Bioterrorism

Introduction

History and Scientific Foundations

Applications and Research

Impacts and Issues

Primary Source Connection

BIBLIOGRAPHY

Introduction

After years of “back burner” low priority research, work on defensive measures against bioterrorism began in earnest in the United States soon after the anthrax attacks in 2001. Scientists are now developing strategies designed to protect the United States against a potentially limitless variety of biological weapons. The psychological impact of the anthrax attacks of late 2001 was enormous compared to the number of people actually killed and sickened during the episode. This is in keeping with the pattern of effective terror tactics in which expenditures of time, effort, and funds can be minimal, but impact on the target population is maximized.

History and Scientific Foundations

Since 2001, most defensive activity against bioterrorism threats has been focused on preventing or combating known “Class A” threats, including the organisms that cause anthrax, plague, smallpox, tularemia, and viral hemorrhagic fevers, as well as botulinum toxin. Activity to develop new drugs and vaccines is budgeted under Project Bioshield, which is directed by the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC).

Bioterrorism agents are essentially identical to biological warfare agents. Such agents may be classified operationally, as deadly or incapacitating agents, and as agents with or without the potential for secondary transmission (the ability to spread disease from one person affected by bioterrorism to another who was not exposed during the attack). Bioterrorism agents can also be classified according to their intended target, as when they are intended to sicken or kill people, animals, or vegetation such as crops; and according to type, including replicating pathogens (duplicating disease-causing organisms such as viruses, bacteria, or fungi), toxins, or biomodulators (immune system altering agents). Replicating pathogens and toxins are recognized as the greatest current threats.

Applications and Research

Smallpox

Although many pathogens could be used to attack the U.S. population, only a few, including the smallpox virus, could cause illness or panic that could overwhelm existing medical and public health systems. The WHO authorizes two laboratories in the world to maintain stores of smallpox virus for research purposes, and authorities fear that additional smallpox virus may exist hidden away in laboratories other than the two WHO-designated repositories.

A new outbreak of smallpox could spread rapidly. The CDC strategy for controlling a new outbreak of smallpox incorporates principles that were used 30–40 years ago in eradicating the disease and have proven their effectiveness. They are based on knowledge that smallpox is mostly transmitted by close, face-to-face contact with infected individuals, while only a few cases could be transmitted by dry or aerosolized particles in close proximity to persons with the disease. New cases develop two weeks after exposure and take another two weeks to progress to pustules and scabs, giving a newly aware medical community some time to respond.

Smallpox vaccine is a live-virus vaccine composed of vaccinia virus that induces antibodies that also protect against smallpox. Smallpox vaccine production ceased in the early 1980s and current supplies of smallpox vaccine are limited. The CDC expects that new vaccines manufactured using cell cultures will be available within two to four years under the Bioshield program. Limited new supplies of the current vaccine are being manufactured under Bioshield.

After several years of considering mass vaccination as an alternative, CDC has settled on a ring vaccination strategy to combat a new smallpox outbreak. This includes isolation of confirmed and suspected smallpox cases with tracing, vaccination, and close surveillance of contacts to these cases as well as vaccination of the household contacts of the smallpox cases. Ring vaccination takes advantage of the relatively low infectivity of smallpox and focuses currently scarce vaccine resources where they will do the most good, minimizing adverse events, including rare deaths that could occur during indiscriminate mass vaccination.

Anthrax

Anthrax is an infectious disease caused by a spore-forming bacterium, the spores of which are very persistent and hard to break down in the environment, which makes anthrax a persistent public health threat in spite of available treatment with familiar drugs.

There are three forms of anthrax infection: skin, gastrointestinal, and inhalational anthrax. Inhalational anthrax, with the highest death rates, occurs when spores are inhaled and infect the lungs. The treatments for all types of anthrax are the antibiotics ciprofloxacin, tetracycline drugs such as doxycycline, and some types of penicillin.

The anthrax vaccine is primarily given to people in the military and is only recommended for individuals considered to be at high risk of contracting the disease, such as scientists who handle anthrax bacteria. Current government efforts are focused on encouraging the development of new anthrax vaccines intended to prevent inhalational anthrax before and after exposure. The emergency response to anthrax consists of administration of antibiotics and spore cleanup by workers using personal protective equipment. Unvaccinated, exposed people and remediation workers begin taking preventative antibiotics at the time of their exposure and continue for at least 60 days.

Plague

Plague is caused by the bacterium Yersinia pestis. Bubonic plague is the most common type of naturally occurring plague, and is transmitted through the bite of an infected flea or exposure through a cut. Symptoms of bubonic plague include swollen, tender lymph nodes, headache, fever, and chills. If untreated, bubonic plague may result in death.

In pneumonic plague, the lungs are infected with the plague bacterium. People with pneumonic plague can transmit plague to other people, whereas bubonic plague cannot be spread from person to person. Antibiotics approved by the FDA to treat plague are streptomycin, doxycycline, and other tetracycline drugs. The public health response to pneumonic plague would be similar to that of anthrax, with the addition of quarantines that could impact sizable crowded geographic areas.

Impacts and Issues

The response to the 2001 anthrax attacks has been extensively analyzed as researchers attempt to model the optimal response to future attacks. The 2001 attacks were small-scale events, affecting a relatively few people in restricted geographic areas. In a recent study of a small-scale attack, Veterans Administration researchers conducted a cost-effectiveness analysis using a simulation model to determine the optimal response strategy for a small-scale anthrax attack against U.S. Postal Service distribution centers in a large metropolitan area. (A cost-effectiveness analysis compares the relative effectiveness of two or more alternatives in view of their costs and attempts to determine the best value for money.) The study compared three different strategies: (1) pre-attack vaccination of all U.S. distribution center postal workers, (2) post-attack antibiotic therapy followed by vaccination of exposed personnel, and (3) post-attack antibiotic therapy without vaccination of exposed personnel. The results showed that post-attack antibiotic therapy and vaccination of exposed postal workers is the most cost-effective response compared with post-attack antibiotic therapy alone. This was due to the greater prevention of death and disease when post-attack vaccination is combined with antibiotics. Pre-attack vaccination of all distribution center workers is less effective and more costly than the other two strategies. This is because vaccinating all postal employees would be very expensive, and the immunity conferred by the current vaccine is not perfect or always permanent, and the time between vaccination and an anthrax attack is indeterminate.

Some commentators have decried the resources and energy being poured into bioterrorism defense. According to this perspective, bioterrorism preparedness programs have wasted public health resources with little evidence of benefit. For example, several deaths and many serious illnesses have resulted from the smallpox vaccination program, but there is no clear evidence that any threat of smallpox exposure has existed since the eradication of the disease. Even the anthrax attacks were linked to secret U.S. military laboratories; without these laboratories the attacks probably would not have been possible. The huge effort to prepare the country against bioterrorist threats is seen by some critics as a great distraction from the need to allocate public health resources to address other health needs, and has been conducted at the expense of some vital programs.

Nevertheless, the anthrax attacks did demonstrate the havoc that malign individuals could wreak with sufficient determination, access to pathogens, and laboratory resources. As public protection will always be the primary responsibility of government, leaving the population totally unprepared for the eventuality of bioterrorism is simply not an option in the post-9/11 world. Accordingly, The Center for Law and the Public's Health at Georgetown and Johns Hopkins Universities drafted the Model State Emergency Health Powers Act (MSEHPA or Model Act) at the request of the CDC. The Model Act provides states with the powers needed to detect and contain either bioterrorism or a naturally occurring disease outbreak. To this extent, bioterrorism preparedness appears in sync with more conventional public health preparedness. Legislative bills based on the MSEHPA have been introduced in most states. This legislative effort has uncovered problems of state law obsolescence, inconsistency, and inadequacy. Most current state laws provide inadequate public protection whether a disease outbreak would be natural or intentional. They often date back to the early twentieth century and predate the immense changes in public health science over the past half-century.

The Model Act is structured to support five basic public health functions to be facilitated by law: (1) preparedness, comprehensive planning for a public health emergency; (2) surveillance, measures to detect and track public health emergencies; (3) management of property, ensuring adequate availability of vaccines, pharmaceuticals, and hospitals, as well as providing power to abate hazards to the public's health; (4) protection of persons, powers to compel vaccination, testing, treatment, isolation, and quarantine when clearly necessary; and (5) communication, providing clear and authoritative information to the public. The act is also based on a legal framework to protect personal rights.

WORDS TO KNOW

PATHOGEN: A disease-causing agent, such as a bacteria, virus, fungus, etc.

QUARANTINE: Quarantine is the practice of separating people who have been exposed to an infectious agent but have not yet developed symptoms from the general population. This can be done voluntarily or involuntarily by the authority of states and the federal Centers for Disease Control and Prevention.

RING VACCINATION: Ring vaccination is the vaccination of all susceptible people in an area surrounding a case of an infectious disease. Since vaccination makes people immune to the disease, the hope is that the disease will not spread from the known case to other people. Ring vaccination was used in eliminating the smallpox virus.

TOXIN: A poison that is produced by a living organism.

Use of Spectroscopy in Identifying Pathogens

Traditional detection of pathogens such as bacteria and viruses involves serologic (blood) testing in which potential pathogens in a tissue sample from an infected patient are cultured in the laboratory, and various stains and reagents are made to react with proteins of the pathogen's outer membrane. This is a slow and laborintensive process. A new technique of rapidly identifying bacteria such as anthrax called desorption electrospray ionization recently developed at Purdue University could be used for homeland security. This technique enables the fast “fingerprinting” bacteria using a mass spectrometer. The analysis of bacteria and other microorganisms usually takes several hours. The spectrographic technique ionizes molecules outside of the spectrometer's vacuum chamber. Ionized molecules can then be manipulated, detected, and analyzed using electromagnetic fields. This technique is extremely sensitive, capable of detecting 1-billionth of a gram of a particular bacterium and identifying its subspecies, which is the level of accuracy required for detecting and monitoring infectious microorganisms. The technology can determine the subspecies and collect other information by observing the pattern of the pathogen's outer membrane proteins, and creates a sort of fingerprint as revealed by mass spectrometry. Such accuracy and timeliness makes the technology particularly apt for detecting bioterrorism agents, as word of an intentionally caused outbreak would need to be spread very soon after the appearance of suspected cases in order to prevent rapid transmission of the pathogen.

Involving the General Public in Preparedness

The public health emergency responses being fashioned by the CDC to a bioterrorist attack focus mainly on readying emergency and medical workers to cope with infection transmission, panic, and decontamination. While there has been some refinement in terms of how agencies and response personnel should coordinate their efforts, so far there have been few urgent instructions or preventive measures disseminated to the general public. On the other hand, promising new research on detection technologies, vaccines, and medicines to prevent or combat infections is now being funded under Project Bioshield.

Most bioterrorism policy discussion and response planning has been conducted among experts and has not involved much public participation. The capacity of the public to take an active role and even to lead in the response to bioterrorism is often discounted, or policymakers have assumed that local populations would get in the way of an effective response. This bias is based on fears of mass panic and social disorder. While no one really knows how the population will react to an extraordinary act of bioterrorism, experience with natural and technological disasters and disease outbreaks indicates that the public response would be generally effective and adaptive collective action. Therefore, the public should be viewed as a partner in the medical and public health response. Failure to involve the public in planning could hamper effective management of an epidemic and increase the likelihood of social breakdown. Ultimately, actions taken by nonprofessional individuals and groups could end up having the greatest impact on the outcome of a bioterrorism attack. Guidelines suggested for integrating the public into bioterrorism response planning include (1) treating the public as a capable ally in the response to an epidemic; (2) enlisting civic organizations in practical public health activities; (3) anticipating needs for home-based patient care and infection control; (4) investment in public outreach and communication strategies; and (5) ensuring that planning reflects the values and priorities of affected populations.

Primary Source Connection

In an excerpt for the following journal article, the authors argue for a greater role for the biomedical research community in defense efforts against bioterrorism. Bradley T. Smith, PhD, is a Fellow, Thomas V. Inglesby, MD, is Deputy Director, and Tara O'toole, MD, MPH, is Director, all at the Johns Hopkins Center for Civilian Biodefense Strategies, Baltimore, Maryland.

Biodefense R&D: Anticipating Future Threats, Establishing a Strategic Environment

INTRODUCTION

The ultimate objective of the U.S. civilian biodefense strategy should be to eliminate the possibility of massively lethal bioterrorist attacks. A central pillar of this strategy must be an ambitious and aggressive scientific research, development, and production (R&D&P) program that delivers the diagnostic technologies, medicines, and vaccines needed to counter the range of bioweapons agents that might be used against the nation. A successful biodefense strategy must take account of the rapidly expanding spectrum of bioweapons agents and means of delivery made possible by 21^st century advances in bioscientific knowledge and biotechnology. Meeting this challenge will require the engagement of America's extraordinary scientific talent and investments of financial and political capital on a scale far beyond that now committed or contemplated. The purpose of this article is to provide a brief analysis of the current biomedical R&D&P environment and to offer recommendations for the establishment of a national biodefense strategy that could significantly diminish the suffering and loss that would accompany bioterrorist attacks. In the longer term, a robust biodefense R&D&P effort, if coupled to substantial improvements in medical and public health systems, could conceivably render biological weapons ineffective as agents of mass lethality.

THE PROBLEM: 20^TH AND 21^ST CENTURY BIOWEAPONS

The advantage is now firmly with those who would seek to deploy offensive bioweapons; the state of biodefense is relatively weak. Following the terrorist attacks of 2001, the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health (NIH) received $1.7 billion to fund biodefense research projects. NIAID has since established a “roadmap” describing the scientific research needed to devise new “countermeasures” (i.e., diagnostic technologies, therapeutic drugs, and vaccines) for the pathogens thought to be the bioweapons agents of greatest concern. Much of the NIAID roadmap has, appropriately, focused on developing countermeasures for the six CDC Category A bioweapons threats (anthrax, smallpox, plague, botulism, tularemia, and the viral hemorrhagic fevers) for which there are striking gaps in available countermeasures…, and a selection of other bioweapons threats on the CDC's Category B and C lists (collectively termed “20th century bioweapons” in this article).

Growing numbers of people in the scientific community now recognize that looming just ahead is a far more daunting array of potential engineered bioweapon agents (collectively termed “21st century bioweapons” in this article). The life sciences are at the beginning of a revolutionary period. Scientific understanding of living systems and how to manipulate them is expanding exponentially, fueled by advances in computerization, the global dispersion of bioscientific expertise as well as biological databases, and substantial economic investment in biomedical and agricultural research and product development.

A prime example of these powerful advances was the identification in 2001 of the approximately 40,000 genes in the human genome. Scientists are rapidly learning how to translate this genomic “parts list” into a sophisticated understanding of how specific genes control human biological systems in the body. Such discoveries will bring great benefit to humankind, but they will also allow the development of a new constellation of powerful 21^st century bioweapons.

There are already countless portents of the coming power of bioscience and how it will propel bioweapons developments. Scientists have shown that it is possible to create strains of the bacterium that causes anthrax to be resistant to the most powerful existing antibiotics. They have demonstrated the capacity to make viruses that can overcome vaccine-induced immunity. Viruses can be genetically modified to increase their ability to kill infected cells, or to become capable of attacking entirely new target species. Viruses and bacteria can be manipulated in ways that make them better able to survive environmental stress and to be disseminated over distances in the air as weapons. Technologies already exist that could be used to protect pathogens from detection or destruction by the human immune system. These are only a small sample of the developments ahead on the bioscience landscape.

The “dual use” aspect of bioscience does not pertain only to specific, isolated technological applications, as is the case in nuclear weapons work. Rather, it is biological knowledge itself that is the source of the power that can be applied toward beneficent or malevolent ends. The knowledge needed to engineer a more lethal viral or bacterial bioweapon is essentially the same as that needed to understand how that virus or bacteria causes disease and how to create an effective vaccine against it. The distinction between good biology and its “dark side” lies only in intent and application. With rare exception, it will be very difficult to sequester new bioscientific knowledge that might be applied to building biological weapons without simultaneously harming beneficial biomedical research and essential biodefense R&D&P.

Given the size, momentum, and global dissemination of the bioscientific enterprise and the great demand for the medical and agricultural products being created, the rapid global advance of bioscience is essentially unstoppable. A successful biodefense R&D&P strategy must accept that the growth and international diffusion of bio-scientific knowledge and technologies will continue at a phenomenal pace and must seek to leverage these powerful forces against the bioterrorist threat. …

CONCLUSION

The full power of the nation's biomedical research, development, and production enterprise is not yet engaged in biodefense, and given the current environment, funding levels, priorities, and lack of clear vision for the biodefense R&D&P program, large numbers of the best biomedical scientists are unlikely to engage. Current biodefense initiatives, when compared to other U.S. government efforts to address top national security threats, suggest that the U.S. government either does not yet understand the grave nature and scope of the bioterrorist threat or is not prepared to commit fully to a robust biodefense research, development, and production effort. This must change if the nation is to counter the coming bioweapons threat and set the course to eliminate bioweapons as weapons of mass lethality.

Editor's note: Referenced citations omitted.

Bradley T. Smith, Thomas V. Inglesby, Tara O'toole

BRADLEY T. SMITH, THOMAS V. INGLESBY, ANDTARAO'TOOLE. “BIODEFENSE R&D: ANTICIPATING FUTURE THREATS, ESTABLISHING A STRATEGIC ENVIRONMENT.” BIOSECURITY & BIOTERRORISM. 1(3):193–202, 2003.

See AlsoWar and Infectious Disease; Public Health and Infectious Disease.

BIBLIOGRAPHY

Books

Fong, I.W., and Kenneth Alibek, eds. Bioterrorism and Infectious Agents: A New Dilemma for the 21st Century. New York: Springer, 2005.

Periodicals

Cohen H.W., R.M. Gould, V.W. Sidel. “The Pitfalls of Bioterrorism Preparedness: the Anthrax and Smallpox Experiences.” Am J Public Health, (2004): 94:1667–1671.

Glass T.A., M. Schoch-Spana. “Bioterrorism and the People: How to Vaccinate a City against Panic.” Clinical Infectious Diseases (2002) 34:217–23.

Gostin L.O., J.W. Sapsin, S.B. Teret, et al. “The Model State Emergency Health Powers Act: Planning for and Response to Bioterrorism and Naturally Occurring Infectious Diseases.” JAMA (2002): 288:622–628.

Web Sites

Centers for Disease Control and Prevention (CDC). “Bioterorism.” <http://www.bt.cdc.gov/bioterrorism/> (accessed June 13, 2007).

Kenneth T. LaPensee

Bioterrorism

What Is Bioterrorism?

The History of Bioterrorism

How Can Biological Agents Be Spread?

What Are Potential Biological Agents?

What Can We Do to Protect Ourselves?

Resources

Bioterrorism is the intentional use of harmful biological, or living, organisms or their toxic products to cause injury or death to people or animals.

KEYWORDS

for searching the Internet and other reference sources

Anthrax

Biological agent

Biological warfare

Bioweapon

Botulism

Plague

Smallpox

Tularemia

Vaccination

What Is Bioterrorism?

Also known as biological warfare, bioterrorism is a form of warfare that uses specific microorganisms*, such as harmful bacteria and viruses, to cause illness or death deliberately in people or animals. When organisms are used in this way, they become weapons.

*microorganisms

are tiny organisms that can be seen only using a microscope. Types of microorganisms include fungi, bacteria, and viruses.

The History of Bioterrorism

The use of microorganisms to spread disease intentionally is not new to the twenty-first century. In 1346, it is believed that the Tartar army tried to capture the port city of Caffa on the Black Sea in the Crimea by catapulting bodies of plague (PLAYG) victims over the city walls. A plague epidemic* ensued, and Caffa surrendered. During the French and Indian Wars in the eighteenth century in North America, the British were rumored to have given blankets contaminated with smallpox to Native Americans, leading to an epidemic of the disease.

*epidemic

(eh-pih-DEH-mik) is an outbreak of disease, especially infectious disease, in which the number of cases suddenly becomes far greater than usual. Usually epidemics are outbreaks of diseases in specific regions, whereas worldwide epidemics are called pandemics.

The Tartars and the British troops did not know that certain microorganisms cause disease. They knew only that disease was rumored to have spread from dead bodies or, in the case of smallpox, even from the blankets that touched victims. People were not aware that microorganisms are at the root of infectious disease until the latter part of the nineteenth century, when scientists began to understand the connection. In 1876, the German scientist Robert Koch had proved that anthrax (AN-thraks) bacteria cause anthrax. After World War II the United States and other nations experimented with harmful biological organisms and various methods of transmitting them. In 1972 the Biological Weapons Convention treaty was signed by more than 100 countries around the world, including the United States and the Soviet Union, to stop research and production of biological organisms as weapons of war.

It is likely that some countries in the world today—especially those harboring or supporting known terrorist groups—continue to manufacture and store stockpiles of dangerous microorganisms, such as those that cause anthrax. The use of bioterrorism to wage warfare is favored among terrorists or fringe groups because it requires few resources compared with traditional warfare and can potentially harm large numbers of people.

How Can Biological Agents Be Spread?

Deadly microorganisms (also known as biological agents or bioweapons) can be spread purposely through air or food and water supplies or by intentionally infecting someone with a highly contagious agent and letting that person circulate in a community, starting a massive wave of disease. But the handling and release of many of these organisms are dangerous and could be deadly for potential terrorists trying to use them.

Some organisms can be aerosolized (AIR-o-suh-lized), meaning that they are processed into the tiniest of particles, in a wet or dry form, that can be sprayed or released into the air so that large numbers of people can inhale them. Aerosolized organisms can be dispersed by aerosol containers, small crop-dusting planes, ventilation systems, or contamination of an object that can carry disease throughout a region, like the anthrax-tainted letters received by various government and media employees in the United States in late 2001.

Some harmful biological organisms become weakened, however, as they spread into water or food supplies, making them less likely to cause significant harm to anyone who comes into contact with them. For example, a person would have to inhale thousands of anthrax spores* to become sick. A terrorist group trying to use anthrax as a bioweapon would have to use a highly concentrated form to be able to harm large numbers of people via contaminated packages or envelopes.

*spores

are a temporarily inactive form of a germ enclosed in a protective shell.

What Are Potential Biological Agents?

The U.S. Centers for Disease Control and Prevention (CDC) separates biological organisms into categories according to their virulence (VEER-uh-lents), or ability to cause disease. The most virulent biological diseases are also the most likely to be used by terrorists. These diseases are anthrax, smallpox, plague, botulism (BOH-chu-lih-zum), and tularemia (too-lah-REE-me-uh).

Anthrax

Anthrax is caused by the bacterium Bacillus anthracis. The bacteria can form spores, which have a hard coating that allows them to survive in harsh environments. The spores are found naturally in soil and can infect grazing animals, most often livestock such as cattle, sheep, or horses. The disease is not contagious from person to person, and natural human infection is rare.

There are three types of anthrax, distinguished by the three different ways in which a person becomes infected: cutaneous (kyoo-TAY-nee-us) anthrax, which infects the skin; inhalation (in-huh-LAY-shun) anthrax, which results from breathing in large numbers of concentrated spores; and gastrointestinal* (gas-tro-in-TES-tih-nuhl) anthrax, which is caused by ingesting spores. Cutaneous anthrax causes brownish-black ulcers, or sores, that turn into scabs on the skin. Symptoms of inhalation anthrax include rapid onset of fever, chills, headache, nausea, and vomiting, with victims quickly experiencing difficulty in breathing. Gastrointestinal anthrax is very rare and causes severe abdominal* pain, diarrhea (dye-uh-REE-uh), and hemorrhaging* from the gastrointestinal tract.

*gastrointestinal

means having to do with the organs of the digestive system, the system that processes food. It includes the mouth, esophagus, stomach, intestines, colon, and rectum and other organs involved in digestion, including the liver and pancreas.

*abdominal

(ab-DAH-mih-nul) refers to the area of the body below the ribs and above the hips that contains the stomach, intestines, and other organs.

*hemorrhaging

(HEM-rij-ing) describes a condition in which uncontrolled or abnormal bleeding occurs.

All forms of anthrax can be treated with antibiotics if they are diagnosed early, but the inhalation and gastrointestinal types of anthrax are extremely deadly if left untreated. Even with treatment, patients with inhalation or gastrointestinal anthrax can die from the disease. There is an anthrax vaccine*, but it is given only to people in the military and people such as veterinarians who routinely handle livestock and are therefore more likely to come into contact with the natural form of the disease.

*vaccine

(vak-SEEN) is a preparation of killed or weakened germs, or a part of a germ or product it produces, given to prevent or lessen the severity of the disease that can result if a person is exposed to the germ itself. Use of vaccines for this purpose is called immunization.

Smallpox

Smallpox is a deadly viral infection that is caused by the variola virus and is found only in humans. In the twentieth century smallpox claimed millions of lives, but in 1980 the World Health Organization (WHO) declared the disease to have been eradicated (eliminated) from the human population following an aggressive worldwide vaccination (vak-sih-NAY-shun) program. Routine vaccination against smallpox in the United States ended in 1972, and the last known natural case of smallpox was in 1977 in Somalia in Africa. Today there are two official facilities that store samples of the virus: the CDC in Atlanta, Georgia, and the Russian State Research Center of Virology and Biotechnology in Koltsovo.

Smallpox is the most contagious disease known and is transmitted through direct contact with the lesions* of an infected person, by inhaling infected droplets of moisture released into the air by coughing patients, and even by handling contaminated clothing that contains fluid from smallpox sores. The symptoms of smallpox are high fever, headache, backache, vomiting, and a painful rash of lesions that covers the face, arms, and body and often leaves scars. The disease is fatal in up to 30 percent of cases, and at this time there is no known medication that can cure smallpox. Vaccination given within 4 days of exposure to the virus sometimes can prevent smallpox or lessen its symptoms, including the rash.

*lesions

(LEE-zhuns) is a general term referring to sores or damaged or irregular areas of tissue.

The CDC keeps an emergency supply of smallpox vaccine in the event that bioterrorism attacks with smallpox occur in the United States. In 2002, some vaccine-making companies received approval from the CDC to make an additional supply of the vaccine, should it be needed on a more widespread basis.

In order to protect U.S. citizens against the threat of a bioterrorism attack, President George W. Bush announced in late 2002 that some members of the U.S. military will be vaccinated against smallpox and he called for health care workers to volunteer to receive the vaccine.

Plague

Plague, caused by the bacterium Yersinia pestis (yer-SIN-e-uh PES-tis), has been around for centuries. It can take three forms: bubonic (byoo-BAH-nik), septicemic (sep-tih-SEE-mik), and pneumonic (nu-MOH-nik). Bubonic plague, the most common form, involves the body’s lymph nodes*; septicemic plague enters the bloodstream, causing internal bleeding and shock*; and pneumonic plague infects the respiratory tract*. The last form is potentially important in biological warfare because Yersinia pestis bacteria can remain alive in the air for up to an hour, making aerosolized transmission possible.

*lymph

(LIMF) nodes are small, bean-shaped masses of tissue that contain immune system cells that fight harmful microorganisms. Lymph nodes may swell during infections.

*shock

is a serious condition in which blood pressure is very low and not enough blood flows to the body’s organs and tissues. Untreated, shock may result in death.

*respiratory tract

includes the nose, mouth, throat, and lungs. It is the pathway through which air and gases are transported down into the lungs and back out of the body.

Yersinia pestis is found in rats and other rodents in all parts of the world, including the United States. Plague can spread from infected rats to humans by direct bites or from fleas. The pneumonic form of plague is the only kind that is contagious among humans; transmission takes place by being in close contact with someone who is coughing or sneezing. Symptoms of the plague include fever, chills, headache, abdominal pain, painful and swollen lymph nodes (called buboes, BYOO-boze), chest pain, coughing, bloody sputum*, and septic shock*. There is no vaccine available in the United States, but antibiotics can treat the disease successfully if it is diagnosed early.

*sputum

(SPYOO-tum) is a substance that contains mucus and other matter coughed out from the lungs, bronchi, and trachea.

*septic shock

is shock due to overwhelming infection and is characterized by decreased blood pressure, internal bleeding, heart failure, and, in some cases, death.

Botulism

Botulism is caused by the toxin* produced by the bacterium Clostridium botulinum. The bacteria can be inhaled or swallowed, or they can enter the body through a wound, but the disease is not contagious from person to person. The toxin produced by the bacteria affects neurotransmitters* in the body, causing nerve damage and temporary paralysis*, including the muscles for speaking, swallowing, and breathing. Botulism can lead to respiratory failure* and even death. The bacterium and its toxin could be used to produce bioweapons. An antitoxin* against the Clostridium botulinum toxin is available from the CDC, but there is currently no vaccine available.

*toxin

is a poison that harms the body.

*neurotransmitters

(nur-o-trans-MIH-terz) are chemical substances that transmit nerve impulses, or messages, throughout the brain and nervous system and are involved in the control of thought, movement, and other body functions.

*paralysis

(pah-RAH-luh-sis) is the loss or impairment of the ability to move some part of the body.

*respiratory failure

is a condition in which breathing and oxygen delivery to the body are dangerously altered. This may result from infection, nerve or muscle damage, poisoning, or other causes.

*antitoxin

(an-tih-TOK-sin) counteracts the effects of toxins, or poisons, on the body. It is produced to act against specific toxins, like those made by the bacteria that cause botulism or diphtheria.

Tularemia

Tularemia is caused by the bacterium Francisella tularensis and is highly infectious. It occurs naturally in mice, rabbits, squirrels, and other small mammals. The disease is not contagious among humans, and human infection is rare. Tularemia can be transmitted through contact with infected animals or contaminated water or soil. The disease is potentially dangerous as a biological weapon, because even small numbers (less than 10 to 50) of the aerosolized bacteria can cause serious disease, such as life-threatening pneumonia*. Symptoms include fever, chills, headache, cough, and extreme tiredness. Patients also may have painful ulcers on the skin; swollen, painful eyes; and abdominal pain. Early treatment with antibiotics may prevent or limit the severity of the disease.

*pneumonia

(nu-MO-nyah) is inflammation of the lung.

What Can We Do to Protect Ourselves?

Following the terrorist incidents and anthrax scare of fall 2001, the U.S. government proposed that billions of dollars be channeled into improving national resources that provide protection against and treatment of the effects of bioweapons. The Office of Homeland Security was formed in late 2001 to oversee the government’s preparation for and defense against future acts or threats of bioterrorism that might occur in the United States. The government has authorized an increase in federal stockpiles of antibiotics to treat anthrax, plague, tularemia, and other potential bioweapons, as well as the production of additional supplies of smallpox vaccine. Research continues in the development of better medical treatment and the creation of vaccines for protection against biological agents. Medical professionals and emergency response teams are being trained to diagnose the diseases and respond quickly to the epidemics that could result from bioterrorism. Experts advise that people not stockpile antibiotics out of fear of possible biological warfare, because they could end up using the medicine incorrectly or in the wrong situation. Stockpiling also can lead to a shortage of certain antibiotics and make them unavailable to people who truly need them to treat other diseases.

See also

Anthrax

Botulism

Plague

Smallpox

Tularemia

Zoonoses

Resources

Organizations

Center for Civilian Biodefense Strategies, Johns Hopkins University, 111 Market Place, Suite 830, Baltimore, MD 21202. The Center for Civilian Biodefense Strategies carries information about possible bioweapons and posts news updates on the preparedness and response plans of public health agencies and the work of the Department of Homeland Security.

Telephone 410-223-1667 http://www.hopkins-biodefense.org

U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333. The CDC’s website carries information about bioterrorism and fact sheets about various biological agents and threats, including anthrax, smallpox, plague, botulism, and tularemia.

Telephone 800-311-3435 http://www.cdc.gov

World Health Organization (WHO), Avenue Appia 20, 1211 Geneva 27, Switzerland. WHO tracks disease outbreaks and emergencies around the world and posts information at its website about potential biological weapons.

Telephone 011-41-22-791-2111 http://www.who.int

BIOTERRORISM

The issues associated with bioterrorism are as broad in their scope and as challenging in their complexity as any in bioethics. These issues engage the resources of basic sciences, history, political philosophy, sociology, healthcare administration, and public health, as well as clinical medicine. In some instances they present unique concerns, in others they are variations on more familiar bioethical problems. In providing a sound bioethical account of these problems this entry will presuppose that the terrorist threat in question is morally unjustifiable either because the cause it represents or the means used to advance this cause cannot be rationally defended.

Public Health and Civil Liberties

There is broad agreement that individual liberties of speech, movement, and personal privacy may be abrogated when they present an imminent risk of serious harm to other persons and when no other means of ameliorating this risk is available. This doctrine is familiar within the traditional domain of public health. An additional element presents itself when there is an intentional threat to public safety from persons or states that seek to advance a political agenda.

Whether the political element is in itself sufficient justification for permitting the state to have greater latitude in the abrogation of civil liberties than it would in a naturally occurring public health emergency is an issue that may be raised. One might argue that the intentionality of a terrorist act, expressed through a biological attack, is liable to sow panic in a fashion that differs from the psychological effects of a naturally occurring epidemic. Whether that is the case or not is an empirical matter, and whether it is sufficient justification for a more aggressive response is a matter of political philosophy.

It is clear that the tactics required to minimize the harms of a disease outbreak are not substantially altered by the cause of the contagion. In the case of highly contagious and dangerous diseases like smallpox, public health theory calls for the identification and isolation of primary cases and the creation of a ring around plausible secondary cases. This surveillance and containment strategy requires that all those exposed, and their immediate contacts, be vaccinated, isolated, and quarantined if they become ill. Treatment of all cases within that ring should be sufficient to control the epidemic.

Conceivably a disease might be more likely to appear simultaneously in several distant places as part of a terrorist conspiracy than it would as part of a natural event. There is disagreement among public health experts concerning the point at which a certain number of far-flung individual cases would constitute a dire emergency that would render the ring strategy inadequate.

Although bioethics has emphasized self-determination, the public health context presents demands that are incompatible with strict adherence to individual rights. Some have argued that, especially in an emergency, effective public health interventions may entail justifiable limitations on civil liberties that would at other times be unacceptable. Limitations on such rights as speech, privacy, and travel should not be excessive or arbitrary, and they must be rationally linked to protection of the public. They may be imposed no longer than required by the circumstances.

Not all agree that more stringent restrictions on civil liberties may be required by a bioterrorism event. Some oppose abrogating the right to refuse treatment and any requirement that doctors treat patients against their will. These critics also question the practicality and effectiveness of large-scale quarantine. All these actions tend to under-mine the most important defense against panic, which is trust in government authority. Adequate and equitable healthcare for all would, under this view, go farther than draconian measures to build public trust and elicit cooperation in an emergency.

Resource Allocation in a Response to Bioterrorism

Standard accounts of a formal principle of justice require that similar cases be treated similarly. In an extreme event healthcare institutions may not have the capacity to absorb large numbers of patients that suddenly present themselves. An important problem is whether differential treatment is always morally wrong, or whether it can be justified in some instances.

The classic approach to sorting battlefield injuries is triage, a nineteenth-century French policy based on the strictly utilitarian principle of the greatest good for the greatest number. Depending on the particular model, triage utilizes three or five categories that range from urgent to non-urgent to care not needed. Although triage has become a familiar term in the civilian medical world, especially in busy emergency rooms, in its original military context the idea included a criterion of social merit, that the argument for care in any particular case turned on the potential for the individual to return to duty.

Under ordinary circumstances clinical triage differs from battlefield triage. In the former case the most seriously ill are not simply set aside. Rather, resources are made available through such ad hoc means as the temporary diversion of ambulances to other emergency rooms (Kipnis). Under extreme conditions these routine bypass procedures may not be feasible. A social worth criterion could be transferred to civilians if the circumstances were sufficiently dire that, for example, the very survival of the community was threatened. According to theologian Paul Ramsey, the comparative social worth of individuals can justifiably be measured in these highly defined circumstances.

First priority must be given to victims who can quickly be restored to functioning. They are needed to bury the dead to prevent epidemic. They can serve as amateur medics or nurses with a little instruction—as the triage officer directs the community's remaining medical resources to a middle group of the seriously but not-so-seriously injured majority. Among these, one could argue, a physician should first be treated (Ramsey).

A social worth criterion applied to extreme conditions appears to be incompatible with respect for each individual person, for the inevitably unsuccessful act of treating some is sacrificed in exchange for the potential survival of a valuable individual whose survival would in turn benefit the larger number. However, an argument can be made that the unequal treatment is justifiable precisely because one respects all of the others whose survival is made more likely because of the treatment of this one. Respect for all the others that might survive is respect for each of them as individuals, hence egalitarianism is preserved (Childress, 2003).

But not all who are possessed of critical skills may be required for the benefit of the community. Rather, only a few may be needed, therefore it would be unfair to guarantee all of these individuals a place at the head of the queue. Instead, to ensure that at least some of them survive without providing inappropriate advantages to all of them, essential workers may be entered into a weighted lottery in such a way that their selection is more likely, on average, than that of others (Childress, 2003).

As has been observed, the successful management of a bioterrorism event requires a high degree of public trust. Therefore, criteria for triage and resource allocation should be formulated as part of a public consensus process. Transparency in the development and application of resource allocation principles under extreme conditions should include their defense and readjustment in light of public reaction. Precedent can be found in the case of the allocation of organs (Childress, 1997). The articulation and adjustment of allocation principles must take place well in advance of the event itself.

The Obligations of Emergency Health Workers

Healthcare workers are often expected to undergo a degree of discomfort and inconvenience in executing their duties. This expectation is justified by the vulnerability of those under their care, a vulnerability grounded in illness and in the knowledge differential between doctor and patient. Similar role-related obligations apply to other professionals, such as attorneys or securities analysts, whose clientele is inherently vulnerable by virtue of social status or lack of relevant information. Perhaps because of the concreteness and intimacy of their work, no other professional group is held to as high a standard in this regard as are those in healthcare.

The degree to which healthcare workers must compromise their own well being for the sake of others is often unclear. The role-related duties of healthcare professionals imply at least a modest degree of self-sacrifice for the sake of others who are in need of their services. Ordinarily these sacrifices are limited to brief periods of discomfort or inconvenience, particularly embodied in the rigors of the medical residency. At the extreme, martyrdom and other supererogatory acts spell out the limits of these duties, but detailed guidance is lacking. Although emergency health workers have been designated as a special group with more extensive duties under circumstances that demand urgent attention, this designation is not informative about the boundaries of their obligations (World Medical Association, Pan American Health Organization).

One set of considerations has to do with the support emergency healthcare workers are given in executing their tasks. Professionals cannot be expected to perform their responsibilities in the absence of adequate materials, much less expose themselves to conditions that put them at risk. Governments must provide "an effective and centralized authority to coordinate public and private efforts." (World Medical Association). In the context of terrorism the society under threat should also provide the material support required for emergency healthcare workers to do their job, particularly as there is an expectation that their personal welfare is at somewhat greater risk than that of other health professionals (Eckenwiler). The failure to provide suitable support is not an excuse for the healthcare worker to abandon his or her post. Rather it reflects the reciprocity that skilled professionals may fairly expect considering the physical and psychological stresses to which they are exposed.

Another consideration relevant to the question of the limits of emergency healthcare workers' duties is that of moral responsibilities to distant others, as compared to appropriate concerns for one's own welfare or that of significant persons in one's life. As the victims of catastrophe are less familiar to us, as they become more distant in space or culture, it may become more psychologically challenging to relate to their circumstances, especially if their plight competes with that of someone in greater geographic or social proximity.

A feature of the healthcare workers' morality that should, in principle, set them apart from the rest of society is that their circle of concern knows no distance. Yet it is worth asking if this presumption of universal concern, of impartiality, is always sound when it competes with more local concerns about one's own family, friends, and colleagues. Further, partiality is not a vice if it is conceived as one way in which human beings express their individuality through the uniqueness of their relationships (Eckenwiler). Healthcare professionals functioning in emergencies may not be expected and should not be required to subvert justifiable tendencies to place primary value on personal relationships when forced to allocate their caregiving under extreme conditions.

The Role of Private Sector Institutions

Many of the human and material resources that may be required in catastrophic circumstances are in the private sector, especially pharmaceutical manufacturers and managed care organizations. Nonpublic entities are generally agreed to have some responsibilities to the society that provides a stable framework for their business activities, responsibilities that must only increase in the event of social emergency. The contours of these corporate social responsibilities assume a special character in the context of bioterrorism.

Yet private industry cannot be expected or required to resolve all societal problems that are more appropriately considered the province of public entities, such as providing access to medication or healthcare for all. Rather, these private interests have a duty to participate in the public discourse that seeks the resolution of policy problems and to engage in business practices, such as fair pricing policies, that make solutions practicable. The rationale for this duty can be expressed in terms of the primary moral purpose of any business, to produce goods or services that contribute to the pursuit of the good life (DeRenzo).

Within this scheme drug companies can be said to have certain obligations with regard to the bioterror threat. For example, they are obligated to provide security to guard against any potential vulnerabilities in their production activities or storage arrangements. They should make positive efforts to help ensure that medications are available for the treatment of bioweapons injuries with a wide therapeutic range and based on different mechanisms, rather than simply produce medications similar to those already available. For cases wherein there is only one patented drug for a certain indication that is related to a bioterror threat, government may consider a stop the clock mechanism that permits at least temporarily lifting the patent so that production and distribution can be accelerated. (DeRenzo)

Managed care organizations (MCOs) have concentrated a large portion of the highly skilled healthcare work force in the private sector. Not limited to bioterrorism, this arrangement raises questions about the relationship between corporate responsibilities and threats to the public health. Controlling of costs while also providing excellent healthcare has proven to be a significant challenge to the industry, and quality improvement efforts have proven disappointing in resolving the cost-quality tension. Because public health agencies have limited resources, any severe public health problem would further tax the private healthcare system as MCOs would be obligated to provide care for victims even if they are not enrolled in some defined health or insurer plan (Mills and Werhane).

In one sense, as the burden of providing care for a potentially large patient population at risk from bioterrorism falls on MCOs—in the form of vaccination, treatment of victims and planning for attacks—the tension between cost and quality will become still more pronounced. In another sense, however, the requirements of physical survival in extreme circumstances render the cost issue moot, as the best possible care will simply have to be provided. From an economic standpoint the goods and services involved are decommodified or removed from the marketplace because market mechanisms are unable to deal with such conditions. Instead, MCOs should think of themselves as part of a wider system of healthcare, along with government agencies, the pharmaceutical industry and academia. Paradoxically, the threat of bioterrorism introduces a community perspective into privatized healthcare in a way that normal economic and political conditions do not (Mills and Werhane).

Research Ethics and National Security

The development of human research ethics, and of biomedical ethics itself, has been decisively influenced by experience with the involvement of human subjects in national security experiments. The signal event in this often dispiriting history was the exploitation of concentration camp prisoners in experiments under the cover of World War II, many sponsored by the Nazi German military apparatus. The culmination of the Nazi doctors' trial in 1947 was the creation of the Nuremberg Code, which set down rules for human subjects' research and is generally considered a landmark document in biomedical ethics (Moreno).

Subsequent policies regulating human experiments on biological, chemical and atomic warfare in the U.S. military during the cold war specifically referenced the Nuremberg Code. However, these policies were not always followed, in some instances because the activity in question was not considered to be a medical experiment but a training exercise. Secrecy has itself proven to be among the greatest single obstacles to developing consistently applied ethical standards in this area.

The populations that have been involved in national security research represent a wide range, from military personnel, conscientious objectors, and institutionalized persons including prisoners, mental patients and medical patients. Military personnel in particular occupy a complex role because they are expected to subject themselves to risks that would not be required of others, and must accept medical interventions that will preserve or reestablish their fitness for duty (Moreno). Certain basic ethical standards have been recommended, such as appropriate security clearance for all parties, including subjects, prior review by an institutional review board, an appeals process, informed consent, and record keeping (Advisory Committee on Human Radiation Experiments).

Like the other bioethical issues associated with bioterrorism, the development of ethical standards for the involvement of human beings in national security experiments requires the resources of several disciplines. Still more challenging, is the application of these standards, which requires a level of engagement with the political system that clearly identifies bioethics as a practical moral activity.

jonathan d. moreno

SEE ALSO: Coercion; Epidemics; Freedom and Free Will; Harm; Hazardous Wastes and Toxic Substances; Holocaust; Homicide; Immigration, Ethical and Health Issues of; Race and Racism; Warfare: Chemical and Biological Weapons

BIBLIOGRAPHY

Advisory Committee on Human Radiation Experiments. 1996. Final Report of the Advisory Committee on Human Radiation Experiments. New York: Oxford University Press.

Childress, James F. 1997. Practical Reasoning in Bioethics. Bloomington, IA: Indiana University Press.

Childress, James F. 2003. "Triage in Response to a Bioterrorist Attack." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

DeRenzo, Evan G. 2003. "The Rightful Goals of a Corporation and the Obligations of the Pharmaceutical Industry in a World with Bioterrorism." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

Eckenwiler, Lisa A. 2003. "Emergency Health Professionals and the Ethics of Crisis." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

Kipnis, Kenneth. 2003. "Overwhelming Casualties: Medical Ethics in a Time of Terror." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

Mills, Anne E., and Werhane, Patricia H. 2003. "After the Terror: Healthcare Organizations, the Healthcare System, and the Future of Organization Ethics." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

Moreno, Jonathan D. 2001. Undue Risk: Secret State Experiments on Humans. New York: Routledge.

Ramsey, Paul. 1970. Patient as Person. New Haven, CT: Yale University Press.

U.S. v. Karl Brandt et al., Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law No. 10 (October 1946–April 1949).

Bioterrorism

Bioterrorism refers to the use of lethal biological agents to wage terror against a civilian population. It differs from biological warfare in that it also thrives on public fear, which can demoralize a population. An example of bioterrorism is provided by the anthrax outbreak which occurred during September-November 2001 in the United States. Anthrax spores intentionally spread in the mail distribution system caused five deaths and a total of 22 infections. The Centers for Disease Control (CDC) classifies bioterror agents into three categories:

• Category A Diseases/Agents that can be easily disseminated or transmitted from person to person and that can result in high mortality rates while causing public panic and social disruption. Anthrax, botulism, plague , smallpox, tularemis, and viral hemorrhagic fever viruses belong to this category.
• Category B Diseases/Agents that are moderately easy to disseminate and that can result in low mortality rates. Brucellosis, food and water safety threats, melioidosis, psittacosis, staphylococcal enterotoxin B, and typhus belong to this category.
• Category C Diseases/Agents that include emerging pathogens that could be engineered for mass dissemination in the future because of availability or ease of production and dissemination and that have potential for high mortality rates.

The anthrax attacks of 2001 were very limited in scope compared to the potential damage that could result from large-scale bioterrorism. A large-scale bioterrorism attack on the United States could threaten vital national security interests. Massive civilian casualties, a breakdown in essential services, violation of democratic processes, civil disorder, and a loss of confidence in government could compromise national security, according to a report prepared by four non-profit analytical groups, including the Center for Strategic and International Studies and the John Hopkins Center for Civilian Biodefense Studies.

Probably the first sign of a bioterrorism attack is when people infected during the attack start developing symptoms and showing up in hospital emergency departments, urgent care centers, and doctors' offices. By this time, people infected in the initial attack will have begun spreading it to others.

An added concern is that most physicians have never treated a case of a bioterrorism agent such as smallpox or Ebola . This is likely to cause a delay in diagnosis, further promoting the spread of the contagious agent. For example, based on past smallpox history, it is estimated that each person infected during the initial attack will infect another 10–12 persons. In the case of smallpox, only a few virus particles are needed to cause infection. One ounce of the smallpox virus could infect 3,000 persons if distributed through an aerosol attack, according to William Patrick, senior scientist in the United States biological weapons program before its official termination in 1969, in a 2001 Washington Post Magazine interview. Given these numbers, a terrorist with enough smallpox virus to fill a soda can could potentially infect 36,000 people in the initial attack who could then infect another 360,000–432,000. Of these, an estimated 30% or 118,800–140,400, would likely die.

Using disease as a weapon is not a new idea. It goes back at least hundreds of years and possibly much further back. One account of the beginning of the great plague epidemic which occurred in Europe in the fourteenth century and killed a third of the population states that it started with an act of bioterrorism, as reported by A. Daniels in National Review. The Tartars were attacking a Genoan trading post on the Crimean coast in 1346 when the plague broke out among them. Turning the situation into a weapon, the Tartars catapulted the dead and diseased bodies over the trading post walls. The Genoans soon developed the deadly disease and took it back with them to Genoa, where it soon engulfed all of Europe. Another example from early North American history is provided by the British soldiers who gave smallpox-infected blankets to Native Americans in the 1700s.

The Hague Conventions of 1899 and 1907 included clauses outlawing the deliberate spread of a deadly disease. However, during World War I, German soldiers attempted to infect sheep destined for Russia with anthrax. After the war, 40 members of the League of Nations, the precursor of the United Nations, outlawed biological weapons. But many countries continued biological warfare research. During World War II, the Japanese mass-produced a number of deadly biological agents, including anthrax, typhoid, and plague. They infected water supplies in China with typhoid, killing thousands, including 1,700 Japanese soldiers. Bioterrorism entered popular literature more than a century ago when science fiction writer H. G. Wells wrote "The Stolen Bacillus,", a novel in which a terrorist tries to infect the London water supply with cholera , an acute and often deadly disease.

Throughout the Cold War era, several nations, including the United States and Soviet Union, developed sophisticated facilities to produce large amounts of biological agents to be used as weapons. Most nations have renounced the manufacture, possession, or use of biological weapons. However, a few rogue nations, including Iran, Iraq, and North Korea, still have active biological warfare programs according to the United States military. Many experts in the field believe that terrorists could obtain deadly biological agents from these rogue nations, or from other terrorist or criminal groups active in nations of the former Soviet Union.

Among the Category A Diseases/Agents , six highly lethal biological agents are most likely to be used by terrorists, according to the CDC. Depending on the biological agent, disease could be spread through the air, or by contaminating the food or water supply.

• Anthrax, caused by Bacillus anthracis, is an acute infectious disease that most commonly occurs in hoofed animals but can also infect humans. Initial symptoms are flu-like and can occur up to several weeks after exposure. Treatment with antibiotics after exposure but before symptoms develop is usually successful in preventing infection. There is a anthrax vaccine used by the military but it is not available for civilian use. About 90% of people who are infected die.
• Botulism is a muscle-paralyzing disease caused by a toxin produced by a bacterium called Clostridium botulinum. The botulinum toxin is the single most poisonous substance known, according to the Center for Civilian Biodefense Strategies. It is a major bioterrorism threat because of its extreme potency and high rate of death after exposure. It is not contagious and would likely be used by terrorists to contaminate food or water supplies. Flu-like symptoms, along with difficulty speaking, seeing, or swallowing, usually occur 12–72 hours after exposure.
• Plague is a disease caused by Yersinia pestis, a bacterium found in rodents and their fleas in many areas around the world. When released into the air, the bacterium can survive for up to an hour. Of the three types of plague (pneumonic, bubonic, and septicemic), pneumonic is the one most likely to be used by terrorists since large stockpiles were developed by the United States and Soviet Union in the 1950s and 1960s. Symptoms include fever, headache, weakness, chest pain, and cough. Early treatment with antibiotics can reduce the risk of death.
• Smallpox is caused by the variola major virus and was eliminated from the world in 1977. However, the Soviet Union had large stockpiles of the virus in the 1980s and much of it may still be stored in the former Soviet republics and available to terrorists. Smallpox spreads directly from person to person and can be dispersed in the air. Also, the amount needed to cause infection is very small. Symptoms, including high fever, fatigue, and head and back aches, commonly develop in about 12 days. Flat, red skin lesions follow initial symptoms. Death occurs in about 30% of the cases. There is a vaccine against smallpox but routine vaccinations ended in 1972. The government has an emergency supply of about 15 million doses of the vaccine.
• Tularemia, an infectious disease caused by the bacterium Francisella tularensis,, is usually found in animals but can also infect humans. It could be delivered in a terrorist attack through food, water, or air. Symptoms of tularemia include sudden fever, chills, headache, muscle ache, dry cough, weakness, and pneumonia. The disease can be treated with antibiotics if started early. As of May 2002, the U.S. Food and Drug Administration (FDA) was reviewing a possible vaccine for the disease.
• Exotic diseases, including viral hemorrhagic fevers, such as Ebola, and arenaviruses, such as the one causing Lassa fever, are also biological agents of interest to terrorists. The Ebola virus is one of the most lethal known, and easily spreads from person to person, with no vaccine or effective treatment presently known.

The possibility that bioterrorists may strike at food and water supplies is of serious concern to health and environmental officials. Such an attack initially could be perceived as unintentional food poisoning , which might delay recognition of the outbreak, and complicate identification of the contaminated food. What many consider an act of bioterrorism by domestic terrorists occurred in The Dalles, Oregon, in 1984. Members of a religious cult contaminated restaurant salad bars with Salmonella typhimurium, a nonlethal bacterium that nonetheless infected 751 people. The incident was reportedly a trial run for a more extensive attack to disrupt local elections later that year.

"The United States food supply is increasingly characterized by centralized production and wide distribution of products," according to a May 2002 article in The Lancet, the "Deliberate contamination of a commercial food product could cause an outbreak of disease, with many illnesses dispersed over wide geographical areas." The article also stated that the anthrax letter attacks of 2001 have shown that even a small biological attack can produce considerable public nervousness and challenge the health care system.

[Ken R. Wells ]

RESOURCES

BOOKS

Alexander, Yonah and Stephen Prior. Terrorism and Medical Responses: U.S. Lessons and Policy Implications. Ardsley, NY: Transnational Publishers, 2001.

Frist, Bill and William H. Frist. When Every Moment Counts: What You Need to Know About Bioterrorism from the Senate's Only Doctor. Totowa, NJ: Rowan & Littlefield, 2002.

Salvucci Jr., Angelo. Biological Terrorism, Responding to the Threat: A Personal Safety Manual. Carpinteria, CA: Public Safety Medical, 2001.

U.S. Government CD. 21st Century Complete Guide to Bioterrorism, Biological and Chemical Weapons, Germs and Germ Warfare, Nuclear and Radiation Terrorism - Military Manuals and Federal Documents with Practical Emergency Plans, Protective Measures, Medical Treatment and Survival Information. New York: Progressive Management, 2001.

PERIODICALS

Daniels, Anthony. "Germs Against Man: Bioterror; A Brief History." National Review (Dec. 3, 2001).

Fabian, Nelson. "Post September 11: Some Reflections on the Role of Environmental Health in Terrorism Response." Journal of Environmental Health (May 2002): p.77-80.

Guterl, Fred, and Conant, Eve. "In the Germ Labs: The Former Soviet Union Had Huge Stocks of Biological Agents. Assessing the Real Risk." Newsweek (Feb. 25, 2002): p. 26.

Maddox, P.J. "Bioterrorism: A Renewed Public Health Threat."MedSurg Nursing (Dec. 2001): p. 333-338.

The Lancet (March 9, 2002): p. 874.

Sobel, Jeremy, et al. "Threat of a Biological Terrorist Attack on the U.S. Food Supply: The CDC Perspective."

ORGANIZATIONS

Centers for Disease Control and Prevention - Bioterrorism Preparedness & Response Program (CDC), 1600 Clifton Road, Atlanta, GA USA 30333 (404) 639-3534, Toll Free: (888) 246-2675, Email: cdcresponse@ashastd.org, <http://www.bt.cdc.gov>

Center for the study of bioterrorism and Emergency Infections—Saint Louis University, 3545 Lafayette, Suite 300, St. Louis, MO USA 63104, <http://bioterrorism.slu.edu>

Texas Department of Health Bioterrorism Preparedness Program (TDH), 1100 West 49th Street, Austin, TX USA 78756 (512) 458-7676, Toll Free: (800) 705-8868, <http://www.tdh.state.tx.us/bioterrorism/default.htm>

Bioterrorism

Resources

Bioterrorism is the use of a biological weapon against a civilian population. As with any form of terrorism, its purposes include the undermining of morale, creating chaos, or achieving political goals. Biological weapons use microorganisms and toxins to produce disease and death in humans, livestock, and crops.

Biological, chemical, and nuclear weapons can all be used to achieve similar destructive goals, but unlike chemical and nuclear technologies that are expensive to create, biological weapons are relatively inexpensive. They are easy to transport and resist detection by standard security systems. In general, chemical weapons act acutely, causing illness in minutes to hours at the scene of release. For example, the release of Sarin gas by the religious sect Aum Shinrikyo in the Tokyo subway in 1995 killed 12 and hospitalized 5, 000 people. In contrast, the damage from biological weapons may not become evident until weeks after an attack. If the pathogenic (disease-causing) agent is transmissible, a bioterrorist attack could eventually kill thousands over a much larger area than the initial area of attack.

According to the Centers for Disease Control and Prevention, there are over 20 known microbial bioterrorism agents. Examples include Bacillus anthracis (the cause of anthrax), Ebola virus, Francisella tularensis (the cause of tularemia), and Yersinia pestis (the cause of plague).

Bioterrorism can also be enigmatic, destructive, and costly even when targeted at a relatively few number of individuals. Starting in September 2001, bioterrorist attacks with anthrax causing bacteria distributed through the mail, targeted only a few United States government leaders, media representatives, and seemingly random private citizens. As of May 2006, these

attacks remain unsolved. Regardless, in addition to the tragic deaths of five people, the terrorist attacks cost the U.S. millions of dollars and caused widespread concern. These attacks also exemplified the fact that bioterrorism can also strike at the political and economic infrastructure of a targeted country.

Although the deliberate production and stockpiling of biological weapons is prohibited by the 1972 Biological Weapons Convention (BWC)—the United States stopping formal weapons programs in 1969— unintended byproducts or deliberate misuse of emerging technologies offer potential bioterrorists opportunities to prepare or refine biogenic weapons. Genetic engineering technologies can be used to produce a wide variety of bioweapons including organisms that produce toxins or that are more weaponizable because they are easier to aerosolize (suspend as droplets in the air). More conventional laboratory technologies can also produce organisms resistant to antibiotics, routine vaccines, and therapeutics. Both technologies can produce organisms that cannot be detected by antibody-based sensor systems.

Among the most serious of protential bioterrorist weapons are those that use smallpox (caused by the Variola virus), anthrax (caused by Bacillus anthracis ), and plague (caused by Yersinia pestis ). During naturally occurring epidemics throughout the ages, these organisms have killed significant portions of afflicted populations. With the advent of vaccines and antibiotics, few U.S. physicians now have the experience to readily recognize these diseases, any of which could cause catastrophic numbers of deaths.

Although the last case of smallpox was reported in Somalia in 1977, experts suspect that smallpox viruses may be in the biowarfare laboratories of many nations around the world. At present, only two facilities—one in the United States and one in Russia—are authorized to store the virus. As recently as 1992, United States intelligence agencies learned that Russia had the ability to launch missiles containing weapons-grade smallpox at major cities in the U.S. A number of terrorist organizations—including the radical Islamist Al Qaeda terrorist organization—actively seek the acquisition of state-sponsored research into weapons technology and pathogens.

There are many reasons behind the spread of biowarfare technology. Prominent among them are economic incentives; some governments may resort to selling bits of scientific information that can be pieced together by the buyer to create biological weapons. In addition, scientists in politically repressive or unstable countries may be forced to participate in research that eventually ends up in the hands of terrorists.

A biological weapon may ultimately prove more powerful than a conventional weapon because its effects can be far-reaching and uncontrollable. In 1979, after an accident involving B. anthracis in the Soviet Union, doctors reported civilians dying of anthrax pneumonia (i.e., inhalation anthrax). Death from anthrax pneumonia is usually swift. The bacilli multiply rapidly and produce a toxin that causes breathing to stop. While antibiotics can combat this bacillus, supplies adequate to meet the treatment needs following an attack on a large urban population would need to be delivered and distributed within 24 to 48 hours of exposure. The National Pharmaceutical Stockpile Program (NPS) is designed to enable such a response to a bioterrorist attack.

Preparing a strategy to defend against these types of organisms, whether in a natural or genetically modified state, is difficult. Some of the strategies include the use of bacterial RNA based on structural templates to identify pathogens; increased abilities for rapid genetic identification of microorganisms; developing a database of virtual pathogenic molecules; and development of antibacterial molecules that attach to pathogens but do not harm humans or animals. Each of these is an attempt to increase—and make more flexible—identification capabilities.

Researchers are also working to counter potential attacks using several innovative technological strategies. For example, promising research with biorobots or microchip-mechanized insects with computerized artificial systems that mimic biological processes such as neural networks, and can test responses to substances of biological or chemical origin. These insects can, in a single operation, process DNA, screen blood samples, scan for disease genes, and monitor genetic cell activity. The robotics program of the Defense Advanced Research Project (DARPA) works to rapidly identify bio-responses to pathogens, and for designs to effectively and rapidly treat them.

Biosensor technology is the driving force in the development of biochips for detection of biological and chemical contaminants. Bees, beetles, and other insects outfitted with sensors are used to collect real-time information about the presence of toxins or similar threats. Using fiber optics or electrochemical devices, biosensors have detected microorganisms in chemicals and foods, and offer the promise of rapid identification of biogenic agents following a bioterrorist attack. The early accurate identification of biogenic agents is critical to implementing effective response and treatment protocols.

To combat biological agents, bioindustries are developing a wide range of antibiotics and vaccines. In addition, advances in bioinformatics (i.e., the computerization of information acquired during, for example, genetic screening) also increases flexibility in the development of effective counters to biogenic weapons.

In addition to detecting and neutralizing attempts to weaponize biogenic agents (i.e., attempts to develop bombs or other instruments that could effectively disburse a bacterium or virus), the major problem in developing effective counter strategies to bioterrorist attacks involves the breadth of organisms used in biological warfare. For example, researchers are analyzing many pathogens in an effort to identify common genetic and cellular components. One strategy is to look for common areas or vulnerabilities in specific sites of DNA, RNA, or proteins. Regardless whether the pathogens evolve naturally or are engineered, the identification of common traits will assist in developing counter measures (i.e., specific vaccines or antibiotics).

See also Contamination; Genetic identification of microorganisms.

Resources

BOOKS

Drexler, Madeline. Secret Agents: The Menace of Emerging Infections. Joseph Henry Press, 2002.

Koehler, T.M. Anthrax. New York: Springer-Verlag, 2002. Tucker, Jonathan. Toxic Terror: Assessing Terrorist Use of Chemical and Biological Weapons. Cambridge, MA, MIT Press, 2002.

PERIODICALS

Glass, Thomas and Monica Schoch-Spana. “Bioterrorism and the People: How to Vaccinate a City against Panic” Clinical Infectious Diseases (January 15, 2002): 34 (2).

Inglesby, Thomas V, et. al. “Anthrax as a Biological Weapon, 2002-Updated Recommendations for Management” Journal of the American Medical Association (May 1, 2002): 287, (17).

OTHER

United States Food and Drug Administration Center for Food Safety and Applied Nutrition. “Food Safety and Terrorism” <http://www.cfsan.fda.gov/~dms/fsterr.html> (accessed October 19, 2006).

Brian Hoyle