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Medical Aspects of Combating Acts of Bioterrorism

Gennady G. Onishchenko*

Russian Ministry of Health


The national strategy for health protection against infectious diseases must also take into account the problem of combating bioterrorism, a problem that is the focus of increasing attention on the part of the government, the public, and specialists in many countries. Underestimating modern biological capabilities and the dangers they entail could have a disastrous impact on the national security of the state.

The imperfect nature of mechanisms for monitoring compliance with the chemical and biological weapons conventions, suspicions regarding the continuation of work on biological weapons programs, and a number of incidents involving attempts to intentionally use biological agents for terrorist purposes are evoking serious concerns that terrorists might actually use biological means as weapons.

One of the first and most illustrative examples of the use of bioterrorism was the intentional poisoning of residents of a small city in the state of Oregon (United States) in September 1984 by means of adding Salmonella typhimurium to the salad dressing at 10 of the city’s most popular restaurants. The aim of this action was to cause a massive number of food poisoning cases and thus affect the outcome of local elections according to the interests of representatives of a cult sect. Two points are worthy of note. First, officials investigating the mass poisoning incident took a year to determine that the Salmonella had been introduced by terrorists. Second, the American authorities prohibited any information about this incident from being published for 12 years because of their concerns that it might serve as an example for other extremists throughout the country.

*

Translated from the Russian by Kelly Robbins.



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Medical Aspects of Combating Acts of Bioterrorism Gennady G. Onishchenko* Russian Ministry of Health The national strategy for health protection against infectious diseases must also take into account the problem of combating bioterrorism, a problem that is the focus of increasing attention on the part of the government, the public, and specialists in many countries. Underestimating modern biological capabilities and the dangers they entail could have a disastrous impact on the national securi- ty of the state. The imperfect nature of mechanisms for monitoring compliance with the chemical and biological weapons conventions, suspicions regarding the continu- ation of work on biological weapons programs, and a number of incidents in- volving attempts to intentionally use biological agents for terrorist purposes are evoking serious concerns that terrorists might actually use biological means as weapons. One of the first and most illustrative examples of the use of bioterrorism was the intentional poisoning of residents of a small city in the state of Oregon (United States) in September 1984 by means of adding Salmonella typhimurium to the salad dressing at 10 of the city’s most popular restaurants. The aim of this action was to cause a massive number of food poisoning cases and thus affect the outcome of local elections according to the interests of representatives of a cult sect. Two points are worthy of note. First, officials investigating the mass poi- soning incident took a year to determine that the Salmonella had been introduced by terrorists. Second, the American authorities prohibited any information about this incident from being published for 12 years because of their concerns that it might serve as an example for other extremists throughout the country. *Translated from the Russian by Kelly Robbins. 12

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10 RUSSIAN VIEWS ON COUNTERING TERRORISM Other subsequent cases involving the attempted use of biological agents for terrorist purposes have triggered a flood of publications and numerous scientific conferences and have spurred many countries, especially the United States, to institute many legislative, legal, organizational, medical, and other measures aimed at countering bioterrorism. The United States has devoted substantial sums to the problem of fighting bioterrorism, including on matters of “internal preparedness,” inasmuch as expert analyses, evaluations, and inspections have led to the conclu- sion that in most cases, public service agencies are not prepared to respond to terrorist attacks involving the use of biological weapons. Efforts are under way to implement a program to develop and create stockpiles of 18 new vaccines, includ- ing a new smallpox vaccine. In addition, funds have been allocated to create a stockpile of medicines and antibiotics, which are intended primarily for use by police, fire, and emergency medical personnel. Appropriate attention is being fo- cused on the fight against terrorism in Russia as well. The Interagency Antiterror- ism Commission was created in 1997, the State Duma passed the Law on Combat- ing Terrorism in July 1998, and the Government of the Russian Federation issued a resolution establishing a federal targeted program in 1999. Although many countries have well-prepared systems for combating ordi- nary terrorism and dealing with emergency situations (floods, earthquakes, acci- dents, and catastrophes), none has put in place a complete set of measures for meeting this new threat. This is because for many reasons it is extremely diffi- cult to combat the use of biological agents for terrorist purposes (the large num- ber of potential agents, the long incubation period, the lag time before symptoms of illness appear, the possibility of secondary infection and the further spread of the disease, and so forth). Medical personnel must also play a special role when bioterrorist acts are carried out. They must understand the epidemiological situation and know the potential biological agents and the symptoms of the infectious diseases they cause, which as a rule would differ from those of naturally occurring illnesses. They must also be aware of treatment protocols and measures for preventing the spread of epidemics. However, the current state of affairs is such that most clinical microbiological laboratories have neither the capabilities nor the experi- ence in real-life detection and identification of infectious agents from a list of those that might be used by bioterrorists, such as anthrax, brucellosis, botulism, cholera, plague, smallpox, hemorrhagic fever viruses, and others. Biological agents of critical importance from the standpoint of civilian pub- lic service preparedness may be divided into the following three categories based on their characteristics: 1. Category A • smallpox (Variola major) • anthrax (Bacillus anthracis)

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11 TERRORISM • plague (Yersinia pestis) • botulism (Clostridium botilinum) • tularemia (Francisella tularensis) • hemorrhagic fevers (filoviruses, arenaviruses, and so forth) 2. Category B • Q-fever (Coxiella burnetii) • brucellosis (Brucella spp.) • glanders (Burkholderia mallei) • melioidosis (Burkholderia pseudomallei) • viral encephalitis (Venezuelan equine encephalitis, Western equine encephalitis, Eastern equine encephalitis, and so forth) • typhus (Rickettsia prowazekii) • psittacosis (Chlamydia psittaci) • foodborne agents (Salmonella spp., Shingella dysenteriae, E. coli 0157:H7, and so forth) • waterborne agents (Vibrio cholerae, Cryptosporidium parvum, and so forth) 3. Category C Newly emerging agents (antibiotic-resistant bacteria and tuberculosis, Nipah virus, AIDS, and so forth) Without denying that health care institutions respond rather adequately to naturally occurring infectious disease outbreaks, it must be noted that a signifi- cant proportion of the methods currently used in Russia to identify pathogens do not meet the necessary standards for identifying biological agents that are used intentionally. These methods have become outdated and are unsatisfactory pri- marily from the standpoint of the time required to use them. The system of scientific, organizational, and other measures aimed at im- proving the preparedness of the health care system for meeting the threat of bioterrorism must not undermine the measures already in place to combat infec- tious diseases. Instead, it should promote the constant improvement of the health care and biomedical research infrastructure and facilitate cooperation involving the capabilities of other agencies, such as the Ministry for Emergency Situations, regional units of the sanitary-epidemiological service, and relevant scientific research institutes. The most important measures to be taken in improving these efforts would include the following:

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12 RUSSIAN VIEWS ON COUNTERING TERRORISM • The major regional centers, especially those with international airports, should have permanently operating infectious disease hospitals equipped to at least the P-3 biosafety level. • These hospitals must be amenable to continuously improving their meth- ods for treating infectious diseases, up to and including being willing to partici- pate in clinical trials of new drugs and actually doing so. • Regional clinical microbiological and immunological laboratories are also needed, and it is important that they be fully operational according to the highest modern standards. They should be associated with the infectious disease hospi- tals mentioned above and should be equipped to at least the P-3 biosafety level. • These laboratories must be open to new technologies and methods of identifying, diagnosing, and deactivating infectious agents, and in this regard, they must support close linkages with the relevant scientific research institutes working in the given field. The following actions should be taken as part of the Federal Scientific Re- search Program on Combating Bioterrorism: • Develop new express immuno-enzyme and other test systems for detect- ing antigens and antibodies as markers for hemorrhagic fever viruses, smallpox, anthrax, tularemia, plague, legionellosis, malaria, and so forth. • Develop various types of polymerase chain reaction (PCR) diagnostic tests, including those using biochip technology, for express diagnosis and detec- tion of pathogens within a few hours or even minutes. • Establish modern, well-equipped PCR laboratories in various regions of Russia. • Conduct additional research on the pathogenic characteristics of espe- cially dangerous infectious agents and search for new medications for treatment and emergency prophylaxis of individuals infected with these agents. • Develop vaccines against infectious agents for which none yet exist or for which existing vaccines are inadequately effective or unsatisfactory for other reasons. • Provide specialized training for medical personnel and laboratory work- ers in safe methods for handling, analyzing, and detecting such agents in re- search centers and clinics with real experience in this area. Efforts in these areas will not only bring real results in the struggle against bioterrorism but will also improve the health care situation in general.