed moment was the 9/11 attacks on New York.

The following year, the World Health Assembly agreed that a concerted effort to address bioterrorism was needed. One of their acts was to drop the 2002 deadline for the destruction of smallpox virus stocks. The USA established several initiatives to address potential bioterrorist threats. Among them, the National Institutes of Health launched the National Science Advisory Board for Biosecurity (NSABB) to monitor potential dual-use research and the Department of Defense launched the Transformational Medical Technologies Initiative (TMTI), a US$1·5 billion initiative to sequence the genomes of key microorganisms with bioterrorism potential and to develop one-size-fits-all measures against them.

For all the international concern and efforts to prepare, there has been no major bioterrorist attack. The TMTI has introduced no new antibiotics into clinical trials, the three drugs that have entered clinical trials are for single pathogens rather than providing multifaceted solutions, and now many of its projects have been redistributed to other defence departments. The NSABB has assessed just six papers. Furthermore, bioterrorism has dropped off the programmes of scientific conferences.

Nonetheless, the fear is still present, even if the threat has not materialised. In this month’s Newsdesk, Kathryn Senior discusses two recent bioterrorism scares involving Bacillus anthracis spores, and the case of research in which investigators generated strains of H5N1 transmissible between mammals spawned much debate about dual-use research—as well as providing the NSABB with two of the six papers.

Groups that would willingly instigate a major bioterrorism attack undoubtedly exist. The consequences of widespread dissemination of anthrax spores or a haemorrhagic fever virus such as Ebola, or release of an engineered highly infective and highly pathogenic influenza are almost too dire to contemplate. However, bioterrorism research is perhaps a diversion—resources invested in combating bioterrorist threats would be well invested in research into the real and present damage of these pathogens in nature. Such research need not be viewed as a separate effort, but a much needed integrated effort in biodefence, since undoubtedly it would provide vital information, vaccines, and drugs for the fight against bioterrorism as well as combating natural infections.

Correspondence: Poliovirus eradication

The Lancet Infectious Disease
Jun 2012  Volume 12  Number 6  p423 – 496

Poliovirus eradication
Carlos Franco-Paredes
Preview |
Your Editorial in the October, 2011, issue covers the theme of polio eradication. Everyone that has a scientific or humanitarian interest in achieving the noble task of eliminating poliomyelitis remains confident that it is an attainable public-health goal in the near future. There is also an agreement that eradication should be a global effort that requires increased financial and political support. However, polio eradication efforts may be at risk of losing political and financial momentum in view of the persistent failures of the Global Polio Eradication Initiative (GPEI) and its inability to consistently reach target dates.

Poliovirus eradication
Masahiko Hachiya, Shinsaku Sakurada, Tomomi Mizuno, Yasuo Sugiura
Preview |
The Editorial,1 in the October, 2011, issue of The Lancet Infectious Diseases discusses innovations for polio eradication. We agree that social factors are one of the most important barriers to a polio eradication initiative. The essential problem is that the Global Polio Eradication Initiative (GPEI) is not consistent with current local priorities. Moreover, the Ministry of Health in Pakistan was devolved, and the relevant federal programme disappeared in June, 2011. Therefore, local governments take more responsibility for immunisation programmes than before.

Ethical dimensions of vaccines against substance abuse

Nature Immunology
June 2012 – Vol 13 No 6

Immune to addiction: the ethical dimensions of vaccines against substance abuse – pp521 – 524
Michael J Young, Dominic A Sisti, Hila Rimon-Greenspan, Jason L Schwartz & Arthur L Caplan

Promising advances have been made in recent years for a unique class of immunotherapies that use vaccination to combat substance-use disorders. Although such vaccines are potentially useful for addictions, they raise a variety of ethical and social questions.

Rationing, Fruglaity, Ethics

New England Journal of Medicine
May 24, 2012  Vol. 366 No. 21

From an Ethics of Rationing to an Ethics of Waste Avoidance
H. Brody
Extract [Free full text]
Bioethics has long approached cost containment under the heading of “allocation of scarce resources.” Having thus named the nail, bioethics has whacked away at it with the theoretical hammer of distributive justice. But in the United States, ethical debate is now shifting from rationing to the avoidance of waste. This little-noticed shift has important policy implications…

Beyond the “R Word”? Medicine’s New Frugality
M.G. Bloche
Extract [Free full text]
Quietly, Washington policymakers have begun to concede the need to weigh health care’s benefits against its costs if our country is to avert fiscal ruin. That costs must be counted against benefits is common sense in other domains — and among health policy professionals. But it’s anathema in public discussion of medical care. To silence talk of tradeoffs, politicians invoke the “R word” — rationing…

Low Childhood Immunisation Coverage in Sub-Saharan Africa: A Multilevel Analysis

PLoS One
[Accessed 26 May 2012]

Individual and Contextual Factors Associated with Low Childhood Immunisation Coverage in Sub-Saharan Africa: A Multilevel Analysis
Charles S. Wiysonge, Olalekan A. Uthman, Peter M. Ndumbe, Gregory D. Hussey 5 Gregory D. Hussey 1 2 1 Vaccines for Africa … -pertussis vaccine by one year of age. An evidence-based … to 145 over the same period. Vaccine-preventable PLoS ONE: Research Article, published 25 May 2012 10.1371/journal.pone.0037905

In 2010, more than six million children in sub-Saharan Africa did not receive the full series of three doses of the diphtheria-tetanus-pertussis vaccine by one year of age. An evidence-based approach to addressing this burden of un-immunised children requires accurate knowledge of the underlying factors. We therefore developed and tested a model of childhood immunisation that includes individual, community and country-level characteristics.

Method and Findings
We conducted multilevel logistic regression analysis of Demographic and Health Survey data for 27,094 children aged 12–23 months, nested within 8,546 communities from 24 countries in sub-Saharan Africa. According to the intra-country and intra-community correlation coefficient implied by the estimated intercept component variance, 21% and 32% of the variance in unimmunised children were attributable to country- and community-level factors respectively. Children born to mothers (OR 1.35, 95%CI 1.18 to 1.53) and fathers (OR 1.13, 95%CI 1.12 to 1.40) with no formal education were more likely to be unimmunised than those born to parents with secondary or higher education. Children from the poorest households were 36% more likely to be unimmunised than counterparts from the richest households. Maternal access to media significantly reduced the odds of children being unimmunised (OR 0.94, 95%CI 0.94 to 0.99). Mothers with health seeking behaviours were less likely to have unimmunised children (OR 0.56, 95%CI 0.54 to 0.58). However, children from urban areas (OR 1.12, 95% CI 1.01 to 1.23), communities with high illiteracy rates (OR 1.13, 95% CI 1.05 to 1.23), and countries with high fertility rates (OR 4.43, 95% CI 1.04 to 18.92) were more likely to be unimmunised.

We found that individual and contextual factors were associated with childhood immunisation, suggesting that public health programmes designed to improve coverage of childhood immunisation should address people, and the communities and societies in which they live.

Nosocomial transmission of measles: An updated review

Volume 30, Issue 27 pp. 3983-4122 (8 June 2012)

Nosocomial transmission of measles: An updated review
Review Article
Pages 3996-4001
E. Botelho-Nevers, P. Gautret, R. Biellik, P. Brouqui

Despite a decrease in global incidence, measles outbreaks continue to occur in developed countries as a result of suboptimal vaccine coverage. Currently, an important mode of measles transmission appears to be nosocomial, especially in countries where measles is largely under control. We therefore conducted a review of the literature by searching PubMed for the term “measles” plus either “nosocomial” or “hospital acquired” between 1997 (the date of the last review in the field) and 2011. The reports indicate that measles is being transmitted from patients to health care workers (HCWs) and from HCWs to patients and colleagues. Here, we explain how outbreaks of measles occurring in healthcare settings differ in some ways from cases of community transmission. We also highlight the need for all HCWs to be immunized against measles.

2009 H1N1 influenza vaccination among day care-aged children, Miami-Dade County, Florida, US

Volume 30, Issue 27 pp. 3983-4122 (8 June 2012)

Regular Papers
Correlates of 2009 H1N1 influenza vaccination among day care-aged children, Miami-Dade County
Original Research Article
Pages 4002-4006
Yessica Gomez, Fermin Leguen, Guoyan Zhang, Erin O’Conne

The aim of this study was to assess factors influencing 2009 H1N1 influenza vaccination among a demographically diverse group of day care-aged children. Day care children were chosen because they were an initial target group for vaccination and are at higher risk of influenza infection than children cared for at home.

A cross-sectional study was conducted from March to May 2010 among parents of day care aged children in 13 day care facilities in Miami-Dade County. Data was collected by an anonymous self-administered two-page 20 question survey which consisted of demographic variables and information regarding 2009 H1N1 influenza vaccine knowledge, attitude and acceptance. Data was analyzed using SAS to conduct both bivariate and multivariate analyses.

There were 773 participants in the study. The response rate ranged from 42% to 72.2% among day care centers. A total of 172 parents (22.3%) and 225 (29.1%) children had received the 2009 H1N1 influenza vaccine. Non-Hispanic White and Black parents were more likely to vaccinate their children than Hispanic and Haitian parents. Primary reasons for non-vaccination included vaccine safety (36.7%) and side effects (27.1%). Among parents who spoke with a health care professional, 274 (61.4%) stated the health care professional recommended the vaccine.

Misperceptions about influenza vaccination among parents created a barrier to 2009 H1N1 influenza vaccination. Parents who got the vaccine, who believed the vaccine was safe and whose children had a chronic condition were more likely to immunize their children. Clear, reliable and consistent vaccine information to the public and health care providers and initiatives targeting minority groups may increase vaccination coverage among this population.