Bioterrorism: Could it Happen? Are We Prepared?

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Bioterrorism: Could it Happen? Are We Prepared?

The best selling book, The Cobra Event, by Richard Preston weaves a chilling tale of a lone terrorist attack in New York City with a lethal, genetically engineered virus. The reader can't help but wonder if such an event could happen in the United States. If so, would we recognize it, and, more importantly, are we prepared to respond? With the recent terrorist attacks on our country, the possibility of a biological or chemical release must be considered much more seriously.

Historical Perspective

As far back as the Middle Ages, long before germ theory was well known, plague infected bodies were catapulted over fortress walls in order to terrorize and conquer. In 1767, during the French and Indian Wars, the British gave blankets previously used to wrap smallpox victims to hostile Indian tribes. In 1945, Germany used raw sewage to poison a reservoir in Bohemia. And finally, in 1979, the accidental release of anthrax spores from a Soviet military facility caused an outbreak of pulmonary anthrax in Sverdlovsk USSR. It wasn't until 1969 that President Nixon dismantled the United States' offensive biological weapons program.

The most significant biological attack in the U.S. occurred in 1984 in Dallas, Oregon when Salmonella was sprayed on eight salad bars by members of the Rajhneeshees in an attempt to manipulate local elections by incapacitating voters. Over 750 residents were affected.

Why Biological Weapons?

While most terrorists still use conventional bombs and bullets, biological weapons, despite having a much lower probability of use, could have a much greater impact overall. In addition, one should consider that:

  1. Biological agents are relatively inexpensive to purchase or produce;

  2. These agents are difficult to detect and the terrorist could be long gone before anyone recognizes the presence of illness caused by these agents;

  3. Biological agents have the capability of causing mass casualties with relatively small quantities. Chemical agents require tons of material to affect the same population that a couple pounds of a biological agent would affect.

Fortunately, it is difficult to produce a "weaponized" form of a biological agent. The organism must undergo difficult drying processes in some cases and be reduced to particles small enough to be effective as an aerosol. There is also the fear and risk of self infection by the perpetrator.

Elements of Preparedness

The covert release of a biological agent would initially go undetected. Infected persons would begin to present at doctors' offices, clinics and hospital emergency rooms days after a release. There would be no explosions, no fires or any visible crime scene. The first responders would be the medical and public health personnel. The longer the disease is undetected and undiagnosed, the more likely that more people would become ill and die. State and federal help wouldn't be at our doorstep in the initial stages, and our local community would be on its own.

However, preparatory activities are well underway in Santa Clara County. The city of San Jose, with the aid of federal funding, has begun training police and fire personnel. The Metropolitan Medical Task Force (MMTF), which would function in a support role to medical providers in a biological event, has been meeting for the last couple years. It is made up of a multidisciplinary group of individuals, including public health experts.

A special agent from the local FBI has been an active participant in our planning. The FBI will be in charge of the criminal investigation during any possible terrorist event.

The Weakest Link in Preparedness

There is no doubt that early detection and recognition will be critical in responding to a bioterrorist attack. This will require a sophisticated surveillance system and a very knowledgeable medical community. The Public Health Department is working with state and federal officials to develop better surveillance systems to detect unusual or suspicious disease occurrences. In addition, we have developed a fax and email rapid alert system to provide information to medical providers. Physicians in the county should have received a fax alert from the Public Health Department on September 11. If you did not, please call our office at (408) 885 4214 and ask to be placed on the Rapid Alert Network list, If you have not already provided your email address, please e mail your name, affiliation and specialty to : We will send alerts by both e mail and fax.

A training seminar held last November in San Jose entitled "Looking for Zebras" focused on recognizing the unusual diseases that might be the result of a bioterrorist attack. "Zebra packets" were produced and distributed to attendees. Additional binders were sent to all local emergency departments and more binders are being printed for institutional use. The primary contents of the "Zebra packet" will also be available on the Public Health website:

The local public health response to bioterrorism is structured according to the"Disaster Medical Health Plan," which guides the medical response during any disaster. A newly established Department Emergency Operation Center (DEOC) within the Public Health Department will serve as the medical response headquarters.

The federal government has led the broader planning effort and has established the National Pharmaceutical Stockpile, which consists of eight separate "push packs" located strategically across the U.S. The "push packs" contain nearly $4 million worth of drugs, vaccines and materials necessary to respond to a massive community disease event. They can be delivered within 12 hours upon request.

Hopefully, we will never need to use the preparation plans being developed. However, it is critical that we are well prepared for an attack, as the consequences could be devastating. I would urge all medical providers to have some understanding of the likely agents and how they might present. This special edition of the Santa Clara County Medical Association Bulletin is a condensed version of the Zebra Packet and provides basic information on the most likely biological agents as well as instructions for reporting.

What are the Likely Agents of Biological Terrorism?

Category A

The U.S. public health system and primary health care providers must be prepared to address varied biological agents, including pathogens that are rarely seen in the United States. High priority agents include organisms that pose a risk to national security because they:

  • can be easily disseminated or transmitted 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.

Category A agents include:

  • variola major (smallpox);

  • Bacillus anthracis (anthrax);

  • Yersinia pestis (plague);

  • Clostridium botulinum toxin (botulism);

  • Francisella tularensis (tularemia);

  • filoviruses,

  Ebola hemorrhagic fever,

  Marburg hemorrhagic fever; and

  • arenaviruses,

  Lassa (Lassa fever),

  Junin (Argentine hemorrhagic fever) and related viruses.

Category B

Second highest priority agents include those that:

  • are moderately easy to disseminate;

  • cause moderate morbidity and low mortality; and

  • require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance.

Category B agents include:

  • Coxiella burnetti (Q fever)

  • Brucella species (brucellosis)

  • Burkholderia mallei (glanders)

  • alphaviruses,

  Venezuelan encephalomyelitis

  eastern and western equine encephalomyelitis

  • ricin toxin from Ricinus communis (castor beans)

  • epsilon toxin of Clostridium perfringens

  • Staphlylococcus enterotoxin B.

A Subset of List B agents includes pathogens that are food-or waterborne. These pathogens include but are not limited to:

  • Salmonella species

  • Shigella dysenteriae

  • Escherichia coli 0157:H7

  • Vibrio cholerae

  • Crtptosporidium parvum

Category C

Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of:

Category C agents include:

  • Nipah virus

  • hantaviruses

  • tickborne hemorrhagic fever viruses

  • tickborne encephalitis viruses

  • yellow fever

  • multidrug-resistant tuberculosis.

Preparedness for List C agents requires ongoing research to improve disease detection, diagnosis, treatment and prevention. Knowing in advance which newly emergent pathogens might be employed by terrorists is not possible; therefore, linking bioterrorism preparation efforts with ongoing disease surveillance and outbreak response activities, as defined in CDC's emerging infectious disease strategy, is imperative.

CDC. Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response. MMWR. April 21, 2000; Vol. 49; No. RR-4.

SCCMA - October 2001 Special Edition 5

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