Infection Protection

In the Event of Bioterrorism: Protecting Families from Deadly Diseases

The threat of bioterrorism is on the minds of many parents. To address those concerns, PKIDs reviewed government reports and talked to biodefense specialists about what parents could do to prepare for an epidemic that could result from natural or terrorist activities.

If a biological weapon is ever released, it could take days for symptoms to develop and for the biological agent to be identified. Over the course of hours or days, hospitals and government health departments will notice an increase in specific disease or symptom outbreaks. They will determine the cause of the epidemic and deploy available antibiotics or vaccines, if they exist, to treat and prevent the spread of disease.

Currently, all doctors, hospitals and medical facilities are on high alert for any unusual disease outbreak that could be caused by suspected biologic agents.

There are about six agents that experts suspect would be used in a bioterrorist attack (see below). Most believe that anthrax and plague are among the most likely to be used. Currently, the federal government plans no widespread use or distribution of anthrax or smallpox (another suspected agent) vaccines, but the policy is under continual review.

If and when a terrorist-inspired epidemic occurs, parents should react the same way they would if there was a sudden, severe outbreak of influenza or some other serious epidemic in their local community.

Parents should limit their and their children’s exposure to infected individuals (if the disease can be transmitted person-to-person) and they can prepare for a possible quarantine within their homes. Here are some guidelines for such a scenario from public health specialists at the Johns Hopkins University Center for Civilian Biodefense Studies.

Prepare as if a hurricane or blizzard was coming. Every coastal home in Florida should have a supply of water, flashlights, fuel and food. Families across the country should do the same. In the event of an epidemic, a government-mandated quarantine or home stay is possible, depending on the agent used, and could range from one to three weeks. Access to grocery and drug stores may be limited during that time.

Place the phone number of local hospitals and city, county or state public health department in a prominent place. Public health departments will be monitoring disease outbreaks and will make recommendations about what precautions families should take. Health departments and other government agencies will decide whether to recommend children stay home from school. They will also advise families where to go for smallpox immunizations or for antibiotics that are used to prevent certain epidemics.

If parents are particularly anxious about what to do in the event of an epidemic, they should talk to their physicians now about any concerns they have and find out how well-informed the physician is.

You should do what you can to prevent the spread of infectious disease, no matter what the cause. If children are ill, don’t send them to school and spread the infection. If parents are ill, stay home.

Keep a first aid kit with antiseptic, bandages, anti-diarrhea medication and over-the-counter pain killers. Dr. Luciana Borio, a fellow at Johns Hopkins University Center for Civilian Biodefense Studies and a critical care medicine fellow at the National Institutes of Health, also recommends that parents should also keep a card with all their children's key medical information, such as medication schedule and food or drug allergies. “If a parent becomes ill, they want to make sure their children are taken care of appropriately,” Dr. Borio added.

Now for some guidelines on what not to do:

Don't stockpile antibiotics, said Dr. Borio. Of the suspected biologic agents that would cause widespread disease, three (anthrax, plague and tularemia) could be treated with antibiotics. But don't call the family doctor for a prescription. Antibiotics quickly expire, dosages vary and the timing of when to take antibiotics and for how long varies depending on the biologic agent used in an attack. For instance, in the case of anthrax, antibiotics must be administered before symptoms appear and in the case of plague, antibiotic treatment must continue for seven days following last exposure. The federal government already has a stockpile of antibiotics that will be deployed to infected areas in the event of an attack.

Don’t bother with a face mask (or dust mask). They won’t keep disease microbes away, said Dr. Borio. They are usually used to keep medical personnel from wiping their noses with their hands, which often carry infectious agents. The masks were seen in New York City to keep air-borne dust and asbestos particles out of noses and throats.

To date, mock or simulated bioterrorist attacks have shown the public safety and medical community to be lacking and disorganized in their responses. However, since the terrible destruction of the World Trade Towers, government agencies have been scrambling to put systems and reporting processes in place to quickly identify any emerging epidemic that could be caused by a bioterrorist.

Suspected Biological Weapons

Here is a summary of suspected biological agents taken from the National Centers for Disease Control and Prevention (CDC) and the Johns Hopkins University Center for Civilian Biodefense Studies.

Anthrax: As little as 100 kg of powdered Bacillus anthracis could cause 300,000 to 3 million deaths if released under the proper environmental circumstances into a densely populated region. The Iraqi government has admitted to producing as much as 8,000 liters of anthrax at their biologic weapon sites discovered during the Persian Gulf conflict.

Although mainly a disease of grazing animals, up to 2,000 cases of cutaneous anthrax occur worldwide in humans each year. Gastrointestinal disease is seen infrequently. There have been no cases of inhalational anthrax in the United States in 20 years. There is currently no atmospheric warning system to detect an aerosol cloud of anthrax spores. The first sign would likely be patients with symptoms of inhalation anthrax, with a non-specific fever and cough.

Those exposed to inhalational anthrax typically experience fever, dyspnea, headache, and chest pain. Once symptoms begin, death follows one to three days later. If appropriate antibiotics are not started before symptoms appear, the mortality rate is about 90 percent.

The United States has an anthrax vaccine that is not available to the civilian population and is not recommended for children under the age of 18. At this point it is available only to the military because of the risk the military may encounter in their work. Vaccine supplies are limited and production capacity in limited.

Plague: There have been 390 cases of plague over the last 50 years in the United States, most of which have followed an infected flea bite. The vast majority (84 percent) of these cases have been of the bubonic variety. Septicemic plague without the formation of buboes occurred in 13 percent of cases. Pneumonic plague has been the least common, accounting for only 2 percent of cases, but this virulent variety would be the goal of a bioterrorist.

Direct aerosolization of plague bacilli would be necessary to initiate this process, and person-to-person contact would spread and perpetuate the disease.

Symptoms begin one to six days after exposure, with fever, cough, and bloody or purulent sputum. Mortality is substantial without treatment.

Because there is no vaccine, uninfected people who have contact with the agent should immediately begin taking antibiotics for seven days from last exposure.

Smallpox: The last case of smallpox on Earth occurred in Somalia, in 1977. In 1980 the World Health Organization certified that smallpox had been eradicated from the planet. Currently, the only known remaining samples of smallpox virus are held in secure facilities at the Centers for Disease Control and Prevention in Atlanta and the Institute for Viral Preparations in Koltsovo, Russia.

As a result of the successful eradication program, smallpox vaccine was removed from the commercial market in 1983. The United States Public Health Service maintains an emergency stockpile of approximately 15 million doses.

Smallpox, a contagious and deadly blistering of the skin accompanied by pain and fever, has the potential to blow up into a worldwide plague. It is easily spread, it has a 30 percent fatality rate, there is no treatment and no one in the United States has been vaccinated since 1972. Vaccination immunity acquired before that time has undoubtedly waned.

The airborne infection can be spread easily from person to person, or from contact with contaminated clothing or bed linen.

It can take 12 to 14 days for symptoms, including high fever, malaise and prostration with headache and backache, to appear.

In 2000, CDC awarded a contract to Oravax of Cambridge, Mass., to produce initially 40 million doses with delivery beginning in 2004. British biotechnology firm Acambis Plc announced recently it would soon begin testing a new smallpox vaccine.

Botulinum Toxin: This toxin poses a major bioweapons threat because of its extreme potency and lethality; its ease of production, transport and misuse; and the potential need for prolonged intensive care in affected persons. Botulinum toxin is the single most poisonous substance known.
Human to human transmission has not been documented.

A number of states named by the U.S. State Department as "state sponsors of terrorism" have developed or are developing botulinum toxin as a biological weapon.

Naturally occurring botulism is the disease that results from the absorption of botulinum toxin into the circulation from a mucosal surface (gut, lung) or a wound. It does not penetrate intact skin. The toxin causes muscle paralysis, and in severe cases, can lead to a need for mechanical respiration.

The average incubation period is 12 to 72 hours after ingestion. Patients with botulism typically present with difficulty speaking, seeing and/or swallowing. Patients may initially present with gastrointestinal distress, nausea, and vomiting preceding neurological symptoms.

Symptoms are similar for all toxin types, but the severity of illness can vary widely, in part depending on the amount of toxin absorbed. Recovery from paralysis can take from weeks to months and requires the growth of new motor nerve endings.

There is an anti-toxin available. In the event that there is a clinical suspicion of botulinum toxin, treatment with antitoxin should not be delayed for microbiological testing. In the U.S., licensed botulinum antitoxin is available from the CDC via state and local health departments.

Tularemia: Francisella tularensis, the organism that causes tularemia, is one of the most infectious pathogenic bacteria known, requiring inoculation or inhalation of as few as 10 organisms to cause disease. It is considered to be a dangerous potential biological weapon because of its extreme infectivity, ease of dissemination, and substantial capacity to cause illness and death.

Human to human transmission has not been documented.

Aerosol dissemination of F. tularensis in a populated area would be expected to result in large numbers of cases of acute, non-specific febrile illness beginning three to five days later. Without antibiotic treatment, the clinical course could progress to respiratory failure, shock and death.

In the United States, a vaccine has been used to protect laboratory personnel routinely working with F. tularensis. Given the short incubation period of tularemia and incomplete protection of current vaccines against inhalational tularemia, vaccination is not recommended for post-exposure prophylaxis.
Given the lack of human-to-human transmission, isolation is not recommended for tularemia patients.

Hemorrhagic Fever Agents: Viral hemorrhagic fever viruses may also be used as bioterrorism agents. These viruses induce fever, prostration and diffuse vascular damage, often leading to thrombocytopenic hemorrhage. Viral hemorrhagic fever patients require intensive medical care and substantial resources. Without proper isolation practices, the spread of these fever viruses is not uncommon.

Additional resources on bioterrorism and disaster planning can be found at:

University of Pittsburgh Medical Center—Center for Biosecurity

American Red Cross

National Centers for Disease Control and Prevention's Bioterrorism Preparedness and Response http://www.bt.cdc.gov or call 1-800-311-3435

American Academy of Pediatrics—Children, Terrorism and Disasters

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Important disclaimer: The information on pkids.org is for educational purposes only and should not be considered to be medical advice. It is not meant to replace the advice of the physician who cares for your child. All medical advice and information should be considered to be incomplete without a physical exam, which is not possible without a visit to your doctor.


Top 4 ways to prevent the spread of disease:

  1. Wash your hands often.

  2. Get immunized.

  3. Practice standard precautions.

  4. Disinfect regularly.