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08.01.99 Post Graduates Medicine The Medical Impact Of Bio Terrorism



08.07.01 Korrekt read this article about one month prior to attacks. "Thermostat" possibly. There may be a much larger issues in New York, maybe a signature linking attacks to article. - time consuming needs review.



09.18.01 Anthrax Attacks Post 911

09.11.01 World Trade Center Attack & Structure Collapse

Reference Chemical Saturation


Employers at the World Trade Center begin to notice exceptionally high absenteeism. Because the center represents such a large concentration of people, it is often seen as a microcosm for infectious diseases in the general urban New York City population. There must be a bad cold or flu going around. Within days, the horror of what has happened in the greater New York City area begins to be seen around the world. The unlucky visitors to New York on "that day" have carried home and planted new seeds of infection. The president, mayor, press, and American people are demanding answers from the Centers for Disease Control and Prevention or anyone who can provide information. The infection has become international news--the biggest story in the world.

An aerosolizer, battery, and motor, together with small tubes containing 1 to 3 million infectious doses of a particular agent, can fit into a device no larger than a standard-sized thermostat box. These diminutive devices can fill a large metropolitan skyscraper or enclosed coliseum with a highly infectious aerosol.


The Medical Impact Of A Bioterrorist Attack
Is it all media hype or clearly a potential nightmare?
Michael T. Osterholm, PhD, MPH



CME learning objectives

To understand the magnitude of the threat of bioterrorism and the current state of unpreparedness
To recognize the distinctive nature of a bioterrorist attack and the difficulties in identifying one
To learn the diseases of highest potential for a bioterrorist attack


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This is the third of three articles on emerging infections

Preview: Invisible but deadly microbes wafting silently through the environment until every corner of breathing space is contaminated only happens on the Starship Enterprise, right? Not according to Dr Osterholm, a well-known expert in infectious disease and epidemiology and a member of a task force working to prepare the nation for such bioterrorist attacks. In this article, he describes the realities of an event of this type and summarizes the current state of preparedness.
Osterholm MT. The medical impact of a bioterrorist attack: is it all media hype or clearly a potential mightmare? Postgrad Med 1999;106(2):121-30

It was the second terrorist attack on New York's World Trade Center towers, only this time, nobody knew about it. Thousands of workers and visitors went about their daily activities as if nothing unusual had happened. There was no bomb blast, billowing smoke, or collapsing concrete. There were no wailing sirens, no body bags, and no flurry of rescue personnel tending the dazed and wounded. There was no live television news coverage; the only visual recording of the day would come from the static eyes of security surveillance cameras. There was no death in the streets and no wild-eyed panic that day. That would come later. And when it did, it would be like nothing anyone connected with managing the crisis--from officials in the White House down to the cops on the beat--had ever seen before.

Even 2 weeks later, no one really knows what is happening. This is when people start showing up in emergency departments throughout the greater New York metropolitan area complaining of flulike symptoms: headaches, backaches, high fever, and sometimes nausea and vomiting. Some of them are so ill that bacterial meningitis is considered, but test results are negative. Patients also have a characteristic rash that immediately suggests chickenpox to emergency department physicians. Although some patients report that they already had chickenpox as children, the diagnosis is not dismissed because personal histories can be unreliable. A few of the more perceptive physicians consider a food-borne staphylococcal infection, which can explain the vomiting and rash, but testing reveals nothing. Patients are sent home with instructions to see their own physician or return if they do not start feeling better.

Meanwhile, a few people show up at hospitals with even more severe flulike symptoms but no rash. Despite aggressive medical support, each dies within 48 hours of presentation. Autopsies show some internal bleeding in the heart, lungs, and gastrointestinal tract, but the actual cause of death remains a mystery.

Employers at the World Trade Center begin to notice exceptionally high absenteeism. Because the center represents such a large concentration of people, it is often seen as a microcosm for infectious diseases in the general urban New York City population. There must be a bad cold or flu going around. Within days, the horror of what has happened in the greater New York City area begins to be seen around the world. The unlucky visitors to New York on "that day" have carried home and planted new seeds of infection. The president, mayor, press, and American people are demanding answers from the Centers for Disease Control and Prevention or anyone who can provide information. The infection has become international news--the biggest story in the world.

People who were sent home from emergency departments now started returning, and in much worse condition. The rash has developed into something horrible and grotesque; it is something physicians have seen only in textbooks. The diagnosis becomes clear: smallpox. A disease supposedly eradicated from the face of the earth has come back to remind people of its potential for destruction. Patients are dying. Bodies are literally piling up in hospital morgues that do not have enough cold storage.

Before the devastation is over many months later, upwards of 400,000 people will have fallen ill, more than 150,000 of whom will die. Many additional generations of cases continue to occur in many states and even other countries. The survivors will bear lifelong effects, including severe scarring and, in some cases, blindness. Widespread panic will come along after the initial terror among healthcare workers and the fundamental breakdown in overburdened medical services, the closing down of Wall Street, and the most vicious and deadly trading in black-market drugs ever witnessed. The lasting effect on the collective psyche of a people who are no longer able to enter a public space without fear and have abandoned their faith in the basic structures of government and society can only be imagined.

For the past several decades, smallpox has been among the most unlikely diagnoses that any clinician would expect to make, regardless of a patient's travel history or other risk factor. However, as noted in the preceding chilling scenario, this could change rapidly. Today such illnesses as smallpox and anthrax routinely make front-page news, in part due to the recent flurry of threatening anthrax-related hoaxes. The growing threat of a real bioterrorism event has become one of the most feared infectious-disease possibilities as we move into the 21st century.

For many members of the medical community, important questions must be answered before this threat can be taken seriously. This article addresses the questions that help clarify bioterrorism as either media hype or a potential nightmare.

Historical perspective
Bioterrorism is not a new means to further political, social, or religious agendas. In 1346, the Tartar army hurled corpses of plague victims over the walls of enemy settlements. However, today's changing factors make the potential for bioterrorism in the United States very different than it was just decades ago. These factors include the growing number of groups and individuals willing or determined to cause mass civilian casualties, the unprecedented availability of traditional biologic-warfare agents, and the means to effectively deliver these agents to large populations. These changes are unparalleled in human history, and because of them, the United States must be prepared for the growing threat of bioterrorism (1,2).

Increasing public awareness of the threat of bioterrorism began after the fall of the Soviet Union in the early 1990s. At that time, several defectors from the former Soviet Union's biologic-warfare program described in detail the efforts to use biologic agents as weapons. The program was funded by two entities, one (ie, Biopreparat) in the Ministry of Medical and Microbiologic Industry and the other in the Ministry of Defense. In the 1980s, more than 60,000 workers were employed in Biopreparat to develop extensive weapons systems using a variety of biologic agents. These efforts have been graphically described in a recently released book (3). One of the authors, Dr Ken Alibek, was the former first deputy chief of Biopreparat. He defected to the United States in 1992 and was one of the first people to draw attention to the potential for use of biologic agents against civilian populations.

The financial and structural collapse of the former Soviet government has been a factor in the dissemination of biologic weapons around the world. Because of severe financial difficulties, many scientists working in programs to develop such agents have departed, and security is critically lax. There is substantial evidence that a number of these scientists have moved to countries well recognized for ongoing efforts in the areas of terrorism and weapon development (4). In addition, nongovernmental terrorist groups and religious cults with scientific expertise have made extensive efforts to procure and develop biologic weapons for use against civilian populations.

The current situation
In 1972, more than 140 countries, including the United States, signed the Biological and Toxin Weapons Convention. This international attempt to eliminate the possibility of biologic warfare or terrorism has been largely unsuccessful in limiting proliferation of weapons and their serious potential. It appears that while Western countries complied, other countries initiated massive programs in weapon development.

Complacency with the issue of bioterrorism was forever shaken by the events surrounding the Persian Gulf War and the discovery of Iraq's biologic-weapons program. The 1995 release of sarin gas in the Tokyo subway by the Japanese religious cult Aum Shinrikyo further illustrated the world's vulnerability to bioterrorism. Although the Japanese government attempted to dismantle Aum Shinrikyo after the attack, the organization continues to operate throughout the world. Today more than 500 members are known to live in Japan, and branches of the cult are found in Russia, Ukraine, Belaruse, and Kazakhstan (5).

In addition, international terrorist experts recognize that the advent of the Internet has played a key role in the ability of terrorists, hate groups, and even potential lone offenders to organize activities that elude detection by traditional intelligence programs. The Internet enables these groups and individuals to easily obtain information regarding procurement of potential agents and instructions on how to effectively disseminate them.

The challenge of biologic agents
To date, most of the federal, state, and local agencies involved in planning and training for terrorism have focused on the classic event involving chemical release or use of an explosive device. In these situations, police, fire, law-enforcement, and other emergency-response personnel descend on a scene where causalities are evident. The news media have depicted preparedness exercises, featuring rescuers wearing hazardous material (HAZMAT) protective equipment, and this training supposedly reflects our nation's preparedness to deal with terrorism associated with weapons of mass destruction.

Unfortunately, in the case of a biologic-agent release, this scenario could not be further from the truth. Because the onset of illness is often delayed, sometimes up to weeks after the release, and because a biologic agent can be disseminated widely throughout an entire city or region, the timing and location of a bioterrorism event may be extremely difficult to identify. Instead of being heralded by red lights and sirens converging on a known point of assault, a bioterrorist attack will be identified gradually by emergency department physicians, infectious-disease consultants, clinical laboratorians, and public health epidemiologists. Their role will be critical in recognition of the release of a biologic agent. To date, the public health and medical care delivery systems have been woefully ill-prepared to meet the challenge of a biologic-agent release (2).

Bioterrorism comes of age
Three basic ingredients must be in place for a bioterrorism event to occur: a terrorist group or other type of perpetrator, availability of selected biologic agents, and an effective method of dissemination.

Existence of terrorists
In the past decade, a spectrum of potential terrorist organizations and individuals has emerged (1). These range from state-sponsored terrorism, such as that seen in such countries as Iraq, Iran, Libya, Syria, Israel, North Korea, and even Russia, to the religious extremist groups that are causing rapidly growing concern, such as those responsible for the bombings of US embassies in Africa in 1998. Although the extent of biologic-weapon development by these religious extremist groups is unclear, some experts suggest that technology has been transferred to the groups by several of the state-sponsored organizations mentioned.

Recently, there is some concern that millennium cult groups, who espouse the end of the world during the year 2000, will use biologic agents to attempt to bring about this outcome. Other cult organizations, such as the Aum Shinrikyo, are not related to the millennium but believe that their mission is to eliminate all those in the world who are not members of their organization. In addition, anxiety is growing that splinter groups or lone offenders, such as those who caused the explosion of the Murrah Federal Building in Oklahoma City, may move from explosive devices to biologic agents as a means of bringing about terror and death in the civilian population. Again, this possibility has been substantially increased with the widespread availability of information on the Internet regarding such activities and instructions on creating devices that can effectively disseminate biologic agents in large buildings or communities.

Availability of agents
The World Directory of Collections of Cultures and Microorganisms currently lists 453 repositories in 67 nations that will supply biologic agents for a variety of purposes. For example, without requiring evidence of professional or academic-research need, 54 repositories will sell and ship Bacillus anthracis (the causative agent of anthrax) and 18 will sell and ship Yersinia pestis (the causative agent of plague). Although none of the organizations that will sell or ship agents without professional justification are located in the United States, it is still possible, although illegal, for US residents to procure these agents.

International sales of biologic agents from government programs through the black market, particularly in the former Soviet Union, is of serious concern and should not be underestimated. For example, several years ago, submarine gyroscopes were smuggled from the former Soviet Union into Iraq, despite the illegality of the shipments out of the former Soviet Union and the United Nations' ban on shipments of such materials into Iraq. This incident demonstrates the ease with which black-market materials can be sold and moved throughout the world.

Method of dissemination
Even with a biologic agent in hand, a terrorist can initiate an attack only if an effective method of disseminating the agent is available. Unfortunately, with the many advances that have been made in aerosol-particle technology for use in industry, aerosolizing devices can be purchased in commercial electronics stores. Such devices can easily create 1- to 3-micro particles. An aerosolizer, battery, and motor, together with small tubes containing 1 to 3 million infectious doses of a particular agent, can fit into a device no larger than a standard-sized thermostat box. These diminutive devices can fill a large metropolitan skyscraper or enclosed coliseum with a highly infectious aerosol. Once again, one of the primary reasons for widespread disclosure of this technology has been its availability on the Internet.

Agents of bioterrorism
Ideal characteristics of a potential biologic-warfare agent include the following: can be produced easily and inexpensively; can be aerosolized (into 1- to 10-micro particles); can survive sunlight, dryness, and heat; can cause lethal or disabling disease; can be transmitted person to person; and cannot be effectively prevented or treated. Unfortunately, a variety of agents meet most, if not all, of these criteria.

Table 1 summarizes bacterial, viral, and toxic diseases most likely to be associated with serious community-wide acts of bioterrorism. Over the past year, a group of experts in bioterrorism has convened at the Johns Hopkins Center for Civilian Biodefense Studies in Baltimore. A review on anthrax was recently published by the group (6), and reviews on smallpox, plague, tularemia, botulism, and hemorrhagic fever viruses will be published in the near future. Clinicians, public health officials, and other government officials will find these reviews to be very helpful in recognizing and responding to the specific diseases.

Table 1. Diseases of highest concern for potential biologic terrorism

Q fever

Viral encephalitides
Viral hemorrhagic fever

Staphylococcal enterotoxin B


Without question, smallpox and anthrax are the two greatest threats as biologic-warfare agents. In comprehensive reviews of these diseases, the experts at the Johns Hopkins center examined the magnitude of potential devastation from aerosol release of one of these agents in a populated area.

Smallpox poses the most serious danger, in part because few US citizens have any significant immunity remaining from vaccinations received more than 30 years ago, and an entire younger generation has received no vaccination at all. Smallpox vaccine has not been produced worldwide for several decades, and only very limited stockpiles still exist. The US inventory consists of fewer than 7 million doses of vaccine. New production of smallpox vaccine, now required to meet current federal standards, is at least 3 and possibly 5 years away from completion. Even a minor outbreak of smallpox would quickly overwhelm the medical community's ability to respond because of the highly infectious and aerosol-transmittable nature of the disease. Other serious aspects of smallpox are lack of any treatment method and a 30% case-fatality rate.

Alibek and Handelman (3) have described in great detail the extent of the former Soviet Union's program to "weaponize" smallpox. In addition, in 1993 the Russian Foreign Intelligence Service confirmed that North Korea was investigating smallpox as a biologic-warfare weapon (7).

The role of anthrax in bioterrorism also is a serious concern. There is no person-to-person secondary transmission after initial release of the agent, as is seen with smallpox, and animal studies suggest that antibiotic treatment early in the course of inhalational infection may be effective. Nevertheless, the possible effects of a terrorist-associated anthrax outbreak are frightening to contemplate (6).

In 1970, a World Health Organization expert committee estimated that release of 50 kg of anthrax from an aircraft over an urban population of 5 million would result in 250,000 casualties (8), 100,000 of whom could be expected to die if not treated. The US Congressional Office of Technology Assessment estimated that between 130,000 and 3 million deaths could follow aerosolized release of 100 kg of anthrax spores upwind of the Washington, DC, area. This impact would exceed that of a hydrogen bomb (9).

The challenge for the future
The challenge for society in dealing with the potential of bioterrorism is daunting. Even a mild event will have an overwhelming impact on the US healthcare system. The illness resulting from such an attack could be widespread, bringing unprecedented numbers of patients to emergency departments. Medical care, clinical laboratory, and mortuary personnel would need to have available and use special protective measures. Because stockpiles of critical vaccines and antibiotics are limited, supplies would quickly run out. Panic would likely ensue among the ill, the possibly exposed, the worried well, and healthcare and other infrastructure support staff.

The US government must undertake a comprehensive review of the current level of preparedness to prevent and respond to possible acts of bioterrorism. Henderson's recommendations (2) serve as a good blueprint for starting that review. Many of us who have had the opportunity to more fully explore intelligence information, to attempt to coordinate even initial planning and response activities at the local level, and to explain, repeatedly, to policymakers and the media that HAZMAT training will not be relevant in a bioterrorist event realize the magnitude of the task before us.

Even with the technologic sophistication available in the United States today, effectiveness in dealing with a bioterrorist event is limited. Current surveillance systems may be inadequate to detect attacks. Because the onset of illness after exposure to an agent is delayed, even the time and location of the attack may be vague. In addition, most of the medical community is unfamiliar with many of the high-threat diseases, so identification of the problem may be further delayed. Many of us who are involved in studying the many aspects of bioterrorism believe that it is not a question of if such an event will occur but rather when, as well as which agent will be used and how extensive the damage will be. Given the enormity of what is possible, we must prepare for a potential nightmare.

Carter A, Deutch J, Zeilkow P. Catastrophic terrorism: tackling the new danger. Foreign Affairs 1998;77(6):80-94
Henderson DA. The looming threat of bioterrorism. Science 1999;283(5406):1279-82
Alibek K, Handelman S. Biohazard: the chilling true story of the largest covert biological weapons program in the world--told from the inside by the man who ran it. New York: Random House, 1999
Miller J, Broad WJ. Iranians, bioweapons in mind, lure needy ex-Soviet scientists. New York Times 1998 Oct 11:A12
Miller J. Some in Japan fear authors of subway attack are regaining ground. New York Times 1998 Oct 11:A12
Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax as a biological weapon: medical and public health management. JAMA 1999;281(18):1735-45
Caudle LC. The biological warfare threat. In: Zajtchuk R, Bellamy RF, eds. Medical aspects of chemical and biological warfare. Washington, DC: Office of the Surgeon General, 1997:451-66
World Health Organization. Health aspects of chemical and biological weapons. Geneva, Switzerland: World Health Organization, 1970:98-9
Simon JD. Biological terrorism: preparing to meet the threat. JAMA 1997;278(5):428-30


Dr Osterholm, former Minnesota state epidemiologist, is chair and CEO, Infection Control Advisory Network, Inc, Minneapolis, and a member of the Working Group on Civilian Biodefense, Johns Hopkins Center for Civilian Biodefense Studies, Baltimore. Correspondence: Michael T. Osterholm, PhD, MPH, Infection Control Advisory Network, Inc, 7716 Golden Triangle Dr, Eden Prairie, MN 55344.

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06.22.07 Page Creation



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