Skip to comments.Biological weapons: Preparing for the worst
Posted on 09/22/2001 8:20:51 AM PDT by Nita Nupress
Special note for Poohbah before we read the first article from Medical Laboratory Observer: http://www.mlo-online.com/about.html Medical Laboratory Observer is a monthly magazine for clinical laboratory professionals. For 30 years, MLO has been a widely read source of clinical laboratory management information. MLOs rigorous peer-review process ensures accuracy, timeliness, and authority. All feature articles published in the magazine are reviewed by experts in the field, the MLO Editorial Board, and the Editor for originality, importance, credibility, and objectivity. A mix of solicited and unsolicited articles is routinely considered for publication in MLO. The process starts with the selection of at least two reviewers based on the topic of the article. When reviews return, the Editor evaluates the manuscript and the comments of the two reviewers. Most manuscripts undergo a revision by the author and again by MLOs editorial staff prior to publication. Our Editorial Board includes a wide variety of professionals who are dedicated to providing comprehensive, up-to-the-minute information to lab directors, managers, and administrators on a wide range of issues in clinical laboratory management. The broad experience of our board members ensures that our readers get relevant, useful information they can use in their laboratories today. Board members, along with the Editor, help determine the editorial direction of the magazine.
The Editorial Board
Medical Laboratory Observer is a monthly magazine for clinical laboratory professionals. For 30 years, MLO has been a widely read source of clinical laboratory management information.
MLOs rigorous peer-review process ensures accuracy, timeliness, and authority. All feature articles published in the magazine are reviewed by experts in the field, the MLO Editorial Board, and the Editor for originality, importance, credibility, and objectivity. A mix of solicited and unsolicited articles is routinely considered for publication in MLO. The process starts with the selection of at least two reviewers based on the topic of the article. When reviews return, the Editor evaluates the manuscript and the comments of the two reviewers. Most manuscripts undergo a revision by the author and again by MLOs editorial staff prior to publication.
Our Editorial Board includes a wide variety of professionals who are dedicated to providing comprehensive, up-to-the-minute information to lab directors, managers, and administrators on a wide range of issues in clinical laboratory management. The broad experience of our board members ensures that our readers get relevant, useful information they can use in their laboratories today. Board members, along with the Editor, help determine the editorial direction of the magazine.
Not for commercial use. Solely to be used for the educational purposes of research and open discussion.
Medical Laboratory Observer
September 1, 2000
No. 9, Vol. 32; Pg. 26
Biological weapons: Preparing for the worst.
Leach, Donna L.; Ryman, Denny G.
Bioterrorism has been given significant attention during the past 2 years by the laboratory industry press and has been the subject of numerous seminars at national meetings of laboratory organizations. The likely precursors to this coverage were the discovery of a huge biological weapons program in Iraq after the Gulf War of 1991, the discovery of a major biological weapons program in the former Soviet Union called "Biopreparat," and the known recruitment of scientists from other rogue nations who worked on Biopreparat. [1,2] Terrorist attacks, such as the dispersal of sarin nerve gas in a Tokyo subway in 1995 by the Japanese cult Aum Shinrikyo, may also have contributed to the added attention bioterrorism has received. [3,4]
Many countries have biological weapons programs with virtually no safeguards against the transfer of weapons or the technology used to manufacture them to potential terrorist groups. These countries (many classified by the US State Department as supporting terrorism) include Syria, North Korea, Russia, Iran, Iraq, Libya, and China.  The threat of a terrorist action against the US that involves lethal biological weapons is not only possible but also probable, according to experts. In his congressional testimony before the Subcommittee on National Security, Veterans Affairs, and International Relations for the US House of Representatives on Oct. 20, 1999, Raymond Zalinskas, PhD, the Senior Scientist-in-Residence for the Chemical and Biological Weapons Nonproliferation Project at the Center for Nonproliferation Studies in Washington, DC, said that the most likely attacks would be on food or water supplies. He also predicted a substantial increase in the possibility of biological attacks using airborne pathogens between 2006 and 2010. 
Three major trends have been cited as responsible for the increased threat of biological weapons: the expertise needed to develop biological agents is rapidly proliferating, the technology needed to manufacture these agents is readily available, and the will to use these agents may be increasing among terrorist organizations. [1-4] Many toxins can be readily produced with minimal scientific knowledge, facilities, and financial support. Biological weapons are appealing to terrorists because they are both cheap to produce and capable of causing cause massive casualties. [2,7] Any "basement laboratory" can produce significant quantities of toxic substances. Advances in genetic engineering also mean that a microbiologist can engineer new organisms that are more lethal and resistant to known antibiotics. Because of this, the threat for bioterrorism is the greatest it has ever been. Terrorist groups with specific political goals may be unwilling to use biological agents out of fear of backlash, but the more fanati c ethnic and religious organizations whose motives cannot be understood in political terms may be more prone to experiment with agents of biological warfare.
The use of biological weapons is not new. Diseased corpses were catapulted into enemy cities in medieval times; and in the Eighteenth century, blankets infested with smallpox were distributed to certain Native American tribes, [8,9]
Attempts to control the use of biological weapons are almost as old as the weapons themselves. Most of the members of the League of Nations signed the 1925 Geneva Protocol renouncing the use of chemical or biological weapons. Later, the 1972 Biological Weapons Convention was signed by 118 countries, including China, Japan, all NATO members, and the former Warsaw Pact countries.  The BWC defined both biological and chemical weapons as instruments of biological warfare and prohibits the development, production, and stockpiling of biological and chemical weapons. Because no verification method exists, however, this pact remains largely unenforceable. 
In 1996, the US government developed the Biological Warfare Defense Program. The purpose of the program was to develop broad-spectrum approaches to neutralizing biological agents (bacteria, viruses, bioengineered organisms, and toxins) used in biological attacks.  This program partners with universities and other organizations to perform research that creates fast, simple methods for detecting and identifying biological agents. It also develops protective gear and mechanisms to destroy organisms before they enter the body. Even though this program provides expertise for the Department of Defense in biological attacks, many innovations will be transferred to the civilian sector for use in a bioterrorism attack.
That same year, Congress passed the Defense Against Weapons of Mass Destruction Act, which mandated that the Secretary of Defense create a program to improve the responses of state and local agencies to emergencies involving biological and chemical weapons. As a result, the Department of Defense established the Biological Weapons Improved Response Program, which uses the resources of he US Army's Chemical and Biologic Defense Command, the Department of Health and Human Services, the Department of Energy, the Department of Agriculture, the Federal Emergency Management Agency, the Federal Bureau of Investigation, the Environmental Protection Agency, and the Centers for Disease Control and Prevention to develop the Biological Weapons Response Template, which will help city and state governments prepare their defenses for an attack. [11,12]
Most published government and military reports state that the nation's medical and government structures would be unable to effectively respond to such a catastrophic event.  The US, local, state, and federal public health infrastructure is already overburdened with other pressing public health issues.  A simulated biological attack staged in New York, Chicago, and Los Angeles in 1996 revealed just how vulnerable the US is to bioterrorism.  Firemen were reported to have rushed into the "contaminated" area without protective clothing, and hospitals reported they would have been overwhelmed in the event of an actual attack. The US government responded in several ways, including appropriating $ 800 million for chemical and biological weapons defense in fiscal year 1997.  These and other government actions indicate that the detection, deactivation, and containment of biological weapons are becoming priorities for the US.
The lab's response
The execution of 4 critical steps will determine the success of the medical community's response to a bioterrorist attack :
* prompt lab identification of agents of biological warfare,
* notification of local, state, and federal health officials,
* notification of appropriate law enforcement agencies, and
* support of healthcare providers who may be faced with caring for large numbers of infected patients.
For their part, laboratory professionals must be aware of potential agents of biological warfare, know how to isolate and identify them, and know what precautions should be taken when handling such agents. Also important is having a procedure for notifying authorities of a suspected bioterrorist attack.
What are biological weapons?
Biological weapons include both biological agents, such as bacteria, protozoa, rickettsia, viruses, and fungi, as well as toxins, such as poison gas and chemicals. This article addresses the most commonly used biological weapons, most of which are biological agents.
Biological and chemical weapons are extremely pathogenic to both humans and animals. Their effects can include acute respiratory paralysis, central nervous system disorders, and organ failure, with death as the final outcome.
According to Zalinskas, the major biological threats to the US include emerging pathogens, reemerging pathogens, and transported infectious diseases.  Terrorist groups could use many different biological agents in a bioterrorism attack. The following biological agents are those put forth by the US Army Medical Research Institute of Infectious Diseases (USAMRIID) as those most likely to be used: Bacillus anthracis, Brucella sp., Burkbolderia mallei, Vibrio cholerae, Yersinia pestis, Francisella tularensis, Coxiella burnetii, Venezuelan equine encephalitis (VEE), viral hemorrhagic fevers, smallpox, botulinum toxin, staphylococcal enterotoxin B, ricin, and T-2 toxins. [8,16,17]
An aerobic, spore-forming, gram-positive rod called Bacillus anthracis causes anthrax. Anthrax is usually found in cattle, sheep, and horses, although other animals can also be infected. The infectious form of the organism is the spore, which remains viable for years in soil, water, and direct sunlight. The incubation period is 1-6 days.
Diagnosis. Initial symptoms include fever, malaise, fatigue, cough, and mild chest pain, which quickly progresses to severe respiratory distress, then shock and death within 24-36 hours after the initial symptoms. The gastrointestinal and cutaneous forms of anthrax are not lethal. A vaccine is available and is now required for all military members. Diagnosis usually comes late in the disease by blood culture or Gram stain of peripheral blood.
Treatment. Penicillin is effective before the symptoms appear, but high-dose antibiotic treatment with penicillin, ciprofloxicin, or doxycycline is recommended. [8,16,17]
Brucellosis can be caused by Brucella abortus, Brucella melitensis, and Brucella suis, which are gram-negative coccobacilli. These organisms are highly infectious, and as few as 10-100 bacteria can produce disease after being inhaled. The incubation period is from 5-60 days, but large aerosol doses can shorten the incubation period. Brucellosis is an incapacitating disease, but the mortality rate is less than 5% of infected individuals. Brucellosis also occurs as a percutaneous or enteric infection, which is contracted by consuming unpasteurized dairy products (especially goat's milk and cheese).
Diagnosis. Brucellosis presents as a nonspecific febrile illness with headache, fever, myalgia, arthralgia, back pain, sweats, chills, and malaise. The bacteria may cause meningitis in 5% of the cases, and the organism can be cultured from cerebrospinal fluid. Patients may present with anemia and thrombocytopenia, and blood and bone marrow cultures may be positive during the acute febrile phase. Enzyme immunoassays are under development as is a polymerase chain reaction test using a protein from B. abortus.
Treatment. Treatment is doxycycline plus rifampin for 6 weeks. Ofloxacin plus rifampin can also be given. For patients with meningitis or endocarditis, rifampin, tetracycline, and an aminoglycoside are administered. [8,16,17]
Cholera is caused by a short, curved, motile, anaerobic, gram-negative rod called Vibrio cholera. Vi cholerae produces an enterotoxin that inhibits water absorption in the small intestine. The organism is transmitted by contaminated water, food, flies, or soiled utensils and can be killed by drying, chlorinating, steaming, and boiling water. This organism can withstand freezing for 3-4 days.
Diagnosis. Diagnosis is performed clinically by observing "rice water" diarrhea and dehydration. Laboratory diagnosis is made by identifying the motile vibrio under phase-contrast microscopy in the field or by culture in clinical laboratories.
Treatment. Treatment with antibiotics will reduce shedding of the organism so that the infected person does not pass as many organisms into his or her body fluids. However, antibiotics will not kill the organism [8,16,17]
Glanders is caused by a small, gram-negative rod called Burkholderia mallei (formerly known as Pseudomonas mallei). This organism usually produces disease in horses, mules, and donkeys, but may also infect humans. Infection occurs through inhalation or through cracks or sores in the skin. Laboratory cultures are considered extremely infectious and require biosafety level 3 practices.
Infections in patients can take 4 forms: acute localized, septicemia, acute pulmonary, or chronic cutaneous. The acute localized form can be either cutaneous or mucosal. In the cutaneous form, patients present with nodules and ulcerations. If the cutaneous form becomes systemic, a papular or pustular rash accompanies systemic invasion, and it can be mistaken for smallpox.
The septic form of this infection presents with a sudden onset fever, rigors, sweats, myalgia, chest pain, phototrophia, lacrimation, and diarrhea. The blood cultures are usually negative, and this form causes death quickly after onset.
The mucosal form involves infection of oral, nasal, and/or conjunctival mucosa, which causes mucopurulent, bloodstreaked discharged from the nose. Turbinate nodules and ulcerations are also present in the nose. Systemic invasion can occur from here.
The chronic form presents with cutaneous and intramuscular abscesses on the legs and arms. There is also enlargement and induration of the lymph glands. Patients with this form of the disease may still erupt into acute septicemia.
Diagnosis. Diagnosis is achieved through a Gram stain of exudates and routine culture. B. mallei takes 48 hours to grow on nutrient agar, but colony growth can be enhanced by the addition of meat infusion media. Antibody detection tests are not positive for 7-10 days and are difficult to interpret because of a high background titer. Complement fixation tests are more specific and are considered positive at a titer of 1:20.
Treatment. Most antibiotics have been tested only on animals, so each organism encountered must be tested to determine susceptibility to antibiotic agents. Experts expect high mortality despite antibiotic use. [8,16,17]
Smallpox is an orthopoxvirus. It has two forms: variola major and variola minor. Variola major produces more severe disease. The virus is highly infectious when transported by aerosols, is easy to make, and the world population does not have immunity to it. In 1980, the World Health Organization declared that smallpox was globally eradicated and approved CDC and the Institute for Viral Preparedness in Moscow to hold live cultures of smallpox. In the 1980s, children in the US stopped receiving smallpox vaccinations, and the military stopped vaccination programs in 1989. This means that a good part of the US population and its military force are now susceptible to variola major. This fact makes smallpox a choice biological agent because even though smallpox was "globally eradicated" and a vaccine exists, countries with live cultures can still use it in biological weapons. The incubation period for smallpox is around 12 days, but because it is extremely infectious as pustules, patients and contacts are quarantin ed for about 16 days after exposure.
Symptoms. The patient infected with variola major presents with malaise, fevers, rigors, vomiting, headache, and backache. After 48-72 hours, patients develop a rash on the face, hands, and forearms, which then extends to the legs and trunk over the next week. Lesions are plentiful on the face and extremities--this is called centrifugal distribution and is diagnostic. Approximately 2 weeks after onset of nonspecific symptoms, pustules form scabs, which then become depressed and depigmented. After healing, scars are left on the skin. Patients are considered infectious until all scabs disappear. Variola major can cause up to 30% mortality among the unvaccinated population.
The early stages of smallpox are indistinguishable from other diseases such as chicken pox or allergic-contact dermatitis. Particularly troubling is the fact that many vaccinated people could contract mild cases of the disease and spread it before they are quarantined.
Diagnosis. Smallpox is usually diagnosed by appearance of virions on electron microscopy of vesicular scrapings. Guarnieri's bodies in vesicular scrapings can be seen with Gispen's modified silver stain, but the inclusions do not differentiate between cowpox, monkeypox, and smallpox.
The problem with smallpox is that it is highly contagious. If a vesicular exanthem (eg, skin eruptions or vesicles on the lips, nose, or tongue) is discovered on a patient, physicians must suspect a biological attack and undertake appropriate quarantine measures. A confirmed case of smallpox is an international emergency and needs to be reported to public health officials immediately. One sobering thought: only persons vaccinated within the past 3 years are considered immune; however, if vaccination is given within 7 days of exposure to smallpox, the disease can be prevented.
Treatment. There are no effective antiviral drugs at this time. Variola immune globulin (VIG) does exist and can provide protection for people who cannot take the smallpox vaccine. [8,16,17]
A gram-negative, nonmotile, nonsporulating, aerobic bacteria named Yersinia pestis is responsible for the plague. Plague is a zoonotic infection that is passed onto humans by fleas. If a human is bitten by an infected flea, this person develops the bubonic form of plague, but the pneumonic form of plague is better suited for a biological weapon because all people are susceptible. The organism can remain alive in water, meals, and grains for weeks; but at near freezing, it can remain alive from months to years. It is killed when exposed to temperatures of 72[degrees]C for 15 minutes and several hours of sunlight exposure.
Diagnosis. The pneumonic plague presents with malaise, high fever, chills, headache, myalgia, cough with a bloody sputum, and toxemia. Patients have bronchopneumonia, which progresses rapidly to dyspnea, stridor, and cyanosis. They die from respiratory failure, circulatory collapse, and a bleeding diathesis. The typical incubation period for pneumonic plague is 2-3 days.
Diagnostic laboratory tests include CBC with a WBC of as high as 20,000/L with increased bands and [greater than] 80% polymorphonuclear cells on the differential. Patients experience a lowgrade disseminated intravascular coagulation (DIC) with a positive fibrin degradation product (FDP) and elevated alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin levels. Presumptive diagnosis consists of finding gram-negative coccobacillus in lymph node aspirate, sputum, or CSF. The gram-negative coccobacillus exhibits safety-pin bipolar staining with Giemsa stain. Definitive diagnosis is made from culture of blood, sputum, bubo aspirates, and CSF. Yersinia pestis will grow on blood and MacConkey agars.
Treatment. Patients must be isolated for 72 hours after starting antibiotics. Antibiotics of choice include streptomycin, tetracycline, chloramphenicol, gentamicin, and ceftriaxone. A vaccine is available, but it is a 3-dose vaccine that requires boosters at 6, 12, and 18 months; then every 1-2 years after vaccination. People who need prophylaxis can take doxycycline to prevent infection in face-to-face encounters with infected people. [8,16,17]
Tularemia is caused by a small, nonmotile, aerobic, gramnegative coccobacillus called Francisella tularensis. This organism can survive in water, carcasses, hides, and for years in frozen rabbit meat. It also survives in soil or water at freezing temperatures and below. It is susceptible to heat and disinfectants.
Tularemia manifests itself in several forms in man: ulceroglandular, septicemic (typhoidal), and pneumonic. The most probable form of the disease caused by a bioterrorism attack would be septicemic tularemia. Septicemic tularemia occurs after intradermal, respiratory, or gastric inoculation of the organism. This is the presenting form of tularemia in 5-15% of cases. Pneumonic tularemia can be primary (inhaled bacteria) or secondary (produced after patient is septic).
Diagnosis. Acute onset of disease usually occurs from 2-10 days after exposure. Diagnosis of tularemia is difficult because signs and symptoms are nonspecific. The organism grows poorly on conventional media or is overgrown by normal flora. Direct Gram stains from ulcer fluids or sputums are usually not helpful.
Treatment. Tularemia is treated with intramuscular streptomycin for 10-14 days or gentamicin. Tetracycline and chloramphenicol are also used, but there are more relapses associated with these drugs. A new investigational drug was recently developed. [8,16,17]
Q fever is caused by a rickettsia called Coxiella burnetii that usually infects sheep, cattle, and goats. Coxiella burnetii is extremely infective via the aerosol route. As few as 1-10 organisms can produce clinical disease when inhaled by a human. The incubation period for this disease is 10-20 days, after which the illness is usually self-limiting--lasting from 2 days to 2 weeks.
Diagnosis. The disease usually presents with headache, myalgia, and fatigue. About half of the patients develop pneumonia, but only 25% of those patients have a productive cough. About one-third of the patients have an elevated WBC, and most patients have an elevated ALT and AST.
Treatment. Tetracycline or doxycycline treatment will shorten the length of the illness, and the fever will disappear after 2 days of antibiotic treatment. A vaccine is available and provides at least 5 years of immunity against Q fever. Prophylaxis with doxycycline or tetracycline can prevent the disease if given 8-12 days after exposure and continued for 10 days. [8,16,17]
Venezuelan equine encephalitis
Venezuelan equine encephalitis (VEE) is caused by an alphavirus of the same name. This virus usually affects horses, mules, and donkeys and is usually carried by mosquitoes. Wet and dry forms are stable and can be released by aerosol or through water and food contamination. The virus can be inactivated with heat and disinfectants.
This virus causes an inflammation of the meninges and the brain, with fatality occurring in less than 1% of infected patients. The disease is usually acute and short-lived. Recovery from this disease produces lifelong immunity. The incubation period is usually 1-5 days before the onset of symptoms.
Diagnosis. Symptoms include malaise, fever, rigors, severe headache, photophobia, and myalgia of the legs and lower back. Secondary symptoms include nausea, vomiting, diarrhea, cough, and sore throat. The WBC differential shows leukopenia and lymphopenia. CSF may contain as many as 1,000 leukocytes/[mm.sup.3] and an elevated protein level. Serological tests such as IgM ELISA, IFA, and complement-fixation tests are available for this virus.
Treatment. Treatment of the symptoms is the only relief for patients infected with this virus. Recovery usually takes 1-2 weeks. There is no commercially available vaccine. [8,16,17]
Viral hemorrhagic fevers
This group of diseases is caused by RNA viruses from the Filoviridae (Ebola and Marburg), Arenaviridae (Lassa fever, Argentine and Bolivian hemorrhagic fever), and Bunyaviridae (Hantavirus, Congo-Crimean hemorrhagic fever, Rift Valley fever, and Yellow fever) families; the Dengue hemorrhagic fever virus; and others (see Table 1). Thankfully, aerosol biological weapons do not exist for some of these viruses, but the symptoms may confuse physicians treating infected people.
Viral hemorrhagic fevers target the vascular system and cause changes in vascular permeability, which then leads to microvascular damage. The initial symptoms include fever, myalgia, mild hypotension, flushing, and petechiae. These symptoms quickly evolve to shock with generalized mucous membrane hemorrhage. Renal failure accompanies the cardiovascular decline, and mortality can be 5-20% or higher. The fatality rates for Ebola are 50-90%.
Diagnosis. A detailed history is important because many of these viral hemorrhagic fevers are spread by mosquitoes or other arthropod vectors. Therefore, if a patient has visited a geographic location where the disease is endemic, a terrorist attack can probably be ruled out. When large numbers of cases are diagnosed in a nonendemic area, however, a biological attack should be suspected. A viral hemorrhagic fever should not be ruled out if the patient presents with hypotension, petechiae, and flushing of the face and chest. Other diseases that may be confused with viral hemorrhagic fevers include typhoid fever, rickettsial disease, relapsing fever, and leptospiral disease. Diseases that lead to DIC such as leukemias, lupus erythromatosus, idiopathic or thrombotic thrombocytopenic purpura, or hemolytic ureniic syndrome can also be confused with viral hemorrhagic fevers and must be ruled out.
Laboratory results include thrombocytopenia (except Lassa), leukopenia (except Lassa, hantaviral, and severe Crimean-Congo hemorrhagic fever), and proteinuria and/or hematuria (found in Argentine hemorrhagic fever, Bolivian hemorrhagic fever, and hantaviral infections). Serological tests for antibodies to Lassa, Argentine hemorrhagic fever, Rift Valley fever, Crimean-Congo hemorrhagic fever, yellow fever, and hantaviral disease may also be used to confirm viral hemorrhagic fevers. These viruses all require biosafety level 4 containment facilities.
Treatment. Supportive therapy is given to patients with viral hemorrhagic fevers. If DIC is present, heparin therapy should be given. Dengue and hantaviral infections should be managed differently than the rest of the viral hemorrhagic fevers because of the severe consequences of Dengue fever and the renal involvement of hantaviral infections. The antiviral drug ribavirin can reduce mortality in Lassa fever. Dengue fever, Yellow fever, Ebola, and Marburg fever are not responsive to ribavirin therapy. [8,6,7]
Clostridium botulinum produces 7 neurotoxins, types A through G. All neurotoxins produce symptoms of botulism. These toxins are considered some of the most toxic substances in the world. (The botulinum toxins are 100,000 times more toxic than sarin nerve gas.) The toxins can be delivered as an aerosol, and people who inhale the toxins will become ill with symptoms of botulism. The toxins can produce paralysis in infected persons because they bind to the presynaptic nerve terminal at neuromuscular junctions and prevent release of acetyicholine and ultimately, neurotransmission.
Diagnosis. Patients can become ill in as little as one day after inhaling the toxins. The initial symptoms include blurred vision, diplopia, photophobia, dysarthria, dysphagia, and dysphonia. Next, skeletal muscles are affected, which causes a symmetrical, descending, progressive weakness that can result in respiratory failure. Patients may also experience dry and crusted mucous membranes--especially in the mouth--and can experience difficulty speaking and lose their gag reflex.
If many patients present with no fever, but exhibit a descending paralysis, botulism should be expected. This condition can be confused with Guillain-Barre syndrome, myasthenia gravis, or tick paralysis. Laboratory testing is not helpful in diagnosing this condition.
Treatment. Antitoxin is available from the CDC, but because it is equine-based, side effects may include anaphylaxis and serum sickness from the horse proteins. A toxoid made from Clostridium botulinum toxin types A, B, C, D, and E has been used on groups at high risk for inhalation of botulinum toxins. The toxoid induces antitoxin production that will protect against the adverse effects of the toxins. [8,6,7]
Staphylococcal enterotoxin B
Staphylococcal enterotoxin B is a pyrogenic toxin that is produced by Staphylococcus aureus and that causes food poisoning. In bioterrorism, this toxin would probably be introduced using an aerosol. It produces a different disease when inhaled as compared with ingestion. Although it would not cause high mortality if used in an attack, it would cause a great number of people to be incapacitated and to require medical treatment. This toxin causes disease by activating a nonspecific immune response from a person, and it induces T-cell proliferation that leads to increased interleukin-2 production, which produces severe nausea and vomiting. Inhalation of the toxin also causes production of tumor necrosis factor and interferon gamma.
Diagnosis. Symptoms begin 3-12 hours after inhalation. There is a sudden onset of fever, headache, chills, myalgias, and a nonproductive cough. Soon after the initial symptoms, nausea, vomiting, and diarrhea occur and lead to heavy fluid loss. The fever ranges from 103 to 106[degrees]F and may last up to 5 days. Severe cases can develop pulmonary edema and acute respiratory distress syndrome.
Laboratory tests are not useful in diagnosing staphylococcal enterotoxin B inhalation, so it must be diagnosed clinically and epidemiologically. This disease presentation is similar to anthrax, tularemia, Q fever, plague, adenovirus, influenzae, and mycoplasma infections. Epidemiologists should be concerned about a bioterrorist attack if large numbers of patients present with the initial symptoms in a short period of time.
Treatment. Treatment is limited to supportive care, no antitoxin or other specific treatment is available. There is also no vaccine on the market to prevent reaction to this toxin. [8,16,17]
Ricin is a toxin that is derived from castor beans. After the oil is extracted from the beans, the waste product contains about 5% ricin. Ricin is easy and inexpensive to produce in large quantities and is toxic to cells because it inhibits protein synthesis. The amount of ricin inhaled determines the severity of disease produced. Sublethal doses will produce fever, chest tightness, cough, dyspnea, nausea, and arthralgias within 4-8 hours of exposure. If enough toxin is inhaled, severe damage occurs in the airways and alveoli, causing death in approximately 18-72 hours. If ricin is ingested, gastrointestinal hemorrhage and hepatic, splenic, and renal necrosis occurs.
Diagnosis. Because of the nonspecific symptoms, an aerosol attack would be diagnosed by clinical and epidemiological data. Ricin is immunogenic, so survivors will have antibody protection for a short period of time.
Treatment. Treatment is only supportive because no antitoxin is available. There is also no vaccine available, but gas masks can prevent inhalation of the toxin. [8,16,17]
Filamentous fungi, especially those of the Fusarium, Myrotecium, Trichoderma, and Stachybotrys genera, produce trichothecene mycotoxins. These mycotoxins are extremely heat stable and resist ultraviolet light inactivation. If the mycotoxins are ingested, they produce a lethal illness called alimentary toxic aleukia (ATA) with the following initial symptoms: abdominal pain, diarrhea, vomiting, and prostration. These progress into fever, chills, myalgias, and bone marrow depression causing granulocytopenia and sepsis. If the patient survives these initial stages, the next set of symptoms are painful pharyngeal/laryngeal ulceration and diffuse bleeding into the skin, bloody diarrhea, hematuria, hematemesis, epistaxis, and vaginal bleeding. Some believe that these mycotoxins were used in Southeast Asia and Afghanistan in the form of "yellow rain" to produce casualties and deaths among the civilian populations. 
Mycotoxins can enter the body through the skin, stomach, or lungs and inhibit protein and nucleic acid synthesis. The first cells attacked are the rapidly dividing cells such as bone marrow, skin, mucosal epithelia, and germ cells. When skin is exposed to mycotoxins, burning, redness, blistering, and skin necrosis occur. When nasal mucosa is exposed to mycotoxins, this produces nasal pain, sneezing, rhinorrhea, dyspnea, wheezing, cough, and blood tinged saliva and sputum. Exposure of the eyes to mycotoxins produces eye pain, tearing, redness, and blurred vision. Once the mycotoxins enter the system, symptoms include weakness, prostration, dizziness, ataxia, loss of coordination, and in fatal cases, tachycardia, hypothermia, and hypotension. Death may occur in minutes, hours, or days.
Diagnosis. Laboratory tests are not available to diagnosis exposure to T-2 toxins. Toxic exposure can only be confirmed when tissue samples taken at autopsy are tested using a mass spectrometer.
Treatment. Again, exposure can be prevented with a gas mask and protective chemical gear. All treatment is supportive because no antitoxins or antifungals are presently available. [8,16,17]
Bioterrorism readiness plan
In 1999, the Association of Professionals in Infection Control and Epidemiology's Bioterrorism Task Force and the CDC's Hospital Infections Program Bioterrorism Working Group collaborated to produce a reference document to help healthcare facilities develop readiness plans in case a bioterrorism attack occurs in their city.  This plan includes reporting requirements; detection of outbreaks; infection control practices for patient management; postexposure management; patient, visitor, and public information; and laboratory support and confirmation. When these agencies developed this initial template, only 4 diseases were considered potential biological agents: anthrax, botulinum toxin, plague, and smallpox. More recently, other agents have been added to the list by USAMRIID.
Reporting requirements. Because healthcare facilities will probably be the first to recognize a bioterrorism attack, they will be responsible for notifying local infection control personnel, administrators, public health facilities, FBI field offices, local police, the CDC, and emergency medical services. Every facility should have these phone numbers available.
Detection of outbreaks. Terrorist attacks using biological agents can occur as announced or unannounced events. Healthcare facilities must be able to deal effectively with both types of attacks. To do this, facilities should determine syndrome-based criteria and epidemiological features of the outbreak to determine if terrorists have used a biological agent.
Infection control practices for patient management. Healthcare facilities must determine what isolation procedures should be used for individual biological agents because some agents are not transmitted via person-to-person contact and others are. Patient placement and patient transport is important to avoid both exposure of the infected patient to other agents and exposure of unaffected patients to toxic agents. In addition, cleaning, disinfection, and sterilization of equipment and the environment are very important to prevent the spread of the agent to other healthy patients. Postexposure plans should include discharge management of patients to ensure reinfection does not occur. Clinical laboratories and pathology departments need to be informed of suspected agents so that extra biosafety precautions can be taken with bodies and bodily substances after postmortem examinations.
Postexposure management. Patients and the environment need to be decontaminated after release of a biological agent. People who were exposed or thought to have been exposed should be (1) given medication to prevent onset of the disease and its symptoms and (2) immunized against a particular biological agent. Healthcare facilities must develop plans for triage and management of large-scale exposure and suspected exposures without shutting down the hospital. Masses of people can overwhelm healthcare facilities, so this possibility should be dealt with up-front so that plans can be made to keep the system flowing. Finally, psychological aspects of bioterrorism must be taken into account and planned for. Mental health professionals need to be an integral patt of the response team.
Patient, visitor, and public information. All 3 audiences must be kept adequately informed to prevent widespread panic. The information given must be clear, concise, and understandable. Fact sheets can be prepared ahead of time and distributed to interested parties. All lines of communication with the outside world need to be coordinated in advance so that misunderstanding and anxiety can be minimized.
Laboratory support and confirmation. Clinical microbiology laboratories routinely identify infectious agents that cause disease in humans and animals. Laboratories provide 80% of objective data used to make a diagnosis; and in a bioterrorism attack, providers will expect the laboratory to identify the bioterrorism agent and its antimicrobial susceptibility pattern. Bioterrorism agents used can be categorized as biosafety level 2 pathogens such as salmonella, biosafety level 3 pathogens such as Venezuelan equine encephalitis, or biosafety level 4 pathogens such as smallpox (see Table 2). Most clinical laboratories routinely identify biosafety level 2 pathogens, and larger laboratories may identify biosafety level 3 pathogens; but only 2 labs in the US have the capability to identify biosafety level 4 pathogens--the CDC and USAMRIID. If an attack with a biosafety level 4 agent occurred anywhere in the country, clinical laboratories would be unable to identify the agent.
The CDC, USAMRIID, and the Association for Public Health Laboratories identified the need for a laboratory network for responding to bioterrorism and emerging infectious diseases.  This network is being developed and would consist of hospital clinical laboratories and physician office laboratories (level A), commercial reference laboratories (level B), public health and military laboratories (level C), and CDC and USAMRIID (level D). Hospital clinical and physician office laboratories would be first-response labs because patients would seek medical care at local facilities as soon as they became ill. (After a covert bioterrorism attack; the disease incubation period could be as short as 1 day or as long as 1 month before victims became symptomatic.) This period of time between exposure and developing symptoms would increase the difficulty of identifying a bioterrorism attack. The level A labs would be responsible for ruling out bioterrorism agents, referring suspected agents to level C labs, and evaluati ng specimens from patients.
The responsibilities of level B labs would be to confirm laboratory specimens referred from level A labs, to isolate and identify bioterrorism agents, to train and educate level A lab personnel, and to test for antimicrobial susceptibility of isolates. If an agent of biological warfare was suspected, commercial reference labs would refer the specimen to level C labs (public health and military labs).
Level C labs would have particular expertise in working with particular organisms, and specimens would be referred to those labs specializing in the characterization or molecular fingerprinting of that organism. This would be necessary to compare and identify isolates from other suspected victims of bioterrorism. These labs would also be responsible for evaluating and distributing devices or new rapid identification methods for identifying biological agents.
Level D labs would be responsible for developing new rapid identification tests for bioterrorism agents, testing all agents for chimeras (genetically altered organism that may not be detectable by current methods), and for culturing and performing antimicrobial susceptibility tests on all biosafety level 3 and 4 bioterrorism agents.
This laboratory network would rely heavily on information technology to provide timely identification and antimicrobial susceptibility of bioterrorism agents. The current vision shows level C and D labs developing new methods and procedures, then passing these newly developed tests to the level A and B labs. A central Web-based repository would be available to laboratories through a secure Internet site. Level D labs would also develop algorithms to aid level A and B labs in ruling out and identifying bioterrorism agents. CDC and APHL envision 2 parallel networks (civilian and military) that can be cross-linked so that both can retrieve relevant data. 
Even though some experts do not anticipate bioterrorism attacks in the next 5 years, the medical community must expect the unexpected. Plans should be developed that have criteria for determining exposure to biological agents, triaging thousands of patients, reducing risk for both unexposed and infected patients, and keeping the public from panicking. As one looks at all the potential biological agents and the similarities between the syndromes produced, detecting and identifying biological agents is a monumental task. The civilian community can look to the military for some answers, but the military detection and identification techniques for biological agents are still infantile--if they exist. When bioterrorist attacks occur in the US, we must be prepared or pay dearly for a lesson learned.
Donna Leach is associate professor and chair of the Clinical Laboratory Science Department and Denny G. Ryman is assistant professor in the Clinical Laboratory Science Department at Winston-Salem State University, Winston-Salem, NC.
(1.) Alibek K. Biohazard. New York: Random House.
(2.) Seldon Z. Assessing the biological weapons threat. Business Executives for National Security Special Report. www.bus.org/pubs/bwc.html. Accessed July 17, 2000.
(3.) Carus SW. The threat of bioterrorism. From the National Defense University's Institute for National Strategic Studies, Strategic Forum. Sept 1997. www.ndu.edu/niss/strforum/forum 127.html. Accessed July 21, 2000.
(4.) Tucker JB. Historical Trends Related to Bioterrorism: An Empirical Analysis. Emerging and Infectious Diseases. Vol. 5, no. 4, July-August, 1999. www.cdc.gov/ncidod/eid/vol5no4/tucker.html. Accessed on April 5, 2000.
(5.) Anderson JH. Microbes and Mass Casualties: Defending America Against Bioterrorism, The Backgrounder. The Heritage Foundation, www.heritage.org/library/backgrounder/bgl182es.html. Accessed on August 17, 2000.
(6.) Zalinskas R. (20 October 1999). Assessing the Threat of Bioterrorism: Congressional Testimony by Raymond Zalinskas. Center for Nonproliferation Studies, Monteray Institute of International Studies, National Defense University.
(7.) MacKenzie D. (September 19, 1998). Bioarmageddon. New Scientist 2000, Online conference reports, www.newscientist.com/nsplus/insight/ bioterrorism/bioarmageddon.html. Accessed on 4/5/00.
(8.) US Army Medical Research Institute of Infection Diseases. Medical Management of Biological Casualties. September 1999. www.nbcmed.org/SiteContent/HomePage/What'sNew/MedManual/Sep99/Current /Handbook.html. Accessed on April 15, 2000.
(9.) Kupperman RH, Smith DM. Coping with biological terrorism. In: Roberts B, ed. Biological Weapons: Weapons of the Future? Washington, DC: Center for Strategic and International Studies; 1993.
(10.) Kozaryn L. (February 9, 2000). Biological Defenses on the Horizon. American Forces Information Service. www.defenselink.mil/news/Feb2000/n02092000_20002092.html. Accessed on 4/5/00.
(11.) Boyce N. Nowhere to hide. New Scientist, Online Conference Reports. www.newscientist.com/nsplus/insight/bioterrorism/nowhere.html. March 21, 1998.
(12.) Hutchinson R. Improving Local and State Agency Response to Terrorist Incidents Involving Biological Weapons. Response to Nunn-Lugar-Domenici Domestic Preparedness Program by Department of Defense. August 1, 2000. dp.sbccom.army.mil/fr/dp_bwirp_interim_planning_guide_download.html. Accessed on August 16, 2000.
(13.) CDC Strategic Planning Workgroup. Biological and chemical terrorism: Strategic plan for preparedness and response. MMWR. April 21, 2000;49(RR04);1-14.
(14.) "US Cities Prepare to Deal with Terror Attacks, But Drills Point to Weankess in Rescue Plans." Wall Street Journal. Monday, June 3, 1996: A16.
(15.) Wilson ML. Bioterrorism Q&A. Laboratory Medicine. 1999;30(9):568.
(16.) Zajtchuk R. Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare. Published by the Office of the Surgeon General, Department of the Army; 1997.
(17.) Murray PR, Baron EJ, Pfsllor MA, et al, eds. Manual of Clinical Microbiology. 6th ed. Washington, DC: ASM Press; 1995.
(18.) APIC Bioterrorism Task Force and CDC Hospital Infections Program Bioterroism Working Group. Bioterrorism Readiness Plan: A Template for Healthcare Facilities. April 13, 1999. www.cdc.gov/ncidod/hip/bio/13apr99APIC-CDCBioterrorism.PDF. Accessed on April 5, 2000.
(19.) Gilchrist MJR. A national laboratory network for bioterrorism: Evolving from a prototype network of laboratories performing routine surveillance. Military Medicine. 2000;165(supplement 2:001):28-31.
(20.) Ascker MS. A civilian-military virtual public health laboratory network. Military Medicine. 2000;165(supplement 2:001):1-4.
CDC: Our national resource for responding to biological attacks
If the unthinkable happens and an attack on the US with biological weapons occurs, an immediate call would be placed to the Centers for Disease Control and Prevention, which has set up an office to coordinate a national response to bioterrorist attacks. The next step would depend on whether the event was a chemical or a biological episode, said Elaine Gunter, Chief, NHANES Laboratory (National Health and Nutrition Examination Survey), CDC. "With biological events, it may be 2 weeks before you know what people are exposed to. They are going to trickle into doctors, county health offices, and hospitals. When a chemical event occurs, people are going to drop like flies. You know something has happened right away," she explained.
"Seven of us in this laboratory are medical technologists. Two of us would be dispatched within 2 hours to help first responders with specimen collection. We would look primarily for certain groups of chemicals, such as organophosphate nerve agents, agents used in riot control, or ricin. We developed a rapid toxic screen that enables us to identify these chemicals with a very small amount of blood or urine." Within 24 hours, 75 chemical agents can be identified through the use of various tests conducted on very high level instruments such as mass spectrometers that are capable of measuring down to parts per trillion, noted Gunter. "In another year, we hope to be able to measure 150 chemical agents within 48 hours." The rapid toxic screen answers 3 critical questions: Which agents were used? Who was exposed? How much exposure occurred? "We're not only looking for the exotic agents. We're looking for agents that are commonly available," she said.
In addition to helping collect blood and urine from victims, the team helps first responders package and ship samples to the CDC. They establish a "really strict chain of custody in accordance with the FBI's guidance because these are forensic specimens that will be used in a criminal trial. We have to be extremely careful," added Gunter.
The CDC's Chemical Terrorism Laboratory Network is composed of the laboratory at CDC and five state laboratories in New York, California, Virginia, Michigan, and New Mexico. CDC provides training, technical assistance, and proficiency testing for the state labs. "We bring them on board basically one method at a time. Most of these methods didn't exist 18 months ago."
On the biological side, the network is a complex one that goes from level A (the physician or county hospital) to level D (the CDC and US Army Medical Research Institute of Infectious Diseases). On the chemical side, the division of laboratory sciences at the CDC is the reference laboratory and has close ties to US Army Medical Institute of Chemical Warfare Agents. The states applied for CDC grants in five areas: preparedness and prevention, detection and surveillance, diagnosis and characterization of biological and chemical agents, response, and communication systems.
The CDC received $ 178 million in fiscal year 1999 to prepare against bioterrorism and to establish this network of biological and chemical labs to assist with measurement. (In addition, the CDC received $ 52 million to establish a pharmaceutical stockpile, which will ensure the availability of drugs, vaccines, prophylactic medicines, chemical antidotes, medical supplies, and equipment that will be needed to support a medical response to a terrorist incident.)
The CDC is holding regional meetings with all the state labs--in Philadelphia, Atlanta, St. Louis, Denver, and San Francisco. "We are telling them who we are, what the CDC's response plan is, and how we can help them so that this becomes a partnership," Gunter explained.
Background reference material on the next author, especially for Poohbah:
Al Venter, a South African journalist...
Al Venter, a regular contributor to Jane's Intelligence Review,...
Al Venter, "Saddam and the West's Worst Nightmare" [4-8]
Al Venter, a Washington-based Middle East expert,...
Al Venter, Jane's Intelligence Review
Al Venter, Iran's Nuclear Ambition: Innocuous Illusion or Ominous Truth (International Defense Review, September 1, 1997)--Good Discussion of Research and Development
Al J. Venter is the Africa and Middle East correspondent for Jane's International Defence Review and a special correspondent for Jane's Intelligence Review and Jane's Defence Weekly.
Al Venter -- referenced four times here: Center for Defense Information (www.cdi.org)
(About CDI -- list of staff)
Al Venter, referenced here: Parameters, US Army War College Quarterly, Winter 2000-01
Not for commercial use. Solely to be used for the educational purposes of research and open discussion.
The Middle East
Pg. 18 ; 0305-0734
A BIO-TERRORIST THREAT UNMASKED;
Terrorist activity is completely international, but within the Unites States a fear of rogue Middle Eastern states pervades. Libya, Iran and Iraq are constantly under the microscope in Washington, along with the activities of organisations such as Hizbullah, Hamas as well as operatives aligned to public enemy number one, Osama bin Laden. Recent reports which warn of the potential use of smallpox as a terrorist weapon have started alarm bells ringing. Al Venter reports from the US capital.
During the 1980s, the Soviet army mass-produced the smallpox virus as a biological weapon. Tons of the virus in liquid suspension were stored in refrigerated tanks; in wartime, the agent could have been loaded into aerial bombs and warheads targeted on US and Chinese cities.
| Specialists at a Johns Hopkins University conference on bio-terrorism last year said that much of Dr Alibek's information had been confirmed by other sources.
Dr Kathleen Vogel, a scientist at Cornell University who toured biological warfare facilities in the former Soviet Union, told a recent meeting of the American Association for the Advancement of Science that she suspected secret stocks of smallpox virus were still being held at Russian military microbiology facilities outside the WHO-approved repository in Novosibirsk.
Dr Vogel reported that scientists formerly employed by the Soviet bio-warfare programme had been offered lucrative jobs in countries categorised by the US State Department as supporting international terrorism. She also expressed concern that samples of smallpox virus might have been sold to such rogue states.
Dr Joshua Lederberg, a Nobel laureate in biology who advises Washington on germ warfare, commented: "We have no idea what may have been retained, maliciously or inadvertently, in the laboratories of a hundred countries from the time that smallpox was a common disease." These would be the most likely sources of supply for potential bio-warfare terrorists, he added.
Because of the Soviet betrayal of the smallpox eradication campaign, the potential use of the virus as an agent of bio-warfare or bio-terrorism continues to worry western governments. The possibility that a nation could use smallpox as a terrorist weapon has serious long-term implications for the international community.
Since the smallpox virus no longer exists in nature, the only way terrorists could acquire seed cultures would be on the international black market. For this reason, Dr Tucker believes that smallpox would be an unlikely weapon for ordinary terrorist groups, but it might be obtained by state-sponsored operatives or by wealthy doomsday cults such as Aura Shinrikyo, which released sarin nerve agent on the Tokyo subway in 1995.
Once terrorists managed to acquire and produce the virus in liquid form, it would be a relatively easy matter to disseminate it with a small aerosol device in an enclosed space such as the London underground or the New York City subway.
Two weeks later, the first victims would come down with fever, aches, and other nonspecific symptoms before developing the distinctive pustular rash. By the time the first patients were diagnosed, they would have already infected the next wave of cases.
Professor Vincent Fiscetti, head of the Department of Bacterial Pathogenesis and Immunology at the Rockefeller University, has observed that in a mass-transport environment, there are people from all over the world. "It takes several days for the symptoms to show, by which time they will have carried it back to their own countries," he said.
Professor Fiscetti maintains that an even more effective delivery method would be to use a low-flying aircraft to disperse an aerosol of the virus over an international event like the Olympics, a World Cup football game or even those making the Haj to Mecca. Geographically small countries such as Israel and Jordan would be especially vulnerable.
One of the reasons international terrorists might be tempted to use smallpox as a weapon is that the United States stopped vaccinating its civilian population in 1972 and all other nations followed suit by the early 1980s. Since smallpox vaccination provides full immunity for only about 10 years, nearly the entire US population is now susceptible to infection. At greatest risk would be the 120 million or more Americans -- roughly 45 per cent of the population -- born since routine vaccination ceased.
Given this vulnerability, the CDC has warned that even a limited terrorist release of emergency and -- in the absence of sufficient stocks of the vaccine world-wide -- could potentially result in the return of smallpox as a global health threat.
In 1996, the WHO agreed to destroy all of the stocks of smallpox virus stored in two official repositories, at the CDC in Atlanta and the Vector laboratory near Novosibirsk, Russia.
Because nobody was certain that other countries did not retain undeclared samples of the virus, however, the US persuaded the WHO in 1999 to delay destruction of the official stocks for another three years in order to conduct more research on the virus and to develop anti-smallpox drugs.
Mike Hammer, a spokesman for the US National Security Council, said that because of escalating concern about the threat of bioterrorism with smallpox, Washington didn't want to take any chances.
The most immediate defensive move that western nations could take would be to build up their stocks of smallpox vaccine, which is made from a distinct, relatively harmless virus known as vaccinia. Considering the numbers of people at risk -- the current US population, alone, is roughly 285 million -- producing more vaccine will be a formidable task.
In addition to acquiring 40 million doses, the CDC plans to continually replenish the vaccine stockpile as specific lots expire, resulting in the production of a total of about 168 million doses by the year 2020. The old lots will be retained because the shelf life of the vaccine is almost unlimited when it is stored in sealed vials at sub-zero temperatures.
Because the smallpox vaccination is associated with a significant risk of complications, particularly in people with eczema or a suppressed immune system caused by HIV infection, pregnancy, or cancer chemotherapy, the CDC does not intend to start vaccinating people except in the unlikely event that an actual case of smallpox is confirmed.
Not for commercial use. Solely to be used for the educational purposes of research and open discussion.
Inhalational anthrax: Threat, clinical presentation, and treatment
Journal of the American Academy of Nurse Practitioners
Vol. 13, Issue 4, p. 164
To provide nurse practitioners (NPs) with a basic understanding of clinical presentation, transmission, diagnosis, pharmacological treatment, and post-exposure prophylaxis of inhalational anthrax.
Selected research and clinical articles and government guidelines.
Inhalational anthrax has an incubation period of 1 to 6 days and is very difficult to diagnose early. The chest radiograph consistently reveals a widened mediastinum and pleural effusion without infiltrates. Mortality for inhalational anthrax is high, despite aggressive treatment after onset of symptoms. Delays in diagnosis contribute to the high mortality rate.
IMPLICATIONS FOR PRACTICE
The potential use of aerosolized anthrax as a biological warfare weapon has renewed interest in inhalational anthrax. Primary care providers are cornerstones in the defense against biological weapons because they may be the first to recognize and report suspicious cases.
Anthrax; bacillus anthracis; biological warfare; woolsorter's disease.
SCOPE OF THE PROBLEM
An infectious disease of antiquity, anthrax has caused outbreaks and numerous fatalities in humans and animals as far back as 1500 BC (Cieslak, & Eitzen, 1999; Pile, Malone, Eitzen, & Friedlander, 1998). Anthrax is caused by Bacillus anthracis (B. anthracis), a large gram-positive spore-forming rod. In spore form, B. anthracis can survive for decades in the environment (Cieslak, & Eitzen, 1999; Penn, & Klotz, 1997).
The potential use of aerosolized anthrax as a biological weapon has renewed interest in this infectious disease. Aerosolized anthrax is lethal in an unprotected population and remains stable and virulent during storage, making it a manageable weapon (Zilinskas, 1999). The United States (U. S.) developed anthrax in the 1950s and 1960s as an offensive biological weapon before terminating its program in 1972 (Franz et al, 1997). Iraq admitted to conducting research on anthrax as a biological weapon during the Persian Gulf war (Franz et al., 1997). In response to this threat, U.S. troops have received the anthrax vaccine; however, the military's vaccination program remains controversial due to questions regarding the safety and efficacy of the vaccine (Shafazand, Doyle, Ruoss, Weinacker, & Raffin, 1999).
An epidemic of anthrax in Sverdlovsk, part of the former Soviet Union, occurred in 1979. Autopsies performed on 42 of the 66 patients who died documented inhalational anthrax. The possible source of the exposure was an accidental release of anthrax from a nearby military facility (Ibrahim, Brown, Wright, & Rotschafer, 1999; Pile et al, 1998; Penn, & Klotz, 1997).
Several bioterrorist threats in the U. S. alleging exposure to anthrax occurred in 1998. Decontamination and prophylaxis therapy was initiated until the threats were proven to be hoaxes (Centers for Disease Control and Prevention [CDC], 1999). As a result of these threats, the CDC developed recommendations for post-exposure prophylaxis and biological warfare response guidelines.
It is important for primary care nurse practitioners (NPs) and physicians to become familiar with anthrax ("Reporting of cluster," 2000). Primary care providers are cornerstones in the defense against biological weapons because they may be the first to recognize and report potential cases (Cieslak, & Eitzen, 1999). In the event of a covert or hidden release of anthrax, health care providers will be the front-line responders in the U. S. (Dixon, Meselson, Guillemin, & Hanna, 1999; "Reporting of cluster," 2000).
This article reviews the pathophysiology, clinical presentation, diagnosis, and treatment of inhalation anthrax and discusses vaccination and post-exposure prophylaxis. The purpose is to provide NPs with a basic understanding of inhalational anthrax, the deadliest form of the disease.
Anthrax most commonly occurs in nature in animals such as cattle, goats, and sheep (Pile et al, 1998). Humans become infected after close contact with infected animals or animal products. In humans, an infection with anthrax can take three forms: cutaneous, gastrointestinal, and inhalational.
Cutaneous anthrax is the most frequently occurring form of anthrax in humans, but it is rare in the U. S. A cut or abrasion of the skin is the usual site of entry for anthrax spores. A painless, pruritic papule will appear in 3 to 5 days. Cutaneous anthrax is recognized by the typical black eschar on the affected areas and is easily treated with antibiotics (Cieslak, & Eitzen, 1999; Dixon et al, 1999).
Gastrointestinal anthrax is usually caused by consuming contaminated meat. Although this form has not been reported in the U. S., it can be fatal (Dixon et al, 1999). Death occurs from blood loss, intestinal perforation, and shock.
Inhalational anthrax is also known as woolsorter disease (Pile et al, 1998). Wool handlers inhale the B. anthracis spores during early processing of animal hides and become deathly ill (Franz et al., 1997). Robert Koch discovered anthrax in 1876, demonstrating for the first time the origin of a specific bacterial disease (Pile et al, 1998). John Bell recognized B. anthracis as the cause of woolsorter disease and established disinfection procedures that became the standard for the British woolen industry. In 1880, William Greenfield developed an anthrax immunization for livestock; subsequently, Louis Pasteur developed a live vaccine for anthrax. In 1881, Pasteur tested the heat-cured vaccine on sheep.
As a result of animal immunization, anthrax has been virtually eliminated as an occupational hazard of textile workers and meat packers in the U. S. (Cieslak, & Eitzen, 1999). However, anthrax remains a problem in Asia, Africa, South America, and southern Europe where animal vaccination programs are sporadic (Pile et al, 1998). The last fatal case of inhalational anthrax in the U. S.occurred in 1976 (Penn & Klotz, 1997).
Inhalational anthrax begins after spores, less than 5 microns in size, enter the body and reach the alveolar spaces (Dixon et al, 1999). The spores are transported by pulmonary macrophages, an antiphagocytic capsule is produced, and germination occurs within the macrophage (Cieslak, & Eitzen, 1999; Dixon et al, 1999; Friedlander, 1999). Macrophages transport the spores to the mediastinal and tracheobronchial lymph nodes where the bacilli cause a hemorrhagic lymphadenitis by growing in regional lymph nodes.
The bacillus produces at least three proteins, known as edema factors (EF), lethal factor (LF), and protective antigen (PA), that interfere with host defenses (Cieslak, & Eitzen, 1999; Friedlander, 1999; Ibrahim et al, 1999). The proteins form toxins called edema toxin and lethal toxin. Edema toxin is formed from EF and PA and produces excessive fluid accumulation. Lethal toxin is formed from a combination of LF and PA and releases cytokines such as interleukin -1 and tumor necrosis factor (Cieslak, & Eitzen, 1999; Dixon et al, 1999; Ibrahim, et al, 1999; Shafazand et al, 1999).
Edema toxin and lethal toxin interfere with host defenses, causing necrosis of lymphatic tissue and the release of high numbers of bacilli into the blood and lymph, which in turn leads to toxemia, septicemia, and in some cases meningitis (Cieslak, & Eitzen, 1999; Dixon et al, 1999). The hemorrhagic lymphadenitis of the mediastinal and tracheobronchial lymph nodes causes a hemorrhagic mediastinitis, which is pathognomonic for inhalational anthrax (Shafazand et al, 1999). Hemorrhagic mediastinitis results in pulmonary lymphatic blockage and pulmonary edema (Dixon et al, 1999). The overwhelming pulmonary edema and septicemia cause death in approximately 1 to 7 days after exposure.
Inhalational anthrax has a reported incubation period of one to six days and is very difficult to diagnose early (Cieslak, & Eitzen, 1999). After incubation, inhalational anthrax is biphasic in nature (Shafazand et al, 1999). The first phase, lasting an average of four days, is a non-- specific flu-like syndrome presenting with low-grade fever, non-- productive cough, myalgia, headache, malaise, and possibly mild chest pain (Cieslak, & Eitzen, 1999; Dixon et al, 1999; Franz et al., 1997; Shafazand et al, 1999). This initial phase, or prodrome, may be followed by a period of one to three days of symptomatic improvement.
The second phase presents with an abrupt onset of acute respiratory distress. Fever, severe dyspnea, cyanosis, and shock mark the rapid deterioration (Cieslak, & Eitzen, 1999; Penn & Klotz, 1997). The enlarged mediastinal lymph nodes may partially compress the trachea and cause stridor (Shafazand et al, 1999). Auscultation of lung sounds may be remarkable for crackles and signs of pleural effusion. Diaphoresis is often present, resulting in hypotension and chills ("U.S.Army," 1996). A decreased level of consciousness and possible coma may be symptoms of meningitis, which occurs when an overwhelming bacterial load is present (Shafazand et al, 1999; Penn & Klotz, 1997; "U.S.Army," 1996). After onset of respiratory distress, shock followed by death occurs within 24 to 36 hours (Franz et al., 1997; "U.S.Army," 1996).
The chest radiograph consistently reveals a widened mediastinum and pleural effusion without infiltrates, which is a hallmark of inhalational anthrax (a typical chest radiograph can be viewed on-line at http://phil.cdc.gov/public/1118.htm). This widened mediastinum is a result of mediastinitis and pleural effusion and may be present as early as the second day following exposure (Dixon, et al, 1999; Cieslak, & Eitzen, 1999; Franz et al., 1997; Ibrahim, et al, 1999; Penn & Klotz, 1997; Pile et al, 1998; Shafazand et al, 1999; "U.S.Army", 1996).
Blood cultures and a Gram stain should be obtained. Grampositive bacilli can be detected during the illness in blood smears; spores are not found in blood samples. Bacillus anthracis cultured from blood confirms the diagnosis (Cieslak, & Eitzen, 1999; "U.S.Army", 1996). A nasal swab, or environmental sample, containing gram-positive B. anthracis supports a diagnosis of anthrax due to intentional release as in war or terrorist activity (Cieslak, & Eitzen, 1999). Detecting circulating antibodies against the toxins with the enzyme-linked immunosorbent assay (ELISA) can help to confirm the diagnosis (Franz et al., 1997; Ibrahim, et al, 1999).
A confirmed or suspected case of anthrax must be reported to the CDC and local health and law enforcement authorities immediately (CDC, 1999). "Although inhalation anthrax in man is usually fatal, prompt recognition of disease may improve outcome and allow for immunization/prophylaxis for other individuals who may have been exposed" (Penn, & Klotz, 1997, p. 29). Immediate reporting may also deter further terrorist activity.
Management Mortality for inhalational anthrax is high, despite aggressive treatment after onset of symptoms. Delays in diagnosis contribute to the high mortality rate. The Sverdlovsk outbreak reported 11 survivors of inhalation anthrax, suggesting that aggressive management and early diagnosis may optimize survival (Shafazand et al, 1999). Support in an intensive care unit is necessary due to severe respiratory distress in the second phase. Standard universal precautions are adequate since human-to-human transmission of anthrax has not been reported (Cieslak, & Eitzen, 1999; CDC, 2000).
Pharmacological therapy. Penicillin G has historically been the drug of choice for treating inhalational anthrax (Cieslak, & Eitzen, 1999; Franz et al., 1997; "U.S. Army", 1996). The recommended dose is 2 million units of penicillin G intravenously (IV) every 2 hours. Penicillin is still recommended in cases where the susceptibility of the organism is known. Adding streptomycin 30 mg/kg intramuscularly (IM) every day has demonstrated a synergistic effect in animal studies (Franz et al., 1997; Ibrahim, et al, 1999).
The possibility of an antibiotic-resistant strain of B.anthracis has prompted experts to recommend ciprofloxacin as the drug of choice until drug sensitivity reports confirm the sensitivity of the organism to penicillin (Cieslak, & Eitzen, 1999; Ibrahim, et al, 1999). Ciprofloxacin was recently approved to reduce the incidence and progression of inhalational anthrax following exposure to aerosolized B.anthracis (Food and Drug Administration [FDA], 2000). Ciprofloxacin also provides the convenience of twice-daily dosing. It is recommended to initiate treatment at the earliest signs of disease with ciprofloxacin 400 mg, IV every 12 hours (Cieslak, & Eitzen, 1999; Franz et al., 1997). An alternative regimen starts with a 200mg dose of doxycycline IV, followed by 100 mg IV every 12 hours (Franz, et al., 1997; Dixon et al, 1999; "U.S.Army", 1996). A 30-day or longer course of antibiotics may help to maintain long-term protection (Ibrahim, et al, 1999). The FDA (2000) recommends ciprofloxacin be administered for a total of 60 days. Cieslak and Eitzen note that these recommendations are based on animal studies and in vitro data: "...no human clinical experience with these regimens exists" (p. 4, 1999).
In children, penicillin G 100,000-150,000 U/kg/day in divided doses every 4-6 hours is preferred (Dixon et al, 1999). The FDA has approved the use of ciprofloxacin in pediatric patients for inhalational anthrax. The recommended pediatric dose of ciprofloxacin for post-exposure inhalational anthrax is 15mg/kg orally twice a day or 10mg/kg IV twice a day (FDA, 2000). Penicillin may also be the drug of choice during pregnancy, although the life-threatening nature of a biologically altered strain of B. anthracis may warrant the use of ciprofloxacin, despite adverse indication, until drug sensitivity is confirmed (Shafazand et al, 1999; "U.S. Army," 1996).
Corticosteroid therapy should be started in cases of meningitis, massive edema, and toxemia. Possible choices include dexamethasone, prednisone, and hydrocortisone (Dixon et al, 1999; Ibrahim, et al, 1999).
Post-exposure prophylaxis. Individuals exposed to anthrax who do not display symptoms will not require support with intensive care or IV antibiotic regimens (Ibrahim, et al, 1999). Post-exposure prophylaxis should be started at the earliest opportunity with ciprofloxacin 500 mg orally every 12 hours or doxycycline 100 mg orally every 12 hours (Cieslak, & Eitzen, 1999; Ibrahim, et al, 1999; FDA, 2000). In the event of an anthrax threat, drug therapy can be delayed 24-48 hours until evidence of release is verified (Cieslak, & Eitzen, 1999). Post-exposure chemoprophylaxis should continue for 4 to 6 weeks until anthrax vaccination provides antibodies or exposure can be excluded (Dixon et al, 1999; CDC, 1999). According to recent recommendations (FDA, 2000), ciprofloxacin prophylaxis should be administered for a total of 60 days.
Fluoroquinolones are not usually recommended for children or during pregnancy due to the risk of arthropathy (Shafazand et al, 1999). However, the CDC (1999) recommends weighing the adverse effects of ciprofloxacin against the potential life-threatening effects of inhalational anthrax. The FDA (2000) has approved the use of ciprofloxacin for prophylaxis in children who have been exposed as a result of an intentional release of inhalational anthrax. The prophylactic pediatric dose of ciprofloxacin is 15 mg/kg orally twice a day or 10 mg/kg twice a day IV (FDA, 2000). The CDC recommends ciprofloxacin in children and pregnant women until sensitivity to penicillin is known. Amoxicillin 40 mg/kg/day orally in divided doses every 8 hours is the recommended prophylactic dose in children once susceptibily to penicillin is determined (CDC, 1999).
Vaccination. Vaccination after a biological incident is recommended, in conjunction with post-exposure chemoprophylaxis (CDC, 1999). The anthrax vaccine can be obtained from the CDC and should be administered in a series of three doses. The first 0.5ml subcutaneous injection should be given as soon as possible after confirmed exposure and repeated at 2 weeks and 4 weeks (CDC, 1999; Ibrahim, et al, 1999). This vaccine has not been evaluated for efficacy and safety in the elderly or children. The anthrax vaccines developed for animals should not be administered to humans (CDC, 2000). Patients should be closely monitored for early symptoms of anthrax during prophylaxis and after antibiotic therapy is discontinued. In animal studies, relapse after antibiotics are discontinued occurred in unvaccinated subjects (Penn, & Klotz, 1997).
Decontamination. Decontamination of people potentially exposed to a biological release of anthrax may be appropriate (CDC, 1999; Cieslak, & Eitzen, 1999). Clothing and personal effects should be removed and sealed in plastic bags; a shower with soap and water is necessary to complete decontamination procedures (CDC, 1999; Cieslak, & Eitzen, 1999). Environmental surfaces can be cleaned with a hypochlorite solution of one part bleach to 10 parts water after an investigation of the release has been completed.
Active immunization by vaccination is the key to prevention of inhalational anthrax in high-risk populations (Friedlander, 1997; Ibrahim, et al, 1999). The FDA approved an anthrax vaccine in 1970 for human use in the U. S. The vaccine has been referred to as MDPH-PA or Michigan Department of Public Health Protective Antigen (Pile et al, 1998; Ibrahim, et al, 1999).
The vaccine should be stored at 2 to 8 degrees Celsius. The schedule for vaccination is 0.5 ml subcutaneously at 0, 2, and 4 weeks, followed by boosters of the same dose given at 6, 12 and 18 months. An annual booster is recommended in the event of continued exposure (Friedlander, 1997). High-risk populations, such as workers who could be exposed to animal products from countries that lack adequate anthrax control or individuals working with anthrax in a laboratory setting, should be vaccinated. United States military at risk for exposure to biological weapons in the Persian Gulf region received the vaccine (Friedlander, 1997).
Reported side effects of the vaccine are local reactions and rare systemic reactions. Local reactions occur in about 30% of vaccine recipients and include edema, warmth, erythema, pruritis, and tenderness with a small painless nodule at the injection site (Ibrahim, et al, 1999; Pile et al, 1998). The most severe local reaction noted is edema from the injection site to the elbow or forearm (Friedlander, 1997). Local reactions have been noted after the first injection which increase with subsequent injections and subside by the 6th and 7th injections, suggesting an allergic reaction (Ibrahim, et al, 1999). Systemic reactions are reported in less than 0.2% of vaccine recipients. Symptoms include mild myalgia, malaise, and headache, which may last from 1 to 2 days (Friedlander, 1997).
New vaccines are being researched and developed that would provide a less frequent dosing schedule. A cost-effective vaccine available for public protection may be developed in the near future (Ibrahim, et al, 1999).
The potential use of anthrax as a biological weapon has renewed interest in the clinical presentation and treatment of this infectious disease. Recognizing the clinical presentation, diagnosing, reporting, and treating casualties of biological warfare are developing responsibilities for the NP It is important for NPs to stay informed of developing technology aimed at prevention and protection against anthrax, and the potential of terrorist activity in metropolitan areas, port cities, military installations, and rural communities. Knowledge of local emergency and disaster plans is important for prompt and efficient response to an intentional or unintentional release of B. anthracis. Methods for procurement of antibiotics and vaccines in case of mass casualties must be part of the disaster plan. Disease reporting protocols for suspected and diagnosed infectious disease should be readily available. Despite the best efforts of NPs and other health care providers, the consequences of an intentional release of anthrax could result in a public health disaster. The knowledgeable and immediate response of NPs in the event of an intentional release of aerosolized anthrax will control public panic and minimize morbidity and mortality.
Centers for Disease Control and Prevention (CDC). (1999). Bioterrorism alleging use of anthrax and interim guidelines for management-United States, 1998. MMWR Morbidity and Mortality Weekly Report, 48(4), 69-74.
Centers for Disease Control and Prevention. (2000). Anthrax - General informaton. Division of Bacterial and Mycotic Diseases, April 5. Retrieved October 10, 2000 from World Wide Web: http://www.cdc.gov/incidod/dbmd/diseaseinfo/anthrax-g.htm
Cieslak, T. J., & Eitzen, E. M. (1999). Clinical and epidemiologic principles of anthrax. Emerging Infectious Diseases, 5(4). Retrieved March 24, 2000 from World Wide Web: http://www.cdc.gov/ncidod/EID/vol5no4/cieslak.htm
Dixon, T. C., Meselson, M., Guillemin, J., & Hanna, R C. (1999). Anthrax. The New England Journal of Medicine, 341(11), 815-826.
Food and Drug Administration (2000, August 31). Approval of Cipro for use after exposure to inhalational anthrax. FDA Talk Paper. Rockville, MD: Author. Retrieved September 5, 2000 from the World Wide Web: http://www.fda.gov/bbs/topics/ANSWERS/ANS01030.html
Franz, D. R., Jahrling, R B., Friedlander, A. M., McClain D. J., Hoover, D. L., Bryne, W. R., Pavin, J. A., Christopher, G. W., & Eitzen, E. M. (1997). Clinical recognition and management of patients exposed to biological warfare agents. Journal of the American Medical Association, 278(5), 399-411.
Friedlander, A. M. (1997). Anthrax. In F. R. Sidell, E. T. Takafuji & D. R. Franz (Eds.), Medical aspect of chemical and biological warfare (467-478). Washington, DC; TMM publications. Retrieved May 7, 2000 from the World Wide Web: http://www.nbc-med.org
Friedlander, A. M. (1999). Clinical aspects, diagnosis and treatment of anthrax. Journal of Applied Microbiology, 87, 303.
Ibrahim, K. H., Brown, G., Wright, D. H., & Rotschafer, J. C. (1999). Bacillus anthracis: Medical issues of biologic warfare. Pharmacotherapy, 19(6), 690-701.
Penn, C. C., & Klotz, S. A. (1997). Anthrax pneumonia. Seminars in Respiratory Infections, 12(1), 28-30.
Pile, J. C., Malone, J. D., Eitzen, E. M., & Friedlander, A. M. (1998). Anthrax as a potential biological warfare agent. Archives of Internal Medicine, 158, 429434.
Reporting of cluster of cases with possible public health significance including those that suggest a possible chemical bioterrorist incident (2000). Maine Epi-Gram, March 2000, 2-3.
Shafazand, S., Doyle, R., Ruoss, S., Weinacker, A., & Raffin, T. A. (1999). Inhalational anthrax: Epidemiology, diagnosis and management. Chest, 116 (5), 1369-1376.
U. S. Army Medical Research Institute of Infectious Diseases. (1996). Medical management of biological casualties handbook, August 1996 (Second edition). Frederick, MD: Author. Retrieved April 27, 1998 from the World Wide Web: http://www.nbc-med.org/FMs/medman/index.htm
Zilinskas, R. A. (1999). Iraq's biological warfare program: The past as future? In J. Lederberg (Ed.), Biological weapons (137-158). Cambridge, MA: MIT.
I'd still stay away from any night games for a while. Especially cool windless ones.
Maybe we should start an on going symptom thread for early detection...(kidding-sort of)
Has anyone ever heard of it?
Unless it was a rerun, an hour ago CNN said that the FBI (FAA?) is prohibiting cropdusters from flying again tomorrow. The newsperson said at least two times it was an "update," so I'm assuming that wasn't old news. They said that so far it's only for tomorrow. What kind of sense is that? Either there's a problem or there's not!
This next one is probably the best article so far. The target audience is emergency room physicians and it was published in a peer-reviewed journal in Feb, 2000. The author, G. Moran, has appeared before Congress, if I'm remembering correctly. (I'll double-check and come back to correct that if I'm wrong.)
It's a done deal that the crop dusters were grounded because of football.
To be honest I think the threat may start to diminish but I'll be on the lookout. I'm downwind from Ft. Dietrick.
If they are going to do a laydown it will probably be chemical (high probability/low risk) and it will need to be a wide spread (non-communicable) and it will need to be airborn.
I think we're over the hump. But I could be wrong.
You can go to www.agaviation.org. Sorry I don't know how to link. Latest is until 12:05 Monday. Go there and click on message.
When I see replies like yours, my first inclination is to stop posting this kind of information and let everyone "fend for themselves," so to speak. After all, as nunya bidness states, the relative chances of a bioterrorist attack happening to any one given person is remote. Even if the terrorists succeeded in committing such an atrocious act, the chances it would "happen to me" are probably low, especially if I don't live in New York or DC. My intent is not to scare anyone or cause anyone to lose even one minute of sleep over this and it bothers me if someone does.
The reason I posted the articles is because of my philosophy about this kind of stuff: Knowledge is a good thing and allows one to have at least a small measure of control over his fate (although God has the ultimate control). This "sense of control" over your environment can go a long way in relieving the anxiety that comes from watching FoxNews & MSNBC all weekend tell us about new arrests, cropdusting manuals and hidden boxcutter knives.
Basic knowledge allows one to make basic preparations, and basic preparations in turn tend to put one more at ease. Somehow, the idea of a respiratory biological agent turned loose on the public is not quite so frightening if you know you can reach in your closet for your gas mask. The Israelis have lived this way for years. I think we'd better start getting used to the changes brought about by the collapse of the WTC towers and start making some small adjustments to our lives to adapt to these changes.
It stands to reason that once someone acquires knowledge about bioterrorism, he has the option of taking positive, proactive steps to prepare for contingencies. And that's the tricky part: If he doesn't, he may experience even more anxiety. And of course, the part that's out of my control here is what the reader does once he's read the information and acquired the knowledge. ;-)
Many people (perhaps most) would rather not even know about these types of things because it just causes too much anxiety. I can respect that approach to life and don't want to intrude on anyone's method of coping. But what these people don't realize is that this allows the terrorists to "win" without even doing anything. With something as serious as bioterrorism, the words "out of sight" are probably not equivalent to "out of mind." The suppressed anxiety is still there, it just manifests itself in some other way!
With all that in mind, I've decided to post some information so people won't be so anxious about this...
Maybe this will help: For gas masks (don't forget replacement filters)
cheaperthandirt.com 1-800-421-8047 (they're sold out, but this is the only company I can vouch for. Call for update.)
More here: http://www.google.com/search?hl=en&q=%22gas+mask%22+order++&btnG=Google+Search
For antibiotics, you can:
-Get them from an aware, friendly doctor (highly recommended but sometimes hard to find unless you know one who trusts you. They can't just go around dispensing antibiotics to everyone because there's the potential for abuse.)
-Order them online from an overseas pharmacy (you may get ripped off unless you ask around for references first. I don't have any.)
-Take a trip across the border to Mexico (no prescription required; they're cheap & made by the same US manufacturers)
-Go to your local pet supply shop and get the fish antibiotics (I'm not recommending this--proceed with extreme caution!)
Remember, the odds are that you won't even need any of this stuff. ;-)
So true...I just loaned my friend my copy of Nuclear War Survival Skills yesterday as he was interested in building a shelter for his family. I printed out the book for Y2K and three-ring bound it with dividers. Lots of good info there.
I remember wondering at the time if it was some sort of abortive bioterror attack. Now I'm really wondering.
I am not an epidemiologist by any means, but it seems rather a strange disease to suddenly appear on the East Coast- several times, IIRC. Is there any repository online of weird disease outbreak data nationwide over say, the last 10 years that we might have a gander at?
I would have thought you would know that.
This type of warfare is so easy and inexpensive to do. Even a regular vehicle can easily be converted into a chemical/biological generator, but I won't give specifics.
About the gas mask issue. For OUR family that's pretty hopeless. EVEN cheaper than dirt makes it financially impossible with 9 in the family. I'm SURE there are others in the same boat. Maybe this is wrong thinking, but shouldn't the govt be doing something along those lines of protecting us little people?
I believe there is two strains of another deadly biological that needs to be included on the list.....HRC2004 and HRC2008
It's "for your information."
But what is IIRC?
IIRC = "if I recall correctly"
They are flying again... Unless of course, someone changes there mind tomorrow :) You can go to the FOX site to read the whole thing, if you'd like.
VIA FOX NEWS CHANNEL 12:05 a.m. local time. 9/25/01
Shortly after midnight Monday, the duty officer at the FAA in Washington confirmed the ban was being lifted, first with the Eastern Time Zone.
"At five minutes after, the ban is being lifted in each time zone," said the officer, who did not give his name.
Will hotlink to this muy doomer thread.
Too bad this unimaginable nightmare has become a reality watch :_(