Biological Warfare — An Emerging Threat Reshma Agarwal*, SK Shukla**, S Dharmani***, A Gandhi*** As we approach the 21st century, there is an increasing worldwide awareness and threat regarding theuse of biological warfare agents both for war and terrorist attack. Biological agents include microorganismsor biological toxins that are used to produce death in humans, animals and plants. They are characterizedby low visibility, high potency, substantial accessibility and relatively easy delivery. Biological warfareagents are unconventional weapons that can be delivered by unconventional means like aerosol sprays,food and water contamination, conventional explosive munitions or by covert injections. Because oftheir concealed delivery, easy transportation and difficult identification they are readily adaptable forterrorist operations or to gain political advantages. The detection of such attack requires recognition ofthe clinical syndromes associated with various biological warfare agents. Diagnosis can be made onclinical grounds and on investigations. Protective measures can be taken against biological warfare agents.
These should be implemented early (if warning is received) or later (once suspicion of agent use ismade). After the confirmation of diagnosis emergency medical treatment and decontamination areperformed in rapid sequence. Patients are then evacuated and specific therapy is given according to theagent involved. Appropriate emergency department and hospital response could significantly limit themorbidity and mortality of biological warfare agents. INTRODUCTION
treatment and for prophylaxis of exposed persons.
Environmental pollution could pose continuing threats. We Biological warfare has been waged intermittently for nearly have tried to present in this article a comprehensive review 2,500 years1 and the deliberate use of microorganisms on biological warfare and its consequences.
and toxins as weapons has been attempted throughout thehistory. Biological warfare has evolved from the crude use of HISTORIC BACKGROUND
cadavers to contaminate water supplies to the development The history of biological warfare is difficult to assess of specialized munitions for battlefield and covert use. The because of a number of confounding factors. These include modern development of biological agents as weapons has difficulties in verification of alleged or attempted biological paralleled advances in basic and applied microbiology. These attacks, the use of allegations of biological attacks for include the identification of virulent pathogens suitable for propaganda purposes, the paucity of pertinent microbiological aerosol delivery and industrial scale fermentation process to or epidemiological data and the incidence of naturally produce large quantities of pathogens and toxins.2 Biological occurring endemic or epidemic diseases during hostilities.2 weapons are cheap, can cause mass casualties and arerelatively easy to produce, even by developing nations. Long The use of biological agent is not a new concept2 and standing sources assign the following costs to prosecute a history is replete with examples of biological weapon use.
war : conventional arms $ 2,000/Km² vs chemical weapons $ Attempts to use biological weapons date back to antiquity.
600 /Km² vs biological weapons $1Km².3 These factors have Scythian archers infected their arrows by dipping them in led to the attraction of terrorist groups as well to chemical decomposing bodies or in blood mixed with manure as far and biological weapons. The deployment of these agents is back as 400 BC.1 Persian, Greek and Roman literature from no longer a hypothetical scenario but a life-threatening 300 BC quote examples of the use of animal cadavers to contingency. It presents serious challenges for patient contaminate wells and other sources of water.
In 190 BC, at the battle of Eurymedan, Hannibal won a naval victory over King Eumenes II of Pergamon by firing *Associate Professor; **Director, Professor and Head; ***Post earthen vessels full of venomous snakes into the enemy ships.
Graduate Student, Upgraded P.G. Department of Medicine, MLNMedical College, Allahabad (U.P.) In 18th century AD, British forces distributed small pox Received : 13.4.2004; Accepted : 20.6.2004 infected blankets to native Americans to create transmission of disease. During First World War, Germans developed and produce mass casualties or as plant pathogens to destroy anthrax, glanders, cholera and a wheat fungus for use as crops, devastate the food chain and cause famine.
biological weapons.4 Likewise, during Second World War, Contamination of food and water is another mode of delivery Japanese operated a secret biological warfare research and to targeted population. The use of biological warfare agents carried out human experiments with plague, anthrax, syphilis has far reaching consequences. The threatened use of BW on Chinese prisoners.4 In 1940s and 50s, United States and agents can result in fear and panic in a population, whether Britain continued research on various offensive biological under attack or being threatened to gain political advantages weapons like anthrax and botulinum toxin and also continued in political activities. The stress associated with a biological to the 60s. In 1970s, USSR and is allies were suspected of attack could create high numbers of acute and potentially having used yellow rain (trichothecene mycotoxins) during chronic psychiatric casualties.9 Because of their concealed campaigns in Cambodia and Afghanistan, which caused delivery, easy transportation, difficult identification and easy alimentary toxic aleukia (ATA) in civilians.5 In 1979, 66 people escape of performer before BW agent release is apparent, were killed due to accidental release of anthrax from a weapons they are readily adaptable for terrorist operations. They may facility in Sverdlovsk, USSR.6 Since the 1980s, terrorist also be employed during political events (especially organizations have become users of biological agents. The multinational events)10 to create injury or political disorders.
most frequent bioterrorism episodes have involved Modes of Delivery
contamination of food and water. In September, 1984, BWA are unconventional weapons and can be delivered international contamination of restaurant salad bars in Oregon by unconventional means. The most effective method is by followers of Bhagwan Rajneesh infected 751 persons with aerosol sprays (most likely to be used by terrorists and military Salmonella typhimurium.7 Recently, in a short span of time, groups), because of their particle size (1-5µm) due to which i.e. from Sept. to Nov. 2001, 23 cases of bio-terrorism occurred they are most efficiently delivered to their target (air sacs of in US which mostly involved, postal workers, where letters lung).11,12 Aerosol generators, generate particle of optimal contaminated with anthrax were handled or opened.
size and deliver aerosol via point source (fixed aerosol devices Definition
with sprayers) of line source (such as moving vehicle, airplane, Biological weapons or biological warfare agents include boat). Other modes of delivery are food and water microorganisms or biologic toxins that are used to produce contamination, conventional explosive munitions and by death or disease in humans, animals and plants.5 The ability of infectious agent to cause widespread illness and thus to Portal of Entry
cause societal disruptions and panic, together with low cost These BW Agents mainly enter through respiratory tract of these agents led to their being called as “Poor Man’s (following inhalation of aerosolized BWA). Others routes are exposed mucosal surfaces, (nose/mouth/eyes), GIT (through Desirable biological weapons are characterized by low contaminated food and water), intact skin (barrier against visibility, high potency, substantial accessibility and relatively most BWA except mycotoxin) and injection (traumatic easy delivery (as an aerosol with particle diameter size 1- Environmental Detection
Classification of Biological Warfare Agents (BWA)
Currently no reliable detection system exists for BWA.
The biological warfare agents can be classified as : Biological Integrated Detection System (BIDS), which is Clostridium perf toxin, Staph enterotoxin B, a multi-component system that provides monitoring, sampling detection and presumptive identification. BIDS is vehicle based and must be located in BW aerosol cloud to detect Hemorrhagic Fever, Small Pox, Rift Valley Fever, agents. These technologies use components that automatically determine the count/size of particle, determine if particles are living organisms, classify some basic cellcharacteristics using Ag-Ab analysis for identification.
A Short Range Biological Standoff Detection System Saxitoxin (derived from paralytic shellfish) (SRBSDS), which employs UV and laser-induced Ricin (cytotoxin derived from caster bean mesh) fluorescence to detect aerosol clouds.
Biological Warfare Agents - Uses and Consequences
A Long-Range Biological Standoff Detection System Biological warfare agents are still used as they were before (LRBSDS), which employs laser system mounted in a 20th century. The employment of BWA is not limited to war helicopter to scan, designated area of interest.
alone, but can occur at anytime, at any place and by anyone.
Portal Shield System, which consists of network of They can be employed as weapons of mass destruction.
biological and chemical point detectors, linked to computer/ Aerosols of biological warfare agents may deliver incapacitating or lethal inocula over large geographic areas Joint Biological Point Detection System, which is an inconsistent (e.g., compressed time course) automatic air-sampling device and provides visual and Other inconstant elements (e.g., number of cases, audible alarms in presence of biological warfare agents.
mortality and morbidity rates, deviations from disease By Examination of Environmental Samples. Point source munitions will leave environmental residue of BWA near point Indications of possible BW agent attack include the Management of Biological Warfare Agent Casualties
Disease entity that is unusual or that does not occur Recognition of biological warfare injuries.
Multiple disease entities in the same patients, indicating that mixed agent have been used in the attack Large number of both military and civilian casualtieswhen such populations inhabit the same area Data suggesting a massive point-source outbreak High morbidity and mortality rates relative to the number Medical personnel must be familiar with signs and Illness limited to fairly localized or circumscribed symptoms of BWA casualties and must attempt to distinguish between epidemic of natural origin and BW attack.
Low attack rates in personnel who work in areas with CLINICAL RECOGNITION OR DIAGNOSIS
filtered air supplies or closed ventilation systems Successful management of exposure to BWA relies on Absence of a competent natural vector in the area of early recognition. Medical units should rely on information outbreak (for a biological agent that is vector-borne in not only from detectors and intelligence sources, but also from casualties themselves. This applies particularly to BW Lab Diagnosis
weapons/agents since at present there are no rapid methods Most of the attacks are clinically recognized.
of identification or detection. Some of the problems in They are further identified by usual lab tests (microscopy, recognition and diagnosis of BWA attack are discussed here.
culture, ELISA, mass spectroscopy, animal inoculation Unlike chemical agents, which typically lead to violent methods, Ab detection (e.g. IgM), PCR and by detection disease syndromes within minutes at site of exposure, disease of metabolic products of infections/toxic agents in clinical resulting from biological agents have incubation period of days.14 This attack may not be apparent until days or even weeks after the attack has occurred. Therefore, the firstindication that a BW attack has occurred may be large number Triage is done as whether EMT or decontamination of patients simultaneously presenting with a similar disease.
Such an event could be confused with naturally occurring Immediate : Casualties who require life saving care within epidemic. Early identification of BW attack may be further a short time, when that care is available and of short confounded by difficulties in early clinical diagnosis. Other potential confounding factors are, lack of clinical experience Delayed : Casualties with severe injuries who are in need with potential BW agents, and possible difference in clinical of major or prolonged surgery or other care and who will presentations from a naturally acquired disease versus an require hospitalization, but delay of this care will not aerosolized agent. Classic, fully differentiated syndromes may adversely affect the outcome of the injury.
not be apparent until late in the clinical course. The nature Minimal : Casualties who have minor injuries, can be and timing of symptoms will vary with the route of exposure, helped by non-physician medical personnel, will not be nature and dose of agent used. Early recognition of first few evacuated, and will be able to return to duty shortly.
cases of disease enable medical personnel to implement BWdefensive measures.14 Emergency Medical Treatment (EMT)
Preliminary criteria for suggestive outbreaks of disease EMT and decontamination may be performed in rapid that could provide indications of a possible biological weapons sequence. Treatment follows the universally accepted algorithm of first ensuring the adequacy of airway breathingand circulation.16 Decontamination
Decontamination is the physical process of removing residual chemicals from persons, equipment and the Case distribution geographically and/or temporally Table 1 : Summary of Biological Warfare Agents severe resp. distress, stridor, resp.
mediastinitis and thoraciclymphadenitis) shock, and deathwithin 24-36 hrs.
*Parenchymal infiltrates unusual.
*Hemorrhagic meningitis may alsooccur.
lesions at same developmental stage) *Viral isolation, spreads to lower extremitiesand then to trunk; lesions deeplyseated in dermis.
*Death in - 35%.
environment. Every person arriving at Medical Treatment (c) Patient is placed in PPW (Patient Protective Wrap) for Facility (MTF) from biological warfare contaminated area is protection from BWA and should be isolated in designed considered contaminated unless there is positive proof to Medical Evacuation
(a) Initial decontamination involves removal from the After the identification and decontamination of casualties, contaminated environment, removal of all contaminated measures must be taken to prevent contamination of clothes and copious irrigation with water.
ambulance and air evacuation assets. Many BWA casualties (b) Exposed person is revised with dilute household bleach may be safely evacuated using basic infection control guidelines.20 The United States Army Medical Research Table 1 : Summary of Biological Warfare Agents (contd) *Streptomycin 30mg/kg IM qdDuration: 60 days unlessvaccinated.
3 days) for serious complications *DOD cell-culture derived vaccinia released by CDC if smallpoxcase(s) confirmed.
loading dose followed by17 mg/kg IM or IV q 8In mass casualty situation:*Doxycycline 100 mg PO bid:*Ciprofloxacin 500 mg PO bid*Chloramphenicol 1 g IV g6HDuration: 10-14 d days for serotypes A, B. E.
*DOD heptavalent antitoxinfor serotypes A-G.
Institute of Infectious Diseases maintains an aero-medical isolation team (AIT) which is a rapid response team with Some of the therapies recommended vary from those found worldwide aircraft capability. It is designed to safely evacuate and manage patients with potentially lethal communicable BW exposure (aerosol) may produce a disease with disease. It offers portable containment lab and limited clinical features different from naturally occurring disease environmental decontamination and specialized consultant eg. inhalation (BW) versus cutaneous (endemic) expertise. Indications for deployment include cases of highly contagious, lethal or unidentified disease including casesfrom suspected BW attack.
An adversary (enemy/opponent) may develop BWAresistant to standard antibiotic therapy.
Specific Therapy
Specific Therapy is given according to specific agent given Prevention
Torok TJ, Tauxe RV, Wise RP, et al. A Large communityoutbreak of salmonellosis caused by intentional Prevention is done by active immunization, contamination of restaurant salad bars. JAMA 1997; 278:389- chemoprophylaxis and personal protective equipment.
Chemoprophylaxis and vaccinations are discussed in Lawrence CM, Dennis LK. Basic considerations in infectious diseases. In Harrison’s Principles of Internal Medicine, 15th The primary responsibility of those who treat victims of BWAs is to protect themselves by wearing adequate Holloyway HC, Norwood AE, Fullerton CS, et al. The threat of biological weapons. Prophylaxis and mitigation of psychological and social consequences. JAMA 1997;278:425-7.
10. US Army Medical Research Institute of Infectious Disease.
Medical Management of Biological Casualties Handbook, 4th Joint service light weight integrated suit technology.
ed. Fort Detrick, Frederick, Maryland : 2001.
11. Medical Management of Biological Casualties Handbook, 3rd ed. USA Army Medical Research Institute of Infectious Disease, Fort Detrick, Frederick, 1998.
HEPA filter (High Efficiency Particulate Air) masks.
12. Eitzen EM. Use of Biological weapons. Medical Aspects of Double layer of battle dress uniform T-shirt.
Chemical and Biological Warfare. Washington : Office of theSurgeon General, TMM Publications, 1997:437-466.
13. Headquarters, Department of the Army, Washington D.C.
Biological weapons have recently attracted the attention Field Manual 8-284, Treatment of Biological Warfare AgentCasualties, 17 July, 2000.
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the nature of the threat of bioweapons as well as appropriateresponses to them requires greater attention to the biological 15. Wiener SL. Strategies for the prevention of a successful biological warfare aerosol attack. Mil Med 1996;161:251-6.
characteristics of these instruments of war and terror.22 Mediacommunications, planning for war quarantine and 16. Keim M, Kaufmann AF. Principles for emergency response decontamination and the role of community leaders are to bioterrorism. Ann Emerg Med 1999;34:177-82.
important in the migration of psychological consequences.23 17. Tucker JB. National health and medical services response to Now 140 nations have participated in the Biological and Toxin incidents of chemical and biological terrorism. JAMA1997;278:362-8.
Weapons Convention (BWC) which prohibits the acquisitionof biological materials for hostile purpose and armed 18. Richards CF, Burstein JL, Wackerlie JF, Hutson HR.
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ability to manage large scale biological weapon attacks andthat requires continued education, training and forethought.
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Biological warfare. A historical perspective. JAMA1997;278:431-2.
21. Pile JC, Malone JD, Eitzen EM, Friendlander AM. Anthrax as a potential biological warfare agent. Arch Intern Med CDC Nicotine poisoning after ingestion of contaminated ground beef. Michigan 2000. MMWR 2003;52:413-6.
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