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BIO-TERRORISM
A Threat or Trifle for Global
Public Health?
Ulrich Laaser & Ibrahim Khan
Section of International Public Health
Faculty of Health Sciences
University of Bielefeld
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Outline of the Presentation
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Definition & Introduction (Public Health Perspectives)
Historical Perspectives
Key Biological Agents & Modes of Bio-terrorism
Anthrax: Epidemiology and Dynamics of Infection
Impact & Magnitude of Infectious Emergency
Clinical Management & Public Health Preparedness ?
Conclusions
Recommendations
Recommended Sources of Literature
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Definition of Bio-Terrorism?

It can be described as "the use, or threatened
use, of biological agents to promote or spread
fear or intimidation upon an individual, a
specific group, or the population as a whole for
religious, political, ideological, financial, or
personal purposes"
CDC, 2002.
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Silent Biological Killers

Dispersal of microbes or their toxins to
produce illness, death and terror
 The paths of infection can be
contaminated water, food, air and
packages.
 Microbes
– Bacteria
– Viruses
– Toxins
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The Nature of Biological
hazards

Biologoical Agents & Weapons represent a
unique ” Environmental ” Hazard. The
pathogens involved are natural in a sense the
way they occur naturally in our environment,
However they are unnatural in the way in
which they are inflicted upon us or society.
Dr.E. Noji (CDC)
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The Motive Behind Bioterrorism ?
•Fears, scares, disruption in social life
•Inducing Human sufferings and damage
•Endorsing political, religious & others motives
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Bioterrorism: Early History
 BW used for thousands of years back. In the
18th Century French and Indian War One of
the most notorious example, when British
Officers gave blankets from smallpox
victims to Indians aligned with French,
Caused an epidemic in tribes and was
thought an effective means of incapacitating
group
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Bioterrorism: History
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1940s: BW techniques refined
– Aerosol methods developed
• Particles suspended in a mist or spray
• Additives included to prevent decay
– Mass production facilities
– Mass delivery systems
• Bombs, bomblets
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Bioterrorism History:
Japan
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Japan: First modern BW program
– Unit 731: Japanese-occupied Manchuria,
1932-45
• Ping Fan: “Death Factory”
– 3,000 doctors, technicians and soldiers
– Biological experiments on prisoners
– Annual budget $2.5 million
• Biowarfare weaponization
– Plague, Anthrax, Cholera
• Performed crude field tests
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Bioterrorism History:
Japan
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Japan: World War II
– BW attacks launched:
• Salmonella, typhoid placed in rivers
• Porcelain bombs with plague-infected fleas
• Populations inoculated with cholera
– Planned attacks:
• Anthrax placed in fragmentation bombs
• “Cherry Blossoms at Night”
– Kamikaze pilots to spread plague over S. California
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Bioterrorism History: U.S.
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United States:
– Last of world powers to start BW
program
• British: Anthrax bomb tested on sheep, 1942
– 1944: US bomb loaded with Anthrax
• Plans to drop on 6 German cities
– War ended before bombs sent to Europe
– 1952: Pine Bluff site opened
• 1958: Missile with BW warhead
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Biological Weapons
Convention: The First Step
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Biological Weapons Convention in 1972 in USA & other
countries pledged to ban the Development, Production
& Stockpiling of Bacteriological (Biological) & toxin
Weapons.
Some historical events disclosed the intentions of some
countries that development is still underway Despite
this convention.
– The anthrax incident in Sverdlovsk in USSR in
April, 1979 affected 200-1000 people
– Gulf War Syndrome & 1991 UN announcement on
Iraq,s Capability (B.Anthrax & the toxin of C. Perfringens)
Source: CDC, 2001
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Special Features Related to
Bio-terrorism
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Potential for Mass Casualties
Short Window for Effective Intervention
Use of Rare or unusual Organisms:
– Variola Major, Burkholderia Psuedomallei
– Genetically manipulated organisms
– Anti-biotic resistant organisms
Requires different agency coordination & integration (e.g., Law
enforcement)
Physicians, Public Health and paramedics have limited knowledge,
practical Experiences on the subject and resources
Source: CDC, 2001
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Bioterrorism: Cost-effectiveness
Weapon of Mass
Destruction
Cost of casualties
($ per square km)
Conventional
2,000
Nuclear
800
Nerve gas
600
Biological weapon
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Chemical-Biological Expert Panel, U.N., 1969
The Threats of Bio-Disasters
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Current Depots of lethal Viruses & Bacteria can go into
wrong hands (anthrax in USA after Sep, 11 )
 Use on large Scale is difficult but small Scale attacks
 Availability of Vaccines & Anti-Biotic for Massive Use
 No Proper Public Awareness exists on the subject
 Unlike Chemical & Nuclear, BT is silent and lately
detected
 Clinical & Public health Preparedness is non-existent
or weak in many Countries (both developed & non-developed Countries)
th
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Critical Biological Agents
Category A
 High Priority
organisms
 Pose high risk N.
Security
 Easily disseminated or
PTP transmission
 Cause high mortality,
 Potential for major
public health impact
might cause public
panic & social
disruption &
 require special action
for Health
preparedness
Category B
 2nd highest Priority
orgs.
 Moderate
dissemination or PTP
transmission
 Cause Moderate M &
M,
 Potential for major
public health impact
 require special action
for Public Health
preparedness
Category C
 3rd highest Priority
orgs.
 Engineered for mass
dissemination in
future due to
availabilityease of
production &
Dissemin.
 Potential for high M
& M,
 Potential for major
public health impact
Source: WHO, 2001
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Critical Biological Agents
A Agents
C Agents
 Variola major
 C. Burnetti (Q fever)  Nipha Virus
(Smallpox)
 Brucella Sp.
 Antaviruses
 B. Antrhacis (Anthrax)
(Brucellosis)
 Tickborne
 Yersinia Pestis (Plague)  Venezuelan
Homm.FV
Encephalitis
 C. Botulinum toxin
(Botulism)
 Staphylococcus
 T.Encephalitis V
Enterotoxin B
 F.Tularensis
 Yellow Fever V
(tularemia)
 Epsilon Toxin of C.
 MDRPerffringens
 Ebola H. fever virus
Tuberculosis
 Food, waterborn
 Marburg HFV
 Lassa Fever V
 Argentine HFV
B Agents
pathogens
 Salmonella Sp.
 Shigella Dysent.
 E.Coli
 V.Cholerae
Source: WHO, 2001
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Anthrax is a Preferred Biological
Warfare Agent because
• It is highly lethal.
• 100 million lethal doses per gram of anthrax
material (100,000 times deadlier than the
deadliest chemical warfare agent).
• Silent, invisible killer.
• Inhalational anthrax is virtually always fatal
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The Impact of Bio-terrorism:
The Case of Anthrax
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Evaluation of Organisms as
Bio-terrorist Tools
Organism Property
Anthrax Smallpox
Plague
Available, easy to grow
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?
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Easy to disperse to many
people
Person to person to spread
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Causes serious/ fatal disease
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No Proven Treatment
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
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BIOLOGICAL WARFARE: IMPACT
[release of 50 kg agent by aircraft along a 2 km line upwind of a
population center of 500,000 – Christopher et al., JAMA 278;1997:412]
Agent
Rift Valley fever
Tick-borne
encephalitis
Typhus
Brucellosis
Q fever
Tularemia
Anthrax
Downwin No. dead No.
d reach,
incapacitat
km
ed
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400
35,000
1
9,500
35,000
5
10
>20
19,000
500
150
85,000
125,000
125,000
>20
>20
30,000
95,000
125,000
125,000
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History of Anthrax as Biological Weapon
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Epidemiology of Anthrax
(2001)
USA
17 confirmed infections
3 deaths (2 in Washington DC, 1 in Florida)
7 ill with inhalation anthrax
7 cases skin anthrax
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13,300 postal workers taking antibiotics as
protective measure
Anthrax:
Less barriers to production.
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Low cost of producing the anthrax material.
Not high-technology. Knowledge is widely available.
Easy to produce in large quantities.
It is easy to weaponize.
It is extremely stable. It can be stored almost indefinitely as a dry
powder.
It can be loaded, in a freeze-dried condition, in munitions or
disseminated as an aerosol with crude sprayers.
Currently, we have a limited detection capability
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Key Points of Pulmonary
Anthrax
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The Use of Bio-Agents
 Site: The Dalles, Oregon, 1984
 Agent: Salmonella typhimurium
 Method of transmission: Restaurant salad bars
 Number ill: 751
 Responsible party: Members of a religious community
had deliberately contaminated the salad bars on
multiple occasions (goal to incapacitate voters to
prevent them from voting and thus influence the
outcome of the election)
Source: Torok TJ, et al. JAMA 1997;278:389-395
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Type of Disease Transmission
Direct Projection
Large Droplets
1 meter spread
Pertussis
Smallpox
Indirect spread
Vehicle Born
Drinking Water
Cholera
Indirect spread
Droplets Nuclei
1-5 Microns airborne
Tuberculosis
Anthrax
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PERSON-TO-PERSON
ACQUISITION
Disease
Transmission
Risk
Andes virus
Undefined
Low
Anthrax
Contact with skin lesions Rare
Ebola, Lassa,
Marburg, CongoCrimean, AHF, BHF
Smallpox
Contact with infective
fluid, droplet?
High
Contact, droplet,
airborne
High
Plague (pneumonic)
Droplet
High
Q fever
Contact with infected
placenta
Rare
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STEPS IN MANAGEMENT
1. Maintain an index of suspicion
2. Protect thyself
3. Assess the patient
4. Decontaminate as appropriate
5. Establish a diagnosis
6. Render prompt therapy
7. Practice good infection control
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STEPS IN MANAGEMENT
8. Alert the proper authorities
9. Assist in the epidemiologic investigation
10. Maintain proficiency and spread the gospel
US Army, Biologic Casualties Handbook, 2001
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The Triangle of Infectious
Diseases Emergency
Infectious Person
Transmission
Susceptible Person
Organism
Time
Place
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DETECTING A BIO-TERROR
EVENT?
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Epidemiologic features
– A rapidly increasing disease incidence
– An unusual increase in the number of people seeking
care, esp. with fever, respiratory, or gastrointestinal
symptoms
– An endemic disease rapidly emerging at an
uncharacteristic time or in an usual pattern
– Lower attack rate among persons who had been indoors
– Clusters of patients arriving from a single local
– Large numbers of rapidly fatal cases
– Any patient presenting with a disease that is relatively
uncommon and has bio-terrorism potential
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DETECTION OF OUTBREAKS
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Recognition
– Syndrome criteria
– Epidemiologic features
Communication
Medical
– Triage, psychological aspects, lab support, public
information
– Patient isolation (Follow UNC guidelines),
decontamination
– Post-exposure prophylaxis, treatment of infected
persons
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What constitutes Preparedness for
Bio-terrorism?
 To
upgrade the capacities and
readiness of the State and local
public health institutions &
jurisdictions’ to be prepared for
dealing with the Public health
threats & Emergencies in the
communities.
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ARE WE WELL PREPARED ?
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Do we have a common comprehensive Policy
(protocols, guidelines, manuals) on
Is it likely that early recognition (clinical
identification) of a biological attack would occur?
Are communication lines established?
Do we have sufficient medications for postexposure prophylaxis and therapy?
Are there sufficient medical facilities to manage
exposure and infection?
THE ANSWER TO ALL OF THE ABOVE IS NO!!!
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STEPS IN MANAGEMENT
1. Maintain an index of suspicion
2. Protect thyself
3. Assess the patient
4. Decontaminate as appropriate
5. Establish a diagnosis
6. Render prompt therapy
7. Practice good infection control
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STEPS IN MANAGEMENT
8. Alert the proper authorities
9. Assist in the epidemiologic investigation
10. Maintain proficiency and spread the gospel
US Army, Biologic Casualties Handbook, 2001
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What makes Stringent
Public
Health Measures in the
event of an Attacks?
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Measures to Protect Public
Health
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Identification of the Source, Immediate Removal of The Source if
known
Established surveillance & Monitoring System for prompt
detection & Response
Infection Control & assessment of extent of contamination of
Environment and identification of risk management
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Deployment of material from the National Drug Stockpiles
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Mass Fatality Management to provide respectful & safe
disposition
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Public Health Measures for
Emergency Situation
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Networks of Information exchange among laboratories,
Pharmacies, Research medical and Public Health institutions to
identify unusual pattern of diseases in the community
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Mass Patient Care, Auxiliary & Treatment Facilities
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Massive Immunization or Prophylactic Drug Treatment
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Emergency measures to save lives, alert Hospitals & Health Care
Centers to provide facilities for early detection
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Management & Prevention of secondary contamination and those
who are exposed
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Post Exposure Infection
Control
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Stringent Public health Safety Measures of
– Isolation and adequate Quarantine Measures
– Keep patients in homes, not hospitals
• forcible quarantine if necessary
– Vaccinate the contacts
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Adding to the Responsiveness
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Good Media Coverage & updates on the event, safety
information
Law enforcement agencies, Federal authorities
supplement local activities
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Coordinating medical & Public Health Response to
Mass Causality Events
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Security in Food Protection, supply and Hygiene
control
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Strengthening targeted education & Training
Massive Public education campaign on vital agents
used in such attacks
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Conclusion
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Due to increase security measures large scale bioterrorism is less likely to occur but Preparedness is
essential
 It require specific Public Health Policy & and
integrated action for which Prior Readiness &
Preparedness is essential
 Develop competency standards for physicians, nurses
& Paramedics that focus on emergency care of &
definitive treatment of mass causalities from nuclear,
biological or chemical disasters.
 Increased Security of research institutions where lethal
viral are kept
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Recommended Literature
Resources in German & English
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Robert Koch InstituteBerlin(http://www.rki.de/GESUND/GESUND-BT.HTM)
Arztblatt (http://www.aerzteblatt.de/archiv/artikel.asp?id=29063 )
Arztkammer (http://www.aerztekammersaarland.de/85/20011023Biowaffen/)
Book:
http://www.baxter.de/fachkreise/bioterrorismus/Baxter_Ellipse_S
mallpox.pdf
WHO (http://www.who.int)
CDC (http://www.cdc.gov/)
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