The Irish Medicines Board has bought 600,000 doses of smallpox vaccine. But little else is being done to prepare for bioterrorism, writes Dr Muiris Houston, Medical Correspondent
The one that scares me to death, perhaps even more so than tactical nuclear weapons, and the one we have least capability against, is biological weapons
Gen Colin Powell
I will show you fear in a handful of dust
T.S. Eliot
'Terrorists release smallpox in the London Underground." A couple of years ago, this would have sounded like the summary of a thriller storyline. But this week the British government showed it was seriously preparing for just such a scenario.
And if covertly released across the Irish Sea, smallpox could spread to the Republic before the initial act of terrorism had become apparent. Because the virus has an incubation period of seven to 19 days, carriers could enter the Republic from Britain, unaware of their exposure.
The Government here has a plan drawn up by an expert committee on how to counter the threat of bioterrorism. But failure to implement many of its recommendations is leaving the country seriously under- prepared for a bioterrorism attack, according to doctors who spoke to The Irish Times.
The possibility of an attack by terrorists using an agent such as smallpox, anthrax or botulinum toxin has risen in recent weeks. With Iraq due to make a declaration on weapons of mass destruction to the UN today, the US could decide to launch an attack in the Middle East in response to what it sees as an unsatisfactory outcome. A threatened Iraq could respond by unleashing biological weapons - hidden abroad - in the West.
And the latest Al-Qaeda warnings have specifically mentioned Britain, Italy, Germany and France as potential future targets for terrorist action. Osama bin Laden's group has shown an interest in obtaining biological and chemical weapons; although the question is whether they have acquired either the material or the expertise to use such weapons.
Biological weapons are infectious agents - usually viruses or bacteria - that have been prepared and formulated to allow easy dispersal. Category A agents (see table below) pose the highest risk to public health: they can be easily disseminated or transmitted person to person; they cause a huge death rate; their capacity to cause public panic and social disruption is high, and they require special preparatory action if public health authorities are to react appropriately.
Although many older Irish people would have been vaccinated against smallpox in their childhood, immunity only lasts 10 years.
In order to achieve a state of readiness here, the Government set up a committee, Contingency Planning for Biological Threats. This produced a document last May, which noted that "the translation of this protocol into action will require a concentrated interagency and interdepartmental response". The protocol outlined six "short-term" goals:
- To organise on-call rosters to ensure that appropriately trained individuals are available on a 24-hour basis should an emergency arise;
- To stockpile appropriate antibiotics, antivirals, anti-toxins and vaccines, and arrange for appropriate storage;
- To designate hospitals as centres for reception of patients with smallpox and quarantine units for those who may have been exposed to smallpox and their contacts;
- To arrange the procurement and distribution of adequate quantities of protective clothing and equipment;
- To consider vaccination of staff in smallpox units and emergency personnel;
- To prepare information material on biological agents for key health professionals.
Of these six goals, only two have been achieved: the National Disease Surveillance Centre has prepared and distributed bioterrorism information to health professionals, and the Irish Medicines Board (IMB) has obtained 600,000 doses of smallpox vaccine. According to Dr Joan Gilvarry, medical director of the IMB, adequate stocks of antibiotics - such as ciprofloxacin for the treatment of anthrax - are also in place.
Worryingly, however, there are no arrangements to ensure that public health specialists - who would act as emergency team leaders - will be available on a 24-hour basis. The Irish Medical Organisation (out of sheer frustration, according to informed sources) this week instructed public health doctors not to co-operate with the Department of Health until the issue of on-call rosters was dealt with.
One senior public health specialist says: "I do not believe that the Minister for Health has been told the full truth about the extent of our unpreparedness by his officials."
Especially worrying, he says, are the lack of protective equipment for frontline staff and the failure to immunise emergency medical and nursing personnel. Another infectious disease expert expresses "deep concern" at the failure to designate hospitals as reception centres for patients with smallpox.
Doctors say this week's decision by the British to vaccinate key personnel emphasises how far behind the Republic is in its preparations. Up to 500 key medical and military personnel, who will form 12 teams on 24-hour stand-by throughout Britain, are to be vaccinated over the coming weeks.
However, there is some good news from the National Virus Reference Laboratory (NVRL) here. According to Prof William Hall, head of the facility at Belfield, Dublin, a biological level class three (plus) laboratory will be operational there by the end of the year. Such a laboratory means the Republic can safely analyse suspect smallpox specimens and produce a result within six hours. The NVRL uses the latest in molecular diagnostic techniques, which allows it to differentiate smallpox from other pox viruses. The fact that NVRL specimen packs ensure the inactivation of a suspect virus before it is transported to Belfield adds a further layer of safety, according to Prof Hall.
But Dr Darina O'Flanagan, director of the National Disease Surveillance Centre, says: "We urgently need to progress our plans to be ready for a possible bioterrorism incident. There has been a lot of work done on guidelines to date, but we need to progress this work to the point where we are prepared at a regional level to deal with a potential threat."