CONTROVERSIES • CONTROVERSES Bioterrorism: an emerging threat Eric Grafstein, MD; Grant Innes, MD rior to the 1998 Vancouver Asian participated in a chemical arms race BWC, bringing an end to widespread PPacific Economic Summit, emer- that culminated in the development of biological warfare research. gency physicians were briefed on the mustard gas by the Germans. By possibility of terrorist-related biolog- 1918, over 100,000 men had died The modern era ical or chemical weapons incidents. from exposure to chemical weapons.2 As part of a training exercise, the After the war, a backlash of moral Recent events in the former Soviet “victim” of a chemical weapon attack revulsion led to the development of Union, Iraq, Japan, and Oregon have was brought to our ED. Because of the Geneva Protocol (1925), which led industrialized countries to become confusion and ignorance, the “vic- prohibited future use of chemical or increasingly concerned about the risk tim,” the physician, several members biological agents. of bioterrorism. of the ED staff, and a number of other Between 1932 and 1945, Japan con- Despite signing the BWC, the Soviet patients also became “casualties.” ducted biological weapons research in Union continued a vast biological occupied Manchuria. At least 10,000 weapons program,1,3,4 producing and A history of biological warfare prisoners died after being infected stockpiling several agents, including with anthrax, meningitis, cholera or anthrax and smallpox. A former deputy Biological warfare is not just a twenti- plague. During this period, Japan chief of research for the biological eth century phenomenon. During the launched biological attacks on at least weapons program reported that the French and Indian War (1754–1767), 11 Chinese cities. Infectious agents Russian military had mounted small- Sir Jeffery Amherst, commander of were deployed by directly contaminat- pox virus in bombs and intercontinen- the British forces in North America, ing water and food supplies, by spray- tal ballistic missiles for strategic use.5 devised the plan of using smallpox ing cultures from aircraft, by dropping In a related event on April 3rd, 1979, against hostile Native Indian tribes.1 bacteria-filled bombs, or by releasing Soviet technicians at a Sverdlovsk mil- On June 24, 1763, one of Amherst’s clouds of plague-infected fleas over itary installation failed to activate criti- officers acquired several contaminat- major cities.2 In a single attack on cal air filters. Up to a gram of anthrax ed blankets from a smallpox hospital Changteh in 1941, 10,000 Chinese cit- spores was inadvertently released, and presented them, as a gift, to a izens and 1700 Japanese troops died, killing 68 people and rendering a 4000- group of Native Americans. Shortly predominately from cholera. square-mile area uninhabitable.1,3,6 This thereafter, smallpox decimated tribes During the 1950s and 1960s, nuclear, event is testimonial to the hazards of along the Ohio River Valley. This out- biological and chemical weapons pro- working with biological agents. break may or may not have been relat- liferated, primarily in the arsenals of the Iraq remains a major concern. It is ed to Amherst’s gift.2 United States and the Soviet Union. But the only country since World War II Almost 2 centuries later, on a sunny the concept of biological weapons that has deliberately released biologi- spring afternoon in 1915, German remained abhorrent to individuals and cal weapons against its enemies (Iran) troops at Ypres deployed chlorine gas governments alike. This general disdain and its own people (the Kurds). against the French. Within minutes, ultimately spawned an international Between 1985 and 1991, Iraq accu- thousands were overcome. During the treaty, the Biological Weapons Con- mulated a variety of biological agents next 3 years, all of the major powers vention (BWC), which proscribed the including botulinum, Yersinia pestis, development, production, storage, or dengue virus, anthrax, and smallpox.1,2 St. Paul’s Hospital, Vancouver, BC This article has been peer reviewed. acquisition of biological weapons. On The Iraqis claim to have produced April 10, 1972, 79 nations signed the 90,000 litres of botulinum toxin, 8300 October • octobre 1999; 1 (3) CJEM • JCMU 205 Downloaded from https://www.cambridge.org/core. IP address: 170.106.34.90, on 01 Oct 2021 at 15:38:36, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S148180350000422X Grafstein and Innes litres of anthrax, and to have distrib- anthrax threats has increased from 1 agencies as part of a disaster plan. uted 200 bombs and warheads con- in 1997 to 37 in 1998. There were 10 Biological events are different. taining these agents to various mili- additional threats during the first 2 They may be clandestine; there may tary bases.4,5 Iraq has complied mini- months of 1999 alone.10 While none be no recognition that an attack has mally with United Nations (UN) have been associated with actual occurred. Because biological agents requests for nuclear and chemical spore release, these incidents generate have incubation periods, an immedi- weapons site inspections, and has fear among the general population, ate deluge of casualties is unlikely. resisted all attempts to locate biologi- strain public health resources, and Rather, victims are likely to present cal weapons factories. Despite defeat undermine the urgency of response over a period of weeks with flu-like in the Gulf War, Iraq’s development required by the medical, public health, illnesses (anthrax) or chickenpox-like facilities, scientific personnel, and municipal and provincial agencies. rashes (smallpox). Patients may be biological warfare capability remain Bioterrorism is a growing threat as spread over wide areas and present at essentially intact.7 we approach the millennium.4 Today diverse health care facilities. Since During the 1990s, a fanatical reli- at least 17 countries are believed to few physicians have seen smallpox, gious group, Aum Shinrikyo, made have active biological weapons pro- anthrax or plague, recognition will be several attempts to aerosolize anthrax grams.3 Recipes for biological agents delayed. Days or weeks may pass and botulism are available on the before public health agencies become throughout Internet, and groups aware of the biological attack, during Tokyo.2,3,5 In Biological terrorism with basic scienti- which time the outbreak can spread 1992, group is a low probability, fic knowledge can widely.5 The potential for casualties is members trav- high consequence develop deadly bio- huge. Whereas conventional terrorist elled to Zaire, logicals at low cost. activities like bombings kill dozens or the site of an event. Several dissident hundreds, a single act of bioterrorism Ebola virus groups have the may kill thousands or millions.11 outbreak, to acquire samples for use skills necessary to cultivate lethal Initial cases will present to emer- as biological weapons.2,8 In 1995, in pathogens8 and the will to deploy gency departments, and ED physi- one of the most notorious terrorist them. Biological weapons will be cians will constitute the first line of attacks in history, Aum Shinrikyo deployed again, but we have no ability defense.5,11 Because biological agents placed sarin nerve gas in 5 subway to predict or prevent an attack, little threaten not only the lives of the pri- cars converging on central Tokyo. ability to detect one when it occurs, mary victims, but also those of physi- This attack affected over 5000 people, and limited ability to manage the con- cians and hospital staff, rapid diagno- causing 1000 hospitalizations and 12 sequences. sis is important; therefore emergency deaths.2 physicians, particularly those in large Biological incidents have also Bioterrorism and the cities, should be trained to recognize occurred in North America. In emergency department the syndromes caused by the most September of 1984, the Rajneeshee likely biological warfare agents.11 religious cult contaminated 10 restau- It is crucial to understand the differing Early syndrome recognition facilitates rant salad bars in the Dalles, Oregon, nature of biological and chemical life-saving vaccination of high-risk area with Salmonella typhimurium.9 agents (Table 1), since these differ- populations (e.g., ED staff) and allows Subsequently, 751 community mem- ences mandate different public health, for early post-exposure therapy for bers developed salmonella gastroen- first responder, and medical responses. victims. In the event of a smallpox teritis, demonstrating the ease with Chemical agents produce immedi- release, rapid recognition and re- which a motivated group can perpe- ate dramatic effects. In the Tokyo sponse could mitigate the effects by trate an act of bioterrorism. Six years sarin gas attack, symptoms appeared 100-fold, but only if initiative is ago, in April of 1993, Canadian cus- within hours and thousands of people shown. Early identification of a dead- toms agents stopped an Arkansas man were affected. In such incidents, the ly pathogen may mean the difference carrying weapons, ammunition, neo- key health care responders are fire- between life and death for ED staff Nazi literature, and enough ricin to fighters, paramedics, police and mili- and patients, and could prevent thou- kill 30,000 people.4 tary.5 This medical response is typical- sands or tens of thousands of casual- In the United States, the number of ly practised and promoted by local ties over the ensuing months. 206 CJEM • JCMU October • octobre 1999; 1 (3) Downloaded from https://www.cambridge.org/core. IP address: 170.106.34.90, on 01 Oct 2021 at 15:38:36, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S148180350000422X Bioterrorism Epidemiology of bioterrorism can take months, as it did with the and botulism. Of these, smallpox and Pacific Northwest Salmonella out- anthrax are the greatest threats.5 Knowledge of basic epidemiological break, to confirm that an incident was, principles is important in dealing in fact, an act of bioterrorism.