BIOTERRORISM FACT SHEET

MAILMAN SCHOOL OF PUBLIC HEALTH

COLUMBIA UNIVERSITY

BIOTERRORISM FACT SHEET

This document is designed to provide general information in an accessible format for a lay audience. For more detailed and comprehensive discussions of biological and chemical agents the reader may wish to refer to the web sites listed as references.

FREQUENTLY ASKED QUESTIONS ABOUT BIOTERRORISM

Q. How concerned should I be about chemical or biological attacks?

A. Efforts to use anthrax spores as a weapon in the fall of 2001 raised our concern about the possible use of biological, chemical or other unconventional weapons against civilians here in the United States. While there is reason to be alert to this possibility, it is equallly important not to overestimate the threats to our safety.

Using biological material as a weapon for mass dissemination requires significant technical know-how that makes it technically challenging for terrorist organizations. There have been some instances of letters containing anthrax sent to national media and federal government offices, resulting in some cases of disease. Of the handful of cases that have occurred to date, most have been cutaneous (skin) anthrax, which is the most likely form of the disease and has responded well to antibiotic therapy. There have also been a few cases of inhalational anthrax, which is more serious, but is also more difficult to contract. See below for more information on anthrax, steps you can take to protect yourself, and for links to other websites that contain useful information.

It is also important to put the threat of biological warfare in its rightful context -- as an unexpected outbreak of infectious disease. The public health system has considerable experience in dealing with natural outbreaks of infectious diseases, and has increased its ability to respond to what may be the intentional releases of biological agents. Our public health system is presently at a high state of readiness and the Centers for Disease Control and Prevention (CDC) is prepared to dispatch epidemiologists, as needed, to step up the nation's surveillance efforts. New York City, for example, has some of the best expertise in the world when it comes to dealing with infectious disease outbreaks, sharpened by recent experience with the West Nile virus, AIDS, and tuberculosis.

Looking ahead, it is critical to sustain and strengthen these public health capabilities so that the public health system can consistently maintain and improve the necessary state of readiness. Strengthening public health capabilities for monitoring and controlling unexpected outbreaks of infectious disease, and enhancing preparedness through professional and public education, will provide the best defenses against bioterrorism.

Q. Is the water supply safe?

A. Yes. Most metropolitan water systems are safe and are sufficiently large that anything purposely put into them would be greatly diluted. In addition, the steps taken during water treatment processing make it extremely difficult to contaminate the final product. However, during a state of heightened alert, city, state, and federal agencies are even more intensively monitoring the water supply and it is likely that any problems will be rapidly detected. Results to date indicate that the water supply in large cities such as New York remains safe.

Q. Should I buy a gas mask?

A. No. We do not currently recommend gas masks. Gas masks are clumsy pieces of equipment, useful only in situations of high local threat. For a gas mask to be effective, you must put it on at the right time: you must be wearing the gas mask before exposure, and continue wearing it until the danger is past. It is unlikely that you will know exactly when to put on the gas mask. Most masks can only be worn for a few hours before the filters need to be changed, and in any case it is impractical to wear a gas mask for extended periods (they are simply too uncomfortable). You should also be aware that there are many different masks available for sale and they vary in quality and in purpose. In addition, masks need to be properly fitted to work effectively, and can make breathing difficult in people with impaired heart and lung function.

Q. Should I get a supply of antibiotics for use against biowarfare agents?

A. We don't recommend trying to keep a store of antibiotics in your home for use in case of a biological attack. While several antibiotics are effective against such possible bacterial threats as anthrax or plague, there are a number of reasons why we do not recommend stockpiling antibiotics at this time. It is very difficult, if not impossible, to know when to take the antibiotic. In most cases, people are likely to take antibiotics when they are not needed, thereby encouraging resistance to common pathogens and undermining their effectiveness when they are needed. Antibiotic use can result in serious adverse effects (e.g., clostridium difficile colitis, allergic reactions, and interactions with other medications). In addition, keeping a supply for future use may prove ineffective as antibiotics lose their strength over time, and may even deteriorate and become harmful.

The federal government has stockpiled supplies of antibiotics and other emergency supplies (called "Push Packs") that can rapidly be deployed for just such emergencies as a possible bioterrorist attack. Following the September 11 event, New York City requested these supplies as a precautionary measure and they were rapidly delivered. Since then, the distribution system has been further strengthened in response to lessons learned from recent experience.

Q. What are some of the possible bioterrorist threats?

A. Among the possible bioterrorist threats most often mentioned are anthrax, plague, and smallpox. Many of these infections begin as flu-like illnesses. If you get flu-like symptoms, they are most likely due to influenza or another common upper respiratory infection. Flu-like symptoms include: fever, fatigue, and muscle or joint aches. Flu and other common upper respiratory infections also include nasal or sinus congestion. In the unlikely event of a flu-like illness that suddenly seems to take an unusual course – such as pneumonia, severe chills, bloody sputum, rash on face and extremities, or bloody diarrhea – call your doctor immediately. Remember too, that in the elderly, serious infections may develop with little or no fever.

Q. What is anthrax?

A. Anthrax is an infection caused by a bacterial agent (Bacillus anthracis), and is a naturally occurring disease of livestock, and occasionally of people, like veterinarians or butchers, who work with livestock. The organism is a sporeformer, and infection is caused by exposure to spores. Anthrax does NOT spread person to person.

The most common manifestation of exposure to anthrax spores is cutaneous (skin) anthrax. The first sign is usually localized itching (within days to about a week after exposure, but may take longer), developing over the next few days into a boil-like lesion and eventually (about 2-6 days later) forming a characteristic ulcer with a black center. (The lesion, called an eschar, is so characteristic it gave anthrax its name -- anthrax is Greek for "coal.")

This form of anthrax responds very well to antibiotic treatment, with complete recovery the rule. Exposure alone is not sufficient to cause infection. Washing extensively with soap and water will reduce risk of infection. Infection is unlikely to occur unless skin is broken or abraded.

Gastrointestinal anthrax can occur if large numbers of spores are ingested. Signs of gastrointestinal anthrax include nausea, vomiting and bloody diarrhea.

Inhalation anthrax is very uncommon. Infection generally requires inhaling relatively large numbers of spores (typically 10,000 spores or more). Incubation period (time from exposure to onset of disease) is typically 1-6 days, although cases may occasionally occur later (up to 60 days). The disease typically starts as a flu-like illness and then progresses over the next several days to pneumonia with severe respiratory distress. Later on meningitis (severe headache, stiff neck) and internal bleeding may develop. Early diagnosis is key. Inhalation anthrax should be treated with antibiotics as soon as it is suspected.

Anthrax may also be prevented in persons not yet ill by giving appropriate antibiotics to those who have been exposed. Antibiotics are given long enough (usually 60 days) to protect against even the rather late development of the disease. Vaccine is NOT essential for treatment, but, when available, may be used as an extra precaution against late development of the disease. At this time, the anthrax vaccine is in limited supply and only used for persons likely to have occupational exposures and for military personnel thought to be at higher risk for potential exposure to anthrax in combat settings.

Q. What is plague?

A. Plague is an infection caused by the bacterium Yersinia pestis. Although plague is famous as the "Black Death" of history, and can be fatal if untreated, it is responsive to antibiotics and fatality rates are generally low when the disease is recognized and treated early. Plague is typically spread to humans by infected fleas, and human to human spread only develops in rare cases of pneumonic (pulmonary) disease. There are pockets of naturally occurring plague in many parts of the world, including occasional cases in the southwestern United States. Natural cases are usually by the bite of an infected rodent flea or by handling infected animals, resulting in the bubonic form (with high fever and enlarged, tender lymph nodes, often in the groin, about 2-10 days after infection). Occasionally, the infection can involve the lungs (pneumonic plague). Pneumonic plague can also occur if a sufficient dose of organisms is inhaled. The incubation period (time from infection to onset disease) is about 2-3 days. Initial symptoms are high fever, chills, and bloody sputum. The pneumonic form can spread from person to person, but appropriate respiratory precautions can prevent spread and, if diagnosed and treated early, the infection can be controlled with antibiotics.

Q. What is smallpox?

A. Smallpox is an infection caused by a virus, and can spread from person to person. It was once a dreaded natural disease, but was eradicated as a natural infection over 20 years ago. As most stocks of the germ were destroyed at that time, it would be difficult for terrorists to obtain material for new cultures. Although a smallpox outbreak is very serious, past experience with natural outbreaks indicates that rapid public health response, involving early recognition of cases and vaccination of those exposed, would succeed in controlling the outbreak.

Incubation period is 7-17 days (typically just under two weeks). About 2-3 days after a flu-like beginning (fever, malaise, and often headache), a characteristic rash appears, usually starting on the face and hands, with and all lesions developing simultaneously (unlike chickenpox, where the lesions appear in a series of "crops").

Smallpox vaccinations are no longer routine in the United States. The last naturally occurring human case took place in Somalia in 1977. Smallpox vaccine was removed from the commercial market in 1983 as a result of the successful worldwide eradication of smallpox. According to the CDC, the federal government has an emergency stockpile of vaccine sufficient to immunize the entire country should that become necessary, and a new vaccine is under development.

Because of the risks of smallpox vaccine (especially for people with compromised immune systems or certain skin disorders) and the great difficulty any terrorist would have in getting access to smallpox virus, general vaccination is not recommended at this time.

Q. Should I get vaccinated?

A. The use of anthrax or smallpox vaccine is not warranted at this time. As stated earlier, the anthrax vaccine is not needed for the prophylaxis of potential exposures to anthrax, and the threat to the general population of either anthrax or smallpox is far less than the risk of reactions to the vaccines.

Q. What other precautions should I take to protect myself and my family?

A. Taking certain preventive measures in the event of an emergency, and using good judgment on general safety issues, makes sense and can reduce your anxiety about what to do when faced with the unexpected. Practical tips on these matters, including some suggested by the American Red Cross, are highlighted below:

Decide on a meeting place, away from your home or place of work, in the event you are evacuated. Make sure that all members of your household know about the meeting place.
Since local telephone lines can be overburdened in an emergency, it is helpful to identify someone out-of-town—ideally, in a place far enough away so as not to be affected by the same event—who is a central point of contact in case of an emergency. Be sure that all household members have the telephone number, and email address if available, of the contact person.
If you have school-age children, know the school emergency plan, as school telephones may be flooded with calls in an emergency. You should know if the school will keep children there until a parent or designated adult can pick them up or if they will be sent home on their own. Be sure that the school has accurate information about how to reach parents and responsible caregivers.
Keep a household emergency supply kit at home. It is a good idea to have some essential items on hand, in an easy to carry container, in the event of a power outage or if you should you be required to leave evacuate your home. These items include: a battery powered radio, a flashlight, extra batteries, a first-aid kit, bottled water, and any special needs items required by members of your household. You might also wish to include a whistle, high-energy snacks (such as power bars), gloves, and disposable dust or surgical masks for use in dusty environments if you need to reduce dust inhalation and eye and throat irritation .
Individuals who have a history of heart and lung conditions, or are in areas where smoke or dust is visible, are advised to remain indoors with the windows shut and air conditioners on recirculate or turned off. Persons with difficulty breathing or chest pain are advised to seek medical care immediately.
Keep a pair of comfortable walking shoes at your place of work. Public transportation systems may not function on normal schedules in an emergency and you may have to walk a long distance to get home or to a shelter.
Use common sense when it comes to safety. For instance, know how to exit your home quickly in case of emergency, and be sure to know where the emergency exists are located at your place of work and in other settings.
As always, observe good food hygiene. Wash your hands before preparing food. Be sure that meats and eggs are thoroughly cooked. Discard any food items that look or smell odd. Discard any bulging cans.
You may wish to keep antidiarrheals (such as Imodium) on hand for emergencies.
As a general precaution, homes and offices should keep on hand one gallon of water per person.

Q. Should I take precautions when opening suspicious mail or packages?

A. Use common sense. If you receive a suspicious package or letter from someone you don't know, don't open it. The Centers for Disease Control and Prevention (CDC) advises that you contact your local post office if you are concerned about the contents of a package you receive in the mail. Sending potentially hazardous agents through the mail for the purpose of deliberately causing harm to human health is a criminal offense.

More information on how to handle suspicious mail

Q. I find I'm really feeling anxious about these events. I'm having trouble sleeping and concentrating. What should I do?

A. It is normal to feel apprehensive in the current situation. Often, talking about your feelings with others is helpful. If your concerns are very troubling, and interfere with your normal life, don't hesitate to seek counseling. Professional counseling may be available through your employer, local social service agencies, or place of worship, as appropriate.

People living in the New York metropolitan area, especially those personally affected by the disaster, those providing care to the victims or their families, and those working on the relief effort are likely to experience emotional distress. The following American Red Cross and Department of Mental Health Hotlines can provide direct access to services:

American Red Cross (212) 787-1000
English Life NET (800) 543-3638
Spanish Life NET (877) 298-3373
Chinese Life NET (877) 990-8585

More information on dealing with risk

Q. Who prepared these materials?

A. This document was prepared by The Center for Public Health Preparedness at the Mailman School of Public Health, Columbia University. The Center is part of a national system of academic centers for public health preparedness established with funding from the Centers for Disease Control and Prevention (CDC). The Center for Public Health Preparedness works in close collaboration with the New York City Department of Health (NYCDOH), Columbia's School of Nursing and Columbia Presbyterian Medical Center, including the School of Nursing and with the other New York City health institutions. The Center is at the forefront of efforts to ensure that public health workers have the skills and competencies required to effectively respond to public health threats, with a special emphasis on preparing the frontline public health workforce to deal with the special threats posed by infectious diseases, bioterrorism, and other emergency situations.

Stephen S. Morse, PhD, Director of the Center for Public Health Preparedness, is a virologist/microbiologist and is an expert in emerging infectious diseases viruses and bioterrorism. Prior to directing the center, Dr. Morse served as program manager at the Defense Advanced Research Projects Agency (DARPA), Department of Defense, where he co-directed the Pathogen Countermeasures program, and directed the Advanced Diagnostics program. His book, "Emerging Viruses," (Oxford University Press), was listed by the "American Scientist" as one of the 100 top science books of the 20^th century.

Paul J. Edelson MD is a Professor of Clinical Pediatrics at Columbia University’s College of Physicians & Surgeons and an Investigator at the Center with a special interest in the clinical and psychological management of public health emergencies. He is a specialist in infectious diseases and has been a consultant to a wide range of federal, state, and city medical and scientific research agencies.

Other Mailman School of Public Health contributors to this document include: Allan Rosenfield, MD, Dean; W. Ian Lipkin, MD, Professor of Epidemiology and Director of the Center for Immunopathogenesis and Infectious Diseases; and, Susan V. Smith, MPH, Assistant Dean for Program Development.

Below, you will find a listing of web sites that have more information about bioterrorism and related issues.

RESOURCES AVAILABLE ON THE WEB

The following web sites contain information that complements what we present here. Although we have reviewed these sites, the Mailman School is not responsible for their content.

Bioterrorism

USAMRIID (US Army Medical Research Institute of Infectious Diseases)

"Blue Book" ("Medical Management of Biological Casualties"):

http://www.usamriid.army.mil/education/bluebook.html

CDC Bioterrorism Preparedness and Response:

http://www.bt.cdc.gov/

List of pathogens and data sheets:

http://www.bt.cdc.gov/Agent/Agentlist.asp

"Emerging Infectious Diseases" (journal): Special Issue on Bioterrorism:

http://www.cdc.gov/ncidod/eid/vol5no4/contents.htm

CDC Strategic Plan for Bio & Chem Terrorism (MMWR April 21, 2000):

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4904a1.htm