Terrorism [Byers et al.] is the intentional use of indiscriminate violence to create fear and terror as a means to achieve an ideological, financial, religious, or political aim. It is often used against non-combatant targets. Terror tactics may include biologic, chemical, nuclear, or explosive events.
Bioterrorism is the intentional release of biological agents to cause illness or death in humans, animals, or plants. These agents may be bacteria, fungi, toxins, or viruses. They may be naturally occurring or human-modified.
The agents are typically found in nature, but they may be altered in a laboratory to increase their resistance to antibiotics, and ability to spread in the environment. Biological and chemical agents may be spread through the air, food, or water. Terrorists use biological agents because they are often difficult to detect and illness onset may be delayed for hours to days increasing dispersal.
Bioterrorism agents are a common choice for terrorists because they easy and inexpensive to produce, easy to disseminate, and can cause widespread effects. The challenge with bioweapons is that they may affect both enemy and friendly forces. Terrorists use biologic weapons as a method of creating mass panic.
In the history of humanity, the intentional infliction of casualties on civilians was considered inappropriate. Civilians are usually not attacked for their own sake unless they happen to be living or working in an area that has tactical or strategic value. Unfortunately, bioterrorism agents are difficult to control and affect military personnel as well as civilian men, woman, and children.
In the last 100 years, the United States and the international community have experienced multiple acts of terrorism and bioterrorism which have targeted civilians.
During World War I there was widespread use of chemical weapons that often affected the civilian population resulting in many deaths. Since this war, most countries have agreed not to use chemical and biologic weapons. Unfortunately, with our present age of terrorism from individuals, splinter groups, and dictators, there is an ever-present risk that these agents will be used.
To date, other than the dropping of nuclear bombs by the United States to end World War II, there have been no recent acts of nuclear attack or nuclear terrorism. Nuclear terrorism is an act of terrorism in which a terrorist organization detonates a nuclear device. The possibility of terrorist organizations using nuclear is considered plausible as terrorists could acquire a nuclear weapon. However, despite thefts of small amounts of fissile material, all low-concern, there is no credible evidence any terrorist group has succeeded in obtaining the necessary multi-kilogram critical mass amounts of weapons-grade plutonium required to make a nuclear weapon.
It is, unfortunately, becoming a common event on an international scale when terrorists use explosive devices to inflict casualties on the civilian population.
What is terrorism? What is a mass casualty incident?
Terrorism is generally considered to be the use of force or violence outside the law to create fear among citizens with the intent to coerce some sort of action. Health professionals should be aware bioterrorism is a perfect vehicle for terrorists to strike fear into the hearts and minds of citizens in the hopes they will bend the will of the people to support their agendas. All health professionals need to be prepared for this potentially catastrophic event. [Aven et al. 2015]
The goal or function of a terrorist is to create mass hysteria. Health professionals must learn to mitigate this effect by being able to recognize an attack and treat and calm victims.
Terrorist acts can be either covert or overt. In a covert attack, the terrorists are attempting to take advantage of the element of surprise. Health professionals must be diligent in evaluating the possibility of a covert attack when multiple patients arrive with similar signs and symptoms. In this setting, the healthcare system may be quickly overloaded unless the institution and staff have prepared and have systems in place to handle a large influx of patient volume. The sooner an event is recognized as an attack; the sooner additional resources can be activated to assist providers. Unless the system prepares in advance, the number of victims triaged may quickly overwhelm the system and result in the terrorist’s goal of creating mass panic.
In an overt attack, terrorists rely heavily on mass hysteria and panic as an impact multiplier. They may announce responsibility immediately for a large-scale event. The number of victims quickly overwhelms even prepared systems that have a well-defined emergency response plan. In either a covert or overt terrorist attack, the system may be flooded with victims.
Weapons of Mass Destruction
Weapons of mass destruction include biological, chemical, or nuclear weapons potentially causing mass casualties. The mnemonic CBRNE assists in remembering weapons of mass destruction:
Biological warfare agents are bacteria and viruses that infect humans, animals, and crops resulting in an incapacitating or fatal disease or crop destruction. Symptoms may not appear for days to weeks. Often the bacteria or virus is weaponized, and the changes will affect a broader segment of humans, animals, or crops than the normal pathogen.
In a biological warfare terror event, healthcare providers must deal with uncommon pathogens that rarely affect humans. Healthcare facilities will be inundated with victims. The arrival of one or more victims with an odd presentation may be the initial indication that an act of terrorism has occurred.
Biologic agents may be dispersed by several techniques including contaminated water and aerosol sprays. They can also infect individuals and place them on airplanes, buses, or large events that will disperse the virus quickly.
All healthcare providers should have the knowledge to identify and initiate a local response to an act of bioterrorism. The starting point is the status quo or their normal patient population. If there is a significant deviation from the norm, the provider should consider the fact that they may be on the cusp of an endemic deliberately perpetrated on society.
Providers must be aware of clinical features including:
These factors reflect changes from the status quo in the community. An astute clinician with a sense of the community’s general normal health can make a significant difference in how soon a response to the threat begins. If the person admits to no foreign travel in endemic areas of rare viruses, and the suspicion is high, contacting the local health department or CDC is in order.
Classification of Bioweapon Diseases
The Center for Disease Control has identified 30 organisms that might be weaponized and has grouped them into three categories. Classification is based on ease of dissemination, morbidity and mortality, panic potential, and level of public health requirements.
Category A: High Risk
ANTHRAX: CUTANEOUS, GASTROINTESTINAL, AND INHALATIONAL [Narayanan et al. 2018]
Bacillus anthracis is found in the soil and is normally transmitted by handling contaminated animals and animal products. It is a spore-forming organism. Anthrax spores are highly permeable to the porous skin. An anthrax vaccine does exist but requires many injections to be effective. Anthrax is one of the few biological agents for which federal employees receive vaccination. It may be diagnosed with Gram stain (gram + rod shaped).
BOTULISM [Joseph et al. 2013]
Botulism is a neurologic disorder that causes life-threatening neuroparalysis as a result of a neurotoxin produced by Clostridium botulinum. The three main clinical presentations of botulism are as follows: Infant botulism, Foodborne botulism, and Wound botulism.
PLAGUE: BUBONIC [Bossi et al. 2003]
Bubonic plague is a highly contagious, acute, febrile illness transmitted to humans by the bite of a rat flea. Human-to-human transmission is rare. The disease is caused by a rod-shaped bacteria known as Yersinia pestis. Plague is distributed worldwide and is more commonly reported in developing countries. Survival of the bacillus depends on flea-rodent interaction; human infection does not contribute to the bacteria's survival in nature.
SMALLPOX (Variola Major) [Voigt et al. 2016]
Smallpox is a highly contagious acute disease caused by the variola virus, an Orthopoxvirus in the Poxviridae family.
TULAREMIA OR “RABBIT FEVER” [Barras, et al. 2014]
Tularemia or rabbit fever is caused by Francisella tularensis which is a bacteria spread by ticks, deer flies, or contact with infected animals. It may be also be spread by breathing contaminated dust or drinking contaminated water.
VIRAL HEMORRHAGIC FEVER (Marburg, Ebola, Lassa, and Machupo viruses) [Cenciarelli et al. 2015]
Viral hemorrhagic fevers caused by a viral infection. They are caused by five families of RNA viruses: Arenaviridae, Bunyaviridae, Filoviridae, Flaviviridae, and Rhabdoviridae. Fever and bleeding disorders characterize all types, and all can progress to high fever, shock, and death.
Category B – Low Risk [Moran et al. 2002]
ABRIN TOXIN FROM ABRUS PRECATORIUS (ROSARY PEAS)
Abrin is a toxic toxalbumin that is found in the seeds of the rosary pea. It is more toxic than ricin. Abrin is a ribosome inhibiting protein similar to the ricin.
BRUCELLOSIS (BRUCELLA SPECIES)
Brucellosis is a very contagious zoonosis that may be contracted by consumption of undercooked meat, unpasteurized milk, or contact with other secretions. It is also known as Mediterranean fever, Malta fever, or Undulant fever. Brucella is small gram-negative, nonmotile, non spore-forming, rod-shaped coccobacilli bacteria. It is a facultative intracellular parasite resulting in chronic disease.
EPSILON TOXIN OF CLOSTRIDIUM PERFRINGENS
Epsilon toxin is produced by Clostridium perfringens types B and D is one of the most potent poisonous substances known. Epsilon toxin binds to endothelial cells of brain capillary vessels before passing through the blood-brain barrier.
FOOD BACTERIUM (ESCHERICHIA COLI O157: H7, SALMONELLA, SHIGELLA)
The foodborne disease usually results from food contaminated by pathogenic bacteria, viruses, or parasites; or toxins such those found in poisonous mushrooms. The incubation period ranges from hours to day depending on the agent and the amount of consumption.
GLANDERS (BURKHOLDERIA MALLEI)
Glanders is an infectious disease usually affecting donkeys, horses, and mules but it can be contracted by cats, dogs, goats, and humans. It is caused by Burkholderia mallei from contaminated feed or water.
MELIOIDOSIS (BURKHOLDERIA PSEUDOMALLEI)
Melioidosis is an infection caused by gram-negative Burkholderia pseudomallei found in the soil and water. It is phylogenetically related closely to Burkholderia mallei which causes glanders.
PSITTACOSIS (CHLAMYDIA PSITTACI)
Psittacosis, parrot fever, or ornithosis is caused by Chlamydia psittaci and contracted from infected parrots.
Q FEVER (COXIELLA BURNETII)
Coxiella burnetii causes Q fever. The bacteria is found in cattle, goats, sheep, cats, and dogs. Infection occurs from inhalation from a spore-like variant and contact with feces, milk, semen, and urine of infected animals. The disease may also tick-borne. The bacterium is an obligate intracellular parasite.
RICIN: RICINUS COMMUNIS (CASTOR BEANS)
Ricin is a toxic lectin produced by the castor oil plant and found in the seeds. A dose the size of a few grains of table salt can kill a human. The LD 50 is about 22 micrograms per kilogram of body weight. Injection or inhalation is more toxic than oral ingestion.
STAPHYLOCOCCUS AUREUS (Enterotoxin Type B)
S. aureus is a gram-positive bacterium frequently found in the flora of the nose, respiratory tract, and skin. It is a common cause of abscesses, food poisoning, respiratory infections and sinusitis. Pathogenic strains produce virulence factors such as protein toxins and cell-surface protein that binds and inactivates antibodies. Antibiotic-resistant methicillin-resistant S. aureus (MRSA) is a worldwide problem.
TYPHUS (RICKETTSIA PROWAZEKII)
Typhus, also known as typhus fever, is caused by Rickettsia prowazekii which is spread by body lice and Orientia tsutsugamushi, spread by chiggers, and Murine typhus, due to Rickettsia typhi spread by fleas.
VIRAL ENCEPHALITIS (VENEZUELAN EQUINE ENCEPHALITIS, EASTERN EQUINE ENCEPHALITIS, WESTERN EQUINE ENCEPHALITIS)
Encephalitis is an acute inflammation of the brain caused by either a viral infection or the immune system mistakenly attacking brain tissue. Encephalitis refers to an acute, diffuse, inflammatory process. While meningitis is an infection of the meninges, a combined meningoencephalitis can occur. An infection by a virus is the most common cause of encephalitis.
WATER SUPPLY THREATS (VIBRIO CHOLERAE, CRYPTOSPORIDIUM PARVUM)
The water supply and water treatment facilities are a possible target for terrorists.
Category C [Moran et al. 2002]
Category C agents are emerging pathogens that could be engineered for mass dissemination because of their availability, ease of production and dissemination, mortality rate, and ability to cause a substantial health impact.
Influenza A (H1N1) virus is a subtype of influenza A and a common cause of the human flu. It is an orthomyxovirus that contains haemagglutinin and neuraminidase. Haemagglutinin causes red blood cells to clump together. Neuraminidase is a glycoside hydrolase enzyme that moves the virus particles through the infected cell.
Hantaviruses or orthohantaviruses are single-stranded, enveloped, negative-sense RNA viruses within the Hantaviridae family of the order of Bunyavirales. These viruses have the potential to kill humans. Humans become infected from contact with rodent feces, saliva, or urine.
Human immunodeficiency virus and acquired immune deficiency syndrome are conditions caused by infection with human immunodeficiency virus.
Nipah virus (NiV) infection is a zoonosis that causes severe disease in humans. The natural host of the virus is the fruit bats of the Pteropodidae family, Pteropus genus. Human-to-human transmission has also been documented. NiV infection in humans has a range of clinical presentations, from asymptomatic infection to acute respiratory syndrome and encephalitis.
Severe acute respiratory syndrome (SARS) is a zoonotic viral respiratory disease caused by the SARS coronavirus.
A chemical weapon is a specialized munition that uses chemicals formulated to inflict harm or death. Chemical weapons are classified as weapons of mass destruction, and they are distinct from nuclear weapons, biological weapons, and radiological weapons. Chemical weapons can be dispersed in a gas, liquid, and solid forms.
Under the Chemical Weapons Convention, there is a worldwide ban on the production, stockpiling, and use of chemical weapons. Notwithstanding, large stockpiles of chemical weapons exist, usually justified as a precaution against an aggressor.
Types of Chemical Agents [Kotora et al. 2015]
BLISTER: Distilled mustard, mustard gas, lewisite, mustard/lewisite, mustard/T, nitrogen mustard, phosgene oxide, and sulfur mustard
A blister agent or vesicant is named for its ability to cause severe chemical painful water blisters on the bodies of those affected. Vesicants have potential medical uses including wart removal, but they are fatal if small amounts are ingested.
BLOOD AGENTS: Cyanogen chloride, hydrogen cyanide
A blood chemical agent is a toxic compound that affects the body by being absorbed into the blood. They are fast-acting, highly lethal toxins that are typically volatile colorless gases with a faint odor. They are usually either arsenic or cyanide-based.
CHOKING AGENTS: Chlorine, chloropicrin, nitrogen oxides, phosgene, and sulfur dioxide
Chemical agents which attack lung tissue, primarily causing pulmonary edema, are classed as lung-damaging or choking agents.
INCAPACITATION: BZ, CS, CN, and LSD
An incapacitation agent that produces temporary physiological or mental effect which will render individuals incapable of the performance of their duties.
NERVE: Organic pesticides, sarin, soman, and tabun
Nerve agents are organic chemical (organophosphates) that disrupt nerve transfer messages to organs by blocking acetylcholinesterase, an enzyme that catalyzes the breakdown of acetylcholine. Nerve agents are easily vaporized, and may enter through the respiratory system. The skin can also absorb them. A full body suit is required for exposure protection.
Nuclear weapons are weapons of mass destruction. Nuclear warfare can produce destruction in a much shorter time and have a long-lasting radiological result. A major nuclear exchange would have long-term effects, primarily from the fallout released that could last for centuries. If a nuclear war occurs, it is expected many will die acutely followed by deaths from starvation and the international catastrophes to the health and welfare of citizens that would ensue. So far, 2 nuclear weapons have been used, both by the United States near the end of World War II. While it ended the war sooner, saving countless lives. These 2 bombings resulted in the immediate deaths of approximately 120,000 people.
There are two types of nuclear weapons: fission and fusion.
All existing nuclear weapons derive some of their explosive energy from a nuclear fission reaction. Weapons whose explosive output is exclusively from fission reactions are referred to as atomic bombs or atom bombs.
Fusion weapons produce a large proportion of energy in nuclear fusion reactions. Such fusion weapons are referred to as thermonuclear weapons or hydrogen bombs. All such weapons derive a significant portion of their energy from fission reactions which are used to "trigger" fusion reactions. The primary pathologic effect of ionizing radiation causes damage to DNA. The common pathway of injury is radiation deposits energy into the electron orbitals of atoms in the biologic medium.
Localized exposure to high doses of radiation causes cutaneous burns. Blistering, desquamation, erythema, and ulceration may occur 2 to 3 weeks after irradiation with the onset and severity increased with exposure.
Acute Radiation Syndrome
Acute radiation syndrome occurs after exposure to substantial ionizing radiation. Acute radiation syndrome may occur at a minimum dose of 1 Gy and is fatal at doses greater than 10 Gy. At 3.5 Gy, 50% of those exposed die within 60 days without medical treatment.
Acute radiation syndrome progresses through 4 stages:
Prodromal symptoms develop after irradiation, the greater the dose, the sooner the onset and the greater the duration and severity. Symptoms include nausea, vomiting, diarrhea, anorexia, abdominal cramping, and eventually dehydration.
Early onset of prodromal symptoms indicates a poor prognosis.
Acute radiation syndrome has three subsyndromes: cerebrovascular, gastrointestinal, and hematopoietic.
Greater than 30 Gy causes cerebrovascular syndrome which is uniformly fatal. Doses greater than 100 Gy results in death in a few hours. Vascular damage results in significant cerebral edema, resulting in cardiovascular collapse. The patient will develop nausea, vomiting, ataxia, hypotension, tachycardia, and convulsions followed by death.
Exposures of 5 to 12 Gy result in gastrointestinal syndrome. Irradiation causes cell death of the intestinal mucosal stem cells in the crypts. After the loss of mucosal cells, the stem cells are unable to produce new cells, resulting in denudation of the gastrointestinal tract. As the normal cells are destroyed, bacterial growth proliferates, and nausea, vomiting, bloody diarrhea, dehydration, abdominal cramps, and weight loss develops. Often the prodrome is rapid, which is followed by a latent period. Treatment includes fluids, electrolytes, and antibiotics. Unfortunately, death usually occurs in 3 to 10 days.
Exposures of 2 to 5 Gy causes the hematopoietic syndrome. Lymphocytes die from radiation caused apoptosis, and precursor cells in the bone marrow are destroyed which prevents the production of leukocytes and platelets. Gradually circulating cells die off with no replacements; the syndrome progresses to infections and possible hemorrhage. Early supportive care, treatment and prevention of infections, and cytokine therapy may decrease morbidity and mortality. However, death commonly still occurs from multi-system organ failure.
Treatment of Acute Radiation Syndrome
Large-dose Radiation Exposure
Hematopoietic Growth Factor
Personal Protective Equipment [Byers et al. 2006]
Emergency responders to a nuclear explosion may not know they are being exposed to radiation unless they utilize a radiation detecting device. There is no practical personal protective equipment to protect responders against penetrating gamma radiation. Monitoring devices are the only means to ensure that responders do not enter an area where exposure is excessive.
Personal protective equipment to prevent skin contamination is effective against particulate-borne radiation hazards (i.e., alpha and beta particles). Typical firefighter gear is adequate. Decontamination of personnel and equipment should follow exposure.
Protection of organs from radioactive particulates may be provided by wearing an appropriate particulate respirator.
Triage: Contaminated individuals are identified by proximity to the known release, signs, and symptoms. If the patient requires life-saving treatment, this supersedes decontamination. Staff must wear PPE and stabilize the victim before entry into decontamination.
Decontamination: The patient is monitored while contaminated clothing is removed and placed in hazardous waste containers and depending on the agent, appropriate decontamination techniques are deployed to remove the hazardous substance. Removing clothes alone may reduce 75% or more of the contamination. This should be followed by a water shower with liquid soap.
Post-decontamination: After the victim is decontaminated, a second clinical triage is conducted.
The facility should be prepared to handle wastewater and solid waste. Morgue services should be available for contaminated bodies.
Radiation Whole-Body Contamination
Preparedness [Feeney et al. 2015]
Health professionals must be able to respond to an act of terrorism. This requires education and a working knowledge of the potential biologic and chemical agents that may be deployed and treatment options available to counter ill effects.
Facilities must evaluate the institution's role in a local biologic or chemical emergency. Facilities must assist in the coordination of activities of the emergency response agencies within the community. The best way to respond is to have a prepared plan and practice it before an untoward event.
The Center for Disease Control provides the Health Alert Network (HAN) to provide urgent information about public health incidents. HAN provides a mechanism for rapid distribution of health information to over 1 million email recipients. Messages are in four levels:
The ever-present potential of a terrorist bombing concerns as it may well lead to countless casualties; however, a biologic, chemical, or nuclear attack may rise to the level of an international catastrophe. Healthcare professional must prepare as individuals and as a team to care for the victims. It is important for each of us to acquire the information and skills needed to respond and to take steps to limit to the morbidity and mortality associated with a such an attack.
Unfortunately, many political organizations are using terrorism to try to achieve their goals. It is difficult to explain terrorism, we must live with it, and as health professionals prepare ourselves to deal with it.