The History of Bioterrorism

Fred T Muwanga MD Msc

Definition of bioterrorism

Bioterrosim is the threat or use of biological agents by individuals or groups motivated by political, religious, ecological, social or for other ideological objectives to inculcate fear or cause illness or death in order to achieve their objective. (Carus 1998*).

Reported Cases of Bioterrorism World war II - Polish resistance

organizations used biological agents against German forces

1952 - Mau Mau, an independence movement in Kenya , used a plant toxin to poison livestock.

1966 - Dr.Mitsuru Suzuki a Japanese physician, infected healthcare providers and patients with Salmonella typhi

1981 - Dark harvest group got anthrax contaminated soil from Gruinard Island and damped it on Porton Down.

1984 - Rajneeshees in Portland, Oregon(USA)used Salmonella typhimurium to contaminate restaurant salad bars.

1995 - AUM Shinrikyo used sarin nerve gas in the Tokyo subway in Japan

2001 - Anthrax contaminated s mail sent to various people in USA.

CasualtiesIncident Number of Cases Number of deaths

Polish Resistance Not reported 200 Germans

Mau Mau Not reported 33 head of cattle

Dark Harvest None None

Rajneeshes 751(45 hospitalised)

no deaths

AUM Shrinkyo 5500 ( 641 seen atSLIH* on day 1 &349 following week)

106 hospitalised atSLIH. 12 deaths (2at SLIH)

Dr.Suzuki 200 4 deaths

Anthrax(USA) 22 4 deaths

Motive for bioterrorismIncident Motive

Polish resistance Resistance against foreign occupation

Mau Mau Resistance against colonialism

Dark Harvest Send a political message

Rajneeshes Win a local election by incapacitating thenon-Rajneeshee voters

AUM Shrinkyo Seize control of Japan through massmurder, causing fear and apprehension

Dr.Suzuki Revenge for unfair treatment he receivedat the medical training

Anthrax (USA) Inculcate fear

The Polish Resistance

One official from the Polish resistance organization claimed to have killed 200 Germans by using biological agents during the second World war. No details of the planning and execution are available.

There has been no official confirmation of this report.

The Mau Mau The Mau Mau was an African independence movement

in Kenya. It comprised of soldiers from most of the eastern Africa countries. It fought for independence from the British. The toxin that was used to poison the cattle was derived from an African milk bush . They also attempted to use arsenic. The intended to cause a direct economic loss and create terror among the rural population. This would result in loss of public faith thereby motivating people to wage war against the British colonialists.

Dr. Suzuki Dr.Suzuki was a Japanese physician and bacteriologist . He

had extensive experience in laboratory science. He injected patient and healthcare providers with salmonella

typhi. 200 people developed typhoid and dysentery, killing four. The motive was revenge - he was angry about the treatment

he was receiving as a resident in his medical training. However, there are suggestions that he wanted to create

clinical cases for his academic research into salmonella typhi.

The Dark Harvest

The Dark Harvest protested against the testing of an anthrax bomb on Gruinard Island by the British during World war II and the continued anthrax contamination. The group collected anthrax contaminated soil from the Island and discarded it on the grounds of Britain’s biological and chemical weapons research center in Porton Down.

The Rajneeshes

The Rajneeshes used a home made brew of poisonous salmonella typhimurium and sprinkled it secretly on the fruits and vegetables in salad bars, poured in the blue cheese dressing and on table-top coffee creamers in ten restaurants in The Dalles in Oregon(USA). They purchased the seed stock of salmonella from a medical supply company.

The Rajneeshes (contd)

The Rajneeshes - a sex and religion cult, originated from Poona, India. Their leader - Bhagwan Shree Rajneesh fled India because of tax fraud. In 1984 they had taken over the city council of Antelope and created an intimidating police force and had set their eyes on winning the Wasco County elections. They had two strategies. They planned to bring in homeless people to vote for Rajneesh and secondly, to contaminate the water supply to incapacitate non-Rajneesh voters. The salad bar-spiking was just a test run. Most patients presented within 2-3 days with food symptoms suggestive of food poisoning. Some of the hospitalized had perforations of the colon and colon abscesses.

AUM Shrinkyo (Japan).

The AUM Shrinkyo was a “Supreme Truth doomsday cult” of 40 members led by Shoko Asahara. The membership included skilled scientists and technicians with training in microbiology. They attempted to develop weapons using B.anthracis, botulinum toxin, C.burnetii and Ebola. It is reported that they tried nine times to disseminate biological agents without success. Their main aim was to take over Japan through mass murder and causing fear and apprehension among the Japanese citizenry. They used sarin an organophosphate nerve gas.

The Tokyo subway attack was carried out by five two man teams who planted toxic sarin gas at several stations.

AUM Shrinkyo (contd) Reports of toxic fumes in a subway station began at approximately

08.17am (Tokyo time) and symptoms began immediately. The nerve gas was concealed in lunch boxes and soft drink containers and placed on subway train floors. It was released as the terrorists punctured the containers with umbrellas before leaving the trains. the incident was timed to coincide with rush hour, when trains were packed with commuters. Over 5,500 people were injured in the attack.

On day one, 641 victims were seen at St.Luke’s International Hospital. 5 arrived with cardiopulmonary or respiratory arrest with marked miosis and extremely low serum cholinesterase(6IU/L), 2 died and 3 recovered. 349 were treated at SLIH in the following week.

SLIH treated the largest reported patient population exposed to the gas.

Hospitalized patients (AUM Shrinkyo)

106 patients were hospitalized*. The major signs and

symptoms were: miosis, headache, blurred vision or visual darkness - shown

by almost all patients dyspnea, nausea, ocular pain, vomiting, muscle weakness

and agitation. post-traumatic stress disorder(PTSD) - whereas other

symptoms disappeared within weeks.PTSD persisted longer Secondary contamination of house staff occurred in 23% of

cases. They presented with ocular pain, headache, sorethroat, dyspnea, nausea, dizziness, nose pain

Diagnosis (AUM Shrinkyo)

Diagnosis was based on signs and symptoms that were

indicative of organophosphate poisoning which included: Miosis and miosis related symptoms such as visual darkness,

ocular pain, headache related with near vision. Respiratory symptoms - rhinorrhea, cough, dyspnea and

respiratory failure due to nicotinic effect on respiratory muscles or muscarinic effect on smooth muscle and secretory glands of the airway leading to bronchoconstriction and excess bronchial secretion.

Convulsive seizures in two patients.

Laboratory diagnosis (AUM Shrinkyo)

Blood samples taken a few hours after sarin exposure in 451 patients showed the following:

a shift to the left 50% had decreased ChE levels, and all severely ill

patients showed markedly decreased ChE levels 67% showed a respiratory alkalosis 60% had increased white blood cell count 11% had increased creatinine phoshokinase

Management The five acute cases had cardiopulmonary resuscitation. All patients were given Intravenous atropine sulfate(2mg)

and 2g or more of pralidoxime iodide(PAM), dose depending on severity of symptoms. Those who received higher doses of PAM(>3g) tended to have faster improvement in their serum ChE levels.

Intravenous Diazepam(5-20mg) was used to control those that presented with seizures.

Psychiatric management of PTSD. 60% had PTSD and percentage remained the same over a period of 6 months.

Anthrax (USA)

The latest use of biological agents for terrorism involved sending mail contaminated with anthrax spores. The actual perpetrators not known yet

The first case was reported in Florida - 63 year old male resident of Palm beach County who presented with fever and altered mental status. he died and autopsy revealed inhalational anthrax as the cause of death.

The second patient was a 73 year old co-worker of the index patient, admitted for a pneumonia. A nasal swab yielded positive culture for B.anthracis; PCT test for B.anthracis on pleural fluid was positive .

Confirmed cases of anthrax by StateCase status Florida New York

CityNewJersey

WashingtonDC

Total

Confirmed 2 5 5 5 17

cutaneous 0 4 3 0

Inhalational 2 1 2 5

Suspect 0 3 2 0 5

cutaneous 0 3 2 0

Inhalational 0 0 0 0 0

Total 2 8 7 5 22

Source: CDC Update Novemeber 2, 2001

Case finding and diagnosis There was enhanced case

finding by initiating retrospective and prospective surveillance systems.

Environmental assessments and sampling were done at the index patient’s home, work site, travel site, mail or package delivery.

questionnaires were administered at the index patient’s work site

Center for Disease Control (CDC) developed a case definition for a confirmed case and for a suspect case of anthrax.

post exposure prophylaxis with ciprofloxacin or doxycycline was given to prevent inhalational anthrax after a confirmed or suspected exposure.

CDC case definition of anthrax Confirmed case - Clinically compatible case of

cutaneous, inhalational or gastrointestinal illness that is laboratory confirmed by isolation of B.anthracis from an affected tissue or site

OR

- Other laboratory evidence of B.anthracis infection based on 2 supportive laboratory tests

Suspect case - Clinically compatible case of

illness without isolation of B.anthracis and no alternative diagnosis, but with laboratory evidence of B.anthracis by one supportive laboratory test.

OR - Clinically compatible case of

anthrax epidemiologically linked to a confirmed environmental exposure, but without corroborative laboratory evidence of B.anthracis infection

Lessons learnt Motives for bioterrorism vary

and could include: - murder(Aum Shrinkyo) - gaining political mileage (Mau Mau

and Dark harvest) - desire for revenge (Dr.Suzuki)

- Cause fear (Anthrax cases) - Incapacitation (Rajneeshes)

- anti-agriculture (Mau Mau)

Terrorists do not usually announce their intent

secondary contamination can occur (SLIH workers)

There are various methods of dissemination:

Direct application (Dr.Suzuki)

Food or water contamination (Rajneeshes)

Aerosol contamination (Aum Shrinkyo and anthrax cases)

The effects of bioterrorism can be immediate(illness and death) or long term (Post-stress disorder)

Response and prevention of bioterrorism Response involves: emergency measures to save

lives active case finding through

surveillance establish diagnostic criteria(case

definition) and case management prevention and management of

secondary contamination Accurate laboratory work

Prevention measures Strategy formulation that stress

deterrence as well as crisis and consequence management.

Do a threat analysis so as to define the requirements

contingency planning with clear definition of roles

global surveillance of disease outbreaks to create more understanding on emerging threats

Questions for reflection

With largely theoretical knowledge on bioterrorism, how best can we understand the problem we are faced with ?

What ability and/or capacity does the world have to respond to the challenges of bioterrorism?

What is the dividing line between bioterrorism and criminal activity ?