INTRODUCTION

Anthrax | Smallpox | Plague | Botulism | Tularemia | Links & References

http://www3.baylor.edu/~Charles_Kemp/bioterror.htm

It is not if, but where and when

In light of the September 11, 2001 World Trade Center and Pentagon attacks, biological terrorist acts in the United States seem more likely than ever before. We know there are people willing to die to kill Americans and we know that nations with a history of supporting terrorism have biological warfare (BW) capability. BW capable terrorist states include Iraq, Libya, Syria, and Iran - all of which have close ties to transnational terrorist groups such as Al-Qaeda, Armed Islamic Group of Algeria, and Al-Jihad of Egypt (Dao, 2001; Davis, 1999; McGovern, Christopher, & Eitzen, 1999; Sanger & Kahn, 2001). The threat is not limited to these nations or groups, but all do present a clear danger. According to the U.S. Central Intelligence Agency, operatives of Al-Qaeda (the Osama bin Laden group) "have trained to conduct attacks with toxic chemicals or biological toxins" (Broad & Peterson, 2001). Click here to read the "fatwa" that inspired 9/11. Click here for Hamas's response to September 11. See U.S. Department of State Report on Global Terrorism published May, 2002

Most planning for biological attack response is at local levels and preparedness is poor (Moser, White, Lewis-Younger, & Garrett, 2001; Wetter, Daniell, & Treser, 2001). In most locales, civilian resources to meet BW attacks are limited to resources currently in use, i.e., hospitals, EMS, law enforcement, and private providers; which, in the case of a significant attack, are likely to be quickly overwhelmed (Broad & Peterson, 2001; Garrett, Magruder, & Molgard, 2000; Terriff & Tee, 2001; Wetter, Daniell, & Treser, 2001).

The Centers for Disease Control (CDC) has developed strategic plans for domestic BW. These plans are focused primarily on planning, detection and surveillance, laboratory analysis, emergency response, and communications (CDC, 2000). The federal government has begun establishing stockpiles of pharmaceuticals essential to treat victims of BW, but these are unlikely to be adequate to the task if there is a large attack (Khan, Morse, & Lillibridge, 2000). The military is better prepared than other government entities to meet domestic BW attacks, but a harsh reality is that in a widespread attack, military resources might not be diverted to civilian interests - except to prevent civilian encroachment on military facilities.

CDC Contact: Duty Officer of the day at 404-639-2807 (8:00am to 4:00pm) or 404-639-7100 (after hours)

Biological agent attacks present a unique problem in warning and response: In many cases, if the attack proceeds as planned, the people under attack would not be aware that the attack occurred until hours or days later, depending on the agent and its incubation. Thus emergency departments and primary care providers are likely to be the earliest warning source (as well as among the first to be secondarily exposed). Response, of course, would be hindered by already busy resources overwhelmed by enormous numbers of extraordinarily sick and contaminated victims; by inadequate facilities and medications supplies - and in many cases, by inadequate planning and training (Broad & Peterson, 2001; Henry, 2001; Mabee, 2001; Macintyre, Christopher, Eitzen, Gum, Weir, DeAtley, Tonat, & Barbera, 2000; Siegelson, 2000). The inability to respond to a significant BW attack would most likely lead to massive social and political disorder (Bardi, 1999).

While there are a variety of means of BW agent delivery, the most likely in a domestic context is aerosol (Burrows & Renner, 1999). This is because the most lethal weaponized agents (anthrax, plague, smallpox, tularemia, and botulinum toxin) are efficiently delivered by aerosol methods and because other means either do not work or are inefficient. Contamination of a large-scale water supply is difficult because of (1) the volumes water in large-scale supplies would necessitate very large volumes of the agent, (2) not all weaponized agents are waterborne threats (including the most lethal agents), and (3) the presence of more efficient and common means of delivery (Burrows & Renner, 1999). Person-to-person (secondary aerosol) transmission will occur with some agents, especially plague and smallpox.

On a smaller scale, it is possible that attempts may be made to contaminate food with agents such as botulinum, staphylococcus enterotoxin B, and cholera. (I wrote the previous sentence before the onset of the low-level anthrax mail attack of fall, 2001. Now we know what even a very small attack can do in terms of social disruption.) It is possible that more than one means of delivery and several agents may be used simultaneously in an attack (Davis, 1999).

Critical Biological Agents: Category A

Note: Category A agents pose a risk to national security because they "can be easily disseminated or transmitted from person to person; cause high mortality, with potential for major public health impact; might cause public panic and social disruption; and require special action for public health preparedness" (CDC, 2000, p. 5).

• Anthrax (Bacillus anthracis)

• Smallpox (variola major)

• Plague (Yersinia pestis)

• Botulism (Clostridium botulinum toxin)

• Tularemia (Francisella tularenis)

• Ebola and Marburg hemorrhagic fevers (filoviruses) (separate section - not yet presented here in "weaponized" [a word of the times] discussion)

• Lassa, Junin, and related arenaviruses (separate section - not yet presented here in weaponized discussion)

In this article only the first five agents are discussed (links in several places on this page), as they are the most likely biological agents to be used in a domestic terror BW attack. Of these five, four are known to have been extensively studied by the Soviet Union/Russia and the capacity to produce these as weaponized agents was measured in hundreds of tons. Iraq also developed and likely still has capability to produce and deliver several Class A agents as well as Class B and chemical agents (Davis, 1999; Kortepeter & Parker, 1999). A subsequent article will discuss chemical agents such as nerve, blood, and blister agents.

Empiric therapy

Although there is not widespread acceptance (or rejection) of the idea, the battlefield concept of empiric therapy may be indicated when large numbers of people present with undifferentiated febrile illness with similar time of onset and under credible threat of biological attack. Under such circumstances, and when medical facilities are not readily available, empiric therapy is ciprofloxacin 500 mg po (or IV) every 12 hours or doxycycline 200 mg po (or IV) initially and then 100 mg every 12 hours until danger has passed, been dismissed, or specific therapy initiated (Cieslak, Rowe, Kortepeter, Madsen, Newmark, Christopher, Culpepper, & Eitzen, 2000). Note that the authors are writing about battlefield conditions - which we may see in the homeland.

A summary of major BW agents and properties follows below.

Table 1. Summary of Selected Class A Biological Warfare Agents (If there are problems printing the table, paste into Word and print.)

URL: http://www.baylor.edu/~Charles_Kemp/bioterror.htm (Last update 1/25/2002)

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Links & References (separate file)

Author: Charles Kemp, FNP, Senior Lecturer in Community Health - Louise Herrington School of Nursing Baylor University.

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