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Bio Terrorism a Looming Threat

Bio Terrorism a Looming Threat

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Published by Cathalijne Zoete
History shows that bioterrorism is a real threat to peace and stability. We should not underestimate how dangerous it is. Read the full text
History shows that bioterrorism is a real threat to peace and stability. We should not underestimate how dangerous it is. Read the full text

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Published by: Cathalijne Zoete on Dec 13, 2011
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Emerging Infectious DiseasesVol. 4, No. 3, JulySeptember 1998
Special Issue
Until recently, biological terrorism had beenlittle discussed or written about. Until recently, Ihad doubts about publicizing the subject becauseof concern that it might entice some to undertakedangerous, perhaps catastrophic experiments.However, events of the past 12 to 18 months havemade it clear that likely perpetrators alreadyenvisage every possible scenario.Four points of view prevalent among nationalpolicy circles and the academic community at various times have served to dismiss biologicalterrorism as nothing more than a theoreticalpossibility. l) Biological weapons have so seldombeen deployed that precedent would suggest theywill not be used. 2) Their use is so morallyrepugnant that no one would deign to use them.3) The science of producing enough organismsand dispersing them is so difficult that it is withinthe reach of only the most sophisticatedlaboratories. 4) Like the concept of a “nuclearwinter,” the potential destructiveness of bioweaponsis essentially unthinkable and so to be dismissed.Each of these arguments is without validity.Nations and dissident groups exist that haveboth the motivation and access to skills toselectively cultivate some of the most dangerouspathogens and to deploy them as agents in acts of terrorism or war. After the Gulf War, Iraq wasdiscovered to have a large biological weaponsprogram. In 1995, Iraq confirmed that it hadproduced, filled, and deployed bombs, rockets,and aircraft spray tanks containing
and botulinum toxin (1,2); its workforce and technologic infrastructure are stillwholly intact. Also in 1995, the Japanese cult, Aum Shinrikyo, released the nerve gas Sarin inthe Tokyo subway. The cult also had plans forbiological terrorism (3); included in its arsenalwere large quantities of nutrient media,botulinum toxin, anthrax cultures, and droneaircraft equipped with spray tanks. Members of this group had traveled to Zaire in 1992 to obtainsamples of Ebola virus for weapons development.Of more recent concern is the status of one of Russia’s largest and most sophisticated formerbioweapons facilities, called Vector, in Koltsovo,Novosibirsk. Through the early 1990s, this was a4,000-person, 30-building facility with amplebiosafety level 4 laboratory facilities, used for theisolation of both specimens and human cases.Situated on an open plain surrounded by electricfences and protected by an elite guard, the facilityhoused the smallpox virus as well as work onEbola, Marburg, and the hemorrhagic fever viruses (e.g., Machupo and Crimean-Congo). A visit in the autumn of 1997 found a half-emptyfacility protected by a handful of guards who hadnot been paid for months (P. Jahrling, pers.comm., 1998). No one can say where the scientistshave gone, nor is there confidence now that this is
Bioterrorism as a Public Health Threat
D.A. HendersonThe Johns Hopkins University, Baltimore, Maryland, USA
 Address for correspondence: D.A. Henderson, The JohnsHopkins University, The Johns Hopkins School of Medicine,615 North Wolfe Street, Baltimore, MD 21205, USA; fax: 410-955-6898; e-mail: dahzero@aol.com.
The threat of bioterrorism, long ignored and denied, has heightened over the pastfew years. Recent events in Iraq, Japan, and Russia cast an ominous shadow. Twocandidate agents are of special concern—smallpox and anthrax. The magnitude of theproblems and the gravity of the scenarios associated with release of these organismshave been vividly portrayed by two epidemics of smallpox in Europe during the 1970sand by an accidental release of aerosolized anthrax from a Russian bioweapons facilityin 1979. Efforts in the United States to deal with possible incidents involving bioweaponsin the civilian sector have only recently begun and have made only limited progress. Onlywith substantial additional resources at the federal, state, and local levels can a credibleand meaningful response be mounted. For longer-term solutions, the medicalcommunity must educate both the public and policy makers about bioterrorism and builda global consensus condemning its use.
Vol. 4, No. 3, JulySeptember 1998Emerging Infectious Diseases
Special Issue
the only storage site for smallpox virus outside theCenters for Disease Control and Prevention.The number of countries engaged inbiological weapons experimentation has grownfrom 4 in the 1960s to 11 in the 1990s (4).Meanwhile, the bombing of the World TradeCenter and the Oklahoma City Federal Buildinghave dramatized the serious problems even smalldissident groups can cause. A comprehensive review of the problemsposed by biological terrorism and warfare hasbeen published (5). Four observations deservespecial note. First, biological terrorism is morelikely than ever before and far more threateningthan either explosives or chemicals. Second,official actions directed at the threat to thecivilian population (less than 2 years in themaking) have been only marginally funded andminimally supported (6). Third, preventing orcountering bioterrorism will be extremelydifficult. Recipes for making biological weaponsare now available on the Internet, and evengroups with modest finances and basic training inbiology and engineering could develop, shouldthey wish, an effective weapon (7) at little cost.Fourth, detection or interdiction of thoseintending to use biological weapons is next toimpossible. Thus, the first evidence of suchweapons will almost certainly be cases in hospitalemergency rooms. Specialists in infectiousdiseases thus constitute the front line of defense.The rapidity with which they and emergencyroom personnel reach a proper diagnosis and thespeed with which they apply preventive andtherapeutic measures could spell the differencebetween thousands and perhaps tens of thousands of casualties. Indeed, the survival of physicians and health-care staff caring for thepatients may be at stake. However, today fewhave ever seen so much as a single case of smallpox, plague, or anthrax, or, for that matter,would recall the characteristics of such cases.Few, if any, diagnostic laboratories are preparedto confirm promptly such diagnoses.Of a long list of potential pathogens, only ahandful are reasonably easy to prepare anddisperse and can inflict sufficiently severedisease to paralyze a city and perhaps a nation. In April 1994, Anatoliy Vorobyov, a Russianbioweapons expert, presented to a working groupof the National Academy of Sciences theconclusions of Russian experts as to the agentsmost likely to be used (8). Smallpox headed thelist followed closely by anthrax and plague. Noneof these agents has so far effectively beendeployed as a biological weapon, and thus no realworld events exist to provide likely scenarios.However, we have had several well-documentedsmallpox importations into Europe over recentdecades; two bear recounting.Smallpox is caused by a virus spread fromperson to person; infected persons have acharacteristic fever and rash. Virus infectioninvariably results in symptomatic disease. Thereare no mild, subclinical infections amongunvaccinated persons. After an incubation periodof 10 to 12 days, the patient has high fever andpain. Then a rash begins with small papulesdeveloping into pustules on day 7 to 8 and finallychanging to scabs around day 12. Between 25%and 30% of all unvaccinated patients die of thedisease. There was, and is, no specific treatment.Until 1980, essentially all countries con-ducted vaccination programs of some sort,whether or not they had endemic disease (9).Until 1972, the United States mandatedsmallpox vaccination for all children at schoolentry, although the last cases had occurred in1949, 23 years before. In the United Kingdom,four standby hospitals were to be opened only if smallpox cases were imported, and in Germany,two state-of-the-art isolation hospitals wereconstructed in the 1960s specifically for theisolation of smallpox cases should they occur.In 1962, the initial response of U.S. officialsto the occurrence of a single case of smallpoxillustrated extreme concern. That year, a youngCanadian boy returned from Brazil, traveling byair to New York and by train to Toronto by way of  Albany and Buffalo (10). Shortly after arrival inToronto, he developed a rash and was hospitalized.In response to this single case, senior U.S.government officials seriously considered a plan of action that called for the border with Canada to beclosed, for mass vaccination campaigns to beconducted in all cities along the route from New York through Albany, Syracuse, Rochester, andBuffalo, and for vaccination of all who had been inGrand Central Station on the day the Canadianboy was there. Sensibly, this plan was soonscrapped for more modest measures, albeit notwithout considerable debate.The potential of aerosolized smallpox tospread over a considerable distance and toinfect at low doses was vividly demonstrated inan outbreak in Germany in 1970 (11). That year,
Emerging Infectious DiseasesVol. 4, No. 3, JulySeptember 1998
Special Issue
a German electrician returning from Pakistanbecame ill with high fever and diarrhea. OnJanuary 11, he was admitted to a local hospitaland was isolated in a separate room on theground floor because it was feared he might havetyphoid fever. He had contact with only twonurses over the next 3 days. On January 14 arash developed, and on January 16 the diagnosisof smallpox was confirmed. He was immediatelytransported to one of Germany’s specialisolation hospitals, and more than 100,000persons were promptly vaccinated. The hospitalhad been closed to visitors because of aninfluenza outbreak for several days before thepatient was admitted. After the diagnosis of smallpox, other hospital patients and staff werequarantined for 4 weeks and were vaccinated; very ill patients received vaccinia-immuneglobulin first. However, the smallpox patienthad had a cough, a symptom seldom seen withsmallpox; coughing can produce a large-volume,small-particle aerosol like what might occurafter its use as a terrorist weapon. Subse-quently, 19 cases occurred in the hospital,including four in other rooms on the patient’sfloor, eight on the floor above, and nine on thethird floor. Two were contact cases. One of thecases was in a visitor who had spent fewer than15 minutes in the hospital and had only brieflyopened a corridor door, easily 30 feet from thepatient’s room, to ask directions. Three of thepatients were nurses, one of whom died. Thisoutbreak occurred in a well-vaccinated popula-tion. An outbreak in Yugoslavia in February 1972also illustrates the havoc created even by a smallnumber of cases. Yugoslavia’s last case of smallpoxhad occurred in 1927. Nevertheless, Yugoslavia,like most countries, had continued populationwide vaccination to protect against imported cases. In1972, a pilgrim returning from Mecca became illwith an undiagnosed febrile disease. Friends andrelatives visited from a number of different areas; 2weeks later, 11 of them became ill with high feverand rash. The patients were not aware of eachother’s illness, and their physicians (few of whom had ever seen a case of smallpox) failedto make a correct diagnosis.One of the 11 patients was a 30-year-oldteacher who quickly became critically ill with thehemorrhagic form, a form not readily diagnosedeven by experts. The teacher was first givenpenicillin at a local clinic, but as he becameincreasingly ill, he was transferred to adermatology ward in a city hospital, then to asimilar ward in the capital city, and finally to acritical care unit because he was bleedingprofusely and in shock. He died before a definitivediagnosis was made. He was buried 2 days beforethe first case of smallpox was recognized.The first cases were correctly diagnosed 4weeks after the first patient became ill, but bythen, 150 persons were already infected; of these,38 (including two physicians, two nurses, andfour other hospital staff) were infected by theyoung teacher. The cases occurred in widelyseparated areas of the country. By the time of diagnosis, the 150 secondary cases had alreadybegun to expose yet another generation, and,inevitably, questions arose as to how many otheryet undetected cases there might be.Health authorities launched a nationwide vaccination campaign. Mass vaccination clinicswere held, and checkpoints along roads wereestablished to examine vaccination certificates.Twenty million persons were vaccinated. Hotelsand residential apartments were taken over,cordoned off by the military, and all known contactsof cases were forced into these centers undermilitary guard. Some 10,000 persons spent 2 weeksor more in isolation. Meanwhile, neighboringcountries closed their borders. Nine weeks after thefirst patient became ill, the outbreak stopped. In all,175 patients contracted smallpox, and 35 died.What might happen if smallpox werereleased today in a U.S. city? First, routine vaccination stopped in the United States in 1972.Some travelers, many military recruits, and ahandful of laboratory workers were vaccinatedover the following 8 years. Overall, however, it isdoubtful that more than 10% to 15% of thepopulation today has residual smallpox immunity.If some modest volume of virus were to bereleased (perhaps by exploding a light bulbcontaining virus in a Washington subway), theevent would almost certainly go unnoticed untilthe first cases with rash began to appear 9 or 10days later. With patients seen by differentphysicians (who almost certainly had neverbefore seen a smallpox case) in different clinics,several days would probably elapse before thediagnosis of smallpox was confirmed and analarm was sounded.Even if only 100 persons were infected andrequired hospitalization, a group of patientsmany times larger would become ill with fever

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