Bioterrorism and Me

By:

Members of the J300 class in the History of Public Health

Indiana University Bloomington

Spring 2005

Table of Contents

Contact Information...... 5

Home Preparations...... 5

Introduction...... 6 Jessica Mackey, Julia Thomas, Kyle Carmichael

Table 1 Summary of Symptoms and Incubation Period (time from exposure to onset of symptoms)...... 8 Tarrah Beavin, Chris Erickson, and Jon Pollock

Part 1 Diseases Category A Diseases Anthrax ...... 10 Tyler Christman and Julia Thomas Botulism ...... 13 R. Cory James, Matthew Frano, and John Keucher

Plague ...... 16 Emily Stachowicz and Tarrah Beavin Smallpox...... 18 Jessica Mackey, Sangeeta Sakaria, and Peter Cheun Tularemia (Rabbit Fever)...... 21 Kevin Kruse and Neal Patel Viral Hemorrhagic Fevers...... 23 Theo Lutz, Elisabeth Benoit, Melissa Fanning Category B diseases Glanders...... 26 Matthew Frano, Sangeeta Sakaria Venezuelan Equine Encephalitis (VEE)...... 28 James Riley West Nile Virus...... 30 Kyle Carmichael

Part 2 Biological and Chemical Toxins Biological toxins Ricin...... 34 R. Cory James SEB (Staphylococcal Enterotoxin B)...... 36 R. Cory James T-2 (Trichothecene Mycotoxin)...... 38 R. Cory James Chemical toxins

2 Blister agents (Mustard Gas)...... 40 Kyle Mardis Blood agents (Arsine and Cyanide)...... 43 Jon Pollock Nerve Agents G agents (Sarin, Soman, and Tabun...... 45 Jake Agee VX Nerve Gas...... 47 Chris Erickson

Part 3 Targets, Delivery Methods, and Responses Targets...... 49 Kyle Mardis The Delivery of Pathogens and Toxins...... 51 Neal Patel, Kevin Kruse, and Julia Thomas Evacuation and Taking Shelter...... 53 Kyle Mardis Compliance...... 54 Theo Lutz Treatment tips for emergency situations...... 55 Tarrah Beavin Indicators that a terrorist attack may have occurred...... 59 adapted by

Acknowledgments

We want to thank the following people for helping us in revising earlier drafts of this booklet:

Joni Albright, MPA formerly Indiana State Assistant Health Commissioner

Rachel Miller Public Health Coordinator Monroe County, Indiana

Kyle A. Perkinson Public Health Coordinator Sullivan County, Indiana

Scott F. Wetterhall, MD, MPH Senior Program Director, RTI International, Atlanta

And for financial help with printing and distributing this booklet, we want to thank:

John Bodnar Chair History Department

Catherine Larson Dean College of Arts & Sciences

Charlie Nelms Vice President for Student Development and Diversity

A note on how we came to do this project

On the first day of our class each student discussed how he or she wanted to live a useful life. Some planned to do pro bono work in their occupations, others wanted to train to be physicians or public health experts. Everyone wanted to make a difference. Among topics taken up during the semester were some dealing with public implications of tobacco use, road safety, and biological and chemical weapons, and we also studied how people learn about health issues. When this bioterrorism project was suggested, many students reacted by seeing it as a good first step to begin helping other people. In the discussion about whether the class would actually undertake this project, class members decided that by putting together this pamphlet they would be contributing to one of the goals of public health, which is to educate citizens so that they know ahead of time what choices they can make in an emergency. Here's what we found out about how ordinary people can recognize and deal with hazards posed by bioterrorism.

Contact Information

Police Fire Ambulance 911

Poison Control Center 1-800-222-1222

Department of Home land Security Citizens Line 1-202-282-8000

Centers for Disease Control public response hotline 1-800-CDC-INFO

Indiana Public Health Office 1-317-233-8000 emergency number 1-317-233-1325

Home Preparations

There are many decisions to be made to prepare home and work for a bioterrorist attack. We have not tried to discuss these decisions or the specific steps that should be considered, but decided instead to refer readers to some web pages that do cover these issues:

healthandenergy.com/preparing_for_terrorist_attacks.htm

homebuying.about.com/cs/saferooms/a/disaster_kit.htm

www.backwoodshome.com/articles2/arnet74.html, which discusses disaster preparation in general www.vdes.state.va.us/library/famdis.cfm

5 Introduction

Jessica Mackey, Julia Thomas, Kyle Carmichael

Chemical and biological warfare --CBW-- has been employed for hundreds, and probably thousands, of years in ways that might now be considered “primitive.” Modern advances in science and technology make warfare by such means a greater threat today. The new CBW weapons are deadlier, and there are now more opportunities for using them. They have been employed occasionally in wars between nations, and more systematically during World War I. Since the 1990s these weapons have also been used by terrorist groups in attacks on their enemies and in attempts to draw attention to their objectives. Biological terrorism --bioterrorism for short-- is one of the main threats of the 21st century because terrorist groups have learned out to obtain and deploy biological and chemical weapons. And America is a likely target for an attack.

Bioterrorism remains for many people an unknown area. The country as a whole needs to take some steps to enhance protection. Since September 11, 2001 much has been done to plan and organize national defenses. These defenses are essential, but they often seem to be at too great a distance from individuals. Individuals, too, need to plan to defend themselves. The goals of this pamphlet are to explain how to recognize what are regarded as the leading bioterrorist threats, and to provide suggestions about what to do in the event of an attack.

Our aim is to inform rather than to alarm. The main premise of this pamphlet is that everyone can learn how to recognize the diseases and toxins likeliest to be used in bioterrorism, and everyone can learn some useful steps to take against each specific disease and toxin.

Early detection of terrorist attacks will save lives, quite dramatically for some agents. That means that individuals need to know how to recognize and detect the weapons of bioterrorism, or at least when to be suspicious that such weapons have been used. And it means getting in touch immediately with local and national authorities.

Bioterrorism is the use of bacteria or viruses or a chemical compound with the intent of making people ill or causing death. These diseases and chemicals can be spread through the air or water, and by direct contact. Following a categorization introduced by the Centers for Disease Control, we distinguish two groups of diseases. Category A diseases are the most dangerous and the likeliest to be used in bioterrorist attacks. Category B diseases are less lethal and are less likely to be used, but they are still considered dangerous disease agents. Terrorists may elect to use biotoxins and chemical weapons as well as diseases, selecting toxins that cause sickness or death in a large proportion of the people who come into contact with them, and which have a more or less immediate effect. The biotoxins, such as ricin, SEB, and T-2, use live organisms to make chemicals. Other weapons are made from chemical agents. There is no sharp dividing line between biotoxins and chemicals.

6 Each chapter below discusses a particular disease or toxin, or aspects of bioterrorism that concern individuals, such as likely targets, delivery methods, and how to respond. The chapters on diseases and toxins are organized in a way meant to help readers find topics and obtain information quickly.

Many diseases and compounds could be used as weapons. Here we select those that are widely considered the likeliest ones to be used. For a bacteria, virus or chemical compound to threaten us, it must be easily produced and transported, and it must either be powerful enough to affect many people or able to cause disease or injury with unusually small doses. Diseases and agents that are difficult to detect immediately are also attractive for use in bioterrorism. One chapter is devoted to each disease or compound, giving a brief overview. Each chapter explains how to recognize a disease or agent, and what to do with yourself, others, and your belongings if an attack is suspected.

Biological weapons and toxins are appealing to terrorists because such weapons can affect a large number of people and because some of them can be produced with relative ease. A person with limited scientific training may be able to cultivate bacteria or viral agents in a small space without expensive equipment. The production of weapons of this kind is usually easier than making other weapons of mass destruction, such as a nuclear bomb. The quantity of material needed to sicken or kill many people varies from agent to agent, but for the most part more damage can be done with a smaller quantity of a disease or a biological agent than with other types of weaponry.

There are also important disadvantages to using biological weapons. One problem of producing and transporting a biological weapon made from a living organism is that the environment of the weapon must be carefully maintained. Most organisms will not survive exposure to extreme heat or cold, and some do not have a life span long enough for their production, transportation, and delivery as bioterrorist weapons. Another problem that might discourage the use of a bioweapon is the challenge of containing the weapon to one specific area while protecting the attackers. It may be impossible or impractical to prevent the weapon from affecting the very people using it in an attack.

Biological and chemical weapons may or may not threaten Americans in the future; it is impossible to know. We can hope that we never need to use the information in this pamphlet. Still, it is useful to know how to recognize such weapons and how best to protect ourselves in case of an attack. Good understanding of the nature of the threat can help us protect ourselves, our family members, and our friends, and help public health authorities reduce the damage to our community and our nation.

7 Table 1

Summary of Symptoms and Incubation Period (time from exposure to onset of symptoms)

Disease or Earliest symptoms Time until these Likeliest method of toxin after contact symptoms delivery in bioterrorism appear anthrax generalized several hours to aerosol or powder weakness, a dry one week cough, sore throat, and runny nose botulism muscle weakness depends on type aerosol or contaminated without fever food or drink plague fever and chills 1 to 3 days aerosol, dry or wet smallpox flu-like, followed 7 to 17 days aerosol or powder by a rash around the mouth tularemia flu-like 3 to 5 days aerosol or powder viral fever and fatigue, depends on the aerosol or direct contact hemorrhagic then specific to the type of VHF with contaminated fevers type of VHF objects

glanders sudden onset of 1 to 5 days aerosol fever Venezuelan flu-like 1 to 5 days aerosol, wet or dry equine encephalitis West Nile sudden onset of 3 to 14 days aerosol virus fever

ricin flu-like 6 to 8 hours powder or mist staphylococcal depends on degree 8 to 24 hours aerosol enterotoxin B of exposure T-2 skin pain and 2 to 4 hours aerosol as mist or (trichothecene nervousness droplets mycotoxin) blister agents skin blisters 1 to 6 hours aerosol, gas or liquid blood agents varies by type 2 to 24 hours aerosol G agents severe coughing a few minutes to aerosol as vapor or liquid (sarin, soman, and discomfort in 18 hours and tabun) the lungs if “G” agent is inhaled VX nerve gas contractions in immediately if aerosol as gas or liquid involuntary inhaled muscles

Part 1 Diseases

Introduction

Every human disease caused by a germ is a potential candidate for use as a bioterrorism weapon because it can be transmitted to people. But some diseases have attracted more attention from germ warfare scientists, who select the germs on which to conduct experiments, and by experts on bioterrorist threats, who try to figure out which diseases may be weaponized in the germ warfare programs underway in other countries. The experts draw attention especially to diseases that cause sickness in an unusually large proportion of the people infected, those that cause death at a high rate, and diseases that require only a small number of pathogens to cause sickness or death. Bioterrorists are also likely to prefer diseases that can be distributed in aerosol form, diseases that pose a smaller risk to the people preparing them for terrorist use, those that can be obtained from government germ warfare labs, perhaps on the black market, and those that are easier to concoct with comparatively simple equipment.

No one disease has all of these characteristics, but a number of diseases have several of them. This section discusses diseases of leading importance in two categories. Category A diseases are the most dangerous and the likeliest to be used in bioterrorism. Category B diseases are less lethal and are less likely to be used, but they are still considered leading disease agents.

9 Category A Diseases

Anthrax by Tyler Christman and Julia Thomas

Anthrax disease is an effective biological weapon because it is relatively easy and inexpensive to produce. Anthrax bacteria form protective coatings, called spores, and contact with a small number of spores causes disease. Infection can occur in three ways: inhalation, intestinal absorption, and cutaneous (on the skin) contact.

Humans can contract natural cases of anthrax, although such cases are rare in the US. They have been more common among people who have direct contact with animals or animal products such as leather, fur, and raw meat. In a bioterrorism attack anthrax would not be limited to people in contact with animals and animal products. Instead, terrorists would more likely target densely populated areas, people holding positions and occupations of power, or people in the military. While natural anthrax still exists in farming and grazing communities, weaponized anthrax targeting densely populated areas is a different threat. People living in such areas are at risk because release of a small quantity of anthrax in aerosol form could reach and infect a large number of people.

Causative agent: spore-forming bacterium Bacillus anthracis.

Time required for symptoms to appear: several hours to one week. Since sickness usually begins after several days, it is often difficult to pinpoint the source of infection.

Signs and symptoms: early symptoms of the most dangerous form of anthrax, acquired through inhaling the bacteria, resemble those of a common cold, followed by include loss of appetite and vomiting. The symptoms of anthrax disease differ among the three types:

Inhalation anthrax is caused by inhaling or breathing in anthrax spores, and is the likeliest route to be used by terrorists. Initial symptoms are similar to that of a common cold. The infected person will experience generalized weakness followed by a dry cough, sore throat, and runny nose, followed by loss of appetite and vomiting. Sickness caused by inhaling anthrax spores differs from the flu or common cold in that the individual will develop severe breathing problems and respiratory shock.

Intestinal anthrax is caused by eating anthrax spores or the uncooked meat of an infected animal. Early symptoms of intestinal anthrax include loss of appetite and vomiting. As the disease progresses, the individual will experience severe abdominal pain, vomiting of blood, and severe diarrhea.

Cutaneous anthrax is an infection of the skin which is caused by anthrax spores entering through a cut or skin abrasion. This is the most common form of natural anthrax disease.

10 Early symptoms of cutaneous anthrax are itchy red bumps on the skin, which develop into an open sore after one to two days. The sore grows into a painless ulcer with a black center. The area around the sore may swell.

Fatality rate: without treatment, inhalation anthrax is usually fatal. Intestinal anthrax is fatal in 25 to 60 percent of the cases. Cutaneous anthrax is usually not fatal when appropriately treated by a doctor.

Attack rate: contact with spores usually results in sickness.

Recovery: treated early enough, victims will show improvement following treatment and full recovery after a course of treatment that may last up to 60 days.

Prevention: methods to prevent natural anthrax include wearing protective gear when examining animals and animal products, washing one’s face and hands after contact with animal products, and cooking meat thoroughly. Preventing anthrax infections from weaponized forms is a bit more challenging. Since anthrax can take the form of an aerosol or a powder, it is important to use common sense when dealing with such items. Avoid contact with any unusual or suspicious powders or aerosols. In past anthrax attacks, powders containing anthrax have been mailed. Suspicious mail should not be opened.

If you think you are at risk to be exposed to anthrax, you may call the U.S. anthrax Vaccine Immunization Program at 1-877-GETVACC or 1-877-438-8222. The vaccine has been recommended for persons frequently handling animal products, military personnel, doctors, veterinarians, and scientists who might be in contact with the bacteria

Treatment: treatment of anthrax is most effective in the earliest stages of the disease. All forms of anthrax are treated by a combination of antibiotics. The first antibiotic is usually given at a hospital by injection. Additional antibiotics are then taken at home by mouth in pill form over a period of up to 60 days. It is important to complete the entire dosage of antibiotic pills to prevent the disease from re-infecting the individual.

Natural transmission: anthrax disease is transmitted by breathing in anthrax spores, eating anthrax spores, or by spores entering the body through a cut or abrasion on the skin. People rarely contract this disease from other people, and when they do it is through contact with the open sores of cutaneous anthrax.

Germ Warfare Modes of Transmission: anthrax disease can be transmitted via a powder or aerosol. A germ warfare attack would be most effective in an unventilated area with a large number of people. The spores remain stable for a long period of time; they release bacteria when they find a suitable environment, such as the human body.

Germ warfare characteristics: anthrax is an effective low-cost method of producing a large number of fatalities through inhalation. But it is extremely difficult to work with as a bioterrorism agent. For effective use the bacteria would have to be modified from the

11 form found in animals to make it more virulent and resistant to antibiotics. Then it would have to be milled into a form small enough to be inhaled, but not so small that it would immediately be exhaled again. Finally, the terrorists would probably elect to attack indoors, thereby avoiding the effects of even a slight wind, which would disperse the spores before they have much effect.

Confirmation of diagnosis: presence of anthrax bacteria in the body confirms anthrax disease.

Response: before opening letters or packages, consider whether there are signs of anthrax, such as powder on the surface. If so, or if an opened item contains a suspicious powder, cover the item or its spilled contents with anything handy, such as a newspaper, leave the room and seal it off, wash your hands with soap and water, and report your suspicions to the local police. Contact a doctor. Remove your clothing and put it in a plastic bag, and then take a shower. Anyone else in the room should take these same steps.

If you suspect that anthrax has been sprayed into a room, turn off any ventilation, leave the room, close the door, and report to the police.

Seek medical assistance and notify the proper local and state public health authorities.

Germ warfare development and use: the British successfully tested anthrax as a weapon in 1942, and since then many other countries have learned how to produce anthrax so that it can be used as a weapon. Attacks against individuals occurred first in the US in 2001 when the postal service was used to deliver anthrax in powder form. Considerable expertise is required to make the small particles necessary to aerosolize anthrax, but that can be done by individuals or small groups.

12 Botulism

by Cory James, Matthew Frano, and John Keucher

A microscopic view of botulism

One of the most toxic substances known to science, botulism is a potentially dangerous bioweapon. The bacterium produces a nerve toxin that causes disease. These bacteria form protective spores and do not cause disease until they arrive in a suitable environment, such as the human intestine. There are seven types of botulism toxin designated by the letters A through G. Only types A, B, E and F cause illness in humans.

Foodborne botulism is contracted by eating foods that are infected with the toxin. Wound botulism occurs when the toxin enters a wound. Infant botulism is caused by consuming the spores of the bacteria, which then grow in the intestines and release toxin.

Causative agent: toxin produced by Clostridium botulinum, an anerobic bacterium.

Time required for symptoms to appear: in foodborne botulism, 18 to 36 hours after eating contaminated food, but symptoms can occur as early as 6 hours or as late as 10 days. in wound botulism, 4 to 14 days, because of the time required for incubation of spores and release of toxin. in infant botulism, several weeks.

Signs and symptoms: muscle weakness moving into paralysis, without fever. The symptoms of botulism include double or blurred vision, slurred speech, difficulty swallowing and breathing, dry mouth, and muscle weakness, which are all symptoms of the muscle paralysis caused by this toxin. If untreated, these symptoms may progress to cause paralysis of the arms, legs, trunk, and respiratory muscles. Paralysis begins in the head and face, moves to the respiratory system, and finally affects the legs. Botulism can result in death due to respiratory failure.

13 Fatality rate: untreated botulism is usually fatal, but treated botulism causes death in fewer than 10 percent of cases. Botulism cannot be transmitted from person to person.

Attack rate: most people exposed to this toxin become sick.

Recovery: often requires a long period of time, requiring in many cases the aid of a respirator. In the US mortality from natural botulism, usually from eating spoiled meat or canned food, has dropped to 9 percent, but that figure is considered low for the fatality rate that would occur in a bioterrorist attack.

Prevention: there is a vaccine that is regularly given to lab workers who may be exposed. Supplies are limited, and protection from this vaccine does not develop for several months.

Treatment: an antitoxin is available for treatment, but victims of this toxin must be tested to determine whether they will have an allergic reaction to the antitoxin.

Natural transmission: natural botulism is rare, and usually occurs when people eat foods that are infected with botulism toxin, or when infants swallow spores of the botulinum bacteria in such foods as honey. It may also occur when the botulinum nerve toxin enters a wound.

Chemical warfare modes of transmission: botulism is not easily converted to a weapon. Besides being dangerous to work with, anyone who wants to transform the botulism microbe into a weapon that could cause mass casualties must develop an effective means of dispersing the microbe through the air. That is, they must figure out how to convert the agent into tiny particles, and then how to disperse those particles in an aerosol. The botulinum nerve toxin would remain suspended in the atmosphere as an invisible cloud, where it then could be inhaled into unsuspecting victims’ lungs. This form of weaponized botulism could cause wound or infant botulism.

Botulism may also be weaponized through the contamination of food or drink to induce foodborne botulism. Although foodborne botulism is extremely dangerous because many people could unknowingly be poisoned by consuming contaminated food, this method would probably not inflict mass casualties.

Chemical warfare characteristics: theoretically, one gram of botulinum toxin would be enough to kill more than a million people. But botulism is very unlikely to be used with such efficiency. It is much likelier to cause outbreaks involving hundreds or a few thousand people.

Confirmation of diagnosis: through observation by a physician and blood tests, aided by information about whether numbers of people have developed symptoms that indicate an attack at more or less the same time.

Response: if you think you are developing botulism, seek medical assistance and notify

14 the proper local and state public health authorities. You will not have to be isolated because you cannot communicate your infection through the air. But you will need to be hospitalized to combat the progressive development of symptoms. If your skin has been exposed, wash with soap and water.

Chemical warfare development and use: a number of countries, including Iran and Syria, are believed to have developed botulism toxins.

Plague

by Emily Stachowicz and Tarrah Beavin

Pneumonic plague is a possible bioterrorist threat because it is easy to produce in large quantities, can be disseminated in aerosol form, causes a high fatality rate if left untreated, and has the potential for secondary spread after initial infection.

Although easy to produce because the bacteria occurs in nature, a relatively sophisticated system of production and dissemination technology would be required to weaponize pneumonic plague. The reported existence of weaponized forms stockpiled by the former Soviet Union could allow smaller and less sophisticated groups access to pneumonic plague as a weapon without requiring this advanced technology.

Bubonic plague, transmitted through flea bites, was an infamous killer in Europe between the 1400s and the 1700s. It is always present among rodents in some areas of the world, including the US southwest. This form of plague, which causes buboes (large sores in the groin), is not considered a bioterrorism threat.

Causative agent: Yersinia pestis, a bacterium.

Time required for symptoms to appear: 1 to 3 days. This quick outbreak makes it easier to pinpoint the source of infection.

Signs and symptoms: early symptoms include the sudden onset of fever and chills, followed by weakness, rapidly developing pneumonia, cough, possible watery or bloody sputum, nausea, vomiting, abdominal pain with extremely rapid progress of pneumonia- like symptoms. Buboes are NOT a characteristic of pneumonic plague.

Fatality rate: 5 to 14 percent if treated within 24 hours of first symptoms, nearly 100 percent death rate if not treated within this time period.

Attack rate: according to an estimate by the World Health Organization, if 50 kg of the bacteria that cause plague were released as an aerosol over a city of 5 million people, as many as 150,000 persons would become infected with pneumonic plague and 36,000 of those would be expected to die.

Recovery: in one to two weeks.

Prevention: no vaccine is available in the U.S.

Treatment: antibiotics are administered usually for 7 days.

16 Natural transmission: from person to person through inhalation of the bacteria in the air as a result of coughing or sneezing. Natural occurrences of this disease are rare. Infection does NOT convey immunity.

Germ warfare modes of transmission: the pathogen can be administered as an aerosol in either dry or wet form. After the initial administration, the disease would pass from person to person easily. Because the pneumatic form of plague occurs only rarely in nature (1000-3000 cases per year world-wide), an outbreak would probably indicate a terrorist attack.

Germ warfare characteristics: very unpleasant, rapidly advancing and deadly sickness. Initial outbreaks would likely be misidentified or left untreated until too late, contributing to high early death rates and quick spread.

Confirmation of diagnosis: preliminary results of blood work available in as little as 2 hours, with confirmation requiring 24 and 48 hours.

Response: if you think you have been exposed, seek immediate medical attention. People who must be in close contact with other people suspected of having pneumonic plague should wear a medical facemask to prevent breathing in droplets including the bacteria. In emergency situations where a facemask is not available, breathing through several layers of cloth or clothing can be helpful in preventing infection. Pneumonic plague can be passed through the air from person to person within about two yards. No environmental clean up should be required following an attack because the bacteria can only survive for about an hour in the environment. If exposed, sickness can be prevented by immediately beginning a 7-day antibiotic regimen.

Seek medical assistance and notify the proper local and state public health authorities.

Germ warfare development and use: the U.S. weaponized pneumonic plague in the 1950s and 60s. The former Soviet Union reportedly has several tons of the dry powder form of Yersinia Pestis for use as a bioweapon stockpiled.

Smallpox by Jessica Mackey, Sangeeta Sakaria, and Peter Cheun

In a bioterrorist attack smallpox would probably be spread in an aerosolized form of the virus probably in a closed area such as an airplane or building where many people would be exposed. When the smallpox virus is sprayed into the air, it would go undetected because it would have no odor, color, or taste, and would make no loud noise to alert people.

Edward Jenner developed a vaccine that prevents smallpox in 1796. Vaccinations and the isolation of people with smallpox successfully eradicated this disease in 1978, removing the need for further vaccinations. This lack of immunity combined with a lack of familiarity makes this disease especially dangerous if reintroduced. Since we are unfamiliar with it, it could take us a while to recognize it, and in that period of time many people could be infected. Since the earliest symptoms resemble influenza, individuals are likely to spread the disease unknowingly, thinking that their illness is something minor. Moreover, some estimates show that just one gram of the virus could infect 100 people. In its fully developed form this is a disease quite different from most others because of the size, location, and large number of pox or pustules it cases (see the illustration).

Two photographs of a child with smallpox

source:www.who.int/emc/diseases/smallpox/slideset/pages/spox_016.htm

18 Causative agent: variola major virus.

Time required for symptoms to appear: 7 to 17 days, averaging 10 to 12 days.

Signs and Symptoms: early symptoms resemble those of flu followed by red spots on the tongue and in the mouth. After the incubation period, during which there are no symptoms and the person is not contagious, these stages occur:

• flu-like symptoms develop for two to four days and the period of contagiousness begins.

• a rash then forms around the mouth, at which point the patient has now entered the most contagious and dangerous period of the disease.

• a rash and fever persist for several days until they spread all over the body though most prominently on the arms, legs, and face (see image below for how to distinguish between smallpox and chickenpox). The rash then becomes raised red bumps, which will then fill with an opaque fluid that will have a small crater in the middle much like a bellybutton.

• the bumps then become pustules for about five days, after which scabs begin to form over them. The person remains contagious until all the scabs have finally fallen off the skin.

How to distinguish smallpox from chickenpox.

source: www.bt.cdc.gov/agent/smallpox/overview/overview.pdf

Fatality rate: varies from 10 to 40 percent and is thought usually to be about 30 percent. Some people develop the hemorrhagic form, in which the death rate is higher.

Attack rate: some people exposed to smallpox would probably develop a minor case with no apparent symptoms, but most would develop the disease.

19 Recovery: takes several weeks and will leave patient badly scarred and possibly blind.

Prevention: vaccine is available in small quantities but is no longer administered to the public. Larger quantities can be made with enough time. Vaccine protects for about ten years, whereas a case of natural smallpox provides immunity for life.

Treatment: no known effective treatment.

Natural transmission: smallpox is spread through from person-to-person via respiratory droplets exhaled while breathing. However, in general, it takes a prolonged exposure to an infected person and close contact to transfer the disease.

Germ warfare modes of transmission: smallpox could be dispersed in aerosolized form or perhaps via suicide carriers mixing in crowds. After initial transmission the disease would pass from person to person easily. An outbreak of smallpox in any population would most probably indicate a terrorist attack.

Germ warfare characteristics: because an outbreak caused by terrorists would probably show up after 10 to 12 days, the source or site of the attack would not be immediately evident. The later symptoms are severe and unusual enough that most victims would quickly seek medical treatment, and it is at that point that the attack would be recognized.

The risk of a terrorist attack with smallpox is reduced by the great technical skill required to culture the virus, to make it into powder or liquid form for aerosol use, and to transport it.

Confirmation of diagnosis: physical signs of the disease will be obvious.

Response: as soon as you recognize smallpox in yourself, you should seek medical help immediately. Distance yourself from others and make sure that as soon as you are taken to the hospital, anything you have touched (clothing, bedding) is disinfected properly. To rid items of smallpox virus, you must disinfect with steam, fire, or a sodium hypochlorite bleaching solution. For more information on the government’s smallpox response plan, visit http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp. For more information about this disease visit the Center for Disease Control website at www.cdc.gov or call their hotline at 1-800-CDC-INFO. Your state will also have a plan of action and can inform you on smallpox as well as what your state is doing to protect itself from smallpox and what your state will do if a smallpox outbreak occurs.

Seek medical assistance and notify the proper local and state public health authorities.

Germ warfare development and use: between three and eight countries are believed to hold secret stocks of smallpox virus, and some authorities claim that the Soviet Union developed more virulent strains. It is not known whether smallpox vaccine would protect against other strains of this virus.

20 Tularemia (rabbit fever)

by Kevin Kruse and Neal Patel

Tularemia in natural form is typically a rural disease carried by animals and insects. Hunters properly watch for diseased rabbits, which are sluggish or inactive. About 200 cases occur naturally in the U.S. each year. It is attractive for use as a germ warfare disease because small doses cause sickness. Only 5 to 10 bacteria are enough to cause infection through the skin, and between 10 and 50 bacteria are enough to cause infection when breathed in. Several countries, including the U.S. and Russia, have weaponized the bacterium. Weaponized tularemia can be spread either through an aerosolized form or as a fine powder, to be breathed in. After it is dispersed, tularemia can continue to cause infections for several weeks, longer than most other pathogens.

Causative agent: bacterium (Francisella tularensis).

Time required for symptoms to appear: 3 to 5 days.

Signs and symptoms: flu-like symptoms (fever, chills, headache, and muscle ache); joint pain, dry cough, weakness, severe respiratory illness, and pneumonia.

Fatality rate: 5 to 15 percent in untreated cases, but less than 2 percent in promptly treated cases.

Attack rate: nearly everyone infected will become sick with flu-like symptoms that may develop into pneumonia.

Recovery: antibiotics begun promptly will lead to full recovery.

Prevention: a vaccine has been used to protect laboratory workers that work with two common strains of tularemia. However, terrorists may use a strain that is resistant to the vaccine now available.

Treatment: 12 to 14 day antibiotic regimen using streptomycin and gentamicin.

Natural transmission: tularemia cannot be transmitted from person to person. Natural tularemia is found in many animal hosts and habitats throughout the world and can be recovered from contaminated water, soil, and vegetation. Ticks and small mammals, including voles, mice, water rats, squirrels, rabbits, and hares are natural reservoirs of infection. Humans become infected with tularemia by various modes, including bites by infective insects and animals, handling infectious animal tissues or fluids, or direct contact with contaminated soil or water.

Germ warfare modes of transmission: tularemia can be transmitted via aerosol or fine dry powder form. Because its symptoms closely resemble that of influenza and

21 pneumonia, only an outbreak of these symptoms in an isolated area would be indicative of a biological attack and thus require a bacterial culture to identify the species.

Germ warfare characteristics: it is estimated that if 50kg were dumped from an airplane onto a city of 5 million people there would be 250,000 people infected and 19,000 casualties. Because the initial symptoms produced from tularemia infection are difficult to distinguish from influenza and acute pneumonia, it will be difficult immediately to detect that a bioterrorist attack has occurred. The leading downside to using tularemia as biological weapon is that it cannot be spread from person to person. Therefore, in the event of an outbreak people need not fear infection from those who have already caught the disease.

Confirmation of diagnosis: laboratory tests to identify the bacteria.

Response: prompt treatment with antibiotics for 10 to 14 days will reduce casualties. In a mass casualty situation that would occur in the event of a bioterrorist attack, antibiotics should be given to all individuals displaying possible symptoms of tularemia infection. Meanwhile, because tularemia can persist in an environment for an extended period of time, decontamination of the area should take place immediately with a 10 percent bleach solution.

Seek medical assistance and notify the proper local and state public health authorities.

Germ warfare development and use: the US and Russia developed weaponized tularemia in the 1950’s and 1960’s in an aerosolized form. Other countries are believed to have done so also. It has been reported that weaponized strains of tularemia are resistant to the vaccine and to antibiotic treatment. A likely user would be an organized group with access to airplanes and laboratories to grow and culture the bacterium as well as to prepare it in powdered form.

22 Viral Hemorrhagic Fevers (VHF)

by Theo Lutz, Elisabeth Benoit, Melissa Fanning

This chapter focuses on three Viral Hemorrhagic Fevers, Ebola, Lassa, and Marburg fever, which are known to have been researched as possible agents in warfare. If used effectively in germ warfare these diseases could have a devastating impact because they are so lethal and because so little is known about how to contain, treat, or prevent them. VHF’s have a fatality rate that may exceed 80 percent. The symptoms can be confused with flu for some days, but the final stage, in which bleeding from body orifices begins in many victims, is distinctive (see the photograph).

Some of the viruses associated with VHF naturally reside in animal hosts, most often monkeys and rodents. Natural outbreaks have occurred mostly in Africa. Ebola, Marburg, and Lassa fever can be transmitted from one person to another through close contact with infected people or their bodily fluids. Transmission can also occur through contact with objects contaminated with infected body fluids.

Causative agent: respectively, Ebola, Lassa, and Marburg viruses.

Time required for symptoms to appear: Ebola: 2 to 21 days, followed by an abrupt beginning of fever. Transmission begins after the incubation period. Lassa: 1 to 3 weeks, followed by a slowly developing fever. Marburg: 5 to 10 days, followed by an abrupt beginning of fever.

Signs and symptoms: vary by the type of VHF, but initially can include fever, fatigue, dizziness, muscle ache, loss of strength, and exhaustion. Marburg and Ebola cause a purple rash in many victims. Patients with severe cases show signs of bleeding under the skin, in internal organs, or from the mouth, eyes, or ears. Severely ill patient cases may also show shock, nervous system malfunction, coma, delirium, and seizures. Some types of VHF are associated with kidney failure.

Fatality Rate: 50 to 90 percent.

Attack rate: not enough information is available.

Recovery: people who recover may transmit certain VHFs for several months through semen or urine.

Lassa: the most common complication of Lassa after recovery is deafness. Spontaneous abortion may also occur.

Marburg: recovery may take a long time and even then may be complicated by inflammation of the testicles, liver disease, loss of bowel or bladder control, and eye inflammation.

Ebola: it is not yet known why some patients survive and others do not.

Prevention: there are no vaccines, although promising vaccines were, as of June 2005, being tested for Ebola and Marburg.

Treatment: no effective treatment is known, although ribavirin, an anti-viral drug, has been effective in treating some individuals with Lassa fever.

Natural transmission: hemorrhagic fever viruses are initially transmitted to humans when they come into contact with infected rodents or with the urine, fecal matter, saliva, or other body excretions of infected rodents. These viruses can be spread from person to person through contact with bodily fluids or objects contaminated with infected body fluids, but only rarely by airborne transmission. For Ebola the risk of transmission grows during illness, peaking at the latest stage.

Germ warfare modes of transmission: these are frightening diseases, but they are not easy to use in bioterrorist attacks. The likeliest techniques would be for terrorists to let infected rodents loose in an area, or for individuals already infected to mix with people in a target population.

Viral Hemorrhagic Fevers could be spread by one individual if that person took an object contaminated with infected body fluids and spread it in/on a public place. A pay phone, water fountain, laundry mat, or buffet style restaurant would all be relatively easy places to infect some people and possibly cause panic. Once one person was infected these fevers could be spread from person to person through direct contact with body fluids or blood.

Germ warfare characteristics: it is currently unknown whether these viruses can be made in a powder or liquid form to simplify dispersion. But it is known that Russia and the United States have weaponized some VHFs. Russian researchers found that only a small quantity of viral material would be enough to cause Marburg fever. Aerosol forms of Ebola, Lassa, and Marburg have been prepared.

Cases of any VHF that cannot be linked to rodents, monkeys, or other animal hosts will indicate a bioterrorist attack.

Confirmation of diagnosis: although the means exist to confirm each of these diseases by laboratory tests, most public health laboratories in the US are not equipped to perform these tests.

Response: keep infected people in isolation. In case of death, corpses should be sealed in leak-proof plastic and cremated or buried in a sealed container. Report cases or suspicions immediately to the local health department and to the CDC. Anyone who has touched the body fluids of an infected person, or touched objects with which the infected person has been in contact, should shower immediately with soap and water. Anyone

24 attending the sick person should wear eye protection, a protective gown, gloves, and mask. Use a 10 percent bleach solution to decontaminate objects and surfaces. Discard the clothing of the sick person, using a plastic bag. Sterilize or safely dispose of needles, equipment, and patient excretions.

Seek medical assistance and notify the proper local and state public health authorities.

Germ warfare development and use: VHFs are serious and often fatal. But they are difficult to use as bioterrorist weapons.

A child with Ebola

Category B Diseases

Glanders by Matthew Frano and Sangeeta Sakaria

Glanders is considered to be an attractive disease for biological warfare and terrorism because only a few organisms are required to cause disease and because the death rate among humans is high. This disease is caused by the bacterium Burkholderia mallei and can only exist in infected hosts, which are usually horses, mules, and donkeys. Although rare and sporadic, human transmission of glanders in its natural form occurs in individuals with close and frequent contact with infected animals, such as veterinarians, animal caretakers, and laboratory personnel. The low rate of human transmission is still not understood. There are three routes of infection by the bacteria. In the localized form, bacteria enter through skin by way of a cut or abrasion. The most likely bioweapon use of glanders would be an aerosolized form, causing pulmonary infection in those who inhaled the bacteria. Glanders is deadly if it gets into the bloodstream.

Causative agent: bacteria (Burkholderia mallei); very few pathogens are necessary to cause sickness.

Time required for symptoms to appear: the incubation period depends on the route of infection. In the localized form, the incubation period is 1 to 5 days. In the pulmonary form, the incubation period is 10 to 14 days. If the bacterium enters the bloodstream, infection is usually fatal within 7 to 10 days.

Signs and symptoms: sudden onset of fever and other symptoms, followed by muscle aches, chest pain, muscle tightness, and headache. Additional symptoms include excessive tearing of the eyes, sensitivity to light, and diarrhea. Other signs and symptoms depend on the route of infection. In the localized form, ulcers form at the site where the bacteria entered the body, perhaps with swelling of the lymph nodes. Infections involving the mucous membranes in the eyes, nose, and respiratory tract will cause increased mucus production from the infected sites. If the lungs are infected, a victim may develop pneumonia, an abscess in the lungs, or large pockets of fluid in the lung cavity. In cases of infection via the bloodstream, the bacteria spread from the lungs or skin to the blood, causing fever, shivers, sweating, a decrease in energy, chest pain, diarrhea, and usually death.

Fatality rate: up to 90 percent in those in blood infections with death occurring in 7 to 10 days. Prolonged treatment with antibiotics is believed to reduce the likelihood of death.

Attack rate: nearly everyone infected will become noticeably sick.

Recovery: recovery times vary and glanders may reoccur chronically.

Prevention: there are currently no vaccines available for glanders. In countries where glanders is common in animals, the only prevention methods available are identification and elimination of the infection in animal populations. Transmission can be prevented effectively by using basic blood and body fluid isolation techniques when the presence of glanders is suspected.

Treatment: because human cases of glanders are rare, there is limited information about antibiotic treatment of the organism in humans. Sulfadiazine has been found to be an effective treatment in experimental animals and in humans, but the fatality rate may remain high even with antibiotic treatment.

Natural transmission: natural human infection is most likely due to contact with an infected animal. In addition to animal exposure, cases of human-to-human transmission have been reported. These cases include sexual transmission and infection in family members who cared for glanders patients.

Germ warfare modes of transmission: it is possible to transmit glanders via aerosol, and the disease would break out in people, horses, donkeys, and mules simultaneously, which would not occur in natural glanders. Since this disease does not naturally occur outside Africa, Asia, the Middle East, and Central and South America, cases in humans in the US and Europe may indicate a biological warfare attack.

Germ warfare characteristics: pulmonary infection followed by blood infection.

Confirmation of diagnosis: this disease is diagnosed by isolating Burkholderia mallei from blood, spit, urine, or skin lesions.

Response: isolate the sick person and use protective barriers such as surgical masks, face shields, and gowns when caring for the patient.

Seek medical assistance and notify the proper local and state public health authorities.

Germ warfare development and use: Germany is believed to have used glanders to infect Russian horses and mules on the Eastern Front during World War I. During World War II the Japanese infected horses, civilians, and prisoners of war in China. The US and the former Soviet Union studied this agent as a possible biological warfare weapon in 1943-1944 but did not weaponize it. In a terrorist attack this disease might be used against people, but it is also possible that it might be used against livestock.

Venezuelan Equine Encephalitis (VEE)

by James Riley

Venezuelan Equine Encephalitis, Western Equine Encephalitis, and Eastern Equine Encephalitis are all potentially attractive biological weapons. Although VEE is not the most lethal of the three, it is the one most often considered as a potential weapon because it has caused so many infections in laboratory accidents and because only a small number of pathogens, 10 to 100, are enough to cause sickness. VEE is attractive for use as a germ warfare disease because it would produce incapacitating sickness with severe symptoms in nearly everyone exposed to the virus, and because it is difficult to distinguish from influenza, so that it might not be detected immediately. VEE would kill comparatively few people, but might result in permanent nervous system damage in more victims (hence the term 'brain virus' sometimes used to describe this disease; encephalitis means inflammation of the brain). Initial exposure in germ warfare would be through aerosol forms, which would have maximum effect in seasons when mosquitoes are active.

Causative agent: Venezuelan Equine Encephalitis virus.

Time required for symptoms to appear: 1 to 5 days.

Signs and symptoms: sudden onset of flu-like symptoms (feeling tired, irregular but spiking fever, severe headache, chills); nausea with vomiting, cough, and sore throat may follow. Symptoms last 24 hours to 5 days.

Fatality rate: less than 1 percent. Children are likeliest to die.

Attack rate: nearly everyone infected will become noticeably sick.

Recovery: within one to two weeks.

Prevention: experimental vaccines have been tested in horses and people, but VEE and EEE exist in many strains, complicating the matter of formulating one vaccine to protect against all strains.

Treatment: none, except to relieve symptoms; some anti-viral drugs show promise in animal experiments.

Natural transmission: usually a disease of horses, natural VEE may be transmitted to people by mosquitoes, in which case the epidemic in horses precedes cases in humans. Transmission from person to person is not known to occur. The mosquitoes that carry VEE have a much wider range than the disease itself.

28 Germ warfare modes of transmission: VEE can be transmitted via aerosol in either a wet or dry form of the virus, in which case the disease would break out in people and horses at the same time. VEE does not occur naturally outside Florida and the areas from southern Texas to Brazil and Peru. Thus cases in humans in other locales may indicate a germ warfare attack. The same holds for EEE, which in natural cases in the US has been limited to eastern states, and to WEE, which has been limited to western states. The aerosol form of the virus will not remain infective very long.

Germ warfare characteristics: central nervous system damage may be more common. Although VEE, WEE, and EEE are all relatively easy to work with in a well-equipped laboratory, they are less likely to be produced or used by individuals or small groups and more likely to be used by organized groups with access to airplanes, bombs of a suitable type, and the laboratories needed to concoct the dry-powder or liquid-slurry formulations of the microbes that cause encephalitis. VEE is likeliest to be used to incapacitate troops, but its capacity to infect people over a large area makes it a credible weapon to use against civilians, too.

VEE is believed to have been combined with the less virulent strain of smallpox, a virus with a similar structure, in lab experiments exploring the characteristics of viruses that lead some to cause disease. Bioterrorism experts worry that it might be combined with the virulent strain of smallpox to make a super weapon.

Confirmation of diagnosis: a blood sample may show antibodies 5 to 7 days after the onset of sickness.

Response: during an outbreak, wear insect repellant. Keep infected people in a screened room to prevent mosquitoes from having access to them. VEE is rarely lethal. The best available treatment is for the flu-like symptoms. A 10 percent solution of household bleach will destroy the virus on objects. Wash contaminated clothing with soap and water.

Seek medical assistance and notify the proper local and state public health authorities.

Germ warfare development and use: the US developed weaponized VEE in the 1950s and 1960s, and other countries are believed to have done so also. One estimate suggests that aerosol VEE released by an airplane could infect people over an area as large as 6,000 square miles.

Natural transmission: West Nile is primarily contracted through mosquitoes that have bitten infected birds, though the virus is also found in ticks. In the event of a sudden epidemic of West Nile, an unusually large number of dead birds, particularly crows, suddenly appear. It can also be transmitted indirectly through blood transfusions and organ transplants, and directly through breastfeeding. There is no evidence that West Nile could be transmitted from person to person, and humans are generally regarded as being end-of-the-line hosts.

Germ warfare modes of transmission: West Nile virus could be delivered through aerosol methods directly to people, without the usual mosquito or tick vector. Once in the environment, the virus could be sustained indefinitely and potentially transmitted from human to mosquito to human again. Pesticide equipment can be used to distribute this and other aerosol bioweapons. A bioterrorist attack would be indicated by an outbreak among humans not preceded by the death of birds found to have been infected.

Germ warfare characteristics: aerosol methods of distributing West Nile, entering through the nose, would be more virulent and deadly and thus more likely to result in damage to the central nervous system.

Confirmation of diagnosis: a blood test can be used to identify the presence of West Nile antibodies within 8 to 14 days after illness onset.

Response: if you have come into contact with blood or tissues that may carry this virus, wash your hands and exposed skin with soap and water immediately. Remove mosquito- breeding sites and wear insect repellant in order to impede further transmission of this disease.

Seek medical assistance and notify the proper local and state public health authorities.

Germ warfare development and use: West Nile was weaponized in the 1950s and 1960s and techniques developed for its aerosol dispersal. Since research has been put into other members of the Flavivirus family (Japanese encephalitis and St. Louis encephalitis), that research could likely spill over and be applied to West Nile virus. Many other countries, such as Canada, Germany, North Korea and Russia, are believed to have researched Flaviviruses as potential bioweapons.

The most likely scenario for bioterrorist use is aerosol dispersal that targets either a densely populated, centrally ventilated facility (e.g., a sports arena) or by airplane using a crop-dusting mechanism. Based on research of similar viruses, the aerosol microorganisms would survive for only a matter of hours. However, once in the environment West Nile virus can remain a threat for an indefinite amount of time because of the wealth of hosts and relative ease of transmission from bird hosts to mosquitoes, and then to people.

31 A high level of skill is needed to produce an aerosolized variant of West Nile, which means that the most likely candidate to possess weaponized West Nile would be a dedicated organization, with laboratories to manufacture the virus. Given that West Nile could survive indefinitely after being introduced to a new environment (either by natural or unnatural methods), it has the potential to be used against military or civilian targets. Furthermore, though the scenario is unlikely, mosquitoes can be bred to carry West Nile with surprising ease, with only basic chemistry knowledge needed. The goal of such an attack would not be to kill people, but to incapacitate them and create mass confusion and hysteria.

Part 2 Toxins: Agents of Biological and Chemical Warfare

Terrorists may elect to use biotoxins and chemical weapons as well as diseases, selecting toxins that cause sickness or death in a large proportion of the people who come into contact with them, and which have a more or less immediate effect. The biotoxins, such as ricin, SEB, and T-2, use live organisms to make chemicals. Other weapons are made from chemical agents. There is no sharp dividing line between biotoxins and chemicals; the important thing is to recognize their leading signs and symptoms.

These toxins can be delivered in such ways that they will be inhaled, ingested, or absorbed into the skin. Early after exposure these toxins rarely have symptoms that clearly distinguish them from one another or from some diseases. And methods of dispersal may not lead people to realize that they have been victims of an attack until symptoms develop. Thus the likeliest sign of an attack will be unusual numbers of people developing initial symptoms more or less at the same time.

Among biological and chemical agents, the nerve agents are considered by many experts to be the ones likeliest to be used by terrorists. They are often fatal, comparatively easy to weaponize, and can be made from pesticides and flame-retardants. The main impediment to making them is the complexity of the extraction process.

33 Biological toxins

Ricin

by R. Cory James

Ricin, one of the most toxic and easily produced plant toxins, is derived from the bean of the castor plant. Its toxicity is significantly less than that of botulinum toxin; however, it is likelier to be used as a biological weapon because it is not sensitive to heat or cold and is widely available. It is so widely available because it is a by-product in making castor oil that is used throughout the world as a medicine. Ricin has been used in some cancer treatments to kill cancer cells and also in bone marrow transplants.

The most likely use of this biological toxin would be as a powder, mist, or a pellet, but it can also be dissolved in water. However, the chlorination, used in municipal water supplies, inactivates ricin.

Causative agent: biological warfare agent.

Time required for symptoms to appear: symptoms appear within 6 hours if swallowed, and 8 hours if inhaled, and then become progressively more severe. If death does not occur within five days, the victim will probably recover.

Signs and symptoms: flu-like symptoms, including fatigue, muscle pain, nausea, vomiting, and fever, followed by fluid in the lungs and difficulty in breathing. In severe doses it attacks the organs, causing them to shut down. These symptoms are not specific to ricin poisoning, but if they appear in large numbers of people at about the same time, this or another toxin may be the cause. One comparatively distinctive feature of ricin poisoning is that its flu-like symptoms are accompanied by fever.

Fatality rate: depends on the dosage, route of infection, and bodyweight. Smaller animals seemed to be affected less than those animals with higher bodyweights. Also, injection into the skin can significantly increase your chances of death. As little as 500 micrograms can be lethal.

Recovery: recovery after a light exposure is very prompt.

Prevention: no immunization is currently available, although animal experiments are underway. A gas mask can be used to prevent inhalation.

Treatment: treatment is difficult because ricin is fast acting and irreversible once inhaled.

Natural transmission: accidental exposure is unlikely.

Chemical warfare modes of transmission: aerosolized ricin may be breathed in or swallowed, and the skin and eyes may also be exposed. Once a person has been exposed, ricin cannot be spread from person to person, except through contact with exposed items, such as clothing. It is most lethal when inhaled, so that terrorist attacks would most likely occur from a mist or powder.

Chemical warfare characteristics: ricin is most lethal in powder or mist form. It is difficult to detect because symptoms can occur up to 8 hours after exposure. Since ricin is easily produced, it could be used by almost anyone. There have been cases of just one or two people producing ricin to exact revenge, and one infamous case of an assassination (the Bulgarian writer Georgi Markov in London in 1978).

Confirmation of diagnosis: via urine tests.

Response: leave the area where ricin was released and move to fresh air. Try to remove the toxin from the body as quickly as possible. If you have swallowed ricin, such as in water, flush the stomach with charcoal using activated charcoal tablets. If your eyes and skin have been exposed, cut your clothing off and, handling it with rubber gloves or a stick, put it into a plastic bag, and put that bag inside a second plastic bag. Wash yourself with soap and water. Flush your eyes with plain water for 10 to 15 minutes. Use a 10 percent bleach solution to decontaminate objects. Seek medical assistance because fluids can be given through the veins to encourage flushing ricin from the blood.

Seek medical assistance and notify the proper local and state public health authorities.

Chemical warfare development and use: ricin has been used in a number of small terrorist attacks and in assassinations.

35 SEB (Staphylococcal Enterotoxin B) by R. Cory James

Although less lethal than other biotoxins, such as ricin, SEB is attractive for use in biological warfare because small quantities could be used to incapacitate large numbers of people. SEB would most likely be disseminated in aerosol form, which has the most effectiveness and the greatest spread.

Causative agent: biological warfare agent. Four thousandths of a microgram can cause sickness, and two hundredths of a microgram can cause death.

Time required for symptoms to appear: usually 8 to 24 hours, but sometimes as quickly as 3 hours.

Signs and symptoms: SEB resembles staphylococcal food poisoning. Symptoms from light exposure include a mild cough, headache, and cloudiness of the eyes. More serious exposure leads to fever, vomiting, chest pain, nausea, and accumulation of fluid in and other damage to the lungs. Use by terrorists in aerosol form would probably produce these symptoms leading to toxic shock.

Fatality rate: probably under 1 percent, with deaths occurring among people with the most severe exposure.

Attack rate: a small dose will cause mild symptoms in nearly everyone exposed.

Recovery: usually within a few days but take as long as two weeks.

Prevention: no vaccines are available to humans, although animal tests are underway. Wearing a gas mask will prevent damage in an SEB attack.

Treatment: there are no antidotes specifically for SEB, but antibiotics may be given to combat secondary infections.

Natural transmission: staphylococcal enterotoxins frequently cause food poisoning, often from eating mayonnaise left at room or outside temperature too long.

Chemical warfare modes of transmission: probably in aerosol form, although SEB can also be used to contaminate food.

Chemical warfare characteristics: the symptoms are not clearly differentiated and do not appear immediately. Thus the likeliest signal that an attack has occurred will be the simultaneous development of symptoms in large numbers of people who were exposed in

36 the same locale. If these symptoms do appear, consider what you've eaten and whether your symptoms can be traced to food poisoning.

Confirmation of diagnosis: this toxin can be detected in urine samples, on nasal swabs, and by blood tests.

Response: wash yourself with soap and water. Dispose of any contaminated foods. Use a 10 percent bleach solution to decontaminate objects. Activated charcoal tablets may help if SEB has been swallowed.

Seek medical assistance and notify the proper local and state public health authorities.

Chemical warfare development and use: SEB is attractive as a biological warfare agent because it is easily aerosolized, extremely stable, and can cause widespread sickness. It is most likely to be used as an incapacitating agent because it is effective at making people sickness for up to two weeks.

37 T-2 (Trichothecene Mycotoxin) by R. Cory James

T-2 is a naturally occurring substance that can be manufactured in large quantities and delivered as a weapon of war or terrorism in many different ways. It is likeliest to be delivered in droplets of oily liquid that resemble a yellow rain. T-2 dissipates quickly if released in the air.

Causative agent: biological warfare agent.

Time required for symptoms to appear: 2 to 4 hours, depending on the way T-2 is introduced to the victim.

Signs and symptoms: skin pain, nervousness, and, in the longer run, collapse, shock, and perhaps death. Skin exposure causes blistering and burning. Eye exposure causes burning in the eyes and tearing. Respiratory exposure causes nose and throat pain, cough, wheezing, and chest pain. Swallowing causes vomiting, abdominal pain, and bloody diarrhea.

Fatality rate: varies by the way T-2 is introduced, its purity, and the dosage level.

Attack rate: most people exposed will develop symptoms.

Recovery: depends on how quickly the victim is treated.

Prevention: there are no vaccines for T-2. A gas mask and protective clothing may provide some protection.

Treatment: there is no antidote. Washing within one hour may remove the toxin and prevent sickness. If T-2 has been swallowed, superactivated charcoal given orally may relieve symptoms.

Natural transmission: this and other mycotoxins occur naturally in fungi and moldy wheat and other grains which, if eaten, cause a syndrome called ATA with a 10 to 60 percent fatality rate. ATA results from continued exposure over time, such as from eating foods contaminated naturally.

Chemical warfare mode of transmission: the Soviet Union developed insecticide sprayers, rockets, bombs, and a hand-held weapon to disseminate T-2. It is likeliest to be disseminated as a mist or in rain-like droplets.

Chemical warfare characteristics: small quantities of T-2 are comparatively easy to manufacture, weaponize, and distribute. This agent occurs in nature and does not break

38 down in heat or cold. Since this agent is among the least expensive to make, it may be especially attractive to terrorist organizations against small groups of enemies, or in enclosed places.

Confirmation of diagnosis: blood and tissue tests.

Response: remove contaminated clothing. Wash yourself with soap and water. Washing within one hour may remove the toxin and prevent sickness. If eyes are painful, flush them with a saline solution. Use a 10 percent bleach solution to decontaminate objects. People who have been exposed cannot transmit this toxin, but it can be picked up from their clothing or from contaminated objects.

Seek medical assistance and notify the proper local and state public health authorities.

Chemical warfare development and use: this biotoxin was widely available in the days of the Soviet Union. Reports suggest it is held by Cuba, Cambodia, Afghanistan, and Laos.

39 Blister agents (Mustard Gas)

by Kyle Mardis

Blisters from contact with Mustard Gas

Blister agents, which cause damage of the kind shown in the photograph, are relatively accessible chemicals. Mustard gas is an amber, oily liquid, but for use in terrorism or war is likeliest to be converted to a gas. Mustard gas is likelier to cause injuries that incapacitate a person than to cause death. It usually accumulates in low-lying areas.

Mustard gas causes damage when it comes into contact with exposed skin or the eyes, and when it is breathed in. The most effective preparations may to own a gas mask and be educated as to evacuation routes and emergency procedures offered in your area. Mustard gas may smell like garlic, onions, or mustard, and also may have no odor.

Causative Agent: chemical warfare agent.

Time required for symptoms to appear: 1 to 6 hours after exposure. However, victims usually begin coughing and sneezing immediately.

Signs and symptoms: blister agents are irritants that burn both the skin and eyes, producing blisters. The earliest symptom will be red, itchy skin, followed by yellowish blistering; irritated, tearing eyes followed after severe exposure by sensitivity to light,

40 pain, and perhaps blindness; runny nose, sneezing, cough, diarrhea, fever, nausea, vomiting, and damage to the immune system.

Fatality rate: depends on dosage, but low, around 2 to 3 percent.

Attack rate: most people exposed will develop symptoms.

Recovery: usually takes up to four to five weeks. However, if the eyes are severely exposed, permanent blindness may follow. Victims usually suffer large scars due to burns. Often victims experience secondary infections such as pneumonia that may extend recovery time.

Prevention: there are no vaccines or antidotes for blister agents. Gas masks and protective clothing usually prevent damage, but in prolonged exposure even gas masks and rubber suits may not prevent blisters from developing.

Treatment: no treatment or antidote.

Natural transmission: blister agents are man-made substances, and thus are not found naturally in the environment.

Chemical warfare modes of transmission: these agents may be administered in liquid form or as a gas. They can be delivered in aerosol form, but in the past have most often been used in explosive devices. How long mustard gas remains dangerous depends on weather conditions, and ranges upward from 1 day, and in cold weather, to several weeks.

Because mustard gas may not smell, and because symptoms do not appear immediately, there is no immediate way to recognize an attack. Simultaneous appearance of the symptoms in large numbers of people indicates an attack.

Chemical warfare characteristics: due to the simple nature of the chemical components required to create blister agents, users are potentially anyone with the means and mindset to inflict harm. They are most likely to be released in the air, but may also be used to contaminate drinking water.

Confirmation of diagnosis: since there are no useful laboratory tests, diagnosis depends on the signs and symptoms, and the circumstances of exposure.

Response: once it has become apparent that a blister agent has been released, seek fresh air. Since blister agents, being heavier than air, tend to accumulate in low-lying areas, move to higher ground or in the upper stories of a building.

41 area, and await the help emergency personnel in disposing of the bags. Next wash the entire body quickly, using soap and water. If the eyes have been exposed, flush the eyes with water for 15 to 20 minutes. If the substance has been ingested in its liquid state do not induce vomiting but do administer liquids, preferably thicker substances such as milk.

Seek medical assistance and notify the proper local and state public health authorities.

Chemical warfare development and use: blister agents were first used in a German attack on Allied troops in 1917 using artillery shells to deliver the agent. Except for some sneezing there were no immediately evident effects until two hours later. Due to the availability of ingredients needed to make them, blister agents have the potential to be used by a variety of different terrorist groups. However, their effectiveness is limited and it takes an extremely large amount of the substance to affect large numbers of people.

42 Blood agents (Arsine and Cyanide) by Jon Pollock

Chemicals designed to attack the blood have a slight odor in doses large enough to cause death, but the odor is rarely detected in smaller doses. This feature and their fast action make several blood agents, especially several of the cyanide compounds and arsine, potentially useful for terrorists. These agents would probably be disseminated in aerosol form, and inhalation is the deadliest route.

Arsine, derived from arsenic, is colorless with a faint garlic odor, and may leave a garlicky smell on the victim's breath. Cyanide compounds may be made in crystal and gas forms. Cyanide is sometimes said to smell like bitter almond, but many people are unable to detect an odor.

Causative agent: chemical warfare agents, of which the most likely to be used are cyanide and arsine.

Time required for symptoms to appear: for arsine, 2 to 24 hours after exposure; for cyanide, depending on the strength of the exposure.

Signs and symptoms: for cyanide, light exposure produces symptoms that are not clearly different from many diseases and conditions, such as dizziness, nausea and vomiting, rapid breathing, restlessness, headache, weakness, and rapid heart rate. Heavy exposures lead to convulsions, low blood pressure, loss of consciousness, and respiratory failure, possibly leading to death.

For arsine, light exposure produces symptoms that are not clearly different from many diseases and conditions, such as difficulty in breathing, weakness, headache, drowsiness, confusion, nausea and vomiting, yellow skin and eyes, and dark urine. Heavy exposure leads to loss of consciousness, convulsions, paralysis, and respiratory failure, possibly followed by death.

Fatality rate: depends on the size of the dose. Large doses can cause death within minutes.

Attack rate: varies according to the severity of exposure.

Recovery: slow and may require hospitalization. Arsine may produce permanent kidney damage and memory loss.

Prevention: there is no vaccine for cyanide or arsine.

Treatment: seek medical help. Three antidotes are available for cyanide poisoning. Also, remove your clothing and put it in a plastic bag, wash your body with soap and

43 water No antidotes are available for arsine; it is treated by blood transfusions and intravenous fluids.

Natural transmission: cyanide occurs in the natural environment, and both cyanide and arsine are used in manufacturing processes. Cyanide may be released in fires where synthetic fabrics and polyurethane burn. Arsine was developed initially as an insecticide, and is now used in the manufacture of computer chips.

Chemical warfare modes of transmission: blood agents will most probably be dispersed in aerosol form to be inhaled. It is also possible that cyanide or arsenic could be used to poison the water supply. They are most dangerous in enclosed spaces.

Chemical warfare characteristics: cyanide prevents the cells of the body from using oxygen. Arsine enters the bloodstream and damages red blood cells.

Confirmation of diagnosis: there is no specific test to determine arsine exposure.

Response: if you suspect that cyanide has been released, move out of enclosed spaces and to a location with fresh air. Cyanide is lighter than air. If you suspect it has been released, either leave the building or area or, if that's not possible, stay low to the ground. Arsine is heavier than air and will settle in low-lying places. If you suspect it has been released, move to a higher place with fresh air. Gas masks and protective clothing donned in advance will protect against both agents.

Remove clothing, cutting it off, and place in a plastic bag, and that bag inside another plastic bag. Wear rubber gloves to handle contaminated clothing and other objects, or use tongs or a stick. Wash yourself with soap and water. Rinse eyes with plain water for 10 to 15 minutes. Seek medical help.

Seek medical assistance and notify the proper local and state public health authorities.

Chemical warfare development and use: cyanide is comparatively easy to obtain or make, and thus an obvious toxin for terrorists to consider using. Because, once released, it soon disperses, cyanide may be used in warfare when a force wants to disable an opponent and then move quickly into the area occupied by the opponent. A cyanide compound called Zyklon B was used in the mass execution of Jews by Germany during World War II, and cyanide was used in the 1980s to gas Kurds in the northern Iraqi city of Halabja. Arsine has not been used in warfare.

44 Nerve Agents

The G Agents (Sarin, Soman, and Tabun)

by Jake Agee

Nerve agents with the letter “G” (for German) are classified as non-persistent chemicals. When vaporized they do not maintain their effectiveness for very long, up to 24 hours in summer and up to 3 days in winter. The “G” agents cause rapid effects among people who inhale or ingest them, who may die within minutes. These agents may be vaporized, sprayed, or put into the water supply. They are most likely to be dispersed as a vapor for victims to inhale.

The first sign of an attack may be a number of people in a public place having difficulty breathing at the same time.

Causative agent: chemical warfare agent.

Time required for symptoms to appear: seconds to minutes if inhaled or ingested, up to 18 hours if "G" agent vapor touches the skin.

Signs and symptoms: severe coughing and discomfort in the lungs will occur directly after inhalation of a “G” agent, without fever. In moderate to light exposure: runny nose, watery eyes, small pinpoint pupils, eye pain, blurred vision, drooling and excessive sweating, cough, chest tightness, rapid breathing, diarrhea, increased urination, confusion, drowsiness, weakness, headache, nausea, vomiting, and/or abdominal pain, slow or fast heart rate, abnormally low or high blood pressure may occur.

In heavy exposure: loss of consciousness, convulsions, paralysis, respiratory failure possibly leading to death. Some people are less susceptible to these toxins.

Fatality rate: depends on the amount of “G” agent inhaled, ingested, or absorbed, but these agents are highly fatal.

Attack rate: everyone in contact will show some signs of exposure.

Recovery: motor skills may be impaired up to 3 months.

Prevention: military personnel use an enzyme blocker called Pyridostigmine for pretreatment. A gas mask and chemical suit will prevent harm during an attack. M8 and M9 paper detectors will warn that an attack has occurred.

Treatment: the antidotes atropine, pralidoxime, and diazepam are most effective if injected immediately after exposure.

45 Natural transmission: these agents do not occur in nature.

Chemical warfare modes of transmission: the “G” agents can be vaporized or put into liquid form.

Chemical warfare characteristics: the “G” agents can be manufactured easily by a competent chemist. The delivery of the agent is far more complicated. The delivery systems needed for the “G” agents make them a useful tool to well funded and sophisticated military or terrorist groups, but not for smaller operations. Inhalation is the most effective way of causing quick damage.

Confirmation of diagnosis: depends on the agent.

Response: after being exposed to a “G” agent there are steps that can be taken to delay symptoms and reduce the severity of the effect. Move out of the contaminated area. Quickly decontaminate yourself and other victims. To decontaminate move upwind of the exposure area holding your breath or wearing a gas mask. Wipe any liquid off of your skin. Remove all clothing and, using tongs or a stick, place it into a double wrapped plastic bag. Wash with soap and water. Take an antidote if available.

Seek medical assistance and notify the proper local and state public health authorities.

Chemical warfare development and use: all three agents were developed in Germany, tabun in 1936, sarin in 1938, and soman in 1944. All three may have been used in the Iran-Iraq war in the 1980s. Aum Shunrikyo used sarin in a Tokyo subway in 1995.

46 VX Nerve Gas

by Chris Erickson

VX gas would seem to be ideal for use in a military or terrorist campaign because of its effectiveness at incapacitating people. But this is also the reason why it has not been used on a large scale. It is an extremely dangerous chemical that is lethal in most cases and difficult to contain. The people who release it may also be killed. Initial exposure would most likely be in aerosol form, but may also be in liquid form, which could contaminate the skin, eyes, or could be ingested. The aerosol form is the most deadly of all the delivery methods.

Causative agent: chemical warfare agent; as little as 10 mg can cause death.

Time required for symptoms to appear: symptoms may appear immediately, especially when the agent is inhaled. With a significant dose inhaled or deposited on the skin, death may occur within minutes. Depending on the dosage, it may take up to a few hours to see the signs of exposure.

Signs and symptoms: VX gas attacks the central nervous system and causes motor skills to fail. The earliest symptoms will be contractions of all the involuntary muscles of the body, followed by a lengthy series of possible symptoms: runny nose, watery eyes, small, pinpoint pupils, eye pain, blurred vision, drooling, excessive sweating, cough, chest tightness, rapid breathing, diarrhea, increased urination, confusion, drowsiness, weakness, headache, nausea, vomiting, and/or abdominal pain, slow or fast heart rate, abnormally low or high blood pressure, loss of consciousness, convulsions, paralysis, and respiratory failure possibly leading to death. Even a small amount of the agent that has been exposed to the skin may cause immediate sweating and muscle twitching.

Fatality rate: depends on dosage. If the dosage is over 10mg, it is likely to be lethal. The aerosol form is also more lethal than other forms of exposure.

Attack rate: nearly everyone exposed will develop some symptoms.

Recovery: recovery can be quick depending on whether the victim is treated or not.

Prevention: the best prevention seems to be 1) the destruction of the gas, and 2) preparedness for the event of an attack. There are no vaccines for VX gas, and people cannot build immunity to its effects.

Treatment: the antidote atropine, injected immediately, is an effective treatment.

Natural transmission: VX gas is not found naturally in the environment, so the only modes of transmission are directly from people or mechanisms created by people.

47 Chemical warfare modes of transmission: can be delivered in a gas or liquid form. If the liquid form is heated to a high temperature it can turn into the gaseous form. Dispersed in the air, VX gas could cause many casualties. How far and in what direction it might spread would depend on the wind. Without wind VX gas can stay in an area as long as a couple of weeks and still be concentrated enough to cause casualties.

Chemical warfare characteristics: it is very difficult to recognize an attack of VX gas since it is an odorless and colorless gas. The liquid is oily and amber colored. The best way to recognize an attack would be to realize that the symptoms of VX gas are appearing in a large number of people at the same time, and usually after an explosion.

Confirmation of diagnosis: blood tests.

Response: there is no vaccine for this agent so it is hard to be prepared for an attack as a civilian. Some authorities, such as the New York City Department of Health, suggest that people have home kits with gas masks and protective clothing for use in case of an attack. The best preparedness for civilians may be offered by the plans that city, state and national governments have in place.

Do not try mouth-to-mouth resuscitation of anyone you suspect has been gassed. If you believe that VX gas has been used, get to an area with fresh air. If it is used inside of a building, go outside. If you have been exposed to this gas, remove all clothing and put it in a plastic bag so that it cannot contaminate others since it can remain lethal for a while after contamination. Cut your shirt off so that the agent is not dragged over the eyes. Wash your skin with soap and water but do not rub vigorously or else the agent can be pushed into the skin and cause more effects. Use household bleach to decontaminate. Alcohol, ether, or acetate can be used to wash the oily liquid from the skin.

Seek medical assistance and notify the proper local and state public health authorities.

Chemical warfare development and use: VX gas was developed in the United Kingdom in the early 1950s. This agent is known to be held by the United States, France, and Russia. However, VX gas may have been used in the Iran-Iraq war during the 1980s, and Syria and North Korea may also have some quantities of it.

48 Part 3

Targets, Delivery Methods, and Responses

Targets

by Kyle Mardis

Since the best targets are crowds, either of soldiers or civilians, it is quite difficult to compile a short list of potential targets in the US. Some crowds gather and break up spontaneously, and some can reliably be predicted ahead of time to form at a certain time and break up at a certain time. Terrorists are likely to prefer these predictable crowds. They might decide to attack high profile targets, as Al Qaeda did on September 11, 2001. But any attack that killed or incapacitated even small numbers of people would immediately draw everyone's attention and might lead to alarm or panic. Thus virtually any location where people gather is a potential target for an attack with either disease pathogens or toxins.

Larger cities may be more visible targets, but they also may be better protected. The people who live in some large cities, especially Washington DC and New York City, are also likelier to be alert to the dangers of an attack and watchful about suspicious developments.

If terrorists intend to contaminate as many people as possible, they may prefer these potential targets:

______Potential Civilian Targets______

1) Mass Transit Systems: Subways, Buses, Passenger Trains 2) Office Buildings: Skyscrapers, Factories 3) Shopping Malls: Mall of America 4) Commercial Airplanes or International Airports 5) Sports: Stadiums, Indoor Arenas

______

Using most disease pathogens and toxins, terrorists may prefer to attack sites where there is little wind and no extremes in temperature, and where people cannot quickly escape.

Some experts also suggest that airplanes may be targets, especially on international flights. Terrorists might be tempted by the prospect of infecting 300 to 400 people who would not realize they had been exposed to a disease until days after they had completed their journey, and who might in the meantime infect other people.

49 Some experts also warm about threats to the food and water supply. Contamination of foods that escaped detection until people had eaten them would harm a number of people, but have perhaps more far reaching consequences in the fear spread about future attacks along this route.

______Potential Government/Military Targets______

1) Government buildings in Washington DC, such as the White House 2) Government buildings in state capitals 3) the military academies 4) NASA 5) popular museums, such as the Smithsonian in Washington 6) military bases 7) sites where weapons are stored

______

The Delivery of Pathogens and Toxins by Neal Patel, Kevin Kruse, and Julia Thomas

How are biological weapons most likely to be used? Disease pathogens and biological and chemical toxins can be released in several different ways. They may be delivered using an aerosol (spray), in explosives, through contact with an infected human, or by the contamination of food and water supplies. For practical purposes, certain delivery methods are more likely to be used than others. If the goal is to launch an unforeseen attack on the population of a certain region causing the highest possible number of deaths, an aerosol delivery of the agent is the most likely choice. Small aircraft outfitted with crop dusters could disseminate many different agents.

Food and water contamination A mass contamination of food and water supplies is unlikely because such a large quantity of an agent would be necessary to affect a large number of people. Someone intending to infect or contaminate the population of a city through its water supply would have to possess more of the disease pathogen or toxin than could reasonably be produced or transported. In the case of food contamination, it is more likely that a small-scale attack could occur. Relatively small amounts of bacteria could be placed in the food at a restaurant or dining hall. Such an attack would likely affect hundreds rather than thousands of people, which might make it a less attractive technique. It is also possible to imagine an attack made on crops and livestock. This sort of attack would likely be done with a chemical agent and would also require a sizeable quantity. A small-scale attack on livestock might not result in a high number of deaths, but it could cause significant economic problems and food insecurity.

Delivery by bombs and missiles It is commonly thought that explosions from bombs and missiles are a likely method of delivery for pathogens and toxins. This is not necessarily true. While some agents have been delivered in this way, there are problems. The biggest one is that only a fraction of the agent would survive the explosion. In addition, the explosion of a bomb or missile would be noticeable, giving authorities a reason to begin investigating. Agents may also be delivered by bombs or missiles outfitted to break open on contact with the ground, releasing their agents. But these, too, face the problem that some, perhaps most, of the agent would be destroyed on contact, or would be buried in the ground with the bomb or missile.

Suicide infection Some diseases attractive for use in warfare or terrorism are infections that can be spread easily from person to person. Also a person may be infected with a bacteria or virus for a several days before showing any symptoms of the disease. These two facts combine to make it possible for a person to act as a carrier for some biological weapons. If a suicide

51 infection attack were launched, the carriers would consciously infect themselves with a disease and continue to have contact with other people around them, trying to spread the disease. It would not be possible to do this with some diseases, nor would it be possible, of course, to transmit the effects of biological and chemical toxins in this way. Smallpox is an example of a virus that could be spread through a suicide infection because it is easily transmitted between humans and it can take up to two weeks before the symptoms become apparent. This method of spreading disease would not be as effective for infecting large numbers of people quickly as would aerosol delivery.

Aerosol delivery The likeliest method of delivery for biological terrorism is an aerosol attack, in which a small quantity of any of a number of agents would be enough to infect or contaminate large numbers of people. Because the necessary quantity is small, it would be comparatively easy to launch an undetected, yet destructive assault. The technology required to perform such an assault would be uncomplicated. Any mechanism ordinarily designed to spray cleaning supplies, garden fertilizers, or even perfume could be used to spray an agent of biological terrorism. Such devices would distribute droplets of differing sizes, some visible to the eye and others too small to be seen. It is possible to imagine this low-level technology combined with higher-technology vehicles such as cars or planes in order to enhance its efficiency. A small plane could spray significant quantities of an agent over a densely populated area.

Terrorism experts sometimes explain two specific ways to disperse a disease or toxin through the air. One method is called a line source. This uses a moving device to spread the agent. A plane, car, or train with a sprayer attached is an example of a line source. Natural factors such as wind help to spread a biological weapon by a line source. A point source is the other method of aerosol delivery. A point source is stationary. It would be most effective in a confined area, such as a building or subway tunnel. Abnormal smoke and steam could be indicators of an attack. A pressurized gas released into a crowd of people could also achieve destructive results. The aerosol method of delivery certainly poses the largest threat because of the small amount of agent required to have a large effect in a closed space.

There is some comfort to be gained from remembering that Aum Shunrikyo failed several times trying to release toxins in crowded areas in Japan before finally succeeding with a sarin gas release.

52 Evacuation and Taking Shelter by Kyle Mardis

If a disease or toxin is released, the first response will have to come from people in the immediate area of the release. The CDC suggests two main ways to avoid exposure: evacuation and sheltering-in-place. These are used until homeland security authorities or public health officials decide about the next steps to be taken

Evacuation: If local authorities have been warned that an attack is imminent, they may issue an evacuation order for their area. In that case, those evacuating the area should follow the instructions of local authorities, and cooperate with officials directing traffic while remaining calm, so as to speed up the process as best they can.

After an attack, authorities may direct people to emergency action centers, where supplies will be available to attend the needs of everyone who arrives. During the evacuation, those traveling in cars should close all vents and windows and turn off the heat and air conditioners. Cars are not insulated well but these steps will help reduce the risk of being contaminated.

Individuals themselves can create action plans to follow in the event an evacuation order is issued. Those plans should take into account who will need help in evacuation, who will drive, what car will be used, what route will be taken, and the destination. It is always helpful to keep an emergency kit in your car with first aid supplies, a radio, and supplies of any medications you take.

Sheltering-in-place: The CDC explains that sheltering-in-place means to make a shelter out of the place where you are. If an attack has taken place but evacuation is impossible or too dangerous, then take these steps to protect yourself. First locate a room with few or no windows and doors, preferably a larger room with some sort of water supply (perhaps the master bedroom at home). If possible choose a room on the highest level of the building so as to avoid gases that are thicker than air and tend to collect in low-level areas.

If possible it is helpful to prepare ahead of time and keep supplies in a prepared room at home or at the office. These should include plastic bags, plastic sheeting, duct tape, first aid supplies, a radio, and food and bottled water. After an attack the duct tape and plastic sheeting can be used to seal off windows and doors. If water is not available in bottles, do not drink from the tap. The water in a toilet tank is likely to be safe. Listen to the radio for further instructions.

Individual diseases and toxins require mostly individual protection steps. See the chapters above under the heading Response for advice specific to each particular disease or toxin and, for a summary, see below under Treatment tips for emergency situations.

53 Compliance

by Theo Lutz

In a bioterrorist attack, public health officials will implement plans and procedures appropriate to the circumstances. These will differ depending on the agent used and the scale of the attack. For example, an isolated spread of anthrax spores requires an isolated quarantine and decontamination of affected individuals and places, but an outbreak of smallpox requires broader quarantine and vaccination procedures.

These responses will be carried out by a variety of government officials and agencies. Local fire, police, and health departments alongside state and federal emergency management and public health agencies, including the Center for Disease Control and Department of Homeland Security, will be involved in response measures. These agencies have access to the best available information and must maintain leadership of a response.

Effectively carrying out these plans, which depends on both the quality of the response and the level of compliance of the citizenry, may decide how many people die and the scale of other damage. As the 2005 outbreak of Marburg virus in Africa shows, a compliant or non-compliant population can determine how effective the response to a threat can be. If people hide sick individuals, impede public health officials’ work, or fail to follow the plans selected by public health officials, the effectiveness of a response is impaired and the biological threat may spread. It is important for people to follow the instructions of public safety and health officials.

State government reserves the authority to declare public health emergencies during a bioterrorist attack. When this occurs, public health officials can force individuals to follow instructions. Persons not following government instructions can be quarantined and forced to comply.

54 Treatment tips for emergency situations by Tarrah Beavin

In all bioterrorist attacks, seek medical assistance and notify the proper authorities. Contact telephone numbers appear on p. 4 above.

Category A diseases

Anthrax. During an outbreak, you can reduce potential exposure by not opening suspicious mail, keeping mail away from your face when you open it, not blowing or sniffing mail or mail contents, avoiding vigorous handling of mail, such as tearing or shredding, washing your hands after handling the mail, and discarding envelopes after opening.

Before opening letters or packages, consider whether there are signs of anthrax, such as powder on the surface. If so, or if an opened item contains a suspicious powder, cover the item or its spilled contents with anything handy, leave the room and seal it off, wash your hands with soap and water, and report your suspicions to the local police. Contact a doctor. Remove your clothing and put it in a plastic bag, and then take a shower. Anyone else in the room should take these same steps.

If you suspect that anthrax has been sprayed into a room, turn off any ventilation, leave the room, close the door, and report to the police.

Botulism. If you think you are developing botulism, seek immediate medical attention, and inform health authorities. You will not have to be isolated because you cannot communicate your infection through the air. But you will need to be hospitalized to combat the progressive development of symptoms. If your skin has been exposed, wash with soap and water.

Plague (pneumonic). Do not go within 2 yards of an infected person without a surgical mask. In emergency situations, covering your mouth and nose with several layers of clothing can reduce the risk of transmission.

If you think you have been exposed, seek immediate medical attention. Sickness can be prevented by immediately beginning a 7-day antibiotic regimen.

No environmental clean up should be required following an attack because the bacteria can only survive for about an hour in the environment.

55 Smallpox. Isolate infected people for 7 to 10 days after a rash begins. Do not go within 2 yards of an infected person. If you feel that you have been exposed, seek medical attention as soon as possible. Disinfect anything an infected person has touched with steam, fire, or a sodium hypochlorite solution.

If you recognize smallpox in yourself, seek medical help immediately. Distance yourself from others and make sure that as soon as you are taken to the hospital, anything you have touched (clothing, bedding) is disinfected properly.

Tularemia. Use insect repellant to prevent mosquito bites, make sure to cook food thoroughly and drink only water from a safe source. Watch pets for unusual behavior.

Prompt treatment with antibiotics for 10 to 14 days will reduce casualties.

Decontaminate objects with a 10 percent bleach solution.

Viral hemorrhagic fevers. Do not go within 2 yards of an infected person, wear insect repellant, and keep your home free of rodents.

Category B diseases

Glanders. Isolate the sick person and use protective barriers such as surgical masks, face shields, and gowns when caring for the patient. Consult a local physician and alert appropriate authorities.

Venezuelan Equine Encephalitis. During an outbreak, wear insect repellant. Keep infected people in a screened room to prevent mosquitoes from having access. VEE is rarely lethal. The best available treatment is for the flu-like symptoms. A 10 percent solution of household bleach will destroy the virus on objects. Wash contaminated clothing with soap and water.

West Nile virus. If you have come into contact with blood or tissues that may carry this virus, wash your hands and exposed skin with soap and water immediately. Keep infected people in isolation. Remove mosquito-breeding sites in order to impede further transmission of this disease.

Seek medical assistance and notify the proper authorities.

Biological toxins

Ricin. Leave the area where ricin was released and move to fresh air. Try to remove the toxin from the body as quickly as possible. If you have swallowed ricin, such as in water, flush the stomach with charcoal using activated charcoal tablets. If your eyes and skin have been exposed, cut your clothing off and, handling it with rubber gloves or a stick,

56 put it into a plastic bag, and put that bag inside a second plastic bag. Wash yourself with soap and water. Flush your eyes with plain water for 10 to 15 minutes. Use a 10 percent bleach solution to decontaminate objects. Seek medical assistance because fluids can be given through the veins to encourage flushing ricin from the blood.

SEB. Wash yourself with soap and water. Dispose of any contaminated foods. Use a 10 percent bleach solution to decontaminate objects. Take activated charcoal tablets if SEB has been swallowed.

T-2. Remove contaminated clothing. Wash yourself with soap and water. Washing within one hour may remove the toxin and prevent sickness. If eyes are painful, flush them with a saline solution. Use a 10 percent bleach solution to decontaminate objects. People who have been exposed cannot transmit this toxin, but it can be picked up from their clothing or from contaminated objects.

Chemical toxins

Blister agents (Mustard Gas). Once it has become apparent that a blister agent has been released, seek fresh air. Since blister agents, being heavier than air, tend to accumulate in low-lying areas, move to higher ground or in the upper stories of a building.

Treat victims with anti-burn ointments and painkillers. Also, antibiotics are used to avoid secondary infections that may result from open wounds. For victims, immediately remove all clothing, placing it in plastic bags, which will avoid secondary contamination. Handle bags and clothing with a stick of some other object, place these things out of the area, and await help from emergency personnel in disposing of the bags. Next wash the entire body quickly, using soap and water. If the eyes have been exposed, flush the eyes with water for 15 to 20 minutes. If the substance has been ingested in its liquid state do not induce vomiting but do administer liquids, preferably thicker substances such as milk.

Blood agents (arsine and cyanide). If you suspect that either arsine or cyanide has been released, move out of enclosed spaces and to a location with fresh air. Arsine is heavier than air and will settle in low-lying places. If you suspect it has been released, move to a higher place with fresh air. Cyanide is lighter than air. If you suspect it has been released, either leave the building or area or, if that's not possible, stay low to the ground. Gas masks and protective donned in advance clothing will protect against both agents.

Remove clothing, cutting it off, and place it in a plastic bag, and that bag inside another plastic bag. Wear rubber gloves to handle contaminated clothing and other objects, or use tongs or a stick. Wash yourself with soap and water. Rinse eyes with plain water for 10 to 15 minutes. Seek medical help.

57 Nerve Agents

G agents (Sarin, Soman, and Tabun). After being exposed to any “G” agent, move out of the contaminated area. Quickly decontaminate yourself and other victims. To decontaminate move upwind of the exposure area holding your breath or wearing a gas mask. Wipe any liquid off of your skin. Remove all clothing, placing it into a double wrapped plastic bag. Wash with soap and water. Take an antidote if available.

VX Nerve Gas. Do not try mouth-to-mouth resuscitation of anyone you suspect has been gassed. If you believe that VX gas has been used, get to an area with fresh air. If it is used inside of a building, go outside. If you have been exposed to this gas, remove all clothing and put it in a plastic bag so that it cannot contaminate others since it can remain lethal for a while after contamination. Cut your shirt off so that the agent is not dragged over the eyes. Wash your skin with soap and water but do not rub vigorously or else the agent can be pushed into the skin and cause more damage. Use a 10 percent solution of household bleach to decontaminate. Alcohol, ether, or acetate can be used to wash the oily liquid from the skin. Seek medical assistance and notify the proper authorities.

58 Indicators That A Terrorist Attack May Have Occurred

adapted by Chris Erickson from training.fema.gov/EMIWeb/ downloads/PM-CERT- Unit8Rev2.doc

Environmental indicators of a biological or chemical attack could include:

Numerous sick or dead animals, fish, or birds. Wildlife are often more sensitive to chemical or biological agents than humans. Animals, fish, or birds that are obviously sick, dying, or dead may indicate the presence of a biological or chemical attack.

Unscheduled spraying or abandoned spray devices. Several September 11 terrorists are known to have made inquiries into purchasing and learning to fly crop dusters. Many other types of agricultural sprayers can be used to disperse biological and (more likely) chemical agents.

Vapor clouds or mists that are unusual for the area or for the time of day. Although many biological and chemical agents cannot be seen with the naked eye, the substances in which they are suspended when dispersed may be visible for a period of time after an attack.

The absence of crops, wildlife, or insects that are common for the area, time of day, or time of year. Being aware of what is not in the environment that should be is as important as being aware of what is in the environment but is out of place.

Out of place and unattended packages, boxes, or vehicles. Terrorists have a long history of hiding explosive devices in packages, boxes, or vehicles. Items that are out of place and unattended could signal a possible terrorist attack.

Packages that are leaking may be harmless—but they may also signal a terrorist incident. The terrorists who released Sarin in the Tokyo subway system (Aum Shinrikyo) merely poked holes in bags containing Sarin, then left the area as the poison leaked out.

Materials or equipment that are unusual for the area. Dispersal devices, lab equipment, or quantities of hazardous materials that are not typically located in the area may indicate that a terrorist attack is occurring or is about to occur.

Small explosions that disperse liquids, mists, or gases are an obvious sign that something is wrong.

Physical indications of a terrorist attack include:

Multiple casualties without obvious signs of trauma. This may indicate a biological or chemical attack.

Multiple victims who are exhibiting similar symptoms. Symptoms may range from difficulty breathing to skin necrosis to uncontrolled salivating, uncontrolled muscle twitching, or convulsions. All of these symptoms indicate that a chemical attack may have taken place.

Large numbers of persons seeking medical attention with similar symptoms that are not characteristic of the season. The symptoms of many biological agents mimic the flu or other common illnesses. An unusually large number of persons seeking medical attention for the flu in July could indicate that a biological attack has taken place.

60 Internet Sources (accessed on different dates in April 2005)

cfrterrorism.org/weapons/ for information on chemical agents

fpc.state.gov/documents/organization/33629.pdf

ptcl.chem.ox.ac.uk/MSDS/PH/phenylarsine_oxide.html

training.fema.gov/EMIWeb/ downloads/PM-CERT-Unit8Rev2.doc

www.acponline.org/bioterro/biotoxin.htm

www.atsdr.cdc.gov/MHMI/mmg166.html

www.atsdr.cdc.gov/tfacts8.html

www.au.af.mil/au/awc/awcgate/awc-medi.htm#anthrax Textbooks of Military Medicine on anthrax

www.biohazardnews.net/agent_smallpox.shtml

www.bordeninstitute.army.mil/ for the Textbooks of Military Medicine

www.bt.cdc.gov for information from the CDC about bioterrorism and particular diseases and toxins; for example, for information about pneumonic plague, go to www.bt.cdc.gov/agent/plague/

www.cdc.gov for the main website of the Centers for Disease Control

www.cdc.gov/ncidod/dbmd/diseaseinfo/ for the CDC's website on bacterial diseases and toxins.

www.chem.ox.ac.uk/mom/vx/VX.htm

www.cidrap.umn.edu for a regularly updated source of news and expert clinical information

www.emedmag.com/html/pre/ter/BT0202.asp for a 1970 World Health Organization report. www.emedicine.com for articles on many diseases and bioterrorism issues, for example www.emedicine.com/emerg/topic591.htm

www.emergency.com/nervgas.htm

61 www.fas.org/nuke/intro/bw/agent.htm www.idph.state.il.us/Bioterrorism/factsheets/glanders.htm www.in.gov/legislative/ic/code/title16/ar41/ch9.html (IC-16-41-9) www.jama.ama-assn.org/cgi/content/full/285/21/2763 www.jhu.edu/hurj/research-ding.html for Eric Ding, West Nile Virus and JE Flaviviruses: Threat Assessment as Potential Agent of Bioterror. Hopkins Undergraduate Research Journal, 2004. www.journals.uchicago.edu/CID/journal/issues/v34n7/020165/020165.web.pdf, for Tara O'Toole, Michael Mair, and Thomas V. Inglesby. "Shining Light on 'Dark Winter,'" Clinical Infectious Diseases, 34 (2002), 972-983.

www.kellogg.umich.edu/patientcare/conditions/uveitis.html www.mercola.com/2001/nov/14/smallpox2.htm www.myelitis.org www.nbcmed.org/SiteContent/MedRef/OnlineRef/FieldManuals/ medman/Venezuelan.htm, accessed 4/6/2005 www.newsmax.com for Col. Byron Weeks, 'Plague as a Weapon of War,' Oct. 17, 2001. www.nlm.nih.gov/medlineplus/ency/article/000856.htm www.nyc.gov/html/doh/html/bt/bt_fact_vx.html www.phac-aspc.gc.ca for the Public Health Agency of Canada www.state.gov/documents/organization/25082.pdf www.thewednesdayreport.com/articles/research/weapons_of_mass_destruction_VX.htm www.westnilefever.com/west_nile_virus_symptoms.htm for West Nile Virus Symptoms. West Nile Fever. http://www.who.int/emc/pdfs/Clostridiumbotulism.PDF www.wrongdiagnosis.com/sym/testicle_symptoms.htm

62 Print Sources

Alibek, Ken and Stephen Handelman. 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, 1999.

Borio, Luciana et al. "Hemorrhagic Fever Viruses as Biological Weapons: Medical and Public Health Management," Journal of the American Medical Association, 287 (2002), 2391-2405.

Croddy, Eric. Chemical and Biological Warfare: A Comprehensive Survey for the Concerned Citizen. New York: Springer-Verlag, 2002. Especially useful on chemical weapons and on the countries that have, or have had, CBW programs.

Frist, Bill. When Every Moment Counts: What You Need to Know about Bioterrorism from the Senate's only Doctor. Lanham, MD: Rowman & Littlefield, 2002.

Inglesby, Thomas V. et al. "Plague as aBiological Weapon," Journal of the American Medical Association, 283 (2000), 2281-90.

Osterholm, Michael T. and John Schwartz. Living Terrors: What America Needs to Know to Survive the Coming Bioterrorist Catastrophe. New York: Delacorte Press, 2000.

Regis, Ed. The Biology of Doom: The History of America's Secret Germ Warfare Project. New York: Henry Holt and Company, 1999.

Richter, Donald C. Chemical Soldiers: British Gas Warfare in World War I. Lawrence: University of Kansas Press, 1992.

Tierno, Philip M. Protect Yourself Against Bioterrorism. New York: Pocket Books, 2002.