Bioterrorism

 

Am Fam Physician. 2021 Oct ;104(4):376-385.

Bioterrorism is the deliberate release of viruses, bacteria, toxins, or fungi with the goal of causing panic, mass casualties, or severe economic disruption. From 1981 to 2018, there were 37 bioterrorist attacks worldwide. The Centers for Disease Control and Prevention (CDC) lists anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers as category A agents that are the greatest risk to national security. An emerging infectious disease (e.g., novel respiratory virus) may also be used as a biological agent. Clinicians may be the first to recognize a bioterrorism-related illness by noting an unusual presentation, location, timing, or severity of disease. Public health authorities should be notified when a biological agent is recognized or suspected. Treatment includes proper isolation and administration of antimicrobial or antitoxin agents in consultation with regional medical authorities and the CDC. Vaccinations for biological agents are not routinely administered except for smallpox, anthrax, and Ebola disease for people at high risk of exposure. The American Academy of Family Physicians, the CDC, and other organizations provide bioterrorism training and response resources for clinicians and communities. Clinicians should be aware of bioterrorism resources.

Bioterrorism is the deliberate release of viruses, bacteria, toxins, or fungi with the goal of causing panic, mass casualties, or economic disruption.1 Historical records indicate that biological warfare has occurred throughout history, as long ago as the 14th century B.C.2

WHAT'S NEW ON THIS TOPIC

Bioterrorism

In 2018, the U.S. Food and Drug Administration approved tecovirimat (TPOXX) for the treatment of smallpox.

Bioterrorism is currently considered a low-probability event; however, several pathogens that could be used in bioterrorist attacks (i.e., anthrax, botulism, plague, Ebola virus, and Lassa virus) occurred naturally in endemic regions in 2020.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Tecovirimat (TPOXX) may be used for the treatment of smallpox in addition to post-exposure vaccination.33

C

Consensus guideline

Botulism antitoxin heptavalent (A, B, C, D, E, F, G - equine) should not be delayed for the treatment of suspected botulism poisoning while awaiting formal confirmation.43

C

Consensus guideline

Vaccination for smallpox, anthrax, and Ebola disease should be considered for people at high risk of exposure.2225

C

Consensus guidelines


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Tecovirimat (TPOXX) may be used for the treatment of smallpox in addition to post-exposure vaccination.33

C

Consensus guideline

Botulism antitoxin heptavalent (A, B, C, D, E, F, G - equine) should not be delayed for the treatment of suspected botulism poisoning while awaiting formal confirmation.43

C

Consensus guideline

Vaccination for smallpox, anthrax, and Ebola disease should be considered for people at high risk of exposure.2225

C

Consensus guidelines


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Although many pathogens may be used in a bioterrorist attack, the most concerning agents to national security and public health are anthrax, smallpox, plague, tularemia, botulism, and viral hemorrhagic fevers, in descending order of likelihood1  (Table 13). These pathogens are considered category A agents by the Centers for Disease Control and Prevention (CDC) and are the focus of this article.

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TABLE 1.

Centers for Disease Control and Prevention Potential Biological Agents

CategoriesBacteriaVirusesToxins

A: most concerning to national security and public health because of ease of dispersal, transmission between people, high mortality rates, and the potential to cause panic; significant planning needed for public health preparedness

Anthrax: Bacillus anthracis Plague: Yersinia pestis Tularemia: Francisella tularensis

Smallpox: variola major Viral hemorrhagic fevers: Ebola, Lassa, Machupo, Marburg

Botulism: Clostridium botulinum

B: lower mortality rates compared with category A agents; relative ease of dissemination and moderate morbidity; requires special resources for surveillance and diagnostics

Brucellosis: Brucella species Salmonella* Escherichia

The Authors

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NICHOLAS A. RATHJEN, DO, is a family physician at Madigan Army Medical Center, Joint Base Lewis-McChord, Wash....

S. DAVID SHAHBODAGHI, MD, MPH, is the officer-in-charge and medical director of the East Bliss Health and Dental Center, and the hospital continuing medical education director at William Beaumont Army Medical Center.

Author disclosure: No relevant financial affiliations.

Address correspondence to Nicholas A. Rathjen, DO, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431 (email: nicholas.a.rathjen@gmail.com). Reprints are not available from the authors.

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