The document discusses bioterrorism and several biological agents that could potentially be used as weapons, including anthrax, tularemia, plague, smallpox, botulism, and viral hemorrhagic fevers. It provides details on the history, epidemiology, clinical manifestations, treatment, and documented outbreaks of each agent. The document emphasizes that public health and medical professionals must be prepared to recognize and respond to biological attacks. High-risk targets are also identified, and external links are provided for additional information.

1. Bioterrorism
Written by:
Diane King, RN, BSN, PHN, CEN
San Jose State University
School of Nursing
NURS 214

2. Bioterrorism
 The awareness of the use of biological and
chemical weapons have created concern on the
national and international level.
 “Military and civilian medical and public health
professionals must become proficient in
recognizing that a biological attack has
occurred, activating the appropriate agencies
and personnel to investigate the event, treating
casualties, and preventing spread of
disease.”(http://www.usamriid.army.mil/education/index.htm).

3. Bioterrorism
What is Bioterrorism?
The intentional release of a
toxin, virus, bacteria or germ
(agent) to cause a serious illness
or death
Can be immediate or long term
(may take days or weeks to
observe symptoms)

4. Bioterrorism
 “High-risk targets for acts of terrorism include
military and civilian government facilities,
international airports, large cities, and high-
profile landmarks.
 Terrorists might also target large public
gatherings, water and food supplies, utilities,
and corporate centers.
 Further, terrorists are capable of spreading fear
by sending explosives or chemical and biological
agents through the mail”
(http://www.fema.gov/areyouready/terrorism_general_info.shtm)

5. Bioterrorism Agents
 “Category A diseases as described by the
Center for Disease Control and Prevention
(CDC)are:
 Anthrax
 Tularemia
 Plague
 Smallpox
 Botulism
 Viral hemorrhagic fever”
(http://www.nih.gov/news/pr/mar2002/niaid-14.htm

6. Anthrax
History
 ”A disease caused by a bacterium, Bacillus
anthracis, it has existed for hundreds of years
and still occurs naturally in both animals and
humans in many parts of the world, including
Asia, southern Europe, sub-Sahelian Africa and
parts of Australia.
 There are three forms of anthrax in humans:
cutaneous, ingestion and inhalational.”
(http://www.who.int/csr/delibepidemics/disease/en)

7. Anthrax
Epidemiology
 8,000-50,000 spores (aerosol), transmitted
by inhalation, Ingestion, or inoculation

8. Anthrax
Patient Isolation
 Standard barrier isolation precautions.
Patients do not require isolation rooms.
 Not transmissible person to person
 Incubation 1-6 days
 Duration 3-5 days (usually fatal if
untreated)

9. Anthrax
Clinical manifestations
 Fever
 Malaise
 Cough
 Respiratory distress

10. Anthrax
Treatment
 Ciprofloxin
 Doxycycline
 If vaccine available, 3 doses of anthrax vaccine
 ”The recent reports of anthrax exposure have
spawned numerous websites and emails selling
Ciprofloxacin (Cipro) and other antibiotics for
treatment. The Federal Trade Commission
(FTC) warns that fraudsters often follow the
headlines, tailoring their offers to prey on
consumers' fears and vulnerabilities ”
(http://www.ftc.gov/bcp/edu/pubs/consumer/alerts/alt104.shtm)

11. Anthrax
Use as a biological weapon
 Spores remain viable in soil for many
years

12. Anthrax
Documented Outbreaks
“The worst documented outbreak of
inhalation anthrax in humans occurred in
Russia in 1979, when anthrax spores were
accidentally released from a military
biological weapons facility near the town of
Sverdlovsk, killing at least 66 people.

13. Anthrax
Most people weren't aware of this
weapon until the fall of 2001, when letters
containing anthrax spores sent via the
U.S. Postal Service resulted in 22 cases
of anthrax infection. Eleven people were
infected with cutaneous anthrax. Eleven
others were infected with inhalation
anthrax, resulting in five deaths. “
(http://www.ncbi.nlm.nih.gov/pubmed)

14. Anthrax
Source:http://www.bt.cdc.gov/agent/anthrax/anthrax-images/cutaneous.asp

15. Anthrax
Source:http://www.bt.cdc.gov/agent/anthrax/anthrax-images/cutaneous.asp
ource:http

16. Anthrax
Source:http://www.bt.cdc.gov/agent/anthrax/anthrax-images/cutaneous.asp

17. Tularemia
History
 F. tularensis was discovered in 1911 during an
outburst of rabbit fever, when the disease killed
a large number of ground squirrels in the area of
Tulare Lake in California.
 There are two predominant subspecies: F.
tularensis tularensis (type A), which is found in
North America, is more virulent than F. tularensis
palaearctica (type B), which occurs in Asia,
Europe, and North America.

18. Tularemia
Epidemiology
 10-50 organisms (aerosol)

19. Tularemia
Patient Isolation
 Standard precautions. Respiratory
isolation is not required.
 Not transmissible person to person
 Incubation 3-6 days
 Duration is 2 weeks

20. Tularemia
 Clinical manifestations depend on the route of
entry and the virulence of the agent.
 Typically includes: fever, headache, malaise,
weight loss, non-productive cough.
 There are six forms of tularaemia in humans:
ulceroglandular, glandular, oropharyngeal,
oculoglandular, respiratory and typhoidal.”
(http://www.who.int/csr/delibepidemics/disease/en)

21. Tularemia
Treatment
 Streptomycin
 Gentamycin
 Antibiotic prophylaxis is most effective if
begun within 24 hours

22. Tularemia
Documented Outbreaks
 “In summer 2000, an outbreak of tularemia
in Martha's Vineyard resulted in one
fatality.
 An outbreak of tularemia occurred in
Kosovo in 1999-2000.”
(http://www.ncbi.nlm.nih.gov/pubmed)

23. Tularemia
Documented Outbreaks
 “In 2004, three researchers at Boston University Medical
Center were accidentally infected with F. tularensis, after
apparently failing to follow safety procedures
 In 2005, small amounts of F. tularensis were detected in
the Mall area of Washington, DC the morning after an
anti-war demonstration on September 24, 2005
 In July 2007, an outbreak was reported in the Spanish
autonomous region of Castile and Leonand traced to the
plague of voles infesting the region .”
(http://www.ncbi.nlm.nih.gov/pubmed)

24. Tularemia
Use as a biological weapon
 10-50 organisms (aerosol)

25. Plague
History
 ”An infectious disease of animals and humans
caused by a bacterium, Yersinia pestis, which is
transmitted between rodents by rodent fleas or
to people through infected rodent flea bites.
 It can also be transmitted to humans through
direct contact with infected animal tissue.
 There are three main forms of plague in
humans: bubonic, septicemic and pneumonic.”
(http://www.who.int/csr/delibepidemics/disease/en)

26. Plague
Epidemiology
 <100 organisms (aerosol)

27. Plague
Patient Isolation
 Strict respiratory isolation with droplet
precautions (gown, gloves, and eye
protection) until patient has received at
least 48 hours of antibiotic therapy and
shows clinical improvement.
 Highly transmissible person to person

28. Plague
 Patient Isolation
 Incubation period 2-3 days
 Duration of illness 1-6 days (usually fatal)

29. Plague
Clinical manifestations
 High fever
 Chills
 Headache
 Productive cough-watery then bloody

30. Plague
Treatment
 Streptomycin
 Gentamycin
 Chloramphenicol
 Antibiotic prophylaxis is recommended for
all persons exposed to the aerosol or
persons in close physical contact with a
confirmed case

31. Plague
Use as a biological weapon
 <100 organisms (aerosol)

32. Plague
Documented Outbreaks
 “From 165-1950 (Biblical times)
 The Third Pandemic, originated in China
(1855–1950s).” (http://www.ncbi.nlm.nih.gov/pubmed)

33. Smallpox
Epidemiology
 Highly infectious after aerosolization
 Person-to-person transmission can occur
via droplet nuclei or aerosols expelled
from the oropharnx and by direct contact
 Contaminated clothing or bed linens can
also spread the virus.

34. Smallpox
History
 “An acute contagious disease caused by Variola
virus, a member of the orthopoxvirus family.”
(http://www.who.int/csr/delibepidemics/disease/en

35. Smallpox
Patient Isolation
 Strict isolation in negative pressure room
from onset of rash until scabs separate
 Laundry and waste should be autoclaved
before being laundered or incinerated
 Incubation 12-14 days
 Duration is 4 weeks

36. Smallpox
Clinical manifestations
 Non-specific flu-like prodrome (malaise,
fever, headache), 2-3 days later is rash
 Then synchronously evolving
maculopapular rash progressing to
vesicles then pustules
 Lesions more predominant on the face
and extremities than on the trunk

37. Smallpox
Treatment
 Cidofovir
 Vaccine available & most effective if given
within 3 days of exposure

38. Smallpox
Use as a biological weapon
 Assumed low (10-100 organisms aerosol)

39. Smallpox
Documented Outbreaks
 “The global eradication of smallpox was
certified in 1979, based on intense
verification activities in countries.”
(http://www.who.int/csr/delibepidemics/disease/en

40. Smallpox

41. Smallpox

42. Smallpox
Public Health Images Library (PHIL) id# 131. Source: CDC/Barbra Rice

43. Botulism (food sources)
History
 ”A rare but serious paralytic illness caused by a nerve
toxin that is produced by the bacterium Clostridium
botulinum. Botulism toxin can be inhaled or ingested via
contaminated food or water. There are five clinical
categories:
 foodborne botulism
 wound botulism
 infant botulism
 adult infectious botulism
 inadvertent, following botulinum toxin injection.”
(http://www.who.int/csr/delibepidemics/disease/en)

44. Botulism
Epidemiology
 Botulism neurotoxins (A-F) could be
transmitted by aerosol or contamination of
food and water supplies

45. Botulism
Patient Isolation
 Non transmissible from person to person
 Incubation is 12-36 hours
 Death in 24-72 hours
 Lasts months if not lethal

46. Botulism
Clinical manifestations
 Dry throat
 Blurred vision
 Slurred speech
 Difficulty swallowing
 Progressive descending symmetrical
paralysis

47. Botulism
Treatment
 Antitoxin (limited supply & only available
from the Division of Communicable
Disease Control, California Department of
Health Services)
 Supportive care

48. Botulism
Use as a biological weapon
 Could be released as an aerosol or used
to contaminate water or food supplies
 “Iraq deployed 12,000 liters of botulinum
toxin in over 100 munitions during the Gulf
War in 1991” (Recognizing Bioterrorism
Agents, 2000. Santa Clara County Health
Department Zebra Information Binder)

49. Botulism
Documented Outbreaks
 “In April 1991, 91 hospitalized patients in Cairo
were reported to the Egyptian Ministry of Health
with botulism intoxication.
 Cases of botulism in the northern province of
Iran were studied in March and April 1997.
 In the late 1996, an outbreak of botulism
affected eight young people in Italy.”
(http://www.ncbi.nlm.nih.gov/pubmed)

50. Prevention
“Local drinking water and waste water
systems could be potential targets for
terrorist or other criminal acts. “
(http://cfpub.epa.gov/safewater/watersecurity/publicInvolve.cfm)

51. External Links
 “Raw, unedited footage of terrorism events and
people's reaction to those events can be very
upsetting, especially to children.
 We do not recommend that children watch
television news reports about such events,
especially if the news reports show images over
and over again about the same incident.
 Young children do not realize that it is repeated
video footage, and think the event is happening
again and again.”
(http://www.redcross.org/services/disaster/0,1082,0_589_,00.html)

52. References
American Red Cross
http://www.redcross.org/services/disaster/0,1082,0_589_,00.html
Center for Disease Control
http://www.bt.cdc.gov/agent/anthrax/anthrax-images/cutaneous.asp
http://www.bt.cdc.gov/agent/smallpox/smallpox-images/smallpox3.htm
Source:CDC/Cheryl Tyron. Public Health Images Library (PHIL) ID # 3.
http://www.bt.cdc.gov/agent/smallpox/smallpox-images/smallpox3.htm
Source: CDC/James Hicks. Public Health Images Library (PHIL) id# 284.
http://www.bt.cdc.gov/agent/smallpox/smallpox-images/smallpox3.htm
Source: CDC/Barbra Rice. Public Health Images Library (PHIL) id# 131.
http://phil.cdc.gov/Phil/details.asp
•Environmental Protection Agency
http://cfpub.epa.gov/safewater/watersecurity/publicInvolve.cfm
•Federal Trade Commission
http://www.ftc.gov/bcp/edu/pubs/consumer/alerts/alt104.shtm

53. References
 National Institiute of Health
http://www.nih.gov/news/pr/mar2002/niaid-14.htm
http://www.ncbi.nlm.nih.gov/pubmed
 Santa Clara County Health Department:
Bioterrorism information for clinicians zebra packet.
November 4, 2000.
 U.S. Army and Medical Research Institute of
Infectious Disease
http://www.usamriid.army.mil/education/index.htm
 World Health Organization
http://www.who.int/csr/delibepidemics/disease