The History of Bioterrorism

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The History of Bioterrorism

• Fred T Muwanga MD Msc

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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).

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Reported Cases of Bioterrorism

• 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.

• 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

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Casualties
Incident
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
no deaths
(45 hospitalised)
AUM
Shrinkyo
5500 ( 641 seen at
106 hospitalised at
SLIH on day 1
SLIH. 12 deaths (2
349 following week)
at
SLIH)
Dr.Suzuki
200
4 deaths
Anthrax(USA)
22
4 deaths
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Motive for bioterrorism
Incident
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 the
non-
Rajneeshee voters
AUM
Shrinkyo
Seize control of Japan through mass
murder, causing fear and apprehension
Dr.Suzuki
Revenge for unfair treatment he received
at the medical training
Anthrax (USA)
Inculcate fear
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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.

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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.

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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.

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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 Britains biological and
  chemical weapons research center in Porton Down.

10
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.

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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.

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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.

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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.Lukes
  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.

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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

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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.

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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

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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(gt3g) 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.

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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 .

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Confirmed cases of anthrax by State
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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 patients home, work site, travel
  site, mail or package delivery.
• questionnaires were administered at the index
  patients 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.

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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

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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)

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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

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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 ?