By: ANTON STEVE P. LIM, R.N., PGDip-TS
LEAPS Academy Philippines | PG Diploma in Terrorism Studies
The current definition of terrorism emphasizes that its primary aim is to threaten and terrorize large groups of humans, governments, armies, or society as a whole. Thus, one may assume, in the context of a socio-historical analysis of bioterrorism, that it involves the use of various biological agents by all kinds of actors or groups, including political or military actors and official states, motivated by different reasons (be they political, religious, or other ideological objectives), in order to attain such objectives.
The use of biological agents such as viruses, bacteria, fungi, or their toxins to cause disease or death among human population, food crops and livestock, or to terrorize society and manipulate the government, has increased much possibilities in recent times. It could be by any means of any method, covert or overt, for the transmission of disease from one human to another or to the desired target. For instance, measles, influenza, avian flu, smallpox, plague, and viral hemorrhagic fevers. Bioterrorist agents of major concern have been categorized as A, B and C based on the priority of the agents, and all posing risk to societal security.
The Threat of Bioterrorism
The threat of bioterrorism, in which biological agents are used by extremists as weapons against civilian populations, is a matter of great concern. Nations and dissident groups exist that have both the motivation and access to skills to selectively cultivate some of the most dangerous pathogens and to deploy them as agents in acts of terrorism. Although a bioterrorist attack is difficult to predict, the consequences of a successful attack could be devastating and cannot be ignored.
Bioterrorism and its effects can impose heavy demands on the public health care system which will be called upon to handle the consequences. It causes public health emergency. Early detection and rapid investigation are the keys to contain the attacks. An effective public health care system with strong disease surveillance, rapid epidemiological and laboratory investigation, efficient medical management, information, education and communication will be required to counter any act of covert or overt bioterrorist attack. Thus, the role of public health epidemiologist is critical not only in determining the scope and magnitude of the attack but also in effective implementation of interventions. The most important step in any case of bioterrorist attack is the identification of the event. This can be achieved by generating knowledge about it, having high degree of critical awareness and having a good surveillance system to assist quick detection.
Contagious diseases and other biological weapons were recognized for their potential impact on armies or people as early as the 14th century BC. The Hittites documented examples of Biological Warfare (BW) by sending diseased rams, possibly infected with bacterial disease tularaemia, to their enemies to weaken them.
In the 4th century BC, the Greek historian Herodotus relates that Scythian archers used to infect their arrows by dipping them in a mixture of decomposing cadavers of adders and human blood – a mixture which might have contained Clostridium perfringens and Clostridium tetani, as well as snakes’ venom.
During the 3rd century BC, the military commander Hannibal of Cartagena set fire to the enemy’s fleet with pots full of venomous snakes. Similar examples are reported by historians and anthropologists of the use of arrows or other vessels infected with different products extracted from animal parts or plants in order to attack the human enemy.
The use of arrows for the transmission of plague were documented in history. For instance, in 1346, the Mongols, by throwing diseased cadavers with catapults against their enemies. The attacking enemy army experienced an epidemic of bubonic plague. Similar examples of the use of the technique of catapulting infected cadavers can be found throughout the modern period, from the siege of the Bohemian City of Carolstein by Lithuanian troops in 1422 to the siege of the Swedish army in Reval (Estonia) in 1710 by the Russians.
In brief, here are some featured events in the history of Biological Warfare:
14th century BC - the Hittites send rams infected with tularaemia to their enemies
4th century BC - according to Herodotus, Scythian archers infect their arrows by dipping them into decomposing cadavers
1155 - Barbarossa poisons water wells with human bodies, Tortona (Italy)
1346 - Mongols hurl bodies of plague victims over the walls of the besieged city of Caffa (Crimea)
1422 - Lithuanian army hurls manure made of infected victims into the town of Carolstein (Bohemia)
1495 - Spanish mix wine with blood of leprosy patients to sell to their French foes, Naples (Italy)
1650 - Polish army fires saliva from rabid dogs towards their enemies
1710 - Russian army catapult plague cadavers over the Swedish troops in Reval (Estonia)
1763 - British officers distribute blankets from smallpox hospital to Native Americans
1797 - The Napoleonic armies flood the plains around Mantua (Italy), to enhance the spread of malaria among the enemy
1863 - Confederates sell clothing from yellow fever and smallpox patients to Union troops during the American Civil War
During the subsequent centuries, smallpox represented the most effective, if purposefully used, biological weapon. Introduced in the American continent by the European colonizers, it was explicitly used several times as a way to infect Native Americans during the so called ‘Conquest of the West’.
Below summarizes the use of biological agents during the historic wars:
Anthrax - Bacillus anthracis - World War I; World War II; Soviet Union, 1979; Japan, 1995; USA, 2001
Haemorrhagic - Marburg virus - Soviet bioweapons programme
Plague - Yersinia pestis - Fourteenth-century Europe; World War II
Smallpox - Variola major - Eighteenth-century North America
Tularaemia - Francisella tularensis - World War II
Cholera - Vibrio cholerae - World War II
Encephalitis – Alphaviruses - World War II
Food poisoning - Salmonella species, Shigella species - World War II; USA, 1990s
Glanders - Burkholderia mallei - World War I; World War II
Typhus - Rickettsia prowazekii - World War II
Various toxic syndromes - Various bacteria - World War II
Classification of Bioterrorism Agents
To determine the risks from various agents, the Centers for Disease Control and Prevention (CDC) considers their effect on human health, the degree of contagiousness or method of transfer to humans, and the availability and effectiveness of vaccines and therapies to prevent and treat illness. The level of threat from specific agents is reviewed and revised periodically. New high-risk pathogens may be added to the list as they are discovered. It is also possible that the relative level of threat could change. For example, if an effective vaccine is developed against a particular agent, its level of threat would decrease, whereas if an agent becomes resistant to current therapies, its level of threat could increase.
The classification into Categories A, B, and C is based on the ability of the agent to be disseminated, the mortality rate of the agent, the actions required for public health preparedness, and the capability of causing public panic.
Category A consists of the agents that are considered the highest risk, and much of the biodefense research effort is directed towards these agents. It poses the highest risk to national security; can be easily disseminated or transmitted from person to person; result in high mortality rates and could have a major public health impact; require special public health preparedness actions; have potential to cause public panic and social disruption.
Examples - Anthrax, Botulism, Dengue, Ebola, Hantavirus, Lassa, Marburg,
Plague, Smallpox, Tularemia
Category B agents are ones that could conceivably threaten water and food safety. It poses the second highest risk to national security; are moderately easy to disseminate; result in moderate morbidity rates and low mortality rates; require enhanced diagnostic capacity and disease surveillance.
Examples - Caliciviruses, Chikungunya, Cholera, E. coli O157:H7, Hepatitis A,
Ricin toxin, Salmonella, Typhus fever, Yellow fever, Zika
Category C includes pathogens that are considered emerging infectious disease threats and which could be engineered for mass dissemination; are easily produced and disseminated; have potential for high morbidity and mortality rates and major health impact.
Examples - Antimicrobial Resistance, Hendra, Influenza (highly pathogenic
strains), MERS, Nipah, Prions, Rabies, SARS, Tickborne encephalitis,
Public Health Emergency Preparedness and Response
The responsibilities of public health agencies are surveillance of infectious diseases, detection and investigation of outbreaks, identification of etiologic agents and their modes of transmission and the development of prevention and control strategies.
Maintaining effective disease surveillance and communication systems are fundamental components of an adequate public health infrastructure. Ensuring adequate epidemiologic and laboratory capacity are prerequisites to effective surveillance systems. One approach to early detection is “syndrome surveillance”, in which electronic symptom data are captured early in the course of illness and analyzed for signals that might indicate an outbreak requiring public health investigation and response. Syndrome surveillance has been used for early detection of outbreaks to follow the size, spread and tempo of outbreaks, to monitor disease trends and to provide reassurance that an outbreak has not occurred. Syndrome surveillance systems seek to use existing health data in real time to provide immediate analysis and feedback to those charged with investigation and follow-up of potential outbreaks.
Exposure to the agents of bioterrorism by use of vaccines and antibiotics has dramatic potential for saving lives and expense. The public health approach to bioterrorism must begin with the development of local and state-level plans. Close collaboration between the clinical and public health communities is also critical. To effectively respond to an emergency or disaster, health departments must engage in preparedness activities.
Completion of the following five phases of activities prior to an incident are essential for successful response to a bioterrorist attack.
Preparedness Phase - includes actions to be taken by different agencies to ensure required state of preparedness. These include evaluation of the laboratory facilities and upgrading the same, evaluating the hospital preparedness in emergency response and case management in case of an imminent attack, conduct training of health professionals, rapid response team (RRT) and quick response medical team (QRMT) who would be the first responders, work out the legal provision and their implications, ensure that requirement of safe drinking water is met, ensure availability of adequate stocks of medicines and vaccines, coordinate with security organization, organize mock drills for health professionals, government departments, animal husbandry, security, law enforcing and other agencies so as to assess their preparedness levels to act in case of an attack, prepare contact details so that communications is unhampered during an attack. Public should be kept aware about imminent attacks so that voluntary reporting is encouraged. It is important to carry out review of situation based on current information of threat perception.
Early Warning Phase - in the surveillance system, this includes activities like case definitions, notification, compilation and interpretation of epidemiological data. Early detection and rapid investigation by public health epidemiologist is critical in determining the scope and magnitude of the attack and to implement effective interventions.
Notification Phase - it is mandatory to report any unusual syndrome or usual syndromes in unusual numbers to appropriate authorities. The activities in this phase include rapid epidemiological investigations, quick laboratory support for confirmation of diagnosis, quarantine, isolation, keeping health care facilities geared for impending casualty management and evolving public health facilities for control.
Response Phase - activities include rapid epidemiological investigation, quick laboratory support, mass casualty management and initiation of preventive, curative and specific control measures for containing the further spread of the disease.
In order to achieve them, following steps can be followed:
Assess the situation - Initiate the response by assessing the situation in terms of time, place and person distribution of those affected, routes of transmission, its impact on critical infrastructure and health facilities, the agencies and organizations involved in responding to the event, communicate to the public health responders, local, state and national level emergency operation centers for event management etc.
Contact key health personnel - Contact and coordinate with personnel within the health department that have emergency response roles and responsibilities. Record all contacts and follow-up actions.
Develop action plan - Develop initial health response objectives that are specific, measurable and achievable. Establish an action plan based on the assessment of the situation. Assign responsibilities and record all actions.
Implementation of the action plan - RRTs/QRMTs investigate the outbreak/increase in the disease incidence, collect samples and send it to the identified state/national laboratory for testing. Hospitals are alerted for receiving the patients and their treatment. If necessary tented hospitals are set up. Methods to control the disease and quarantine measures are instituted. Once the disease is identified, treatment protocols are sent to all concerned by the fastest possible means. Standard operating procedures (SOP) for laboratory testing is made by the identified laboratory and the same is sent to all the hospital laboratories and district hospitals for implementation. Laboratory reagents are distributed to the concerned laboratories. Public is taken into confidence to prevent any panic. The list of ‘Do's and Don'ts’ are circulated thorough the print and electronic media. Hospitals ensure appropriate isolation, quarantine, waste disposal and personal protective measures. All contaminated clothing and equipment are carefully disposed of by incineration. An impact assessment team assesses the impact of the attacks on humans, animals and plants.
Recovery Phase - the setbacks suffered as a result of the bioterrorist attack are restored and lessons learnt in this phase are incorporated in the future preparedness plans. The damage done to the public health facilities and the essential items utilized during the response phase are replenished. Public advisories are issued regarding restoration of normalcy. The RRTs compile and analyze data to identify the deficiencies experienced in the implementation of the response measures. The necessary modifications are then incorporated in the contingency plan for future.
Despite the advances in scientific research on bacteriology and, more generally, in biology and medicine, definitive conclusions regarding the effective use of biological attacks in the history of humankind remain difficult to handle. The lack of microbiological and epidemiological data, the weight of political propaganda and issues about military secrecy make the problem particularly difficult to solve for the historical researcher. However, the recurring use of biological weapons (be it speculative or real), which emerged long before the scientific revolution of microbiology at the end of the 19th century, is a striking characteristic of human history.
Biological warfare is a potential threat on the battlefield of daily life. It is vital for neurologists and other health-care practitioners to be familiar with biological and toxic agents that target the nervous system. Most illnesses caused by biological warfare agents are not commonly considered neurological diseases; however, many of these agents may present with headache, meningitis, or mental status changes, in addition to fever and other symptoms and signs.
Bioterrorism remains a legitimate threat for both domestics and international terrorist groups. The government should conduct a timely surveillance, awareness of syndromes resulting to bioterrorism, epidemiologic investigation, and laboratory diagnostics capacities, ability to rapidly disseminate critical information on a need-to-know and need-to-share basis. Managing public information to the media is also vital. Ensuring the adequate supply of medicines availability. Standard operating procedures on the level of health care will go a long way in minimizing the mortality and morbidity of bioterrorism attack.
References and Suggested Readings:
Sharma R., India wakes up to threat of bioterrorism. BMJ. 2001;323:714.
Lane HC, Fuci AS. Microbial Bioterrorism. In: Kasper DL, Braunwald E, editors. Harrison's Principle of Internal Medicine. 16th ed. McGraw Hill; New York: 2005. pp. 1279–1288.
Centres for Diseases Control and Prevention. Emergency Preparedness and Response: Bioterrorism Overview. http://www.bt.cdc.gov/bioterrorism/overview.asp.
Gupta ML, Sharma A. Pneumonic plague, northern India. Emerg Infect Dis. 2002 http://www.cdc.gov/content/13/4/664.htm 2007
Borio L, Inglesby T, Peters CJ, Schmaljohn AL, Hughes JM, Jahrling PB. Haemorrhagic fever viruses as biological weapons: medical and public health management. JAMA. 2002;287:391–405.
Torok TJ, Tauxe RV, Wise RP, Livengood JR, Sokolow R, Mauvais S. A large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars. JAMA. 1997;278:389–395.
Bioterrorist agents: Differential diagnosis, initial laboratory tests, and public health actions. http://www.stanfordhospital.com/PDF//BTAgentsDifferentialDiagnosis.pdf.
J Lederberg (Ed.), Biological weapons. Limiting the threat, The MIT Press, Cambridge, MA (1999)
GW Christopher, TJ Cieslak, JA Pavlin, EM EitzenBiological warfare: a historical perspective
SI Trevisatano, ‘Hittite plaque’ an epidemic of tularemia and the first record of biological warfare Med Hypotheses, 69 (2007)
MD GrmekLesruses de guerre dans l'Antiquité Rev Etud Grec, 92 (1979)
OC EnehBiological weapons—agents for life and environmental destruction Res J Environ Toxicol, 6 (2012)
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