Military healthcare providers urged to be prepared for biological attacks

By Joan Kennedy
OSAGWIMRMD Public Affairs

WASHINGTON, May 31, 2001 (DeploymentLINK) -- "What do you think of when someone's coughing up blood?" asked Army Col. Ted Ciezlak.

"Plague!" answered the audience.

"Okay, how about flaccid paralysis?"

"Botulism!"

"Chest X-ray showing a very wide mediastinum?"

"Anthrax!" yelled the audience. Do you quarantine, he continued. No, it's not contagious, they responded, having listened well to the presentations leading up to Ciezlak's rapid-fire question-and-answer session.

The scene was a recent seminar on bioterrorism held in Washington, D.C., as part of the Reserve Officers Association's Mid-Winter Conference. The two presenters, both medical officers with the U.S. Army Medical Research Institute of Infectious Diseases from Fort Detrick, Md., were Ciezlak and Lt. Col. Mark Kortepeter. Ciezlak is a pediatrician and an infectious disease specialist. Kortepeter is a preventive medicine officer in the Operational Medicine Division at U.S. Army Medical Research Institute of Infectious Diseases, where he teaches the medical management of biological weapons casualties.

Ciezlak and Kortepeter described one hypothetical scenario after another of intentional germ releases on American troops. These included descriptions of widespread flu-like symptoms a week after suspicious "crop-dusting" aerial activity had been observed; an influx of suspected chickenpox cases in troops who had mostly already had chickenpox, and all of whom had attended the same festival a couple of weeks earlier; and Venezuelan flu, in mid-summer and far from Venezuela. With each scenario, the speakers were teaching the most common distinguishing symptoms to look for in a list of viruses and bacteria that can be deployed as weapons.

Unfortunately, said Ciezlak, when someone comes in after having been exposed to a biological warfare agent, the symptoms can easily be as vague as a fever and the "I-don't feel goods." The good news, he said, is that several of the illnesses share the same effective treatment: antibiotics, which can be started before a definitive diagnosis is made.

Kortepeter took the audience through a short history of biological warfare, beginning with reported practices during the Middle Ages of catapulting plague-ridden corpses over enemy walls. He described an incident during the French and Indian War, when blankets infected with smallpox were given by Sir Jeffery Amherst to Indians loyal to the French. This decimated the Indians and paved the way for Amherst to later successfully attack Fort Carillon.

Today, Kortepeter said, there are relatively few biological agents that could pose a massive health threat in the event of a bioterrorist attack. But a well-financed and well organized group can get its hands on agents that could pose an extremely difficult public challenge in terms of trying to limit the number of casualties and controlling the damage.

He cited a contemporary, real-world example of a well-financed, well-organized group attempting to use biological weapons to further ideological causes: the 1984 Salmonella poisoning of 750 people in The Dalles, Oregon, after Rajneeshees contaminated several salad bars in an attempt to influence the outcome of a local election.

Kortepeter said the Aum Shinrikyo cult in Japan - the group responsible for the 1995 sarin subway attack - had acquired the anthrax culture, and that anthrax was the group's first choice to release in its attempts to set off the Apocalypse. But because they were not able to aerosolize the microbe to the required effective droplet size, the group had to use sarin instead and settle for a fraction of the number of deaths anthrax would have caused.

For the past 10 years, Kortepeter said, government concern over potential bioterrorism has heightened, fueled by a marked increase in the number of incidents involving the illegal use of biological agents. Iraq admitted in 1995 to having quantities of anthrax, botulinum toxin and aflatoxin ready to use as weapons. And of the seven countries listed by the U.S. State Department as sponsoring international terrorism, at least five are suspected to have biological warfare programs.

"The sharp increase in biological threats and hoaxes, advances in biotechnological knowledge, and Internet sources on the subject all point to growing interest in the possible use of biological pathogens for illicit purposes," said Kortepeter.

"People keep asking what we really accomplish if we vaccinate all our troops against anthrax," said Ciezlak. "They say, 'Doesn't that just mean that the bad guys would use something else instead?'

Well, maybe they would, said Cieslak, 'but taking away their first choice removes some extremely valuable tactical advantages." For example, because anthrax is not communicable, they could infect and decimate an unvaccinated population and then come in to take over without risking the health of their own forces. "So their second choice would be a far distant second, one that could easily come back to bite them."

Because the early symptoms of anthrax are similar to those of a common cold or flu, by the time the symptoms become pronounced enough to diagnose, it is too late for treatment, Ciezlak said. The best hope doctors have once the diagnosis has been made is to then quickly try to find other people who have come into contact with the bacterium and administer the proper antibiotics along with a vaccine.

It is relatively easy to obtain a culture of anthrax, he said. Fortunately, in order to spread the virus effectively through the air, it has to be aerosolized within a very limited range of droplet sizes. As Ciezlak put it, "If they're too small you exhale as much as you inhale, and if they're too big they get caught in your nose."

"I'm afraid it's going to be only a matter of time" Ciezlak said, before terrorists put the puzzle together. "We have to be ready for the worst. So far, we've been very lucky."

The text of an article, "Potential Biological Weapons Threats," co-authored by Kortepeter, published in the Center for Disease Control and Prevention's publication "Emerging Infectious Diseases," can be also be read online at the CDC's website.