Volume 23, No. 2 - June 1998            Published by the National Foundation for Infectious Diseases

Health experts painted a bleak future this spring with predictions of biological terrorist attacks and life-threatening diseases caused by antibiotic-resistant microbes. The proliferation of biological weapons technology and resistant bacteria, along with lack of physician education and inadequate preparedness, all represent threats to global health. These warnings came from health officials speaking at an April news conference in Washington, DC, sponsored by the National Foundation for Infectious Diseases (NFID).

According to Michael T. Osterholm, PhD, MPH, state epidemiologist and chief, Acute Disease Epidemiology Section, Minnesota Department of Health, "It is likely that a biological terrorism disaster will occur in the United States in the near future," and "we will be ill-prepared." His concern lies with recent world events, such as the break-up of the former Soviet Union, the perceived dominance of the United States as the leading world power, and the rise of international extremist groups.

Dr. Osterholm was one of several infectious disease experts speaking to journalists at the third Richard J. Duma/NFID Annual Press Conference and Symposium on Infectious Diseases held on April 14, 1998, in Washington, DC. NFID conducts the annual press conference, named to honor former NFID President and Executive Director Richard J. Duma, MD, PhD, in support of its mission of educating the public about infectious diseases.

William J. Martone, MD, NFID's senior executive director, cited the importance of the annual press conference: "Through an educated public, we can effectively apply and utilize the wealth of prevention tools we have at our disposal."

Speakers at the press conference focused on such issues as biological terrorism, drug-resistant bacteria, hospital infection control standards, flu epidemics and outbreaks, and creative vaccination techniques.

Dr. Osterholm continued his discussion of potential biological weapons by saying, "Diseases such as anthrax, smallpox, plague, botulism, and viral hemorrhagic fevers are the most likely candidates for biological terrorism." Such diseases, he explained, are inexpensive, easy to produce and disperse, able to withstand the elements, and are capable of producing a deadly disease that has limited treatment available.

Dr. Osterholm expressed concern that in the event of this type of attack, the United States and other countries will not be properly prepared. "For example," he said, "today we have inadequate supplies of smallpox and anthrax vaccines for civilian use, and there are no current efforts to improve upon this situation." In addition, he said the current federal legislation is "seriously lacking" in this area, and he warned that in the event of an attack, health care providers will be overwhelmed.

"It's not a matter of if; it's a matter of when," warned Dr. Osterholm. He recommended several ways to improve our preparedness: enhance both national and international surveillance methods, maintain expertise in rare diseases, strengthen the infectious diseases infrastructure, stockpile antibiotics, prepare vaccines, maintain medical relief teams, and improve federal legislation.

Staphylococcus aureus, a bacteria which is a common cause of both community- and hospital-acquired infections, has become resistant to several antibiotics used to treat it in the last decade, said William R. Jarvis, MD, acting director of the Hospital Infections Program at the Centers for Disease Control and Prevention (CDC). Vancomycin, known as the antibiotic of last resort, has been used in many cases to treat drug-resistant strains of S. aureus. "This led to increasing concern that vancomycin- or glycopeptide-resistant S. aureus would emerge-an organism, which if it were resistant to other commonly used agents, would be virtually untreatable," he said.

However, Dr. Jarvis added that the spread of antimicrobial-resistant pathogens is "secondary to both overuse and misuse of antimicrobials and incomplete compliance with recommended infection control precautions." Studies have indicated that up to 63 percent of vancomycin use is inappropriate.

According to Dr. Jarvis, "The bacteria are very smart." By learning how the antibiotics work, the bacteria find a way around them.

Dr. Jarvis warned that it is only a matter of time before S. aureus fully-resistant to vancomycin, will emerge. His views were echoed by William E. Scheckler, MD, hospital epidemiologist, St. Mary's Hospital Medical Center and professor, Department of Family Medicine at the University of Wisconsin Medical School: "Despite monitoring and containment activities, vancomycin-resistant S. aureus clusters will occur and will be associated with both geographic dispersal and patient death."

To help reduce this risk as well as the risk of other antimicrobial resistance, CDC has published recommendations for the appropriate use of vancomycin. Keys to preventing further emergence of vancomycin-resistant S. aureus include enhanced laboratory methods in identifying resistant strains, active surveillance for these types of infections, and use of proper infection control procedures once patients have been identified.

Concern about decreasing resources available to hospital infection control personnel has forced health care societies and organizations to establish standards for hospital infection control infrastructure. Dr. Scheckler announced the recommendations of a consensus panel report that he hopes all US hospitals will adopt.

Alfred S. Buck, MD, executive vice president, Division of Measurement and Research, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and one of the co-authors of the report, expects JCAHO to evaluate this report for possible incorporation into hospital accrediting standards. "This report summarizes an unprecedented effort to produce a set of recommendations that are evidence-based and comprehensive-arrayed in a fashion consistent with expert opinion and experience," said Dr. Buck.

The recommendations fall into eight categories: managing critical data and information; setting and recommending policies and procedures; compliance with regulations, guidelines and accreditation requirements; employee health; direct intervention to prevent transmission of infectious diseases; education and training of health care workers; personnel resources; and nonpersonnel resources.

The report, "Requirements for Infrastructure and Essential Activities of Infection Control and Epidemiology in Hospitals: A Consensus Panel Report," was published in the February 1998 issue of Infection Control and Hospital Epidemiology.

According to Nancy J. Cox, PhD, chief, Influenza Branch and director, WHO Collaborating Center for Influenza Reference and Research at the CDC, influenza A (H5N1) (or the avian flu), which occurred in Hong Kong this past winter, infected 18 people. "The emergence of the influenza A (H5N1) viruses in humans was an alarm bell for the entire world," said Dr. Cox. She said that although this virus appears to be contained, the possibility remains that this type or similar type of flu strain could appear and be detected in more locations, including the United States.

Dr. Cox discussed studies conducted during the Hong Kong investigation and outlined several key issues. She stressed that we must continue surveillance of these types of flu and improve our readiness for the next pandemic of influenza. "We must remain vigilant because the next influenza pandemic could strike at any time, even if influenza A (H5N1) viruses are contained," she said. Dr. Cox is hopeful that by understanding the reasons for each outbreak, we will be better able to implement the most effective control measures possible given a particular situation.

Challenges for influenza prevention and control include optimizing national and international collaboration for the early detection of new flu strains so that the new strains may be included in the vaccine.

Influenza, or flu, is caused by viruses that infect the respiratory tract and generally results in more severe illness than other respiratory infections. Severe flu epidemics in the United States have cost as much as $10 billion, causing as many as 40,000 deaths and 150,000 hospitalizations.

Much of the illness and death caused by influenza can be prevented by annual influenza vaccination," Dr. Cox said. Unfortunately, many people do not take advantage of this prevention measure, putting themselves at risk each year. High risk groups include all people over 65 years of age, people with chronic pulmonary and cardiovascular conditions, diabetes, immunosuppression, and severe forms of anemia. The vaccine also is recommended for residents of nursing homes and health care workers.

Can we finally throw away the needle and syringe? We may be getting closer, according to Bruce G. Weniger, MD, MPH, assistant chief for vaccine development, National Immunization Program at the CDC. CDC is studying creative ways to deliver vaccines.

Some of the new methods being considered are aerosol vaccines delivered as sprays through the nose, vaccines through skin contact, vaccine pills, and consumption of plants that contain vaccines. CDC is very interested in this research since more and more diseases are becoming vaccine-preventable, and health experts want to allay the "needle phobia" that many people face when going to the doctor.

For children up to 16 years of age, the national immunization schedule currently requires 14 vaccine injections, including as many as four injections in just one visit. "Many providers and parents, however, are reluctant to administer so many injections during a single visit because of the child's fear of needles and pain," Dr. Weniger said.

As a result, many vaccinations are missed or delayed, increasing the child's risk of developing disease. In addition, Dr. Weniger cited other drawbacks of using needles, such as unsterile reuse in developing countries, improper disposal, and needle stick injuries.

Because of the high number of injections that children face, health experts are looking for better ways to deliver new vaccines or improved methods to deliver existing vaccines. For example, Dr. Weniger said the new rotavirus vaccine to prevent infant diarrhea will be administered orally by drops, and the influenza vaccine sprayed into the nose appears promising. Additionally, steps are being taken to combine several existing vaccines into a single injection- much as the measles, mumps, and rubella vaccines have been combined.

The press conference and symposium was sponsored by NFID and was supported, in part, through unrestricted educational grants from Bayer Corporation, Glaxo Wellcome Inc., Pfizer Inc., Pharmacia & Upjohn, Inc., Rhône-Poulenc Rorer Inc., Roche Laboratories, and Zeneca Pharmaceuticals.

• Photos, factsheets, and press release from the press conference