Public Health Management of Bioterrorism

                                      Prabhakar Parimi. MD

“Ingenuity, knowledge and organization alter but cannot cancel humanity’s vulnerability to invasion by parasitic forms of life. Infectious diseases which antedated the emergence of humankind will lost as long as humanity itself, and will surely remain, as it has been hitherto, one of the fundamental parameters and determinants of human history”

William E. McNeill. Plagues and People, 1976(1)




Definition of Bioterrorism and Biological Weapons

Bioterrorism is defined as “the unlawful use of a biological agent or toxin against persons and property, in order to intimidate or coerce a government or civilian population in furtherance of political or social objectives “

Bio-weapon is “a weapon comprising of biological agent or toxin that is designed or intended to cause death or serious injury through release and dissemination”

Historical Perspectives on Biological Weapons:

The use of biological agents or its toxins as weapons is neither novel nor new to the 21st Century. The sequence of events from as early as Herodotus (poisoned arrows of Scythians) and Hannibal (use of poisoned snakes), to the use of biological and psychological warfare, initiated during an epidemic of bubonic plague in Kaffa in14th Century, and from the weaponization and dissemination of anthrax using warhead by the British to the use of postal system in the USA, are the testimony to mankind’s extraordinary abilities to use microbial agents as biological weapons .The concept of bio-weapons antedates dates as far back as 600 BC by poisoning of wells with rye ergot and contamination of water supplies with a purgative such as hellebore. Such acts were to inflict a heavy toll on enemy troops. Herodotus and Thucydides, famous Greek historians, described arrows as tipped with poison, obtained from the decomposed bodies that probably contained tetanus and botulism toxins. These arrows were suggested to have been used by the Scythians archers and also for the poisoning of wells resulting in a massive outbreak that killed many Athenians during the Peloponnesian War (2).

In the 14th and 15th Centuries, knowledge on germs and their role in the causation of diseases was unknown. Many diseases were considered to be caused by miasma or bad air. The decomposed bodies were used as ammunition to transmit diseases and inflict a heavy toll on enemy troops. Between 1340- 1422, humans’ corpses, dead horses and other animals were catapult during the siege of Kaffa, Hainault (Now Northern France) and Bohemia (3). The use of dead corpses as bio-weapons was instrumental for the attack on the city of Kaffa (presently Ukraine) by the Tartar army. This resulted in the beginning of the Dark Age in the Europe due to transmission of bubonic plague. The outbreak of bubonic plague among their own troops, due to abundance of rats, assisted the Tartar army during the capture of Kaffa in 1346.  Bodies of plague victims containing rat fleas were catapulted over the walls of Kaffa to initiate an epidemic in the enemy territory. Rats and fleas that were infected in merchant ships during the war may have contributed to the spread of the disease from Italy to Spain, France and other European countries by 1350. The introduction of the bubonic plague had devastating social, psychological, economic and human fabric consequences in Europe, hence the term Dark Ages. The signs and symptoms of bubonic plague without knowledge of the causation of the disease is well characterized in the 17th century (4). However, the efficiency of this strategy was again tested with success by the Russian Army by catapulting bodies of those who died of plague in Estonia in 1710 (5).


Modern Era: (18th Century to Present time)

            Although the epidemic nature of small pox was recorded between 1350 and 430 BC by the historians, the accurate medical description of transmission and immunity was written in about 910 AD (6 ). Small Pox affected the western civilization and spread to the new world by the Spanish and Portuguese conquerors. The nature of spread and the magnitude of devastation of the native population in the new world may have provided the first example of biological warfare.  During the French and Indian war between 1763- and 1767 (7), the British army was the first to experiment on the use of inanimate objects to transmit smallpox to the susceptible native population. This was the first recorded “bio-weapon” in North America that used blankets and hand kerchiefs under the disguise of gifts to deliberately reduce Native American Indians tribes.

The remarkable scientific inventions of Louis Pasteur (1822-1985) and Robert Koch (1843-1910) and their subsequent work has lead to the understanding of germ theory of disease and advancement of microbiology. This paved the way for the weaponization of microbes in this century.

Modern bio-weapon program was first initiated by Germany during World War 1. Biological agents such as Bacillus anthracis (Anthrax) and Bacillus mallei (Glanders) were used in the covert operation by deliberately infecting and exporting farm animals (sheep, horses and mules) (8). The most remarkable and the extensive biological warfare research and deployment was initiated by Japan from 1932 until the end of World War 11 ( 9). The Infamous Unit 731, under the direction of Dr.Shiro Ishii experimented on biological agents such as Shigella (bacterial dysentery), V.cholerae (cholera) and Yersina pestis (the bubonic plague) as a part of the program on prisoners (10). Field trials and deliberate attacks with biological agents such as cholera, anthrax, plague and salmonella were conducted to either contaminate water and food supplies or to disseminate these agents by spraying from aircrafts. The attack on China using cholera bacteria, resulting in high deaths in Japanese troops in 1941, clearly demonstrate the double-edged nature of bio-weapons. The German Offensive biological weapons program during the World War II focused on the study of natural history of disease and vaccine development in experimentally infected prisoners of Nazi concentration camps, than the weaponization of bacterial agents (11). The weaponisation of anthrax and its effectiveness in dissemination by a conventional warhead  was the focus of British BW Program but  an outbreak of anthrax in sheep and cattle and difficulty in de-contamination of the experimental territory may have affected continuation of  the program(12)

The biological warfare program in the United States of America and Soviet Union germinated out of the Unit 731 during 1940’s. The United States began its offensive biological weapons program in 1942.  The main purpose of the program was to develop research capacity and to test sites for investigation of the number of possible biological agents. During this time, the Soviet Union and Iraq independently developed their successful biological weapons program. The Soviet Union developed extensive research development and production capacity for bio-weapon under the name of Biopreparat in 1973-4. The nature and extent of the Biopreparat was published by  Ken Alibek , the defected former Deputy Director of the Program in a book entitled “ Biohazard: The Chilling True Story  of the Larger Covert Biological Weapons Program told from the Inside by the man who ran it (13).The United Nations Special Commission believes that Iraq is continuing  its biological weapons program but the true scope is unknown. Bioterrorist attacks have occurred in recent history and potential to occur both in the United States and world wide.          

Epidemiology of Bio terrorism:

“I keep six honest serving men  ( they taught me all I knew) their names are what ,why, and when and how and where and who” – Rudyard Kipling (14)

Epidemiological Triad is the underpinning philosophy of understanding bioterrorism for assessing the risk and developing and implementing prevention and control strategies. The Epidemiological triad is the Agent, the Host and the Environment.















A. Agent: Bio weapons / Biological agents:

The biological agents that are thought to be the likely cause of bioterrorist attacks are Bacillus anthracis (anthrax), Francisella tularensis ( tularemia), Yersinia pestis (plague) Variola virus (small-pox) toxins of Clostridium botulinum (botulism). Other agents include Brucella spp ( brucellosis) and ricin/mycotoxins.

Haemorrhagic Viruses: Ebola Virus, Hanta virus , Marburg, Dengue and other haemorrhagic fever viruses such as VEE, AHF etc have all the characteristics required to be a biological weapon such as the ease of infectivity, lack of available treatment and vaccine/s as well as ready availability of  prophylaxis (antibiotics or immuno-globulins)


The characteristics of an ideal biological weapon are the ease of procurement, simplicity of production in large quantities at minimal expense, ease of dissemination with low technology, and the potential to overwhelm the medical system with large numbers of casualties. Dissemination of a biological agent would be silent, and the incubation period allows a perpetrator to escape to great distances from the area of release before the first ill persons seeks medical care

B. Host: Susceptibility, Immunity, Disease Spectrum

Children are more susceptible to bio terrorism agent that is disseminated by release of aerosols as the respiratory rate is high. The inhalation type of anthrax has a high mortality rate. The small pox lesions in early stage could easily be confused with chickenpox infection (15). There are no current vaccines available for most of the above agents. Vaccination against small pox was stopped in late 1970’s when the disease was eradicated worldwide. The Anthrax vaccine is not routinely given to population. Susceptibility also depends on the incidence of immunological related diseases in the population such as HIV/AIDS, Lymphoma/Leukemia, and other immuno-deficiencies. The disease spectrum in these population may be quiet different compared to immuno- competent population.

Risk: The actual risk of these forms of terrorism remains small for the reasons explained bellow. The reason for which the risk remains low is because of the inherent limitations involved in acquiring, producing and turning biological agents into viable weapons. Such limitations are as result of factors such as the availability of the agents and their acquisition and transportation that require complicated storage containers. Also there are extreme obstacles to disseminating biological agents to specific targets since the agents must be kept alive and potent and must be delivered in sufficient quantities to cause the illness. To have an effective result large scale effects might be more efficiently achieved if the agent was delivered in the form of water or an aerosol cloud that would be inhaled by its victims.


C. Social/Environmental Factors: 

Inequity and Inequality, Political/ Religious/ Racial factors:

"Poverty in all its forms is the greatest single threat to peace, security, democracy, human rights and the environment," Michael Moore, head of the World Trade Organization (WTO), (16). Poverty accelerates turmoil and conflict. It creates an ideal environment for the recruitment of terrorists. The perception of oppression may initiate and incite ethnic and religious hatred. It is very obvious that it fuels the violent rejection of the social and economic order in developing countries. World Health Organization (WHO) is developing plans to step up its campaign for a huge increase in health spending in developing nations.  Concerns of poverty are also a factor that is a possible pre-cause for bio terrorism (17). The WHO commission on Macro-economics and Health recommended for an increase of $66 billion in health sector spending in developing countries by 2015 which is expected to boost the economic growth by six fold (18).

Environmental factors such as food shortage, rise in food supplies, unemployment and de-stabilization of social political and economic fabric of a country, contribute to the source of the epidemics of highly contagious agents in the agriculture and live stock sector (19).


Bioterrorism and Public Health:

The New York Times (5 February, 2000) reported that at least 12 countries have acquired or are trying to possess biological weapons. Some of the countries that have been identified to possess biological warfare capability include Iraq, Iran, Libya and Syria – all of them have close links with religious fundamental terrorist groups in the Middle East. (20)

1. Trends of Hoaxes and Cases related to Bioterrorism: The Monterey Institute’s Center for Nonproliferation Studies reported over 415 incidents involving the acquisition or use of chemical or biological agents from 1900 to 1999. Of 151 terrorist events, 33 were due to biological agents. There were two peaks (1995 Aum Shinrikyo and the copy cat attack in 1998 in Japan). The Hoaxes involving biological agents such as anthrax were also noted to peak in 1998.(Larry Wayne Harris; White Supremacist Group). Although there is no clear pattern that is apparent in the types of groups involved in biological incidents, religious fundamentalism have been shown to emerge with in the past few years (21)

2. Hoaxes and Cases related to Bioterrorism:

A. The Americas:

USA and Canada: Between 1998 and 1999, over 6000 persons were affected by a series of anthrax related threats (22)

B. Europe: In Europe, despite the growing number of criminal hoaxes, no cases of anthrax linked to deliberate releases have been reported, and the only contaminated letters were addressed to American embassies abroad. (23.)

C. Latin America and the Caribbean: The first confirmed case of mail contamination with B. anthracis  was reported by Chile. A pediatrician in Santiago, Chile received a letter containing the anthrax spores. This raised the possibility of worldwide bio-terrorism attack (24). Similarly, a letter sent from Miami to a woman in Buenos Aires, Argentina was found to be positive for anthrax. (25). The Caribbean Epidemiology Center, Trinidad (CAREC) received eight suspicious envelopes without powder, nine envelopes with powder and three environmental swabs from Guyana and Trinidad, and all were found to be negative for anthrax. (26)

 D. Asia: In Pakistan, there were conflicting reports of whether or not certain letters contained anthrax. Among 200 suspicious envelopes tested for anthrax in India, anthrax was found in one of the envelopes. Although, anthrax is endemic in southern parts of India, the reappearance of human anthrax cases in several southern states is a cause for concern (27, 28).

2. Outbreaks:

Anthrax:  During an outbreak of anthrax in the city of Sverdlovsk (in former Soviet Union) occurred in 1979 nearly 70 people died following alleged consumption of contaminated meat. Although, USA linked this outbreak to a secret bio-weapons laboratory, the Soviet-Union publicly denied the link between the laboratory and the number of cases of anthrax. (29).


Salmonella Typhimurium: Over 751 individuals developed gastroenteritis following consumption of contaminated salads at several restaurants in Dallas, Oregon in 1984. Forty-five were hospitalized during this outbreak. This outbreak was investigated by the Center for Disease Control (CDC) and the criminal intent of the outbreak was not identified for more than a year (30).

Shigella dysenteriae:  Intentional food contamination in Texas in 1996, harmed approximately 15 persons including laboratory workers (31).

Sarin Gas: Twelve (12) deaths and 5000 injuries were reported in 1995 following inhalation of Sarin nerve gas that was intentionally disseminated in Tokyo Subway system by the members of Aum Shinrikyo cult.


Anthrax in the USA (2001): Twenty two cases of anthrax identified in the USA, were due to the intentional contamination of mail with anthrax spores. Of the 22 cases, 10 were confirmed cases of inhalation anthrax and 12 were cutaneous cases (of which seven were confirmed and five suspected).Most of the cases comprised of people who were exposed to contaminated mail either at workplace (mail room) or media offices.

Psychosocial Effects:

Psychological, behavioral, and social responses to biological terrorism are similar to other natural disasters and infectious disease outbreaks. A wide range of psychological disorders are noted ranging from mild stress to full-blown post-traumatic stress disorder (PTSD), major depression, or acute stress disorder. Recent Anthrax laden letters induced fear and anxiety in individuals and communities. These bio terrorism attacks hope that the fear of future attacks will become more crippling, thus maximizing the impact of the direct damage. The most important intervention for Psychiatric illness following a biological terrorism is the availability of and the access to psychiatric care and treatment as a component of a comprehensive health care service preparedness plan. Initial psychosocial interventions also include effective and accurate risk communication, management of somatic symptoms, and the creation of a recovery environment that restores effective social roles and returns people to their usual sources of social support. Local, state and national bioterrorism preparedness and response plans should reflect realistic consideration of psychological, behavioral, and societal reactions to agents of bio terrorism (32)

Bioterrorism Preparedness Program:

A: Multi-sectoral Disaster and Bioterrorism Response System- Local, State and National Plans.

Text Box:                 Fig 2: Components of the CDC’s Strategic Plan 
1. Enhanced capacity for detection, diagnosis, and management of outbreaks
Assessing Local Capacity
National Pharmaceutical Stockpile
Top off Exercise (Simulation of Bioterrorism associated outbreak)
2. Improved characterization and identification of causative pathogens, toxins and chemicals
Laboratory Response Network for Bioterrorism (State and CDC)
3. Strengthened public health response capabilities to control and contain such emergencies
National Electronic Disease Surveillance System (NEDSS)
4. Information technology infrastructure to rapidly transfer the data and information needed to prepare for and response to these events.
The Epidemic Information eXchange Web Page

The main components of the CDC’s Strategic plan for Bioterrorsim Preparedness and Response are shown the Fig 2





















Upgrading local and State Public Health Capacity : The creation of the Bio terrorism Preparedness and Response Office within the CDC is a step in the right direction. The office is mandated to initiate bio terrorism related programs such as development of national pharmaceutical and vaccine stockpiles, the strengthening of CDC’s laboratory capacity, the augmentation of CDC’s epidemiological capacity and the improvement in surveillance systems. The essential component of CDC’s bioterrorism response plan includes building the public health capacity in state health departments.

The essential component of CDC’s bioterrorism response plan includes building the public health capacity in state health departments such as:

Preparedness planning and readiness assessment;

Epidemiology and surveillance;

Laboratory capacity for biological or chemical agents;

The Health Alert Network (a nationwide, integrated, electronic communications system).

CDC has launched an effort to improve public health laboratories that would likely be called upon to identify a biological or chemical attack. The Laboratory Response Network (LRN), a partnership among the Association of Public Health Laboratories (APHL), CDC, FBI, State Public Health Laboratories, Department of Defense (DOD) and the Nation's clinical laboratories, will help ensure that the highest level of containment and expertise in the identification of rare and lethal biological agents is available in an emergency event. The LRN also includes the Reference Laboratory using advanced technology at CDC, which has the sole responsibility of providing rapid and accurate diagnosis and subsequent analysis of biological agents suspected of being terrorist weapons.

2. Engaging the Medical Community in Bio terrorism Response Planning: The Office of Emergency Preparedness (OEP) within HHS works with medical missions in cases of natural disasters. HHS coordinates and provides health leadership to the National Disaster Medical System (NDMS), which is a partnership that brings together HHS, DOD, FEMA, and the Department of Veterans Affairs (VA). The NDMS provides medical response, patient evacuation, and definitive medical care for mass casualty events.

The NMDS is envisioned to provide additional support to state and local medical resources in cases of national disasters.















3.Coordination among Institutions involved in Bio terrorism Preparedness, planning and implementation (Fig 4).

Institutional Coordination is an important aspect of response planning. The lack of a precise role and responsibilities among federal and state agencies involved in bio terrorist response is generally due to the lack of resources to dedicate to planning interagency collaboration and co-ordination. It is important to develop comprehensive statewide plans embracing all relevant parties- hospitals, emergency services, governmental health agencies as well as non-governmental agencies. Due to the threat to the national security, it is also critical for the co-ordination between the health departments and the law enforcement authorities for criminal investigation (33)

Text Box: Fig 4:  Responsibilities and Coordination Relationship between Federal Agencies, USA
The Federal Bureau of Investigation ( FBI): Lead responsibility for crisis management, immediate implementation of measures and criminal investigation
The Federal Emergency Management Agency (FEMA): Consequence management- coordination of subsequent assistance
The Health and Human Services (HHS) and Office of Emergency Preparedness (OEP): Coordination of all health and medical assistance
The Department of Defense ( DOD): Develop, and implement a domestic preparedness program to improve the ability of local, state and federal agencies to cope with terrorist attacks











B. Early Warning Epidemiological Surveillance and Response System-

1. Integrated Networks linking State, National and Global Reporting Systems for rapid investigation and response.

1.1 Global Systems:

            A. Global Outbreak Alert and Response Network: Biological agents that are most likely to be used in a deliberate outbreak are any infectious agents or its toxins that could be engineered for deliberate use as a weapon. Among such agents are small pox, anthrax, botulism and plague are the pathogens most likely to be used and are believed by many experts to be potential biological weapons. The Global Outbreak Alert and Response Network continuously monitor reports of rumors of diseases and outbreaks of infectious diseases worldwide. This network links more than 70 separate information and diagnostic networks around the world. The Formal Sources (information of the 191 WHO member countries, together with WHO regional and country offices), and informal sources information  are combined ( NGO’s, other partners and the Global Public Health Intelligence Network (GPHIN)) to create an internet based system that is the best and most up to date information on disease outbreaks around the world. Each report is thoroughly checked and verified by specialists at WHO headquarters and an appropriate response is then planned and launched with the national and international partners.

It is essential for the co-operation of national and international institutions in order to strengthen the public health infrastructure. These include specialist laboratories and epidemiologists.

            B. ProMED-Mail: ProMed- mail was established in 1994 to provide an early global warning of emerging diseases in human, animals and plants as well as diseases that may attributable to bio terrorist activities. One hundred and sixty countries comprising over 18,000 members from developing and developed world electronically linked to stimulate sharing of emerging and reemerging infectious diseases worldwide.


1.2. National Systems:

            A. The National Center for Infectious Diseases (NCID/CDC) have set up surveillance systems to track particular disease problems including emerging infectious diseases. Some of the surveillance systems that are operated by NCID/CDC are; National Notifiable Diseases Surveillance System (NNDSS), 121 Cities Mortality Reporting System, Border Infectious Disease Surveillance Project (BIDS), EMERGEncy ID NET , Global Emerging Infections Sentinel Network (GeoSentinel) and Internet-based Reporting Systems comprising of Unexplained Deaths and Critical Illnesses Surveillance System.

            B. The Rapid Syndrome Validation Project (RSVP) is an early warning syndrome based system that links individual health care providers and public health in the State of New Mexico. It provides early warning and response to emerging biological threats, as well as emerging epidemics and diseases (35).

          C. The Early Warning and Response Network System (EWARN) in Sudan: In collaboration with several agencies, EWARN was launched in July 1999 with WHO as the lead agency. The United Nations Fund for International Partnership (UNFIP) comprising the Rockefeller Foundation, the UN Foundation and the Gates Foundation. Currently, there are more than 40 health agencies (including non governmental organizations (NGOs), the International Committee of the Red Cross, UNICEF and WHO) participating in EWARN activities, as well as communities through church groups, community leaders and local counterparts.



C. Health Services Plan: Building human, technological and financial resources for provision of rapid health care services at local and State departments.

1.1 Training:


            Training activities are intended to prepare the health and medical community for contingencies such as bioterrorism and other terrorism events. An identified hospital that is equipped to provide support for training activities can be used to train doctors, nurses, paramedics and emergency medical technicians, to recognize and treat patients with chemical and biological exposures and other public health emergencies. However, each hospital should have a continuous education program on management and control of biological and chemical agents, for health care professionals. Several methodologies such as classroom training, distance learning, and hands-on training activities could be implemented based on resources. The key partners in these training programs are the Infectious Disease Society, Schools of Public Health and Center for Civilian Bio -defense. The scope of FEMA's Integrated Emergency Management Course (IEMC) could serve as a vehicle to integrate the emergency management and health community response efforts.

1.2. Community Level: Bioterrorism preparedness is clearly a goal for the health care at the community level. This could be accomplished by working in collaboration with both the city, county, state, and the federal public health and emergency authorities and with law enforcement at the local and federal levels. Effective, open communication between all groups involved in the prevention and control of bio terrorism related illnesses is the key component of a preparedness plan at the community level (36).

1.3. Home Care

            The home care and hospice organizations should be prepared to manage bioterrorism related events and conditions. A bioterrorism response plan for the special population should be developed and a systematic training on response and control programs for the staff, needs to be implemented. (37)

 1.4 The Public: Public is a key partner in the medical and public-health response for an effective management of an epidemic. Non participation increases the likelihood of social disruption. An integrated response plan, implemented in the response to an epidemic caused by a bioterrorist attack, includes the public and the civic bodies, as capable collaborators (38).

 1.5 Mobilization of Financial Resources : CDC has proposed a $ 348 million investment in anti-bioterrorism in the 2002 budget which is estimated to be an 18 percent increase over fiscal year 2001 funding. The majority of efforts will be focused on coordination, surveillance, rapid response and prevention. A special response to a bioterrorism event includes detecting the biological agent, investigating the outbreak, and providing stockpiled drugs and supplies. The U.S. Department of Health and Human Services (HHS) budgeted $4.3 billion for homeland security and public health which includes grants totaling $865 million to improve public health emergency preparedness and counter-bioterrorism in local and state departments.


Clinical Diagnosis, Control and Prevention strategies: Isolation Precautions, therapeutic guidelines, immuno-prophylaxis and vaccination strategies:

            All hospital emergency departments should have administrative plans, infrastructure, training and medical inventory for biological or chemical weapons incidents. The minimum recommended physical and therapeutic resources for hypothetical bioterrorist incidents such as Sarin and anthrax should be available. Health-care providers, clinical laboratory personnel, infection control professionals, and health departments play critical and complementary roles in recognizing and responding to illnesses caused by intentional release of biologic agents.

Health Care providers may use some of the indicators of intentional release of a biological agent such as 1) an unusual temporal or geographic clustering of illness (e.g., persons who attended the same public event or gathering) or patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak (e.g., >2 patients presenting with an unexplained febrile illness associated with sepsis, pneumonia, respiratory failure, or rash or a botulism-like syndrome with flaccid muscle paralysis, especially if occurring in otherwise healthy persons); 2) an unusual age distribution for common diseases (e.g., an increase in what appears to be a chickenpox-like illness among adult patients, but which might be smallpox); and 3) a large number of cases of acute flaccid paralysis with prominent bulbar palsies, suggestive of a release of botulinum toxin. Agents of highest concern are Bacillus anthracis (anthrax), Yersinia pestis (plague), variola major (smallpox), 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)

The clinical manifestations and syndromes of bioterrorism related infections in children may be atypical. Some of the common syndromes reported were acute respiratory distress syndrome with fever, influenza like illness, acute rash with fever, neurological syndromes and blistering syndromes. It is critical that the diagnosis be established expeditiously and pediatricians obtain information on specific treatment for the management of bioterrorism related infections. The guidelines for pediatric management of bioterrorism related infections should be followed (39). Clinical features and management of anthrax, plague and small pox have been published by CDC and others (40). These guidelines also include chemoprophylaxis and vaccination strategies (41-47).

Clinical laboratories should be prepared to respond rapidly by providing diagnostic tests for the detection, identification of specific agents and provision of rapid results for prompt initiation of treatment and prophylaxis. As first-line responders, clinical laboratory personnel should become familiar with the bio weapons. A standard operating procedure manual describing techniques used in their identification and pre and analytical issues such as specimen handling and personal protective equipment and quality control should be prepared. Accurate assessment of resources in clinical laboratories is important because it will provide local authorities with an alternative resource for immediate diagnostic analysis (48, 49).


Infection Control: Infection control practitioners (ICPs) are important partners in enhancing public health infrastructure in the USA and worldwide. A lack of awareness about the potential threat of bioterrorism and a deficiency in knowledge about the potential consequences of an attack may impact on resource allocation for infection control and training program in heath care institutions (50). The Association of Practioners of Infection Control (APIC) Bioterrorism Task Force and CDC Hospital Infection Control Program Bioterrorism Working Group prepared a document entitled “Bioterrorism Rediness Plan- A Template for Health Care Facilities”. This document provided the framework for infection control activities such as isolation precautions, patient placement in case of small events, patient transport, cleaning, disinfection, sterilization of equipment and environment etc. The report also provides an outline of laboratory policy and public enquiry (51). 


Vaccines are an effective, safe, and relatively inexpensive means of preventing infection; thus, they are important tools for fighting biological terrorism. Vaccines for the two diseases, anthrax and smallpox are not available. However, three other vaccines -tetanus toxoid, influenza vaccine, and hepatitis B vaccine--generally recommended for adults, may be in short supply as a result of recent acts of terrorism (52).155 million doses of smallpox vaccine will be produced by the end of 2002 reaching the required 286 million doses by the end of 2002. The estimated cost per dose of vaccine is about $2.76. The National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health have been studying the possibility of diluting the vaccine by a ratio of 1 to 5 as a potential means of extending the supply. Early results indicate that the diluted vaccine retains the same level of effectiveness as the fully concentrated vaccine. Researchers are also studying whether a 1 to 10 dilution retains the same level of effectiveness, as well. The CDC plan does not call for mass vaccination of the U.S. population in advance of a smallpox outbreak. Based on what we know today, the risk of an outbreak of smallpox is substantially lower than the risk of serious complications from the vaccine. According to the plan, rings of personal contacts, such as family members and co-workers, would be identified and then be vaccinated and monitored. This strategy, known as ring vaccination, is credited with helping to wipe out smallpox in the late 1970s and is still the most efficient approach today.


Development , Enactment and implementation of regulations, legislations, and Policies in collaboration and co-ordination with the World Health Organization and the United Nations (53,54)


Geneva Protocol 1: This first attempt to limit the use of biological agents in warfare was the “1925 Geneva Protocol for the Prohibition of the Use in War of Asphyxiating, Poisonous or other Gases and Bacteriological Methods of Warfare”. Many countries ratified the protocol but reserved the right for retaliation. This protocol was not ratified by the USA in 1925.


In 1969, a proposal was submitted to the United Nations Committee on Disarmament which included “The Prohibition of the Development, Production, and Stockpiling of Bacteriological and Toxin Weapons and Their Destruction (BWC)”. This proposal was ratified by member nations including the USA and the Soviet Union. However, there were few notable violations.


Key Regulations laws that were enacted to restrict biological weapons in the USA (53,54).

Presidential Declaration on biological weapons, 1969: Mr. Richard Nixon, the President of USA has declared the end of US involvement of production and use of biological weapons.

Biological Weapons Act, 1989: This act defines that the development, manufacture, transfer or possession of any biological agent, toxin or delivery system for use as a weapon is a federal crime. The act also broadly defines the biological agents.

Chemical and Biological Weapons Control Act, 1991: This act specifically deals with the economic sanctions and export controls to cut the proliferation of biological arms. This act also prohibited from exporting to certain countries any goods or technologies that might be used to develop biological weapons.

Anti-terrorism and Effective Death Penalty Act, 1996: This act has broadened penalties for development of biological weapons and illegitimate uses of microorganisms to spread disease. This act expanded the regulatory responsibilities of CDC for transport of dangerous biological agents. American Society for Microbiology has recommended the extension of the 1996 Act to include strict measures to prohibit possession of selected

biological agents and toxins and registration of institution that have viable agents with the CDC. The CDC regulatory framework governing hazardous biological agents was adopted in 1997.

            Several other bills were introduced and were passed in 2001. Among them were; Deadly Biological Control Act of 2001, Bioweapons Control and Tracking Act of 2001, Bioterrorism Enforcement Act of 2001 ( Amendment of Antiterrorism and Effective Death Penalty Act of 1996), Antiterrorism Legislation –Public Law, Public Health Security and Bioterrorism Response Act of 2001- Regulation of certain Biological Agents and Toxins, and Bioterrorism Preparedness Act of 2001.



Bioterrorism Response System: (During an incident) 


The bioterrorism attack itself would be either overt (announced, eg: letter threatening anthrax to an individual or agency) or covert. The covert attacks are the most disturbing and might be unnoticed for long time. In these attacks, many victims develop a common illness related to the agent with or without high mortality. It is important to systematically determine the nature and possible impact of the threat by assessment, identification and threat communication as well as simultaneously providing a rapid public health response to individuals and communities 



Threat Agent Assessment:

Fig 5 shows the process of Threat Assessment  in cases of overt or covert attack.








Terrorists or criminals can carry out three types of biological attacks. First, the pathogen or toxin may be injected. This method is best used when the terrorist or criminal wishes to assassinate an individual. Second, a quantity of pathogens or toxins may be used to contaminate or poison foods, beverages, or medicines. This method could cause hundreds of casualties. Third, pathogens or toxins may be suspended in a wet or dry formulation and dispersed over a target area as aerosolized particles. This type of attack could produce thousands of casualties, if the following conditions were met:

(1) The formulation was well designed for aerosol dispersal;

(2) The aerosol particles produced by the dispersal mechanism were of optimal size and could withstand environmental stresses; and

(3) Weather and wind conditions were just right for blanketing the target area with aerosol particles.

It is highly probable that food borne and waterborne pathogens or toxic chemicals may be utilized as biological attacks by terrorists or criminals. The probability that terrorists or criminals will carry out airborne attacks with pathogens is low. The reasons are that it is technically difficult to formulate pathogens and toxins for airborne dispersal, to operate dispersal mechanisms successfully, and to ensure proper meteorological conditions for effective aerosol dispersal. Pathogens or toxins are likely to loose their virulence or toxicity after a relatively short time (days to weeks). In addition, dissemination equipment may not effectively spray solutions containing pathogens or toxins due to the clumping of the stabilizing factor and the pathogens. The environmental stresses, such as UV light and desiccation, may kill or inactivate the aerosolized pathogens or toxins. There are possible applications of advanced molecular biology techniques to develop recombinant bacterial or viral pathogens such as smallpox and Ebola viruses (13) for bioterrorist attacks (56). The spectrum and behaviors of terrorists would also provide the necessary clues for the nature of threat and possible impact on society.


Threat Agent Investigation:  Following the threat assessment, the identification of the nature of the threat, credible or not credible, is conducted by the Federal Bureau of Investigation. The criteria applied for threat agent investigation are;

1.      Spectrum of Terrorists known based on previous data (lone offenders, identified groups, non-aligned terrorists, doomsday/cult-type groups)

2.      Behavior profile and intentions of terrorists

3.      Operational and technical characteristics of threat agent.

Based on the credibility of the threat and its agent, the appropriate response system is implemented.

Threat Communication:

Risk communication is a science approach for communicating effectively in high concern situations and it provides a set of principles and tools for meeting those challenges. It also addresses the problems of effective communication by the exchange of information about the nature, magnitude, significance, control and management of risks. The strengths and weakness of the channel through which information is communicated, such as press releases, public media, small discussions etc, are also addressed by the scientific literature. Stakeholders, government officials and industry representatives and scientists often state that non-experts and lay people irrationally respond to risk information and inaccurately perceive and evaluate risk information. However, the representatives of the citizen groups, worker groups and individual citizens question the legitimacy of the risk assessment and management process. These conflicts result in complex, confusing, inconsistent or incomplete risk messages, lack of trust in information sources and selective and biased reporting by the media that affects how risk information is processed.

            Effective risk communication is based on the sound knowledge, planning, preparation, skill and practices. It is an interactive tool that ensures the respect of different values and treats the public as a full partner. However, personnel involved from many agencies and organizations, lack the knowledge, sensitivity, and skills need for effective risk communication. Such organizations initiate risk communication efforts with inadequate resources and unclear objectives.

            Four risk communication theoretical models; Risk perception model, Mental Noise model, Negative Dominance model and Trust Determination model have been developed to describe how risk information is processed, how risk perceptions are formed and how risk decisions are made for a particular event. These models are very important to provide a foundation for thinking about a coordinated effective communication in a high concern situation such as bioterrorism attacks. There are several factors that could accumulate during a bioterrorist event. These include, an element of surprise, use of unpredicted lethal biological agents, the presence of an unknown perpetrator, the likelihood of wide spread attacks and the delayed detection by Public health agencies.

One of the models that combat the rise in emotions at the time of a biological threat is mental noise risk communication model. Such an event would trigger many risk perception factors that would amplify the perceived magnitudes of risk to high levels. Such perception factors that would most likely to be amplified include involuntariness, uncontrollability, unfamiliarity, ethical and moral violations and distrust in institutions.

            In order to modify the public’s risk perception response to a possible biological threat, a number of actions could be taken. Trust of the public in the emergency response should be established in advance for the effectiveness of any post event response. Also the public needs to be evaluated by introducing the potential for bio terrorist attack in a measured, progressive and interactive manner such as selected school programs, student take home assignments and public education.  Public participation in preparation process and by providing a voice in the decisions that affect them enables the public for a legitimate sense of control under threat. To address the intensity of the emotions evolved by a threat, all emergency response organizations must be committed to producing communication from preparatory stage to final resolution.

Rapid  Public Health Response and Management of Bioterrorist Attack.

Many documented attacks are covert in nature and the normal outcome would be an epidemic. Many of these cases come to the attention of physicians gradually and doctors may become aware of deaths among previously healthy individuals. The correct diagnosis of the type of biological or toxic agent responsible for such the disease depends on the speed and accuracy of physicians and laboratories.

In the case of an outbreak, vaccination of the peoples already exposed to the pathogen defeats the purpose of vaccination, hence containment of the infection is extremely important as is the checking of all contacts an infected person has had with others.

Presently the national governments of the various countries should have contingency plans to cope with any naturally occurring or deliberate outbreak of infectious disease. The international guidelines published by WHO should be used in response to the outbreak. The public health response to the situation should be instantaneous, by investigating the stocks of both drugs and vaccines to ensure that adequate supplies are available to deal with any natural or deliberate outbreak.

A National Health Alert Network (HAN), developed by the Centers for Disease Control and Prevention to act as a communications infrastructure for response to bioterrorist events and other emergencies is being implemented at the State and local health departments (57)

Conclusions: Bioterrorism is a complex and multidimensional issue that require local, national and international collaboration and co-operation for mitigating the effects an attack. While the risk of bioterrorism is small, the possibility of occurrence is real in every community and every country. In this review, an attempt was made to systematically address processes that have been developed and coordinated by both governmental and non-governmental agencies in the USA. The epidemiological concepts to address risk assessment and public health management during preparedness and at the time an attack is conceptualized around the critical role of people in the community. Bioterrorism attacks disrupts the entire social, political and economic fabric of a society and no one solution or solutions solve the problem until the root cause is known. International coalition against bioterrorism with sound national and international polices to improve the health and remove inequity and inequality between underdeveloped and developed world to achieve global socio-economic order may be one of the solutions but until that time, national interventions should focus on protection of health of the population.


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Other Websites:

The Centers for Disease Control (CDC)

 The U.S. Army Medical Research Institute of Infectious Diseases

The Federal Bureau of Investigation (FBI).

The National Medical Disaster System:

Federation of American Scientists: Working Group on Biological and Toxin Weapons

The Association for Infection Control Practitioners.

The Johns Hopkins Center for Civilian Biodefense.

WHO: Health Aspects of  Biological and Chemical weapons.

PAHO/WHO: Pan American Health Organisation.