One step could dramatically improve hospital care and patient safety

Information has many ways of falling through the cracks in hospitals and medical practices.

The wrong test may be mistakenly ordered by the doctor. The ward secretary may order the wrong test. The lab may perform the wrong test, or rarely perform it on the wrong person. The result may not be available until after the patient leaves the hospital, and then gets lost in cyberspace; or it reaches the chart after the doctor has dictated the discharge summary and is never seen.

Usually more than one doctor takes care of each patient, but each may not be aware of everything the other has done, or which tests were ordered and are still pending.

A simple fix would be to require that all electronic medical records systems must be linked to the laboratory and radiology departments, and must be able to generate a list of all tests ordered; their results; and those tests whose results are still pending. At the end of a hospitalization, each doctor would have to sign off on the list, to ensure all tests had been considered.

We currently have a hodge-podge of hundreds of proprietary EMR systems that do not communicate with each other throughout the US, and the system I use does not have this capability.

Electronic medical records are a wonderful idea in theory. In practice, they are fraught with difficulties and potentially may be accessed or "hacked" by unauthorized individuals, making a mockery of patient confidentiality. The problem of confidentiality is central to getting a working EMR system in place throughout the nation, through which doctors and patients can communicate; yet it requires cybersecurity resources beyond the financial resources of hospitals and medical practices in the private sector. This is why the development and maintenance of such a system must be federalized.

MK Shai calls for anthrax vaccine experiment probe

from YNet:

Kadima Knesset Member and former Israeli Defense Force spokesman Nachman Shai on Friday said either a state commission of inquiry or a parliamentary commission of inquiry should be set up to look into the anthrax vaccine experiments conducted on IDF soldiers. MK Shai said, "The fact that the experiment was hidden from the public and the examinees is a moral issue of the highest degree".

More on the Israeli anthrax vaccine experiment on soldiers

From the Jerusalem Post

From the AP

Excerpts from today's Ha'aretz:

Dr. Reuven Porat, who chaired the medical committee, told Haaretz the panel had not been presented with any official documentation that shows the decision to develop, test and produce the vaccine had been authorized by the government. Similarly, there was no authorization presented from the defense minister, who is charged with responsibility for the Institute for Biological Research, and not from the IDF, and there was no proof the chief of staff was consulted about or agreed to the project...

In its report the panel is highly critical of the "secrecy" imposed by the managers of the experiment and ask "whether the secrecy was necessary because the experiment was to be hidden from the Israeli public."

The medical panel noted: "Selecting soldiers as the population for the experiment prevented achieving the declared aim of the experiment, which was to examine its safety and effectiveness in broad use among the general civilian public, the elderly, women, children and sick patients," the committee wrote.

From YNet come these excerpts:

Israel has admitted to developing a vaccine against anthrax, fearing it might be used as a bio-weapon by enemy nations against civilians, and tested it on IDF soldiers. "Once we face a substantial threat, we would be able to vaccinate all citizens, ranging from babies to the elderly, and protect them against the virus," a senior defense source told Ynet. (But the report indicates Israel already had a large enough stock of vaccine for its population prior to beginning this trial--Nass) From PressTV: Some of the soldiers, who say that the experiment has had life-threatening side effects for them are now filing a lawsuit against the Israeli Army, Haaretz reported... Israeli Physicians for Human Rights have also filed a lawsuit against the army over the experiments.

Medical panel: Anthrax experiments on IDF soldiers were unjustified

Another fascinating article on the Israeli anthrax vaccine experiments by Yossi Melman in Haaretz. Excerpts follow. It seems no one in Israel would take any responsibility for the experiment, which is being laid at the feet of (assassinated) former Prime Minister Itzhak Rabin -- but no documentary evidence was given to the Israeli Medical Association committee invesetigating the experiment to support the putative association with Rabin.

In the US, I have been unable to learn who has been behind approval of the anthrax vaccine for mass use, when there exists no experimental evidence for human efficacy, the safety profile is awful, and the need has never been demonstrated.

Following a three-month legal battle in Israel's High Court of Justice, the report was finally approved for publication Wednesday...

The experiments were carried out in light of what was then defined as the "strategic threat of a surprise biological attack facing Israel. However, the report said that it was not clear who the decision makers were who determined the vaccine's necessity...

The Chairman of the medical committee, Dr. Reuven Porat, told Haaretz that the panel was not presented with any official evidence indicating that either the government, the defense minister of the IDF chief of staff had authorized the development, testing, or production of the vaccine...

The report insinuates that it was improper motivation that prompted the launch of the experiments, but it does not specify what these motivations were, saying that the panel "could not make out the true inspiration behind them..."

The report reveals that even while the experiment was taking place Israel already had a stock of vaccines, a fact which further raised the concern that the experiment wasn't necessary; that it was carried out as a result of external pressure. "An accelerated effort to produce large quantities of the vaccine was underway a year prior to the experiment, and by the time the experiments were launched, Israel had enough vaccines to cover the civilian concerns," the report said...

Israel and the IDF accepted the principles of the Helsinki Accords, declaring many times that they meet their standards. In reality, however, the report states that "the military Helsinki committee failed to fulfill its duties in 'Omer 2' in every one of the points examined by the report."

"No scientific justification was found for the experiment, scientific background was lacking, the experiment's design and execution did not suit its goals, and no result would have justified those goals. Also, conventional guidelines were not followed, risks and possible side effects were not thoroughly investigated, and a follow-up mechanism to keep track of participating soldiers was not set up....."

Preventing Bioterrorism (Op/Ed by Rep. Rush Holt)

Preventing bioterrorism:

Thursday, March 12, 2009
BY RUSH HOLT
Last year, the Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism -- itself an outgrowth of the 9/11 Commission and its recommendations -- issued its report. It used alarming language to prod our government to act. It affirmed something that was demonstrated with the deadly anthrax attacks: Terrorists will likely use WMD attacks on America that feature biological weapons. The question now is: Have we implemented "lessons learned" from these attacks that took place in the fall of 2001, which caused such havoc here in New Jersey and across the nation?

I agree with the commission's assertion that "only by elevating the priority of preventing bioterrorism will it be possible to substantially improve U.S. and global biosecurity." To that end, the commission made a number of recommendations for improving biosecurity here at home, including the more thorough and persistent monitoring of personnel working at high-containment laboratories (i.e., those who work with dangerous pathogens) and the designation of a single federal agency for tracking the number of such labs in the United States.

I support those and other measures, but I do not believe Congress and the incoming administration can craft an effective biosecurity program for our country unless and until we take the time to investigate thoroughly the only major (and still unsolved, according to many) bioterror attack on our country to date.
Last week, I reintroduced the Anthrax Attacks Investigation Act, to examine and to report on how the attacks occurred and how we can best prevent similar episodes in the future.

Readers may wonder why the commission did not address the 2001 anthrax attacks in detail in its report. The answer is that examining those attacks was not an explicit mandate of the WMD Commission. This is in contrast to the 9/11 Commission, which was specifically charged with looking at how the Sept. 11, 2001 attacks happened, why the federal government failed to prevent the attacks, and what remedial measures are necessary to prevent a similar catastrophe in the future.

A thorough investigation into the federal government's response to the first modern bioterror attack on our soil is absolutely essential if we are to ensure that we have learned the right lessons from that episode to implement countermeasures and changes in policy that are directly tied to those "lessons learned" -- something that The Times of Trenton repeatedly has pointed out in its frequent coverage of this tragedy.

While many of the WMD Commission's recommendations for improving biosecurity look sound on the surface, none of their specific action proposals are based on a detailed examination of how the 2001 anthrax attacks occurred. More than seven years after the attacks, many critical questions remain unanswered. Chief among them is why the Federal Bureau of Investigation's (FBI) "Amerithrax" investigation focused for so long on the wrong suspect.

The FBI's performance in the wake of the attacks has left me and many other Americans wondering whether the Bureau is truly equipped to handle bioterrorism. Deterring such attacks in the future depends in part on at least the expectation of swift and certain detection and punishment.

Neither happened in the case of the 2001 anthrax attacks. We need to know why the first attack succeeded and why the perpetrator or perpetrators escaped justice.

Just as the 9/11 Commission looked not only at the attacks of that morning, but also at recommended changes in the structure of government agencies, screening methods and even congressional oversight, so should an anthrax commission look at the specific crime, but also at measures for prevention, detection and investigation of any future bioterrorism.

An anthrax attack investigation would help address these kinds of policy questions in a level of detail that the WMD Commission could not.

Rep. Rush Holt, D-Hopewell Township, is chairman of the House Select Intelligence Oversight Panel.

FBI Press Release details the meaning of the ASM presentations in Baltimore last week--with comments

For Immediate Release
March 6, 2009

Washington D.C.
FBI National Press Office
(202) 324-3691

FBI Responds to Science Issues in Anthrax Case

FBI Laboratory Director D. Christian Hassell, PhD issued the following statement:

During a recent American Society for Microbiology Biodefense (ASMBD) meeting in Baltimore , Maryland , questions were raised regarding two scientific analyses conducted during the course of the anthrax investigation. While this information is not new, it is important for the FBI to clarify the science since these findings continue to be misinterpreted by various media outlets.

The first item involves the elemental analysis of the anthrax spores that was conducted by Dr. Joseph Michael, a materials scientist at Sandia National Laboratories. At the conference, Dr. Michael presented analyses of three anthrax letters (Leahy, Daschle, and New York Post). He concluded that the anthrax powder in the three letters shared a chemical fingerprint but did not match the chemical fingerprint of spores in Ivins’ flask. Spores from the letters showed a distinct chemical signature that included silicon, oxygen, iron, tin, and other elements. Spores from Ivins’ RMR-1029 flask did not contain those elements in quantities that matched the letter spores. This is not unusual considering that Ivins’ RMR-1029 preparation had been submerged in water and other chemicals since 1997 and was a mixture of 34 different spore preparations. The letter spores were dried spores, produced from two separate growth preparations as indicated by differences in the New York and Washington, D.C. mailings. Although the chemical fingerprint of the spores is interesting, given the variability involved in the growth process, it was not relevant to the investigation.

It is important to note that the genetic profile of the spores from the letters and the spores from Ivins’ RMR-1029 flask was identical. Ivins’ RMR-1029 spore preparation had the same combination of anthrax mutations found in the letters. Only eight of the anthrax samples collected during the course of the investigation matched the genetic profile in the letter material and all were linked back to RMR-1029. This conclusion was the most significant and relevant scientific finding in the case.

By analogy, if one were to grow a corn stalk from a specific corn seed, the trace chemical fingerprint of the stalk might differ from that of the seed due to different compositions—for example iron—in the respective fertilizers used to grow each; however, the genetic profile of the seed and the stalk would be identical.

The second item involves isotopic analysis of the mailed anthrax. Media reports indicated that FBI scientists had concluded in 2004 that out of many domestic and foreign water samples analyzed only water from near Fort Detrick, Maryland, where Dr. Ivins worked, had the same isotopic signature as the water used to grow the mailed anthrax. This statement is incorrect. While water isotopic analysis was researched, the FBI concluded that there were too many confounding variables to precisely match bacteria that were grown using different materials and recipes. This technique was not relevant to the investigation.

While we have full confidence in our scientific approach, an additional independent review will provide further validation and thus benefit the larger scientific community. Consideration of an outside review began before any public disclosure of the scientific aspects of the investigation. This follows our approach throughout the investigation: to bring in external scientists to review and provide advise on our methodologies.

Nass comments: Even if everything stated above is accurate, the FBI has yet to prove that Ivins himself, not just his flask, provided the parent spores for the anthrax letters.

-- How did the FBI "rule out" as perpetrators over 100 other people who had access to spores from Ivins' flask?

-- How did the FBI ascertain that all of the secondary spore collections, derived from the flask, were 100% secure and could not have been surreptitiously obtained by others?

-- How was the FBI sure that no one else received spores from Fort Detrick, given that Fort Detrick's inventory problems were serious enough for there to have been a temporary "stand-down" of research just last month? Also consider that Ivins' flask was in a separate building from his lab, to which others had access, for over a year.

Since a thorough, complete accounting of its six year long, resource-intensive investigation has yet to be provided by the FBI, the following questions (raised by Representative Rush Holt on October 16, 2008) are additionally relevant:

"Are any of the FBI’s scientific findings inconsistent with the FBI’s conclusions?

Are there any scientific tests that the FBI has not done that might refute their conclusions?

Did the FBI follow all accepted evidence-gathering, chain of possession, and scientific analytical methods? Is it possible that any failure to do so could have affected the FBI’s conclusions?

Is it scientifically possible to exclude multiple actors or accessories?"

It is now 7 months since FBI announced the case was closed. During that time, FBI has released many pieces of (selected) evidence. The latest release, at a special ASM meeting convened for the purpose, was designed to make the scientific case.

The FBI charade has failed. The most basic questions remain unanswered.

Israeli Ministries take 'full responsibility' for anthrax vaccine trials

Article in THE JERUSALEM POST
Mar. 4, 2009
Yaakov Lappin

The Defense Ministry, Health Ministry and IDF said they took "full responsibility" for all side effects suffered by participants in a test of an anthrax vaccine, in a joint statement issued Wednesday.

The statement will be submitted to the High Court next week as a reply to petitions submitted by two IDF soldiers who took part in the trial and suffered negative aftereffects.

The petitioners raised questions about the way the vaccine trial was conducted, and are claiming the monitoring of volunteers and subsequent care provided to them was inadequate.

The vaccine trial, code-named Omer 2, took place between 1998 and 2006, and sought volunteers from elite IDF units. Following the test, a number of participants complained of breathing problems and skin conditions.

A quarter of participants were given an American version of the vaccine, while 75 percent were injected with the Israeli vaccine, which had not been previously tested. Members of both groups suffered side effects.

According to the statement, which was released by the Defense Ministry, 716 soldiers took part in the trial, and 11 later required medical treatment.

"Volunteers were given a detailed explanation about the vaccination, the study, and potential side effects. They were given a sheet to study and sign," the statement said.

"All of the soldiers who requested medical care received it," it added.

The Defense Ministry went on to describe Omer 2 as a project with "strategic importance for the State of Israel," adding, "Thanks to Omer 2, Israel has a medical response for the general public against a most severe threat. We thank the volunteers and appreciate their willingness to take part in this important trial, and their contribution to the general security of residents of Israel."

The vaccine is as safe as the anti-anthrax vaccine developed by the US, the Defense Ministry said.

Academic experts and oversight committees within the IDF closely monitored the vaccine trial, the statement added.

Remembering the anthrax attack

Glenn Greenwald's March 4, 2009 Salon article on Representative Rush Holt's bill and the ramifications of the anthrax attack is a must-read. Great links. Here is an excerpt:

The ultimate establishment organ, The Washington Post Editorial Page, issued numerous editorials expressing serious doubts about the FBI's case against Ivins and called for an independent investigation. The New York Times Editorial Page echoed those views. Even The Wall St. Journal Editorial Page, citing the FBI's "so long and so many missteps," argued that "independent parties need to review all the evidence, especially the scientific forensics" and concluded that "this is an opportunity for Congress to conduct legitimate oversight."
In the wake of the FBI's accusations against Ivins, the science journal Nature flatly declared in its editorial headline -- "Case Not Closed" -- and demanded an independent investigation into the FBI's case. After the FBI publicly disclosed some of its evidence against Ivins, The New York Times reported "growing doubts from scientists about the strength of the government's case." The Baltimore Sun detailed that "scientists and legal experts criticized the strength of the case and cast doubt on whether it could have succeeded." Dr. Alan Pearson, Director of the Biological and Chemical Weapons Control Program at the Center for Arms Control and Non-Proliferation -- representative of numerous experts in the field -- expressed many of those scientific doubts and demanded a full investigation.
There may be legitimate grounds for doubting whether an independent, 9/11-type Commission of the type Holt proposes is the ideal tribunal to conduct a real investigation, but it is clearly the best of all the realistic options. The only other plausible alternative -- an investigation by Congress itself -- is far inferior, as anyone who has observed any so-called "Congressional investigation" over the last decade should immediately recognize (here, as but one example, is the account I wrote about a House hearing last September attempting -- with cringe-inducing ineptitude and total futility -- to "grill" FBI Director Robert Mueller about the FBI's case against Ivins). How effective an independent investigative Commission like this will be will depend on the details of its structure -- its subpoena powers, punishments for defiance, and the independence of its members. That Rush Holt will play a key role, if not the key role, in overseeing its creation is a reassuring feature that the bill he introduced can be actually productive.

HOLT INTRODUCES ANTHRAX COMMISSION LEGISLATION

For Immediate Release Contact: Zach Goldberg March 3, 2009
202-225-5801

HOLT INTRODUCES ANTHRAX COMMISSION LEGISLATION

Bill Would Create 9/11 Commission-Style Panel to Investigate Anthrax Attacks and Government Response

(Washington, D.C.) – Rep. Rush Holt (NJ-12) today introduced the Anthrax Attacks Investigation Act of 2009 (HR 1248), legislation that would establish a Congressional commission to investigate the 2001 anthrax attacks and the federal government’s response to and investigation of the attacks. The bipartisan commission would make recommendations to the President and Congress on how the country can best prevent and respond to any future bioterrorism attack. The attacks evidently originated from a postal box in Holt’s Central New Jersey congressional district, disrupting the lives and livelihoods of many of his constituents. Holt has consistently raised questions about the federal investigation into the attacks.

“All of us – but especially the families of the victims of the anthrax attacks – deserve credible answers about how the attacks happened and whether the case really is closed,” Holt said. “The Commission, like the 9/11 Commission, would do that, and it would help American families know that the government is better prepared to protect them and their children from future bioterrorism attacks.”

Under Holt’s legislation, the commission would be comprised of no more than six members from the same political party. The commission would hold public hearings, except in situations where classified information would be discussed. The commission would have to consult the National Academies of Sciences for recommendations on scientific staff to serve on the Commission. The Commission’s final report would be due 18 months after the Commission begins operations.

“Myriad questions remain about the anthrax attacks and the government’s bungled response to the attacks,” Holt said. “One of the most effective oversight mechanisms we can employ to get answers to those questions is a 9/11 style Commission.”

Examining Other Healthcare Models

Healthcare is highly valued by our society, yet it seems that many of our pundits and politicians are willing to create a new healthcare system from whole cloth. In other words, let's consider this or that experiment, and the winner will be the compromise melange that gets passed by Congress. (Definition of melange: a collection containing a variety of miscellaneous things.)

Well, we already experimented with the theory that government was the problem, tossing strict regulation (of banks, mortgage providers, stockbrokers, the food and drug industries, and military procurement, to name a few) in the wastebin, and where did it get us? Do we really want our healthcare system to be crafted by a bunch of horse-traders, and laden with pork?

I, for one, don't think we have the time or money for another major social experiment. I think it is time to put the available information to work to craft a system that we know will meet our needs, before we put it into place.

So far, there has been deafening silence on the subject of healthcare systems in the rest of the world, and what is wrong and right with them. Yet these models can tell us so much about how different programs are likely to work. We should be examining the other systems under a microscope right now, as the administration and Congress begin taking positions.

Thankfully, blogger Tim Foley at Change.org has begun this conversation, describing how a low-cost, high tech, high drug use system has led to enviable life expectancy and infant mortality rates in Japan. Enjoy his enlightening piece.

NY Times "Postscript" to Scott Shane's article on Ivins of Jan 4, 2009

A two-paragraph article in today's NY Times, sans byline, appears to end discussion of the so-called "chemical signature" said to identify the source of water used to grow the anthrax letter spores:

On Tuesday at an American Society for Microbiology conference in Baltimore, an F.B.I. scientist, Jason D. Bannan, said the water research ultimately was inconclusive about where the anthrax was grown. An F.B.I. spokeswoman, Ann Todd, said on Wednesday that the bureau “stands by the statements” of Dr. Bannan.

It is a postscript to Scott Shane's major article on Bruce Ivins dated January 4, 2009, which reported that a "chemical signature" of the water in which spores were grown pointed to Fort Detrick, Md.

Revealed: Scientific evidence for the 2001 anthrax attacks

from an article by Debora MacKenzie, who has been knowledgeably reporting on anthrax and bioterrorism at the New Scientist for more than a decade:

. . . Next the team developed highly sensitive tests to screen all 1072 samples for four of the mutations. Eight samples had all four. One came from a flask labelled RMR-1029 that Ivins was responsible for at USAMRIID. The other seven came from cultures taken from that flask, only one of which was not located at USAMRIID. So while these findings show the attack spores came from one of these cultures, the FBI has gone further in concluding the attack came directly from the RMR-1029 flask.

Another question is how the attacker turned the water-based slurry of spores in the flask to the fine, dry powder in the letters. . .

How to Heal the Ailing FDA

Six spot-on suggestions from Steve Nissen, MD to the Obama administration.

Anthrax investigation still yielding findings: Chemical composition of spores doesn't match suspect flask.

Nature article by Roberta Kwok discusses the American Society for Microbiology's Biodefense and Emerging Diseases Research Meeting in Baltimore, Maryland on February 24, 2009. Excerpt:

Joseph Michael, a materials scientist at Sandia National Laboratories in Albuquerque, New Mexico, presented analyses of three letters sent to the New York Post and to the offices of Senators Tom Daschle and Patrick Leahy. Spores from two of those show a distinct chemical signature that includes silicon, oxygen, iron, and tin; the third letter had silicon, oxygen, iron and possibly also tin, says Michael. Bacteria from Ivins' RMR-1029 flask did not contain any of those four elements. . .

NICE on Mars

Merrill Goozner discusses a BMJ article by Nigel Hawke about Britain's National Institute for Health and Clinical Excellence, and how it might help those of us in the less-regulated medical world to get useful information on pharmaceuticals. Excerpts:

The global pharmaceutical industry considers Great Britain's National Institute for Health and Clinical Excellence (NICE) about as welcome as salmonella-tainted peanut butter at a Super Bowl party.

NICE has used independent researchers to compare the effectiveness of new drugs (especially cancer drugs) to what's already available. It then proceeds to establish their value by measuring how much they extend life and wellbeing (the dreaded cost-effectiveness analysis, also independently derived). Finally, the agency provides the information to England's National Health Service, which uses it to determine what services it can provide through its limited budget.

Great Britain also has longer life expectancy, lower infant mortality and health care costs about 60 percent of what we pay in the U.S.

NICE may export its model for profit to -- oh, double the horror -- the U.S. "It's clear that what we do and how we do it is of interest to healthcare systems around the world, regardless of how they are funded," NICE chief executive Andrew Dillon told BMJ.

Good for Business, Bad for Patients?

Excerpts from Dr. Jon Abramson's ABC News Op-Ed:

It's perfect. Pfizer buys Wyeth's pipeline, the behemoth marketing power of Pfizer gets leveraged, the work force gets consolidated and the $22 billion borrowed is read as a sign that banks are willing to lend again...

The core problem with American medicine isn't really access or cost. It's that medical knowledge itself has been turned into a commodity, produced and disseminated with the primary goal of optimizing profits rather than health...

What we've got is a good old-fashioned case of market failure. But understanding the magnitude and consequences of the failure of the market to oversee the relevance and integrity of commercially generated medical knowledge is virtually impossible to see unless you're a corporate insider or have a subpoena to gain access to the unspun scientific evidence (closely held as proprietary information by the drug companies) and other corporate documents...

More pictures +/- the complete exosporium

Here (or here, if you are having trouble viewing the first set of images) is a side by side comparison of the Sandia pictures (from Anonymous) with pictures of 2 different batches of anthrax spores from another paper. One picture shows anthrax spores WITH an intact exosporium, the other WITHOUT an intact exosporium. Clearly the Sandia picture most resembles the one WITHOUT an exosporium. This contradicts Sandia's claim that their picture of the mailed spores has an intact exosporium.

More on health financing (NYT Blog): How Do Hospitals Get Paid? A Primer

Wonderful article by economist Uwe Reinhardt clarifying bizarre hospital charges and third-party reimbursements, and how much of the healthcare dollar they waste. Excerpt:

Americans can be forgiven their ignorance on this issue because, as I put it in a recent paper on the subject, the pricing of hospital services is best described as “Chaos Behind a Veil of Secrecy.”

Army releases some e-mails from anthrax suspect/Frederick News-Post

Article by Justin Palk

The U.S. Army released 33 pages of Bruce Ivins' e-mails Thursday from his account at Fort Detrick.

The e-mails, obtained by The Frederick News-Post under the Federal Freedom of Information Act, span the period from September 1998 through January 2002.

The documents contain 16 threads of communication, some including multiple e-mails between Ivins and his correspondents.

The e-mails all address one of three issues: the work of Ivins and other individuals to plan an international meeting of anthrax researchers in Annapolis for the summer of 2001; discussions of lab research; and in two cases, copies of The New York Times articles about the investigation into the 2001 anthrax mailings that Ivins e-mailed to himself.

The news articles both concern the difficulty investigators had early on in tracking the history and origins of the Ames strain of anthrax used in the mailings.

The Army continues to review additional e-mail messages from Ivins.

In August, the Department of Justice announced it considered Ivins, a U.S. Army Medical Research Institute of Infectious Diseases microbiologist, its sole suspect in the 2001 anthrax mailings that killed five and hospitalized 17 others.

Ivins died on July 27 after intentionally overdosing on acetaminophen.

His attorney has maintained Ivins was innocent.

Defense attempting to block report about anthrax trial/Haaretz

Excerpts from the article:

... IDF soldiers were given seven doses of an anti-anthrax vaccine developed by the Nes Tziona biological institute. But there was no extended medical supervision of the vaccinated soldiers.

A year and a half ago, a group of soldiers vaccinated in the experiment asked the IDF and Defense Ministry for all the details of the experiment, saying they suffered from debilitating side effects. The army and Defense Ministry ignored the request and would not recognize the soldiers as disabled veterans - eligible for benefits from the IDF.

Fixing the financial incentives in medicine

Medco (this is the pharmacy benefits company that settled for $155 million over charges of defrauding the federal government and paying kickbacks in 2006) manager Dave Snow has jumped into the healthcare debate. His idea is to force doctors to prescribe pre-selected treatments: if you diagnose A, you treat with B.

Obviously, Mr. Snow doesn't understand why medicine is an art. You have to take into account preexisting illnesses, risk factors, other medications, drugs allergies, drug intolerances, likelihood of compliance, and patient psychological, social and too often, financial factors to come up with a treatment. And then you should negotiate it with the patient to increase compliance and understanding. That is why B is often not the best choice. (Medco may not even offer B on its formulary, which is an additional reason to choose C.)

Granted, there are numerous problems with our medical system, and there are many possible solutions. In contrast to Mr. Snow, let's look a little deeper at why we have so many problems:

1. The financial incentives are all wrong.

a) You don't get paid more for getting things right: you get paid more for ordering more tests, increasing the number of visits, and spending the shortest possible time with the patient. Four fifteen minute visits pay almost twice as much as one hour-long visit. Spend an hour performing a detailed evaluation of a complex patient, get the diagnosis right and bingo! you have just forfeited reimbursements for additional visits, as well as earning considerably less for the hour you just spent than if you had seen patients with 4 sore throats.

b) You don't get paid for keeping people well, in general.

c) Outcome measures are rudimentary. Doctors are currently graded on whether a sufficient proportion of patients have regular mammograms, PAP tests and vaccinations, and whether their patients with chest pain receive appropriate emergency medications. But these measures indicate nothing about the proportion of correct diagnoses, or patient satisfaction. And they may incentivize bad behaviors. For example, the reasonable requirement to give all patients with pneumonia an antibiotic within 4 hours of ER arrival led to excessive antibiotic prescribing in every patient who "might" have had pneumonia.

d) Primary care docs are paid very little relative to docs who perform procedures. Procedures rule medicine. High profit procedures like cardiac catheterizations, neurosurgery, orthopedic surgery, and endoscopy subsidize ordinary patient care in hospitals and clinics. Hospitals pay hospitalists considerably more than they can bring in (in reimbursements from third party payers), in part because hospitals cannot function without them, but also because these primary care doctors order more lucrative tests and procedures on their patients.

e) Due to concerns about malpractice and meeting patient expectations (most patients expect that everything that can be done for them, will be done) doctors order more tests and procedures than are justified by existing guidelines.

f) The medical literature is contradictory on an enormous number of medical issues, so doctors are hard-pressed to trust the literature to give them the best or most accurate answers...leading to increased testing and procedures, since our culture punishes sins of omission much harder than sins of comission, or "doing too much."

g) The negative results of "doing too much" fail to be acknowledged or quantified. How many cancers are caused by unnecessary CT scans? I have no idea. How many patients die after undergoing cardiac catheterizations, when a medication adjustment might have been as effective? Studies of such questions fail to be published in major journals and do not appear to have affected clinical practice.

h) Professionalism currently demands from doctors that they meet the "standard of care" provided by other local practitioners. In part because the medical system is so complex, and there are so many medical tests, procedures and specialties, our expectation of ourselves as practitioners is more about ordering the right test and referring to the right specialist, rather than correctly diagnosing the patient. We expect that the test or the specialist will provide the answers if we do not have them. Cognitive skills have been devalued.

There is little financial or professional incentive to keep studying and struggling to find answers for the most challenging patients. And no financial or other reward if you succeed.

More later...

Coated and uncoated spores may look alike

Pictures of coated and uncoated spores are here, courtesy of Anonymous.

Litigants Argue U.S. Regulators Lacked Basis to OK Anthrax Vaccine

Global Security Newswire article
National Journal Group

Friday, Jan. 16, 2009
By Elaine M. Grossman

WASHINGTON -- The Food and Drug Administration violated its own regulations three years ago in approving the anthrax vaccine to prevent infection by a "weaponized" form of the disease, attorneys for eight Defense Department employees alleged in a brief filed last week at the U.S. Court of Appeals (see GSN, March 3, 2008).

(Jan. 16) - The anthrax vaccine received approval in late 2005 as a protective measure against inhaled anthrax (Emergent BioSolutions photo).

The Pentagon began a vaccination program for more than 1 million service personnel in 1998, during the Clinton administration, and continued the effort under President George W. Bush. However, compulsory shots were suspended from late 2003 through early 2007, after a federal judge found the Pentagon lacked the legal authority to compel inoculations for an unapproved use of the vaccine.

Critics have voiced concern that it is unclear how useful anthrax vaccine is in preventing the highly lethal disease from being contracted through inhalation, and have called attention to the possible risks associated with giving the inoculations to a large population.

The U.S. government recently moved to shield itself from liability in distributing the vaccine in the event of a bio-warfare attack, just as a key advisory panel to the Centers for Disease Control and Prevention approved extending the shots to emergency first-responders nationwide (see GSN, Oct. 17, 2008, and Oct. 23, 2008).

A December 2005 FDA ruling allowed a vaccine previously labeled for use solely in inhibiting anthrax contracted through the skin or the digestive system to also be administered to prevent acquiring the disease via the lungs.

The decision paved the way for the Defense Department to resume mandatory inoculations for service members whose assignments are believed to put them at increased risk of exposure to anthrax during a potential biological attack (see GSN, Sept. 5, 2007).

However, two attorneys who succeeded in temporarily shutting down the mandatory shots program in 2003 remain dissatisfied. They alleged in a second lawsuit, filed in December 2006, that the Food and Drug Administration had not followed its own standards for reviewing a vaccine for approval in issuing its 2005 go-ahead.

The result, they are alleging, is that the vaccine has not been shown to be safe and effective for preventing inhaled anthrax.

U.S. District Judge Rosemary Collyer last year ruled against the plaintiffs, saying the court "will not substitute its own judgment when the FDA made no clear error of judgment."

Plaintiff attorneys Mark Zaid and John Michels took their case to federal appeals court, and the 73-page brief filed last week constitutes their written argument.

"There are ... internal inconsistencies in the [FDA-reviewed] record showing that nobody believed this vaccine was adequate for preventing inhalation anthrax until the DOD decided they were going to conduct this mass inoculation," Michels said in an interview yesterday. "The FDA's failure [in its 2005 action] to explain all of these contradictory statements [in] their own documents is a violation of the Administrative Procedures Act."

The 1946 federal law controls how government agencies draft and issue regulations.

A Defense Department spokesman praised the federal judge's decision.

"We owe it to our service members to give them every possible protection," Bryan Whitman said last year. "Force protection is the No. 1 priority in the Defense Department and the anthrax inoculation program is an important force-protection measure."

In their Jan. 7 brief to the U.S. Court of Appeals, though, Michels and Zaid took issue with the notion that the vaccine has been proven to protect humans from contracting inhaled anthrax.

If the court invalidates the FDA authorization for this use, the Defense Department could be required to obtain informed consent from any personnel receiving the five-shot series (see GSN, Dec. 22, 2008).

In the case, called Rempfer vs. von Eschenbach, the two lawyers are representing Thomas Rempfer and seven other Defense Department personnel ordered to take the vaccines. Defendants are led by FDA Commissioner Andrew von Eschenbach and include the health and human services and defense secretaries.

"The regulatory history of the [anthrax vaccine] was nothing if not convoluted and contradictory," according to the plaintiffs' new court submission. "The main basis" for Collyer's decision to dismiss the case "was the FDA's reliance on a single human test of [the anthrax vaccine] that occurred more than 50 years ago, using an admittedly different vaccine," the complainants stated.

The district court judge's Feb. 29, 2008, decision "ignored the significant disparities" in vaccine testing as well as plaintiff allegations that "undercut" the key medical study's "validity and scientific basis," the brief reads.

"We are alleging," Michels told Global Security Newswire, "the FDA has not done its job."

Agency records show a "significant failure by FDA to follow its own procedures with regard to licensing of the current version of the vaccine using data from a vaccine that was manufactured using different standards, a different anthrax strain, and different methodology," according to the brief. "The District Court's simple acceptance of the representations made by the government was improper and factually unsupportable."

An FDA spokeswoman today declined to offer comment on the court case.

Pending a possible extension in due date, the government has 30 days to issue its own written brief for the appeals court. After that, the plaintiffs will have an opportunity to submit their response. The appeals panel may then request to hear oral arguments on the case before issuing its decision.

Critique of the "chemical signature" assertion and other points by Barry Kissin

Barry Kissin, an attorney in Frederick, Maryland, analyzes several assertions in Scott Shane's January 4 article, by reviewing media and other reports published since 2001. These include the unsupported claim that the "chemical signature" of the water used to grow the letter anthrax could only come from Frederick, Maryland, and that other US government and quasi-governmental biodefense laboratories have been ruled out as sources.

Frederick Police Report out

The Frederick Post has made available a pdf of the Frederick Police Department report regarding its investigation of Ivins' last days.

I have several questions after reading this material. First, I would assume that Ivins made two trips to the Giant Eagle pharmacy an hour apart in order to drop off prescriptions then pick up the medications. The police report claims he purchased one bottle of 70 tylenol pills. Scott Shane said he purchased two bottles of tylenol PM, which includes benadryl, one during each visit to the pharmacy. Prior reports (and one mention in this police report) indicated he ingested tylenol with codeine, which would have required a prescription, and does not appear to have been purchased on July 24.

Thus it still remains unclear what he purchased, what he had available at home, and how much tylenol (and other substances?) he may have ingested. There should have been investigations of the contents of the orange soda and red liquid found in Ivins' bathroom and bedroom, respectively, but the police report fails to indicate whether these materials were collected and studied.

Second, Ivins' disclosure to the Red Cross of his medical history provides support for the hypothesis that Ivins suffered from chronic medical problems that are commonly found in patients who become ill following receipt of anthrax vaccinations. He reported chronic pain issues ("back/joint/bone problems" for which he took neurontin, lidocaine patches, aleve and diazepam); psychiatric issues ("anxiety/PTSD/Bipolar Disorder" and "depression"); and sleep apnea.

All 3 are among the most common symptoms that occur as sequellae of anthrax vaccine, as noted by me but also by the Vaccine Healthcare Centers Network, which screens many patients for sleep apnea. This diagnosis is relatively rare in thin males, but has occurred in 80% of those disabled males I have evaluated in the past 3 years for the sequellae of anthrax vaccine. All those patients had chronic widespread pain disorders and psychiatric sequellae as well.

Third, Ivins had rhabdomyolysis and (probably secondary) renal failure when he arrived at the ER, in addition to the subacute sequellae of liver failure (presumably from a tylenol ingestion). It is not clear what led to his developing this, which seems to have significantly added to the severity of his final illness. Release of more medical information would help clarify whether the known facts fully explain the medical consequences Ivins experienced.

NYT: Portrait Emerges of Anthrax Suspect’s Troubled Life

Scott Shane's newest, detailed exploration of Bruce Ivins can be summarized in Shane's statement, "unless new evidence were to surface, the enormous public investment in the case would appear to have yielded nothing more persuasive than a strong hunch, based on a pattern of damning circumstances, that Dr. Ivins was the perpetrator."

Let me make a few comments on this very detailed story.

...anthrax specialists who have not spoken out previously said that, contrary to some skeptics’ claims, Dr. Ivins had the equipment and expertise to make the powder in his laboratory.

He may well have--but this begs the bigger question of how long it would have taken and whether he could have done so without being detected.


And most importantly:

The science alone could not close the case. “We could get to a lab, to a refrigerator, to a flask,” said Dwight E. Adams, the F.B.I. laboratory director until 2006. “But that didn’t put the letters in anyone’s hand.”

As the bureau’s undercover informant, Dr. Haigwood struck up a breezy e-mail correspondence about scientific grants, pets and travel. Dr. Ivins complained about psychological screening and other “rather obnoxious and invasive measures” imposed at Fort Detrick since the anthrax attacks.

Dr. Nancy Haigwood believed Ivins was the culprit and had additionally, "damaged my property, he impersonated me and he stalked me.” She was afraid he would send her an anthrax letter. Her goal in renewing their friendship was to get him to incriminate himself. So any evidence resulting from their correspondence would need to be viewed from this perspective and in its entirety.

Dr. Ivins still carried resentment from four decades earlier at Lebanon High School in Ohio, where he had been a nerdy, awkward teenager devoted to photography and, even then, to the study of bacteria.

What percent of Ph.D. scientists did not feel nerdy, awkward and excluded as teens, I wonder? (I do not mean to target scientists. The teen years are awkward for most people.)

Though a public debate had raged for years over whether the mailed anthrax had been “weaponized” with sophisticated chemical additives, the F.B.I. had concluded early on that it was not.

The jury is still out on this issue, but many believe otherwise.

By 2004, secret scientific testing established that the mailed anthrax had been grown somewhere near Fort Detrick.

Presumably this comment refers to properties of the water used to grow anthrax; whether such analysis can reliably pinpoint the Frederick, Maryland area remains open to question.

Rockefeller vows fight on Gulf War syndrome

Excerpted from an article in the December 29 Charleston, W.V. Daily Mail:

.... The senator said it was shameful that neither the Department of Defense nor the Department of Veterans Affairs acknowledge Gulf War syndrome as a real illness.

"We were stonewalled by the DOD in hearing after hearing after hearing," Rockefeller said of several meetings on the issue since the early 1990s. "They thought we were wrong, crazy, and came up with some kind of cockamamie theory. No matter what we produced, they'd send it back and call it nonsense..."

"My attitude is that we should never stop fighting until they get the money and benefits they need," Rockefeller said. ... he'd continue to push for those veterans as a member of the Senate Veterans Committee. He also is set to begin his tenure as chairman of the Senate Commerce Committee."

Correction:

There are 2 errors in what I posted below about the forensic analysis discussed in Professor Jacques Ravel's slides. The first correction is that the over 1,100 samples submitted to the FBI were screened for genotypic differences, and may not have been screened for morphologic differences.

The second error is that the slides say wild-type Ames (isolated from a heifer that died in Texas in 1981) did not vary from an anthrax sample isolated from Bob Stevens' cerebrospinal fluid (over 5 million base pairs identical), rather than from the anthrax letters directly.

What I termed slide 16 has a list of 5 different isolates (morphotypes) from the Leahy letter and 3 from the NY Post letter. One of each is termed "wild-type" so you might say there are 4 (Leahy: A, B, C and E/Opaque) and 2 (NY Post: A and B) morphotypes distinct from the majority colony type listed on the slide.

Later the slides indicate that 3 genotypes were identified within the A morphotype. The slides do not indicate how many genotypes were found in the other morphotypes. Nor how these were determined. There are 2 slides on each page. So what I identified as slide 16 is actually page 16, slide 31.

Slide 45 indicates that 4 PCR assays were developed to distinguish genotypes. I don't know from which samples these distinctive genotypes were found, and used.

The over 1100 submitted samples were screened for PCR genotype differences. Some had 1 or 2 variants but only the sample from Ivins' flask had 4. (It is implied that 4 were found in the anthrax letters.)

BOTTOM LINE:

I erred in mixing up morphotypes and PCR assays in my earlier statement. There is nothing in the slides that indicated the 1100 samples were screened for morphologic colony differences.

There is missing information so I cannot say what kinds of samples were used to discern the genotypic differences. But my guess is these were genetic differences within morphotypically distinct colonies.

However, the slides appear to indicate that the morphologic variants differed between the two letters.

If genotypic differences of rare morphotypes are what was used to nail Ivins' flask, the science may be questionable. If the morphotypes varied between the two letters, is it forensically valid to focus on qualitative genotypic differences in a subset of morphotypes? But I am guessing this is what was done. The FBI needs to tell us precisely what methods were used.

New details from the genomic forensic analysis

Dr. Jacques Ravel of U Maryland, formerly of the Institute for Genomic Research (TIGR), spoke at the MIT faculty club on December 16, 2008 to discuss the scientific evaluation of the anthrax letters' spores.

I requested but did not receive an invitation to the event (despite my Bachelor's degree in Biology from MIT and some expertise in the subject). The slides were shared with me later, but each is labeled "do not distribute."

So I will not share them. They should be posted soon on an MIT website associated with the program that brought Ravel to MIT.

Of interest, the morphologic variations in spore colonies were not entirely identical between the NY Post and Leahy letters. Slide 16 indicates that 5 variations were found in Leahy's anthrax, and (only) 3 of those 5 variations were found in the Post anthrax. No other samples had these 3 variations but some (of greater than 1,100 samples screened) had 1 or 2.

There were no genetic polymorphisms between the 2 samples or a wild-type Ames.

Also of interest, Professor Ravel pays a lot of attention to the criminal-legal aspects of the case and the rules of evidence for trial.

An early article on the genomic studies in the Times is worth a read for comparison.

Military: Repeat of anthrax attacks harder today/AP

From the Annapolis Capital, Maryland

"Lennox said military safety reviews in recent months endorsed many of the security changes already made, from improved cameras and lights to satellite surveillance. But other changes were deemed not workable or too expensive, including limits on scientists' hours or a system that would prohibit workers from being alone with a toxin... As for transporting toxins, there are now requirements that two workers be present at all times during transit and that there be satellite coverage of the shipment."

Terrific. Satellite coverage every time the courier or FedEx carrier goes inside a building or gets on an airplane. How is that going to prevent unauthorized transfers of microorganisms and toxins? Do two workers share a bathroom stall?

The army's PR people will have to do better than this to convince the public the next bioattack won't be originating from a government lab.

Confirmation: Letter spores grown in medium to which silicon added

Although this conclusion is nothing new to many of us, it is gratifying to get confirmation from the National Academy of Engineering of the National Academy of Sciences, and to hear a Sandia National Labs scientist, Paul Kotula, acknowledge that 200 tries to reverse engineer the spores did not create an identical match. Which simply says it is likely the FBI does not know exactly how the spores were made, which makes it more difficult to pin their manufacture on any one individual.

Who is Responsible for Zimbabwe's Current Anthrax and Cholera Epidemics?

Zimbabwe media are reporting that Zimbabwe government officials are blaming British operatives during the liberation struggle--and today--for cholera and anthrax epidemics currently affecting the country:

http://www.newsnet.co.zw/index.php?nID=14583
"Dr Ndlovu quoted a research by Tom Mangold, a researcher in Warfare and Jeff Goldberg, an investigative journalist based in Washington DC, who made the stunning revelations that the British operatives during the liberation struggle planted some anthrax and cholera bacterium to wipe away black Zimbabweans and their herds of cattle.

The minister also said the rains are activating the bacterium and there are some operatives currently in the country who are working on planting the epidemics.

Mangold and Goldberg's 1999 book Plague Wars (you can read the entire book if you click on it) recounted my research on Zimbabwe's anthrax epidemic in chapter 22, and discussed the use of other chem/bio agents during the liberation struggle.

I'd like to make clear that the current cholera outbreak is the result of Zimbabwe's failure to provide safe water to its citizens, and is not a form of biological warfare perpetrated from outside. Adding small amounts of bleach to water would prevent this epidemic--that is, if there were adequate water available. Cholera bacteria spread from infected stools. The bacteria produce a toxin that forces huge amounts of water out of the body in the stool. It is the dehydration which kills. If you could provide sufficient fluid to patients using oral rehydration fluids or intravenous fluids, no one would die.

In the 1990 cholera epidemic in Latin America, the death rate was 1% or less as a result of this treatment, which ought to be cheap and available. (The antibiotics used to kill the bacteria are also inexpensive.)

Zimbabwe's lack of clean water, the lack of toilet facilities, the lack of available health care produced this cholera epidemic, not foreign operatives.

As for the current anthrax outbreak, that is different. It is the result of anthrax spores spread between 1978 and 1980 by unknown operatives working to prevent majority rule. The spores remain in the soil, causing unpredictable outbreaks in grazing animals for decades or longer, in areas where the soil supports regrowth of spores during special weather conditions.

Cholera was used to contaminate some rivers in the 1970s, but did not spread widely in Zimbabwe because clean water and medical facilities were available then, and it was rapidly diluted.

Are We Safer From Bioterrorism?--ProPublica

A 3-part series of articles by Marcus Stern looks into the financial costs, usefulness and risks of the $48 billion dollars spent on bioterrorism responses since 9/11/01. Additional material with videos can be found at the thought-provoking, new web magazine FLYP (Nov. 25-Dec 12 issue, main story--and the visuals are lovely).

Off Topic: Egalitarian Approach to Improving the Health Care System

This is an introductory talk I gave in 1995 about health care reform. It seems equally relevant today. I will post additional thoughts on improving our health care system as the new administration considers ways to cover all Americans, improve quality and cut costs. I think it is doable!

Hint regarding a future post: we do not know much about what it costs to produce nor to purchase health care items. Virtually all reimbursements for healthcare are negotiated. Charges and prices have very little meaning, since the amounts that are paid for identical items or services vary widely between health care insurers, negotiating entities and individual practitioners.

Until we have transparency about what all these numbers really are, we will understand nothing about the cost of healthcare.

Anthrax poses new threat in cholera-hit Zimbabwe: charity (Agence France Presse)

If you drop anthrax spores in areas where livestock graze or wild animals roam, anthrax's bitter harvest may keep returning. Under the proper weather conditions, spores can regrow and multiply locally. Animals grazing close to the ground may ingest anthrax-infected soil. The animals die suddenly. And hungry humans who butcher, consume or even use the animals' hide or hair are likely to develop anthrax as well.

In nature, luckily, the human disease is less deadly than the animal disease. The vast majority of affected humans develop cutaneous (skin) anthrax. It is slower to develop, and responds nicely to inexpensive antibiotics... if you have the means to get it diagnosed and treated promptly. A wider epidemic can be prevented by vaccinating herds once the disease is recognized.

Zimbabwe's health services have taken an enormous hit lately and are in shambles. People are dying again from the anthrax that was used against them and their cattle 30 years ago, during a long and dirty civil war for majority rule. An FBI informant claimed that Steven Hatfill told friends he had been involved in the original Zimbabwe epidemic. This is one reason he was suspected of having a role in the anthrax letters. Very little is publicly known about who spread Zimbabwe's anthrax, and how it was done.

However, Zimbabwe's experience tells us that even without causing the deadlier (inhalation) form of the disease, anthrax is a terrible problem. Forming a spore that may be viable centuries later, anthrax cannot feasibly be removed from the soil once it lands there.

Zimbabwe teaches that even as we make plans (and spend 50 billion dollars) to mitigate the effects of a biological attack, we should hesitate. We should step back a few paces. Mitigation is a hopeful concept. It may sometimes be effective. But Prevention is guaranteed to work. That is where our focus in the biological arena should be.

WP Editorial: The Next Attorney General (and the anthrax letters)

Editorial from the Washington Post:

...The new attorney general also should ensure that an independent commission or the inspector general review the anthrax investigation. In the summer, the FBI identified Fort Detrick scientist Bruce E. Ivins as the lone suspect in the 2001 anthrax attacks that killed five and sickened many more. Mr. Ivins took his own life before he could be put on trial. An independent examination of the anthrax probe should review the methods used by the FBI in investigating Mr. Ivins and, before him, Steven J. Hatfill, who was the FBI's initial suspect before being exonerated this year. The review must also examine how Mr. Ivins maintained a security clearance despite apparently suffering from serious mental illness.

Self (inflicted) defense can up risk / Balt. Examiner

Op-Ed, 11/23/08

Two clear facts shine from the clouded mystery of anthrax attacks on America and our government’s tenuous claim seven years later of closing the case with the suicide of a suspect.

Fact No. 1: Government warnings about anthrax being a weapon of mass destruction were false. Somebody dispersed the most lethal strain our tax dollars can produce — weapons-grade or near enough — via the U.S. Postal Service, exposing tens of millions of people, yet managed to infect 22. Five died. But from anthrax vaccination, at least 21 died and thousands reported a wide range of illnesses.

Fact No. 2: If FBI accusations against their prime suspect in the 2001 attack are true, it means billions of dollars taxpayers invested on the premise of prevention actually increased the risk.

When senior biodefense researcher Bruce Ivins died from an overdose of Tylenol 3 after being identified as sole suspect, our central
government declared the crime solved.

However, co-workers at the U.S. Army Medical Institute of Infectious Diseases at Fort Detrick in Frederick say the actions attributed to Ivins over the time the government claims are scientifically impossible.

This is going to be another never-healing wound in America’s body of unsolved mysteries.

But mystery should not distract us from the truth. Our government’s response to bioweapons is raising the danger level from them.

Think it through, citizens. The very vaccination program intended to thwart anthrax apparently sickened and killed more people than an actual mass attack.

After the 2001 attack, our government hurled $41 billion at bioterror with no real coordination or study. High-level labs multiplied threefold. A dozen agencies exponentially increased the number of facilities and workers handling pathogens. Now we have more than 15,000 potential Bruce Ivins.

Meanwhile, our leaders provided no adequate increase in oversight, coordination, training, security, surveillance, testing, background checks or psychological screening.

Statistically, something going horribly wrong now approaches sure thing. That is not just a threat to residents of Frederick, Bethesda and other communities. It is, as the spread of anthrax spores proved, a threat to the whole world.

We learned in 2001 the actual danger from anthrax was lower than vaccine.

But these biohazard labs grow a lot more dangerous pathogens than anthrax. The next one to get out could kill millions.

President Bush must immediately halt programs until we can impose coordinated oversight, then assess security and capacity needs.

We must not let self-defense become self-inflicted catastrophe.

Link to GAO reports
http://www.gao.gov/products/GAO-08-108T High-Containment Biosafety Laboratories
http://www.gao.gov/products/GAO-07-333R Issues Associated with Expansion

Blinded by the Science: Research Advisory Committee Report Includes Data from 9 Studies of Anthrax Vaccine and Gulf Illnesses

And every one of the nine studies found a relationship between receiving anthrax vaccine and developing symptoms of Gulf War Syndrome. In eight of the nine studies, the relationship was statistically significant. The study with non-significant results was partly retracted by the authors (from the group associated with Simon Wessely, a UK psychiatrist and controversial Gulf War researcher/grantee) after widespread criticism. Please view these data for yourself; they are included as Appendix A-12a in the RAC's report.

It is incomprehensible how the RAC could have reviewed and published these data, then claimed that anthrax vaccine had been "ruled out" as a cause of Gulf War illnesses.

Perhaps someday the concept of Science as an apolitical, scrupulously honest endeavor will return to our culture. But for now, governmental Science is just another buzzword.

Costly program with a shady past // Sickening results

Deborah Rudacille of the Baltimore Examiner has two more excellent articles exploring the underside of anthrax vaccine; its manufacturer Emergent Biosolutions (formerly named Bioport); and how the anthrax attacks provided life support to both the vaccination program, which was about to be cancelled, and to Emergent, which produced only one product: anthrax vaccine.

Exhaustively researched, both articles are must-reads:

Sickening results

Costly program with a shady past

Md. lawmakers consider anthrax investigation commission

By Sara Michael http://www.baltimoreexaminer.com/local/112108emsANTHRAX.html
Baltimore Examiner 11/21/08

U.S. Rep. Elijah Cummings’ Washington, D.C., office was shuttered in 2001 after anthrax spores were found, so he’s “very sensitive” to the investigation into the crime, he said.

Now, Cummings said he supports a review of the investigation. U.S. Rep. Rush Holt, D-N.J., proposed legislation in September to create a congressional commission to investigate the attacks and the federal government’s response.

“Whatever we have to do to get to the bottom of this anthrax issue, we need to do it,” Cummings said.

Holt’s bipartisan commission would mirror the 9/11 commission and make recommendations on how to prevent such attacks and respond to future bioterrorism threats.

Holt also has questioned the response.

The tainted letters were mailed from his district.

“Myriad questions remain about the anthrax attacks and the government’s bungled response to the attacks,” Holt said in a statement.

The FBI named Bruce Ivins, a microbiologist at Fort Detrick in Frederick, the sole perpetrator of the 2001 attacks.

Ivins died of an apparent overdose in July.

But lawmakers and scientists alike have raised doubts about the FBI’s conclusion.

Cummings said he “didn’t know” if he agreed with FBI’s conclusion.

“I wonder about that. That’s all I can say,” he said.

U.S. Sen. Ben Cardin, D-Md., also has raised concerns about the FBI’s handling of the case and questioned FBI Director Robert S. Mueller III at a hearing in September.

Cardin was still reviewing Holt’s legislation this week and could not comment yet on whether he supports it, said spokeswoman Sue Walitsky.

U.S. Rep. Roscoe Bartlett, R-Md., who represents Frederick, also has expressed skepticism, saying recently that the law enforcement activities resulted in Ivins’ suicide and “damaged morale” among Fort Detrick employees.

“Congressman Bartlett has not been persuaded by the FBI’s evidence presented to date,” said spokeswoman Lisa Wright.

Bartlett also has shown interest in Holt’s measure, but wasn’t sure Holt will reintroduce it in the next session, Wright said.

Holt’s spokesman Zach Goldberg said Holt does plan to reintroduce the measure.

GWS Report: Funny How the Vaccine Message Changed

Reading the entire chapter on vaccines, the RAC report does a fairly good job of reviewing the evidence (with a few notable omissions) and its recommendations are sound:

from page 125 of the report:

Recent studies have indicated that the current anthrax vaccine is associated with high rates of acute adverse reactions, particularly in women. No information is available on rates of persistent symptoms or multisymptom illness following receipt of the anthrax vaccine. Studies have not identified excess hospitalizations or outpatient visits for diagnosed diseases in the weeks and months following receipt of the vaccine. Limitations in the types of information provided by these studies, however, indicate a continued need for long term follow up, to determine whether excess rates of diagnosed or undiagnosed conditions occur in anthrax vaccine recipients.

and from page 127:

Recommendations

Diverse concerns have been raised in relation to vaccines received for the Gulf War, but relatively little reliable information has implicated individual vaccines as prominent risk factors for Gulf War illness. Several issues related to vaccines received by Gulf War veterans have not been adequately addressed by existing research. These include the need for more thorough evaluation of vaccines as risk factors for chronic health problems in epidemiologic studies, a definitive study to conclusively evaluate the previously-­observed association between squalene antibodies and Gulf War illness, and the need for longer­ term evaluation of symptoms and diagnosed diseases following receipt of the anthrax vaccine.

The Committee therefore recommends the following research:

• In previously-­conducted and future epidemiologic studies of Gulf War veterans, analyze associations between Gulf War illness and individual vaccines, combinations of vaccines, and total number of vaccines received using methods that control for potential confounding by other Gulf War­-related exposures.
• Commission a case­-control study to provide clear answers concerning possible associations between Gulf War illness and squalene antibodies. The study should, at minimum, analyze blinded samples from well­ characterized symptomatic and healthy Gulf War veterans for the presence of squalene antibodies using each of the assays developed for this purpose. It should also assess whether there is an identifiable link between levels of squalene antibodies in ill Gulf War veterans and receipt of the anthrax vaccine or vaccines more generally. The project should be organized and overseen by qualified investigators not affiliated with the federal government or civilian scientists whose initial work raised the squalene issue in relation to Gulf War illness.
• Evaluate the association of anthrax vaccine adsorbed (AVA) with chronic symptoms, Gulf War illness, and diagnosed diseases in personnel known to have received the anthrax vaccine during the Gulf War. These health outcomes should also be assessed at least five years after vaccination in deployment and era subgroups of personnel in the Millenium Cohort study as well as other groups vaccinated in association with the military’s anthrax vaccine immunization program and federal anthrax vaccine trials.

* But what message did the media get when it interviewed RAC members?

LA Times: " the panel... could find no evidence linking it [GWS] to depleted uranium shells, anthrax vaccine and infectious diseases."

US News and World Report: "There are other factors that, while not likely causes of Gulf War illness, can't be ruled out, Steele said. These include exposure to nerve agents, exposure to smoke from oil well fires, and vaccines given to the troops. The panel ruled out depleted uranium and anthrax vaccine as causes.

The Newshour with Jim Lehrer: "James Binns: Many other exposures that were also happening in the gulf at that time, depleted uranium munitions, anthrax vaccines, special paints and solvents that were used, we do say that the evidence does not show that they were significantly connected."

Either the evidence is adequate and reliable, in which case you can "rule out" that exposure as a cause, or you need more evidence and can say very little about whether that exposure may have caused GWS, and in how many veterans. In the case of anthrax vaccine the RAC's chairman and former scientific director are trying to have it both ways. In so doing, they are mirroring behavior of earlier GW scientists and administrators criticized in their report. The committee's work is critically important to help Gulf War veterans, yet flaws of this kind diminish the report's (and committee's) reliability and value to veterans. This is a pity.

Gulf War Illness and the Health of Gulf War Veterans: Scientific Findings and Recommendations

A major report on Gulf War Illness written by the VA Research Advisory Committee on Gulf War Veterans' Illnesses (RAC) was made public on November 17. This is the most important document yet produced on Gulf War illnesses. About 1800 references are cited. The report gets it right about how many have developed the syndrome (25% of those deployed during 1990-1991) and the medical conditions they are experiencing. It emphasizes the desperate need for effective treatments to be developed and used in this population. The report also discusses a number of potential causes of the syndrome, and rules them in or out as significant factors in the report's executive summary.

This report expands on many issues discussed in my September 2007 Senate Veterans Affairs testimony on Gulf War Syndrome. I discussed a greater number of soldiers' exposures (for several of which only limited evidence is available) that were not considered in this report. Overall, my testimony and this report agree about most things.

However, I weighed the existing evidence differently than the RAC did. Yet we both took a weight of evidence approach. How does one weigh evidence? Imho, it always involves subjectivity.

I used an approach which gave more weight to researchers whose work appeared to be of higher quality, and to evidence derived from 3 or more different groups that used different study methods but yielded the same conclusion. I gave less weight to researchers whose work received substantial criticism, was not internally consistent, or used weak methodologies. I disregarded studies whose results conflicted with those of multiple other researchers. I factored in less tangible factors as well: how politicized choices led to certain research being performed (such as a large body of research favoring psychiatric causes, which was also dismissed by the RAC report) while other valid research was omitted or buried. With respect to anthrax vaccine, in the face of limited and contradictory data we drew very different conclusions.

From the Executive Summary: "About 150,000 Gulf War veterans are believed to have received one or two anthrax shots, most commonly troops who were in fixed support locations during the war. Although recent studies have demonstrated that the anthrax vaccine is highly reactogenic, there is no clear evidence from Gulf War studies that links the anthrax vaccine to Gulf War illness. Taken together, limited findings from Gulf War epidemiologic studies, the preferred administration to troops in support locations, and the lack of widespread multisymptom illness resulting from current deployments, combine to indicate that the anthrax vaccine is not a likely cause of Gulf War illness for most ill veterans. However, limited evidence from both animal research and Gulf War epidemiologic studies indicates that an association between Gulf War illness and receipt of a large number of vaccines cannot be ruled out.

...There is little reliable information from Gulf War studies concerning an association of DU or anthrax vaccine to Gulf War illness. The prominence of both exposures in more recent deployments, in the absence of widespread unexplained illness, suggests these exposures are unlikely to have been major causes of Gulf War illness for the majority of affected veterans."

Yet the RAC cited another study of self-reports indicating that approximately 300,000 GW veterans received anthrax vaccine. According to self-reports, the vaccine correlates highly with GWS. According to DoD, most of the self-reports are wrong. But other studies indicate that self-reports in GW veterans are highly reliable. Four studies (from 4 different research groups, and presented by the RAC at meetings I attended) show that anthrax vaccine is correlated with GWS, with a relative risk of 1.5-1.92. A Senate report of 1995 noted that relatively more veterans in support locations had GWS, a reason to suspect anthrax vaccine. Which report is correct on this point?

Why are there limited findings from epidemiologic studies? The RAND report on vaccines, first completed in 1999 and later revised, is the only one of eight RAND reports on Gulf War exposures that has never been released. The two studies billed as investigating the long-term effects of the vaccine (the Tripler and CDC studies) have so far not released the long-term safety data they collected. The Defense Medical Surveillance System, according to the Institute of Medicine (IOM) the most important database for studying anthrax vaccine safety, has been kept under wraps since 2001, when it had to be shared with the IOM. Why have eight expert groups during the last ten years called for long-term safety studies, but none are available? The reason is political.

Due to lack of hard data, the report ignores the many soldiers since the Gulf War who received anthrax vaccine and developed an identical illness as GWS. It also seems to have ignored limited data that current OIF/OEF veterans are developing undiagnosed illnesses at a rate of 15-40%. (According to the Veterans Health Administration Office of Public Health and Environmental Hazards, August 2008, of those 347,750 veterans of the Global War on Terror who have sought care in the VA system, 39.7% have demonstrated "Symptoms, signs and ill defined conditions" while 42.5% have mental disorders, 34.9% have diseases of the nervous system/sense organs, 31.8% have digestive disorders and 47.6% have diseases of musculoskeletal system/connective system. This is certainly a red flag that GWS could be affecting a large number of recent veterans, yet the RAC is unaware that many new veterans may suffer similar illnesses as those of the first Gulf War. "Newly released documents reveal that more than 150,000 soldiers who left the military after serving in Iraq and Afghanistan have been at least partly disabled as a result of service–this translates to one in four veterans."

These veterans have been exposed to vaccines and depleted uranium, but much less routinely to pyridostigmine, and not to sarin. If new veterans are, in fact, developing GWS-like illnesses, it would cast doubt on the RAC's conclusions.)

Scientific impossibility: Did FBI get their man in Bruce Ivins?

"Bruce Ivins was a cold-blooded murderer, a deranged psycho-killer, who in the fall of 2001, cooked up a virulent batch of powdered anthrax, drove to Princeton, N.J., and mailed letters loaded with the lethal mix to five news organizations and two U.S. senators.

At least, that’s what the FBI says.

The letters infected 22 people, killing five, including two Maryland postal workers. The sixth victim of the madness was Ivins himself, a 62-year-old biodefense researcher at the U.S. Army Medical Research Institute of Infectious Diseases, who committed suicide rather than face charges.

Case closed? Neatly wrapped up? ..."

Deborah Rudacille of the Baltimore Examiner provides another in-depth look at the evidence in this case, exploring the time it would take to make the anthrax preparations. She also mentions the presumed contamination by Bacillus subtilis found in some of the letters, whose origin was not investigated by FBI, despite being an important clue. Read the complete article here.

US military chem-bio warfare exposures website unveiled

Justin Palk, Frederick News-Post

http://www.fredericknewspost.com/sections/archives/fnp_display.htm?storyID=88347 From World War II through 1975, thousands of service members and veterans were potentially exposed to chemical or biological weapons as subjects or observers of tests carried out by the Department of Defense. The department unveiled a new website Monday to provide information about what happened during those tests. The data on the site is broadly grouped into three sections: chemical agent tests during World War II; chemical and biological agent tests of Project 112 and its naval component, Shipboard Hazard and Defense or Project SHAD; and Cold War-era chemical and biological weapons testing. The site provides details about specific incidents, such as the release of mustard agent in the Italian port of Bari in 1943 when a U.S. ship carrying the agent to use in response to theoretical German gas attacks was destroyed during a German air raid on the port. Overview sections give broad outlines of what types of testing were performed at what points in history. The biological warfare research at Fort Detrick and the Operation Whitecoat disease immunity experiments are listed under the Cold War section of the site, as are Dugway Proving Ground and Edgewood Arsenal, both sites where chemical weapons research was done. The site does not list the names of service members who might have been exposed to chemical or biological agents. It does, however, include contact information veterans can use to seek help in verifying any potential exposure they may have had, or to provide information they may have about tests the Defense Department conducted. For information, visit fhp.osd.mil/CBexposures/index.jsp