WMD =

Weapons of Mass Destruction

Yet in the fecund mind of a terrorist, there rare doubtless many more possibilities.
During the Cold War (ca. 1945 1991), the United States and the former Soviet Union stockpiled massive chemical and biological weapons arsenals. Yet, in the years following the collapse of the Soviet Evil Empire, the threat of Warsaw Pact forces employing Aside from the immediate care of those directly affected by CB agents, the

psychological impact of this

type of terrorism may prove just as challenging. How can one distinguish the true casualty from the worried well? How does the health care system handle

chemical and biological weapons (CBW) against the

Western NATO countries has all but vanished. The United States, and to a limited extent Russia, have begun destroying their chemical weapons stockpiles. As for biological weapons, no conclusive evidence is available to indicate that these are currently possessed by Russia. The United States long ago (1969) renounced offensive biological weapons research and destroyed all remaining biological weapons in the early 1970s. Other nations, however, such as

mass psychogenic illness in an age of chemical and

biological terrorism? Some have even suggested that, indeed, the psychological effect of bioterrorism is a more prominent threat than its actual use.

North

Korea, are widely cited as having

chemical or biological weapons capabilities. Now, much of the emphasis, in terms of

national security, has shifted

to the use of unconventional weapons unleashed on civilian targets by terrorists. Sometimes referred to as

superterrorism, this includes the possible use of nuclear

(that is, a fission-reaction explosion), radiological (as in the so-called dirty

Regardless of how we view these threats, the immediate questions that should concern us are: How significant is the threat and what should we do about it?
If CB agents fall within the rubric of WMD, then are. looking at acts of violence that involve large numbers of casualties. But what defines a large number casualties (including dead and wounded)? Do we mean dozens, hundreds, or thousands?

biological, or chemical weapons.

bomb), Compared with the many instances of attacks using conventional explosives, the use of weapons employing toxic or infectious agents by terrorists has been rare. 1

Examples:
1. The massive bomb (4 or more pounds) that destroyed the Murrah Building in

Oklahoma City on April 19, 1995, killed 168

and injured hundreds more. Although no toxic chemical pathogens were involved, the scope and scale of destruction qualified this terrorist weapon as a WMD. (Terry Lynn Nichols)

our society. As an example,

the letters containing

anthrax spores mailed on

or after September 11, 2001, resulted in the death of 5 and infected 13 more. A great number of individuals took unwarranted steps, such as

self-

medicating (with antibiotics) and purchasing protective masks.

The anthrax attacks clearly demonstrated the potential to cause large number of casualties, and we can therefore regard them as

2. Cult members of the

Aum Shinrikyo in Japan released sarin nerve agent on the subway

in March killing a dozen people and causing more than a thousand injuries. Limited in terms of lethality but certainly it was a case of

acts of bioterrorism.

chemical terrorism.
3. Another is the deliberate use of pathogens in the U.S., in 1984 the followers of

Bhagwan Shree Rajneesh, in an attempt to

influence local elections in Antelope, Oregon, sickened 51 people with

Salmonella typhimurium, the

causative agent in

1. Intent on causing large-scale death and disruption = inflicting enormous casualties and causing massive disruption to society. 2. Inherent fascination with these exotic agents that for some evoke biblical or apocalyptic connotations. 3. Strike fear and uncertainty acute and long term fear of the unknown. Powerful psychological sensationalized by media.

food poisoning. While

none died as a direct consequence of this attack it qualifies as a case of domestic bioterrorism. 4. But even a small number of casualties caused by these chemical or biological agents can

The mere threat of an attack using dangerous chemical or biological materials can cause

great anxiety and disorder, if not outright panic, in

any society perpetuating

reverberating effects throughout

have 2

fear among the public and

necessitating

resource expenditure.

More sick than dead is expensive. Military vs. Terrorists -limited resources such as funds, flexibility and time -wider scope in the choice of agent such as CB

events are generally self-limiting. A chemical terrorist attack may include small or large numbers of casualties, and, depending on the age used, victims may require special

decontamination

measures.

UNIQUE ASPECTS OF A CB TERRORIST INCIDENT ARE THAT THEY ARE

THE UNPREDICTABLE, UNSTABLE AND DIFFICULT TO HANDLE EVEN BY THE TERRORIST THEMSELVES AND MAY NOT NECESSARILY KILL THE TARGETED GROUP OF PEOPLE OR INTENDED PURPOSE. BUT IT WILL CREATE HAVOC AND ANXIETY TO THE POPULATION AND MIGHT NOT BE DISCOVERED AT ALL IN TERMS OF THE PERPETRATORS AND THE ACTUAL CAUSE OF THE TERROR ATTACK.

Liquid and solid in bomb shells or spray from airplanes and air vents. Volatile liquids can be sprayed readily or let it vaporize by it self. These are: 1. Nerve agents (e.g.; sarin and VX) 2. Tissue (blood) agents (e.g., cyanide) 3. Lung irritants (e.g., chlorine gas) 4. Vesicants (i.e. blister agents such as mustard or lewisite) 5. Psychoincapacitants (e.g., BZ -3quinuclidinyl benzilate and LSD) 6. Pesticides

Water, Food, Beverages and Consumer Products

Challenges Posed by a Chemical Terrorist Attack-overwhelm the healthcare system and staff to triage and treat casualties. 1. 2. 3. 4. Nerve agents (e.g.; sarin and VX) Tissue (blood) agents (e.g., cyanide) Lung irritants (e.g., chlorine gas) Vesicants (i.e. blister agents such as mustard or lewisite) 5. Psychoincapacitants (e.g., BZ -3quinuclidinyl benzilate and LSD)

The real risk is not really the mass casualty but the hundreds or thousands of

logistical and psychological demands

(the worried well) on the healthcare system, which is

expensive. The stress that it brings with the

havoc and anxiety on the government and health authorities including the hospitals and staff and other healthcare workers that can barely able to keep up with the usual flow of patients.

Nerve Agents

In nearly all respects, chemical terrorism

hazardous materials (HAZMAT) event.

is essential a Unlike effects of a contagious biological agent release (e.g. smallpox), chemical 3

VX Rockets

CYANIDE

The act of biological terrorism (bioterrorism) involve the deliberate use of microbial pathogens or toxins. Unlike a chemical incident, the effects from bioterrorism may not be fully known until many hours or days after the event. Infectious of intoxications but most are

NOT contagious EXCEPT

for mandatory containment measures in

smallpox, some hemorrhagic fevers and bubonic plague.

These are: 1. Bacterial agents (including rickettsial organisms) 2. Viral agents (e.g. smallpox) 3. Toxins (derived from plants or animals) 4. Parasites (less likely)

Delivery by intended to be inhaled and lodged in the alveoli of the lungs at about 5 microns. Other methods are either by ingestion or injection which are NOT efficient to cause mass casualty. Coxiella burnetti = Q Fever Chlamydophila psittaci = Psittacosis Francisella tularensis = Tularemia Yersinia pestis = Bubonic Plague Ebola and Marburg Viruses Bacillus anthracis = Anthrax SMALLPOX VIRUS Clostridium botulinum = Botox toxin, Botulism

AEROSOL

Ixod id Ticks

EBOLA

10

ANTHRAX

11

large-scale chemical or biological

not as great as some media reports would have us believe,

terrorist attack is there are at least some terrorist groups and individuals who could attempt to attack civilians with CB agents. This makes preparing for such an event essential. We have already seen that chemical incidents are relatively quick-acting and limited, whereas biological incidents would take time before they are recognized for what they are. In general, one can consider a chemical release or attack to be a

lights and

sirens affair, that is, rapid response

and (hopefully) expeditious treatment of casualties. In a bioterrorist event,

unlikely to know that they were exposed to an infectious agent or toxin until the first symptoms appear, at
however, people would be the very least several hours following the event. Little can be said with certainty as to what would actually happen, or how the public at large would respond in the event of a major chemical or bioterrorist attack. There is general agreement, though, that should a chemical or biological agent be used in a violent act, the effects of this kind of terrorism will extend far beyond its immediate danger to the public. It is, therefore, incumbent

A terrorist attack using chemical or biological weapons is an alarming prospect, all the more so after the tragedy of 9/11. Although the likelihood of a
12

every health care provider to understand all aspects of this threat and to train and prepare for an event all hope will never occur.
on

BIOLOGICAL AGENTS
(Category A Biological Agents of Concern by CDC) Anthrax Botulism Plague Tularemia Smallpox Viral Hemorrhagic Fevers

Emerging Infectious Disease(EID)

Factors Contributing to EIDs 1. Immune Status 2. Climate and weather 3. The Changing Environment 4. Risk Behaviors 5. International Travel and Commerce These are: 1. Diarrheal Diseases 2. HIV/AIDS 3. Malaria 4. Measles 5. Pneumonia 6. TB

leads to one conclusion: smallpox. What might you say to this individual to calm his fears? 2. Which groups appear to be interested in using chemical and biological agents? Why do you think they find these attractive? 3. If one were forced to choose between equipping ambulances with extra atropine auto injectors in the event of a nerve agent release or instead equip these with cyanide antidote kits, which would you choose? Why? 4. In 2002, a spate of mysterious rashes appeared in schoolchildren in the United States and Canada. According to the CDCs Monthly Morbidity and Mortality Report (June 21, 2002), The sex distribution of cases varied among the schools, ranging from 33 percent to 100 percent female. An etiologic agent has yet to be found. Why did the CDC find it relevant to note the gender of the distributed cases? 5. Someone receives an envelope and on opening it discovers a white powder along with a letter that reads, You have just been exposed to anthrax. What should that person do? 6. Working in the Emergency Room, you receive notification that there has been a confirmed attack on an office building using chlorine gas. What type and number of casualties should you prepare for? 7. Your neighbor tells you that he refuses to drink tap water because he fears that terrorists might contaminate it. Should you follow suit? Why?

Diseases of Importance
1. 2. 3. 4. 5. 6. Avian Influenza (Bird Flu) SARS West Nile Fever Malaria Marburg Hemorrhagic Fever Tuberculosis

Study Questions
1. A 33-year-old patient presents with a maculopapular rash of no discernible pattern, and he is very agitated and concerned. He says that he had chicken pox as a child, and the books and magazines he has read indicate that it all 13

approach that considers the biologic, environmental, societal, and , behavioral underpinnings of EIDs is our best defense against this perpetual challenge.

Creatures invisible to the naked eye will continue to outsmart and outwit humans with the complexities of modem living presenting numerous opportunities for them to prove their strength and determination. The public health system must be equally vigilant. Nurses, the largest sector of the health care profession, are poised to take the lead in the fight against these invisible enemies. Improved and increased training is imperative. It is not only important to be able to recognize a newly emerging disease but to also identify the situations that may promote an emerging disease in order to better anticipate their evolution and impact. A holistic 14