Bioterrorism (2)

BIOTERRORISM
DR APARNA RAMACHANDRAN
2ND MDS
DEPT OF PUBLIC HEALTH DENTISTRY

CONTENTS
▪ Introduction
▪ History
▪ Definitions
▪ Agents of Bioterrorism
▪ Classification of bioterrorist agent
▪ Public health emergency preparedness and response 2

CONTENTS
▪ India’s Preparedness against Bioterrorism: Existing
Measures
▪ Role of dentists in a bioterrorist attack
▪ Prevention
▪ Conclusion
▪ References
3

INTRODUCTION
▪ Globally over the years the weapons used have shifted from swords to bullets
and bombs and are now heading towards biological weapons.
▪ The considerable ease of production along with the immense capacity to create
panic has attracted the so called terrorists towards the use of biological agents
as future weapons.
▪ A Bioterrorism attack is the deliberate release of viruses, bacteria, toxins and
other harmful agents used to cause illness or death in people, animals or plants.
4

INTRODUCTION
▪ These agents are typically found in nature but it is possible that they could be
mutated or altered to increase their ability to cause disease, make them
resistant to current medicines or to increase their ability to spread into the
environment.
▪ Biological agents can be spread through the air, water or in food.
▪ Terrorists tend to use biological agents because they are extremely difficult to
detect and do not cause illness for several hours to several days. 5

DEFINITIONS
▪ Bioterrorism is the intentional release or threat of release of biologic agent
(i.e. virus, bacteria, fungi or their toxins in order to cause disease or death
among human population or food crops and livestock to terrorize a civilian
population or manipulate the government.
▪ (Centre for disease control and Prevention 2001)
6

DEFINITIONS
▪ The unlawful use, or threatened use, of micro-organisms or toxins derive
from living organisms to produce death or disease in humans, animals, or
plants. The act is intended to create fear and/or intimidate government or
societies in pursuit of political, religious, or ideological goals.
▪ (Federation bureau of investigation 2005)
7

HISTORY
▪ 14 century medieval siege of Kaffa, Feodosiya,[Ukraine] In this incident, the
Tartars (Mongols) who attacked Kaffa, tossed dead and dying plague victims
into the city in an attempt to spread the disease.
▪ In another well-documented incident at Fort Pitt, Ohio River Valley, the
British troops deliberately spread smallpox among native Indian population by
presenting them with blankets and linens used by smallpox victims.(1700s)
8

HISTORY
▪ During World War I,( 1914-1918)Germany used biological warfare (BW) agents for
sabotage. Horses being shipped to the Allies were infected with anthrax or glanders.
▪ In 1925 Geneva convention banned the use of biological warfare.
▪ Unit731 also referred to as Detachment 731, or the Ishii Company, was a covert
biological and chemical warfare research and development unit of the Imperial
Japanese Army that undertook lethal human experimentation during the Second
Sino-Japanese War (1937–1945) of World War II.
9

HISTORY
▪ The development in this field grew tremendously until the Biological Weapons
Convention.
▪ The biological weapons convention was eventually agreed on in 1972 and
went into effect 1973.
▪ The Convention on the Prohibition of the Development, Production and
Stockpiling of Bacteriological (Biological) and Toxin Weapons and on their
Destruction was the first multilateral disarmament treaty banning the
production of an entire category of weapons. 10

HISTORY
▪ 1978 : Mycotoxins (fungal toxins) were reported to have been used in
Afghanistan in the of yellow rain.
▪ 1984:the most significant biological attack in the united Stated(US) was the
contamination of the salad bars with Salmonella by a religious cult in Oregon.
▪ 1992: Russia had the ability to launch missiles containing weapons-grade
smallpox. A number of terrorist organization, including Al-Qaeda, have
explored the use of biological agent.
11

HISTORY
▪ In September 2001, the American public was exposed to anthrax spores as a
bio-weapon delivered through the US postal system. The centre for disease
control and prevention (CDC) identified 22 confirmed or suspected cases of
anthrax during this attack. These included 11 patients with inhalational
anthrax, of whom five died and 11 patients with cutaneous anthrax (seven
confirmed), all of whom survived.
12

AGENTS OF BIOTERRORISM
▪ U.S. Centres for Disease Control an Prevention (CDC) has categorized
various agents into three main groups A, B & C. Which have potential to
pose a severe threat to public health and safety and officially defined as
“select agents.”
13

CATEGORY A
▪ A high priority agent which includes organisms that pose a risk to national security.
▪ These agents:
▪ Can be easily disseminated.
▪ Cause high mortality.
▪ Cause public panic and social disruption.
▪ Require special action for public health preparedness.
15

▪ A highly contagious virus, caused by the DNA virus, Variola major
transmitted through inhalation of droplets.
▪ 14 days after infections, patients usually complaints of high fevers,
headaches, prostration, and myalgia's.
▪ Then, a diffuse maculopapular rash appears leaving pustules that deflate and
form scabs resulting in areas of the exposed dermis and subcutaneous tissue.
▪ Death usually occurs 6 days after the onset of the rash
SMALLPOX
16

▪ It is one of the highest-threat bioterrorism agents, and its
infection-control measures include early detection, isolation
of infected persons, and public health surveillance of
contacts.
▪ In the 1970s, a vaccination program against smallpox was
introduced worldwide, and smallpox was eradicated.
▪ Only two stockpiles of the virus remain (at the CDC and the
Russian State Research Center) for continued research.
SMALLPOX
17

ANTHRAX
▪ Caused by the spore-forming bacterium Bacillus anthracis, a non-contagious disease.
▪ It occurs in three clinical forms:
1. Cutaneous anthrax - when spores come in contact with the skin and develop into
black lesions, and it occurs most commonly with the handling of infected animals.
2. Gastrointestinal anthrax - it occurs by the consumption of infected animal products
and undercooked/ raw meat
3.Respiratory anthrax - it is caused by the inhalation of spores through respiration.
18

ANTHRAX
▪ It can be diagnosed by blood culture and enzyme-linked ImmunoSorbent Assay.
▪ In its earliest stage, anthrax can be treated with penicillin (IV), tetracycline,
ciprofloxacin, or doxycycline.
▪ This treatment is effective only in the early stage of the disease, and it is
ineffective in the later stages with severe complication.
19

ANTHRAX
▪ A new method, recombinant proteins mainly the recombinant protective antigen are
used effectively to protect human anthrax and are widely available in many countries.
▪ The disadvantage of recombinant protein-based vaccines is need of yearly booster
doses, short protective efficacy, side effects, and poor tolerance in individuals.
▪ When exposed to anthrax, a prophylactic measures of oral ciprofloxacin or
doxycycline must be administered for 4 weeks.
20

TULAREMIA
▪ It is also called “mild plague”, “market men’s disease,” and “deer fly fever”
caused by Francisella tularensis.
▪ Tularemia can present in ulceroglandular, glandular, oculoglandular,
oropharyngeal, typhoidal, and pneumonic forms.
▪ Pneumonic tularemia is the most severe form of tularemia.
▪ Symptoms : fever, headache, myalgia, sore throat, nausea, vomiting, diarrhea,
and dry or slightly productive cough. 21

TULAREMIA
▪ If Francisella tularensis was used as a weapon, the
bacteria would likely be made airborne for exposure by
inhalation.
▪ The bacteria that cause tularemia occurs widely in nature
and could be isolated and grown in quantity in a
laboratory.
▪ Treatment : Aminoglycosides, Fluoroquinolones, and
Chloramphenicol.
22

BOTULISM
▪ Botulinum produced by the bacterium Clostridium botulinum is the most
deadliest toxin.
▪ Botulism causes death by respiratory failure and paralysis.
▪ Diagnosis is difficult as the toxin is not detectable in the serum or stool except
in the nasopharynx where it is detectable 24 h after inhalation.
23

PLAGUE
▪ It is also called as the “black death.”
▪ It is caused by Yersinia pestis.
▪ The disease is transmitted to humans by the flea bites and by aerosol in the
form of pneumonic plague.
▪ Plague mostly presents as the bubonic form but can also appear as septicemic
or pneumonic forms.
24

PLAGUE
▪ Pneumonic plague can lead to death within 24 h of symptom onset.
▪ Options for treatment include streptomycin, doxycycline, and chloramphenicol
25

VIRAL HEMORRHAGIC FEVERS
▪ These are those hemorrhagic fevers which are caused by the Filoviridae
(Marburg and Ebola) and Arenaviridae (Lassa fever and the Bolivian
hemorrhagic fever).
▪ Death due to Ebola is common because of the multiple organ failure and
hypovolemic shock.
26

CATEGORY B
▪ These agents are moderately easy to disseminate, cause moderate morbidity,
require enhanced disease surveillance, and public health diagnostic capacity.
27

CATEGORY C
▪ These agents include emerging pathogens which could be engineered for
mass dissemination in the future and which have potential for high
morbidity, mortality, and major health impact.
28

CHARACTERISTIC OF A FEW BIOTERRORISAM AGENTS
Thavaselvam D ,Vijayarakhavan R, Biological warfare agents J Pharm Bioallied Sci. 2010 Jul-Sep; 2(3): 179–188. 29

MEDIUM TO SPREAD BIOTERRORISM
▪ Food / Water
▪ Aircraft sprayers
▪ Vehicle sprayers
▪ Hand sprayers
▪ Mail
▪ Human Vector
▪ Animal Vector
30

WHY USE BIOLOGICAL WEAPONS ??
▪ Fast acting.
▪ Life span is high.
▪ Capacity to spread is high.
▪ If stored, it will be stable.
▪ It is resistant to
environmental condition.
▪ It is difficult to trace.
▪ It is invisible &
microscopic.
31

METHODS OF DETECTION OF BIOWARFARE AGENT
▪ Bio warfare agents are detected using combined molecular and microbiological
sensing technologies.
▪ Presently, antibody-based immuno-assays, biochemical testing, mass spectrometry,
microbiological culturing and genomic analysis using PCR (used in Biowatch
program of USA) are recommended for primary identification of biological agents
and their specific genes.
▪ These techniques are highly reliable, sensitive and selective.
32

COMBATING BIOTERRORIST ATTACKS
▪ The key element in combating a bio-terrorism strike is rapid identification of
a strike and the agent used; so that effective countermeasures may be
instituted before the agent disseminates widely.
▪ The anthrax attack on the US claimed only a very few victims - thanks to
rapid intervention by bio-weapons specialists on the suspicion of an alert
physician
33

COMBATING BIOTERRORIST ATTACKS
▪ Identification of bio-attacks however may be expected to pose problems
because of,
▪ Occurrence is rare hence ill-recognized
▪ Diseases agents of biological warfare also cause naturally occurring disease,
resemblance of biological toxins to chemical agents rather than infectious
organisms, and the concomitant use of more than one agent.
▪ Thus detection of the agent and subsequent decontamination is difficult,
symptoms are complicated and mortality much greater. 34

Factors which should arouse suspicion of bio-terrorism
are:
Clinical Settings
 Suddenness of onset of disease in many people and close clustering of cases
 Unusually large numbers of cases of a particular disease
 Unusual geographic or demographic distribution.
 An unusual geographical distribution of persons or animals at the time of
their probable exposure could point to deliberate use.
35

• Rareness : the unexplained appearance of an infectious disease of
humans or animals that is ordinarily very rare or absent in a region may
indicate deliberate use.
• Severity of disease following inflammatory infection. Disease initiated
by inflammatory infection may follow a course and exhibit symptoms
differing from and more severe than those characteristic of other natural,
routes of entry.
36

PROTECTION AND PRECAUTIONS
▪ Individual protection focuses on the use of suits, masks, self contained breathing
apparatus, respirators etc. however none of the methods is foolproof and the
effectiveness of individual protection is a matter of duration of exposure, and the
type and dose of the agent to which one is exposed.
▪ Physicians and healthcare personnel are amongst the prime respondents in case of a
bioterrorism strike and because of the very nature of the diseases in such settings
they may be exposed to the agents, especially those that spread by contact or from
person to person, before it is realized that a bio-terror attack has occurred.
37

▪ During the spread of a biological aerosol, the primary route of exposure will
be via the airways and respiratory tract.
▪ Respiratory protection will then be the most important component of physical
protection.
▪ Universal precautions for dealing with potentially infective materials should
therefore always be strictly and assiduously followed.
38

▪ The protection of responders should be based on the standard principles of barrier
nursing and infection control.
▪ VHF-specific precautions involving strict hand hygiene, double gloves,
impermeable gowns, N-95 masks or air purifying respirators, leg and shoe
coverings, face shields, goggles, restricted access, dedicated medical equipment,
environmental disinfection (e.g., 1:100 household bleach) and caring for all
affected cases in the same part of the hospital become of paramount importance
when treating cases of suspected viral hemorrhagic fevers.
39

▪ Vaccination or prophylactic antibiotic treatment of those involved in response
may have to be considered.
▪ This is more likely to be useful in the management of any secondary spread
of the infection than for the primary manifestations of the attack.
▪ Pre-attack vaccination of healthcare providers may be considered if
appropriate vaccines are widely available (e.g. for smallpox and possibly
anthrax).
40

LABORATORY RESPONSE
▪ The Laboratory Response Network for Bioterrorism, formulated by the Centre
for Disease Control and Prevention is an internationally approved consortium of
academic, private and public health laboratories that follow consensus protocols
to rule out and identify micro-organisms that may be used in bioterrorism.
▪ The laboratories are classified as “Sentinel” (screening) laboratories which carry
out simple tests on clinical specimens only and can help in early detection,
presumptive identification and “ruling-out” of organisms, but are not equipped
to make a definitive diagnosis.
42

LABORATORY RESPONSE
▪ They may send samples to “Confirmatory” laboratories which are major public
health laboratories and can perform definitive testing and further
characterization.
▪ Confirmatory labs in India are Microbial containment center NIV Pune, NICD
Delhi, NICED Kolkata, TRC Chennai, EVRC Mumbai, PGI Chandigarh and
JALMAAgra.
▪ The CDC and USMARIID in the United States of America are “Reference”
laboratories capable of high level tests, probing for the universe of organisms
and archiving of samples.
43

▪ The laboratories which are a part of the laboratory response network for terrorism
conform to biosafety levels.
▪ Four biosafety levels are described which consist of combinations of laboratory
practices and techniques, safety equipment and laboratory facilities.
▪ BSL 1 represents a basic level of containment that relies on standard microbiological
practices with no special primary or secondary barriers.
▪ Labs with this level of safety e.g. in teaching institutions, are competent to carry out
work with well characterized strains of viable organisms not known to cause disease
in healthy adult humans.
BIOSAFETY LEVELS (BSL)
44

▪ Laboratories with BSL 2 practices handle a broad spectrum of indigenous
moderate-risk agents known to cause disease of varying severity.
▪ This level of safety involves good microbiological techniques, use of protective
clothing and a combination of open bench-work and use of biosafety cabinets
(BSC) for potential aerosols.
▪ BSL 3 practices are designed for special diagnostic services and research and
involve use of special clothing, directional air-flow and controlled access.
▪ All work is carried out in biosafety cabinets.
45

▪ BSL 4 (Maximum containment) practices are meant for work with dangerous
and exotic agents which cause disease for which no known vaccine or therapy
exists.
▪ BSL4 laboratory in India is located in the national institute of virology under
ICMR
▪ The biosafety levels recommended for reference, confirmatory and screening
laboratories are level 4, 3 or 2 and 1 respectively.
46

▪ These are classified as Class I to Class III.
▪ They work on the principle of removal of
all aerosolized material within them by
means of a draught of air.
▪ Thus they ensure that the hazardous
organism does not contaminate the
technician or the lab.
BIOSAFETY CABINETS (BSC)
48

▪ The BSC Class I provides personnel and environment protection but because of non-
sterile room air passing over the sample does not allow its protection from
contaminants.
▪ BSC Class II provides personnel and sample protection and can be used for
processing dangerous specimens if the technician uses a pressure suit.
▪ BSC Class III has HEPA filtered air inlets and outlets, all penetrations are sealed, the
interior is at negative pressure, is accessed through heavy duty rubber gloves
attached to ports in the cabin and can be connected to an autoclave to decontaminate
all material entering or exiting it.
BIOSAFETY CABINETS (BSC)
49

Public health emergency preparedness and
response to bioterrorist attack :
• The responsibilities of public health agencies are surveillance of infectious
diseases, detection and investigation of outbreaks, identification of etiologic
agents and their modes of transmission and the development of prevention
and control strategies.
• The measures needed to prevent and control emerging infections are strikingly
similar to those needed to check the threat of bioterrorism.
• Ensuring adequate epidemiologic and laboratory capacity are prerequisites to
effective surveillance systems.
50

• One approach to early detection is "syndrome surveillance", in which
electronic symptom data are captured early in the course of illness and
analysed for signals that might indicate an outbreak requiring public health
investigation and response.
• Syndrome surveillance has been used for early detection of outbreaks to
follow the size, spread and tempo of outbreaks, to monitor disease trends and
to provide reassurance that an outbreak has not occurred.
• Syndrome surveillance systems seek to use existing health data in real time to
provide immediate analysis and feedback to those charged with investigation
and follow-up of potential outbreaks.
51

• The model of large scale exposure to the agents of bioterrorism (by use of
vaccines and antibiotics) has dramatic potential for saving lives and expense.
• The public health approach to bioterrorism must begin with the development
of local and state-level plans.
• Close collaboration between the clinical and public health communities is also
critical.
• To effectively respond to an emergency or disaster, health departments must
engage in preparedness activities.
• Completion of the following five phases of activities prior to an incident are
essential for successful response to a bioterrorist attack. 52

(a) Preparedness phase:
This phase includes actions to be taken by different agencies to ensure required
state of preparedness.
These include:
1. Evaluation of the laboratory facilities,
2. Evaluating the hospital preparedness in emergency response and case
management in case of an imminent attack,
3. Conduct training of health professionals,
4. Rapid response team (RRT) and quick response medical team (QRMT) who
would be the first responders, work out the legal provision and their
implications, 53

5. Ensure that requirement of safe drinking water is met, ensure availability
of adequate stocks of medicines and vaccines,
6. Coordinate with security organization,
7. Organize mock drills for health professionals, government departments,
animal husbandry, security,
8. Law enforcing and other agencies so as to assess their preparedness
levels to act in case of an attack,
9. Prepare contact details so that communications is unhampered during an
attack.
54

(b) Early Warning Phase:
• The early warning in the surveillance system includes activities like case
definitions, notification, compilation and interpretation of
epidemiological data.
• Early detection and rapid investigation by public health epidemiologist is
critical in determining the scope and magnitude of the attack and to
implement effective interventions.
55
StandardOperating Procedures (SOP) for responding to a terrorist attack using biological agents. Government of India, Ministry of Home Affairs, 2006.

(c) Notification Phase:
• It is mandatory to report any unusual syndrome or usual syndromes in
unusual numbers to appropriate authorities.
• The activities in this phase include rapid epidemiological investigations,
quick laboratory support for confirmation of diagnosis, quarantine,
isolation, keeping health care facilities geared for impending casualty
management and evolving public health facilities for control.
56

d) Response Phase:
• In this phase the activities include rapid epidemiological investigation,
quick laboratory support, mass casualty management and initiation of
preventive, curative and specific control measures for containing the
further spread of the disease.
57

In order to achieve them, following steps can be followed:
i. Assess the situation:
• Initiate the response by assessing the situation in terms of time, place and
person distribution of those affected, routes of transmission, its impact on
critical infrastructure and health facilities, the agencies and organizations
involved in responding to the event.
• Communicate to the public health responders, local, state and national
level emergency operation centres for event management etc.
58

ii. Contact key health personnel:
• Contact and coordinate with personnel within the health department that
have emergency response roles and responsibilities. Record all contacts and
follow-up actions.
ii. Develop action plan:
• Develop initial health response objectives that are specific, measurable and
achievable. Establish an action plan based on the assessment of the situation.
Assign responsibilities and record all actions.
59

iv. Implementation of the action plan:
• The RRTs/ QRMTs investigate the outbreak /increase in the disease
incidence, collect samples and send it to the identified state/national
laboratory for testing.
• Hospitals are alerted for receiving the patients and their treatment. If
necessary tented hospitals are set up. Methods to control the disease and
quarantine measures are instituted.
60

• Once the disease is identified, treatment protocols are sent to all
concerned by the fastest possible means. Standard operating procedures
(SOP) for laboratory testing is made by the identified laboratory and the
same is sent to all the hospital laboratories and district hospitals for
implementation.
• Laboratory reagents are distributed to the concerned laboratories. Public
is taken into confidence to prevent any panic. The list of 'Do’s and
Don’ts' are circulated thorough the print and electronic media.
61

62
(e) Recovery Phase
• The setbacks suffered as a result of the bioterrorist attack are restored and
lessons learnt in this phase are incorporated in the future preparedness
plans.
• The damage done to the public health facilities and the essential items
utilized during the response phase are replenished. The RRTs compile and
analyze data to identify the deficiencies experienced in the
implementation of the response measures.

63
India’s Preparedness against Bioterrorism: Existing
Measures
• India’s preparedness to deal with bioterrorism leaves much to be
desired.
• The Ministry of Home Affairs (MHA) is the nodal ministry for
countering terrorism, while the Ministry of Health and Family Welfare
(MoH&FW) is responsible for handling epidemics.
• The Ministry of Agriculture (MoA) deals with epidemics in animal and
crop. The Ministry of Defense (MoD) has armed forces inherently
suitable as first responders.
StandardOperating Procedures (SOP) for responding to a terrorist attack using biological agents. Government of India, Ministry of
Home Affairs, 2006.

64
• Indian Council of Medical Research (ICMR) is responsible for the formulation,
coordination and promotion of biomedical research with National Institute of
Virology (NIV) at the apex.
• Other important facilities under the ICMR include the National Institute of
Cholera and Enteric Diseases, National Institute of Epidemiology and Vector
Control Research Centre.
• The National Centre for Disease Control (NCDC), under Director General of
Health Services, has numerous specialized laboratories, but presently lacks
technical expertise to counter bioterrorism

65
• Defence Research and Development Organization (DRDO) has an
extensive network of laboratories.
• Defence Research and Development Establishment (DRDE) is engaged
in research on hazardous chemicals, biological agents, biotechnology,
microbiology, virology and toxicity.
• Defence Materials and Stores Research and Development Establishment
specializes in the production of individual protective equipment (IPE).

66
• The Defence Food Research Laboratory specializes in food quality, safety
and security.
• The Council for Scientific and Industrial Research (CSIR) and the
Department of Biotechnology (DBT) are the other research and development
(R&D) organizations dealing with biotechnology, drugs and toxicology and
are supported by an extensive laboratory network.
• The Indian Council of Agricultural Research (ICAR) is a premium research
institution in the fields of agriculture and animal science.

67
ROLE OF A DENTIST IN RESPONSE TO A BIOTERRORISM
ATTACK
• Dentistry can contribute valuable assets, both in personnel and in
facilities, to the preparation for and in the immediate response to a
bioterrorist attack and its aftermath.
• These assets can make a significant difference in the outcome. In a major
bioterrorist attack, the local needs could be massive and immediate.
• As hospitals become filled, alternate sites for the provision of health care
may be required, and dental offices could fill that need.
Nilima Prakash, P Sharada, GL Pradeep Bioterrorism: Challenges and considerations, J Forensic Dent Sci. 2010 Jul-Dec; 2(2): 59–62.

68
PREPARATION BEFORE AN ATTACK
• Education of the dental profession regarding the medical and oral
manifestations of diseases that may result from a bioterrorist attack will be
important.
• Formal plans for an organized response by dental personnel in case of an
attack must be developed, integrated into each community's response plan,
and practiced periodically.
• Dental offices are equipped with potentially useful equipment and supplies
and should be prepared to serve as decentralized auxiliary hospitals in case
the need arises.

69
• Educational programs that provide information about potential biological
weapons should be developed and made available to dentists through
continuing education courses and to dental students as a part of the dental
school curriculum.
• Up-to-date sources of information should be developed that can be accessed
quickly during an attack and reference materials that can be distributed for
use as needed.

70
• These quick references should be able to provide dentists with a sufficient
level of information concerning the particular agent used in an attack to
enable them to respond effectively.
• Dentists have contact with the general public on a regular basis.
• Armed with knowledge and connected to scientifically based information
sources about agents that may be used in bioterrorism, dentists can educate
their patients and correct information that may be circulating throughout the
general public.
• Special training may be needed for risk communication.

71
• Dental offices are located throughout any given community and have many
of the resources that hospital facilities have: sterilization equipment, air and
gas lines, suction equipment, radiology capabilities, instruments, and
needles.
• They may be called on to serve as local “mini-hospitals” when local
hospital facilities become overwhelmed or when the concentration of
patients is to be avoided, as in attacks involving contagious agents.

72
ASSISTANCE DURING AN ATTACK
• The assistance that dentists and other dental personnel can provide
during the first few days of a significant bioterrorist attack will vary
according to the needs of the community and the resources available.
• These may run the gamut from the packaging of medications in
individual doses to providing a major portion of primary medical care in
a quarantined area if physicians are unavailable because they have
become disabled or have died.

73
DECONTAMINATION AND INFECTION CONTROL
• Dentists and dental auxiliaries are well versed in infection control procedures
and can apply their knowledge in reducing the spread of infections between
patients and between patients and caregivers in mass disasters.
• The decontamination of casualties, when appropriate, can be accomplished
effectively by dental personnel.
• Dentists who have experience in practicing in a hospital setting may be
especially valuable and may be particularly equipped to provide services that
require a close working relationship with physicians.

74
AFTER THE INITIALATTACK
• Dentists trained in forensic odontology will work closely with local
Disaster Mortuary Operational Response Teams, (DMORTs).
• Dentists also may provide local surveillance to detect any spreading of
disease beyond the original area of attack or re-emergence of infections
in the original attack area.

75
DIAGNOSIS AND MONITORING
• Besides assisting in the early identification of the disease or diseases
introduced in a bioterrorist attack, dentists can provide individual patient
diagnosis by observing the physical and behavioural signs people manifest
when the nature of the attack has been determined.
• Salivary swabs may yield important diagnostic or treatment information and
can be collected by dentists for laboratory testing to determine diagnosis
when necessary or to monitor treatment progress.

76
REFERRAL
Dentists can refer suspicious cases to the appropriate specialists for
confirmation, treatment, or both.
IMMUNIZATIONS :
In the event that rapid inoculation or vaccination of the public is required to
prevent the spread of infection by a biological agent, dentists may be recruited
to assist in a mass inoculation program.

77
TRIAGE
• Whenever there are a greater number of casualties that the medical care
system cannot accommodate or whenever medical care resources are
overwhelmed, some system for establishing priorities for treatment must be
established.
• Appropriately trained dentists can fulfil this function, thus freeing up medical
professionals to provide definitive care for the large number of patients.
• This system should be established now, in preparation for potential future
attacks.

78
CONCLUSION
• Bioterrorism is a realistic threat and people should take it seriously and be aware of
it.
• Therefore at the outset proper awareness programmers should be arranged for the
citizens of our country.
• Biological warfare causes large scale health problems and suffering of the
population.
• This leads to the downfall and weakening of government.
• In a country like India, where the population is increasing day by day and has
exceeded a billion, preventive strategies and efforts against bioterrorism need to be
strengthened, improved and made effective.

79
REFERENCES
1. Centres for Diseases Control and Prevention. Emergency Preparedness and
Response: Bioterrorism Overview. Available from URL:
http://www.bt.cdc.gov/ bioterrorism/overview. asp.
2. Kelly J, Henning A. An overview of syndromic surveillance; what is
syndromic surveillance? MMWR 2004; 53: 5-11.
3. Standard Operating Procedures (SOP) for responding to a terrorist attack using
biological agents. Government of India, Ministry of Home Affairs, 2006.
4. Bioterrorist agents: Differential diagnosis, initial laboratory tests, and public
health actions. Available from URL: http://
www.stanfordhospital.com/PDF//BTAgents DifferentialDiagnosis.pdf.

80
REFERENCES
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492Bioallied Sci. 2010 Jul-Sep; 2(3): 179–188.
6. Christopher GW, Cieslak TJ. Biological warfare: A historical perspective.
JAMA 1997;278:412-417.
7. D.A. Henderson , Bioterrorism as a Public Health Threat, emerging infectious
disease 1998 (3) 88-492
8. Nilima Prakash, P Sharada, GL Pradeep Bioterrorism: Challenges and
considerations, J Forensic Dent Sci. 2010 Jul-Dec; 2(2): 59–62.
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