http://www.nytimes.com/2001/10/22/national/22RISK.html

October 22, 2001

THE RISKS

'Cure' for Bioterror May Be Worse Than the Disease

By GINA KOLATA

number of health officials and experts are warning that steps being taken by the government and members of the public in response to threats of bioterrorism carry health risks that may far exceed their benefits.

These experts are focusing on two developments: the rising interest in powerful antibiotics to counter anthrax and the possibility of renewing mass vaccinations for smallpox.

Antibiotics and vaccines, like all medicines, can have harmful side effects, the experts say. In addition, the soaring sales of Cipro — a powerful antibiotic widely if erroneously believed to be the only effective drug against anthrax — raise the prospect that if large numbers of people start taking it, anthrax and other far more common bacteria will become resistant to it.

"Our big problem is not bioterrorism," said Dr. Lucy Shapiro, a microbiologist who heads the Arnold and Mabel Beckman Center for Molecular and Genetic Medicine at Stanford University. "It's our response that's going to lead to a big jump in antibiotic resistance. That's the terror."

The smallpox question arose last week, when the federal government announced that it planned to stockpile 300 million doses of smallpox vaccine, enough to immunize everyone in the country. "Sometime in the future there may be a discussion that may lead to voluntary vaccination for the smallpox bug," said Tommy G. Thompson, the secretary of health and human services.

But some public health experts question the wisdom of vaccinating Americans in the absence of any cases of smallpox anywhere in the world. As with antibiotics for anthrax, they say, in the event of a smallpox outbreak there should be time to get the vaccine to most people who were exposed.

Dr. Jonathan B. Tucker, a bioterrorism expert at the Washington office of the Monterey Institute of International Studies and the author of "Scourge: The Once and Future Threat of Smallpox" (Atlantic Monthly Press, 2001), said the vaccine could prevent the disease from spreading to those who came in contact with an infected person, providing substantial immunity 10 days after vaccination.

"Even within five days, while there is some risk of disease, it probably will not be life- threatening," Dr. Tucker said. "That means there is somewhat less of an imperative to vaccinate prophylactically."

In the absence of disease, it does not make sense to reinstitute vaccinations, he said.

"Given that this is a live virus vaccine, there is a small but significant risk of serious complications," Dr. Tucker said, adding that one in a million who were vaccinated in the 1960's died or had brain damage. The vaccine can cause severe infections in one of 18,000, with the virus spreading throughout the body.

Routine vaccinations against smallpox were discontinued in the United States in 1972, when the disease had been virtually eradicated worldwide. A new vaccine would be made with more modern methods. Nevertheless, experts caution that some side effects are inevitable.

Dr. Tucker noted that a recently vaccinated person can spread the virus to others, possibly making them ill. This was one reason the Pentagon stopped vaccinating troops for smallpox, he said, adding, "They would have to quarantine those who were vaccinated so they wouldn't spread the virus to their families."

As for anthrax, some health experts point out that only a handful of people have developed the disease, with one death so far, and a few dozen more have tested positive for exposure to anthrax spores.

"What we're seeing now, in the big picture of a public health impact is relatively minor," said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases. "It's high on terror and low on impact."

Health experts say they know firsthand how terror can make even the most rational person reach for a bottle of Cipro. But they say that makes it all the more important to spread a temperate message.

"I was in the ABC and CBS newsrooms on Wednesday," said Dr. Allan Rosenfield, the dean of the Mailman School of Public Health at Columbia University. "On Thursday night, I came down with a sore throat and a fever."

Anthrax infections have been found in a CBS News employee and in an ABC producer's baby. Dr. Rosenfield could not help thinking of the disease, and he could not help being tempted to start taking Cipro. But "I didn't take anything," he said. "I was proud of myself."

The next day, Dr. Rosenfield said, he had a few qualms. "I said, `If I made a mistake, I'm dead.' " He has now recovered. He does not have anthrax.

Dr. Shapiro, the Stanford microbiologist, acknowledges that she was shaken by the terrorist attacks. "I'm scared," she said, but added that she, too, was not taking antibiotics.

"They don't have to kill us with anthrax," Dr. Shapiro said, referring to the prospect that diseases might develop a resistance to antibiotics. "They can just change the whole flora and fauna of our pathogen world. This is about the worst thing that can happen in our war on bugs."

Then there is the problem of antibiotic side effects. These can vary from nausea and diarrhea to much more serious medical conditions.

"Antibiotics are justified to treat infections," said Dr. Timothy T. Flaherty, who is chairman of the board of trustees of the American Medical Association. "But without infections, all you're left with are side effects."

Some public health experts warned against hasty reactions to the terrorist threat.

Jerome M. Hauer, a former director of New York City's Office of Emergency Management who advises Mr. Thompson on bioterrorism, added his own word of caution when it came to smallpox. "I think you've got to be careful," Mr. Hauer said, "about public pressure pushing you into medical decisions that could at the end of the day be harmful."

ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.