Chemical and Biological Terrorism

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Chapter 68 Chemical and Biological Terrorism

Fred M. Henretig, MD

1 What happened in Tokyo on March 20, 1995?

On March 20, 1995, at the height of morning rush hour, members of the Japanese Aum Shinrikyo religious cult placed containers of the deadly nerve agent sarin in various downtown locations of the Tokyo subway system and unleashed a new era in terrorism. This same group attempted unsuccessfully to deploy anthrax and botulinum toxin weapons on several occasions. The chemical warfare attack on Tokyo affected more than 5000 victims and caused 12 deaths.

Henretig FM, Cieslak TJ, Madsen JM, et al: Emergency department awareness and response to incidents of biological and chemical terrorism. In Fleisher GF, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 135–162.

Rotenberg JS, Newmark J: Nerve agent attacks on children: Diagnosis and management. Pediatrics 112:648–658, 2003.

2 How is the Tokyo incident typical of recent terrorism?

Prior decades had witnessed numerous attacks targeted at military installations, government officials or representatives, or, on occasion, relatively small groups of ordinary civilians in highly visible circumstances. In the 1990s a new threshold was crossed, however, with the rise of religious terrorism that allows violence as a seemingly justifiable means to accomplish a sacred theological imperative. Several terrorist incidents over the past decade, such as the Oklahoma City bombing and, of course, the attacks of September 11, 2001, on the World Trade Center and the Pentagon have highlighted this new willingness to kill large numbers of innocent people indiscriminately. An especially disturbing scenario in terms of the medical management challenges posed is that of the use of biologic and chemical weapons as a means of terrorism. In 1984, the Rajneeshee cult sickened 750 citizens of The Dalles, a town in Oregon, by intentionally contaminating restaurant salad bars with Salmonella typhimurium. More recently, persons linked to white-supremacist militias have obtained anthrax, stockpiled the highly toxic substance ricin (a biotoxin extracted from castor beans), and have been arrested for transporting the bacterium Yersinia pestis, the etiologic agent of bubonic plague. In 1995, the FBI thwarted an attempt to release a chlorine gas bomb in Disneyland, an attack obviously targeted particularly at children. And then came the mysterious epidemic of illness that began in October 2001.

3 What did we learn from the anthrax outbreak of 2001?

This outbreak was characterized by 22 confirmed or suspected cases (11 inhalational, 11 cutaneous), with five deaths, resulting from presumed or known exposure to anthrax-contaminated mail. At least five letters containing highly weaponized anthrax spores were sent to government and business offices in Florida, Washington, DC, and New York City from Trenton, New Jersey. This means of dispersal represents one mode of attack, but many bioterrorism defense experts fear even more a widespread aerosol release (e.g., from a small crop duster–type airplane) that could potentially sicken hundreds of thousands. As it was, even the 2001 attack resulted in enormous public anxiety and major demands for medical care and public health resources. Antibiotic prophylaxis was prescribed for over 30,000 persons, and decontamination of just the Hart Senate Office Building alone took months and cost more than $20 million.

Centers for Disease Control and Prevention: Update: investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR Morb Mortal Wkly Rep 50:909–919, 2001.

4 Why are such incidents of particular importance to emergency department (ED) personnel?

Such incidents illustrate the potential for biologic or chemical terrorist attacks, thus the imperative that health care workers, particularly first-responders and ED personnel, be familiar with the expedient diagnosis and management of chemical and biologic terrorist events.

5 What are the four basic phases of disaster response?

1 Preparedness

2 Actual response

3 Mitigation

4 Recovery, both short and long term

Agency for Healthcare Research and Quality: Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians: www.ahrq.gov./research/pedprep/resource.htm

6 Why do terrorists use biologic and chemical weapons?

The term weapons of mass destruction (WMD) has been used to denote weapons using nuclear, biologic, or chemical agents in devices intended to kill and injure large numbers of victims. Biologic and chemical weapons are believed by U.S. military and counterterrorism experts to constitute a likely mode of WMD attack on civilian populations by terrorist groups. These agents are relatively inexpensive and technically less difficult to produce and deploy than nuclear weapons, the raw materials for their production are less regulated, and there is wide access to biologic and chemical agent information via the Internet.

Chemical and biologic weapons can be deployed easily, using relatively simple devices, such as garden sprayers, aerial crop dusting equipment, or insect control vehicles. In addition, a conventional attack on factories, chemical production facilities, or tank cars may result in the release of toxic industrial chemicals, with effects similar to those of an attack by military chemical warfare agents. Biologic agents may involve aerosol dispersal or possible contamination of food or water supplies.

7 What are the potential medical consequences of a chemical attack?

Chemical attacks probably would combine elements of traditional mass disasters (e.g., earthquakes), in which large numbers of casualties occur almost immediately, and traditional hazardous materials (HAZMAT) incidents. However, they may be more catastrophic for several reasons:

image Intent to inflict mass casualties

image Hazardous materials of extreme lethality

image HAZMAT site that is extremely toxic to rescue workers

image Less information about agent(s) involved

image Potentially overwhelming numbers of patients requiring emergency medical services (EMS)

image Even larger number of mildly affected or “worried-well” patients self-transporting to EDs and placing additional demands on the health care system

image Mass hysteria and panic

Henretig FM, Cieslak TJ, Eitzen EM Jr: Biological and chemical terrorism. J Pediatr 141:311–326, 2002.

8 Which of these features were observed in the 1995 Tokyo sarin attack?

One ED close to the scene received more than 500 patients, including three in cardiopulmonary arrest. Citywide, over 5000 persons sought emergency medical treatment at more than 200 facilities within a few hours, and about 25% required hospitalization. Of note, 90% of victims went to hospitals by taxi, private vehicles, or on foot rather than by formal EMS transport, further compounding the initial chaos. Until the identity of the agent was known, significant efforts at patient decontamination were lacking, resulting in many symptomatic exposures to hospital staff, although most were mild.

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