By: ANTON STEVE P. LIM, R.N., PGDip-TS
LEAPS Academy Philippines | PG Diploma in Terrorism Studies
Introduction
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.
Historical Backgrounder
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:
Category A
- 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
Category B
- 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, Tuberculosis
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.
Final Thoughts
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.
*****
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