Elsevier

Disease-a-Month

Volume 48, Issue 8, August 2002, Pages 493-564
Disease-a-Month

Biological terrorism: Understanding the threat, preparation, and medical response

https://doi.org/10.1067/mda.2002.129453Get rights and content

Abstract

The thought of an outbreak of disease caused by the intentional release of a pathogen or toxin in an American city was alien just 10 years ago. Many people believed that biological warfare was only in the military's imagination, perhaps to be faced by soldiers on a far-away battlefield, if at all. The “anthrax letters” and the resulting deaths from inhalation anthrax have changed that perception. The national, state, and local governments in the United States are preparing for what is now called “not if, but when and how extensive” biological terrorism. In contrast to the acute onset and first-responder focus with a chemical attack, in a bioterrorist attack, the physician and the hospital will be at the center of the fray. Whether the attack is a hoax, a small food-borne outbreak, a lethal aerosol cloud moving silently through a city at night, or the introduction of contagious disease, the physician who understands threat agent characteristics and diagnostic and treatment options and who thinks like an epidemiologist will have the greatest success in limiting the impact of the attack. As individual health care providers, we must add the exotic agents to our diagnostic differentials. Hospital administrators must consider augmenting diagnostic capabilities and surveillance programs and even making infrastructure modifications in preparation for the treatment of victims of bioterrorism. Above all, we must all educate ourselves. If done correctly, preparation for a biological attack will be as “dual use” as the facility that produced the weapon. A sound public health infrastructure, which includes all of us and our resources, will serve this nation well for the control of the disease, no matter what the cause of the disease.

Section snippets

The genesis of today's bioterrorism threat: The cold war era

In the early 20th century, the goals of the first proliferators of biological weaponry were to select agents and delivery methods that produced the desired effect in a reasonably controlled manner without causing harm to their own troops or citizens. The first, and probably only, use of biological agents on a large scale against human beings in this century was planned and executed by the Japanese against the Chinese during World War II.2 There is also some evidence that the Soviets may have

Classic cold war agents

During the Cold War, which reached its peak in the 1980s, the Soviet Union and the United States and its allies, Great Britain and Canada, developed biological weapons. These nations' programs were developed independently as highly classified endeavors. Yet, of the thousands of bacteria, viruses, and biological toxins available in nature, the proliferators typically selected fewer than 20 agents for weaponization—and their lists were strikingly similar. (There is evidence that the Iraqi program

Individual disease agents

The sources listed below can also be found in the references at the back of this article; however, we believe these two works to be extraordinarily useful and comprehensive as ready sources of essential information on disease agents and preparation for bioterrorist attack, and as such, they deserve special attention.

The attack

The likelihood of a strategic attack by Russian ICBMs carrying Y pestis or variola is much lower than it was 10 years ago. Yet, the likelihood of a biological terrorist attack on our cities is believed by most experts to be higher than it was when the Soviets were the major threat. There are numerous potential scenarios for attack, but in simplest terms, the covert and overt approach will be considered here.

Preparation for a biological attack: What can a medical facility do?

It is the physician and the medical facility, not necessarily the paramedics, police, and fire service that will take the brunt of a biological terrorist attack. The prepared physician, hospital, and medical center have the potential of making an enormous difference in outcome after an attack. Therefore, preparation at this level is critical. Fortunately, much of what should be done in anticipation of a biological terrorist attack is also applicable to any public health disaster or infectious

Conclusion

The limitation and eventual elimination of both chemical and biological weapons are two of the greatest challenges facing the international community in this century. Unfortunately, proliferation of such weapons is continuing despite the best efforts of many nations, including the United States, to prevent proliferation.62 Biological weaponry is the most worrisome issue because of the relative ease in developing and mass-producing potent agents, the continuing difficulties in identifying enemy

Acknowledgment

We acknowledge the extensive assistance provided by Joan T. Zajtchuk, MD, Spec. in HSA, during the revision of this manuscript. Her constructive and detailed editorial oversight contributed to the accuracy and clearer presentation of the subject matter.

Chemical Terrorism Defense

Chemical terrorism differs from biological terrorism in many ways (Table A1).

. Comparison of toxins and chemical agents

CharacteristicsToxinsChemical Agents
OriginNaturalMan-made
ProductionDifficult, small-scaleLarge-scale industrial
VolatilityNone volatileMany volatile
Relative toxicityMany are more toxicLess toxic than many toxins
Dermal activityNot dermally active*Dermally active
UseLegitimate medical useNo use other than as weapons
Odor and tasteOdorless and tastelessNoticeable odor or taste
Toxic

Agricultural Terrorism and Implications for Public Health

For almost all human diseases and zoonotic disease agents that might be used against human beings, the risk of transmission from an exposed individual to another is relatively low. Exceptions, as mentioned above, are smallpox and influenza of the type encountered in the early 20th century. The relatively low transmissibility of most human agents makes production of a mass casualty event dependent on presentation of the agent to the target as a respirable aerosol cloud. A major difference

National Information Resources

National information resources include:

  • Health and Human Services/Centers for Disease Control/National Centers for Infectious Diseases (domestic preparedness) http://www.bt.cdc.gov/

  • Health and Human Services/Office of Emergency Preparedness (consequence management), www.ndms.dhhs.gov

  • Department of Defense/US Army, Borden Institute (Textbook of Military Medicine), http://www.armymedicine.army.mil/history/borden/default.htm

  • Department of Defense/US Army Medical Research Institute of Infectious

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