Preparing for Bioterrorism
By Nathan Kinsey
Abstract:
Bioterrorism is a modern threat that no country on earth is currently prepared for.
There is not enough preventative medicine to combat the most likely methods of attack,
government agencies and citizens have too little information on the threat, and detection
systems are too primitive to prove effective in the event of an attack. There is obviously
no surefire way to prevent all possible biological attacks, but there is still capacity for
critical improvements in the realm of biodefense.
In 2015, the year at the time of writing, it is clear that terrorism is evolving. Modern
terror groups like Islamic State (ISIS) are making great use of new developments such as using
social media to mobilize people globally in a short amount of time. Recruitment techniques are
not the only things that terrorists are updating for this century; they are looking beyond
conventional bombs and chemical warfare towards a deadlier form of attack—pathogens.
Terrorists are evolving at such a pace that most countries are unable to keep up. Such a delay
could prove lethal. All nations, including the United States, are not properly equipped with the
medical knowledge, communication systems, and surveillance programs necessary to prevent
and to respond to acts of biological terrorism.
The most elementary way to prepare for a biological attack is through scientific
advancements in the research of infectious diseases. Both preventative and therapeutic medicine
are simply not sophisticated enough to combat Category A agents. Category A agents are defined
as the most likely pathogens to be used in a bioterrorist attack, due to their highly lethal and
infectious potential. This category includes: smallpox, anthrax, plague, botulinum toxin,
tularemia, and the viral hemorrhagic fevers (Knobler, Mahmoud, and Pray 22). By focusing
future research on the aforementioned pathogens, society as a whole will be capable of warding
off some of the most dangerous agents of biological terrorism.
In order to fully understand modern science’s level of preparation against pathogens, one
must know about the preventative and therapeutic measures that are used to fight off all disease,
whether the result of a terrorist attack or not. There are two main types of preventative medicine:
traditional vaccines and DNA vaccines. Traditional vaccines are typically harmless replications
of a specific aspect of a pathogen. The immune system sees the fake invaders and develops
antibodies to defend against the actual threat. DNA vaccines are a relatively new development
that creates a large response from the immune system to a wide variety of infectious diseases.
They are safer than traditional vaccines, as there is no risk of the recipient developing the illness
from the altered DNA (Wang 1). Alternatively, therapeutic medicine treats infections after they
occur. For example, antibiotics kill bacteria directly, without relying on the immune system.
Similarly, antivirals destroy viruses which are different from bacteria because viruses are not
actually classified as living organisms. Both viruses and bacteria don’t usually cause harm by
themselves, but release toxins that damage the host. Antitoxins are therefore designed to
eliminate these harmful antigens. Lastly, recombinant monoclonal antibodies mimic natural
antibodies and assist the immune system in locating and eliminating pathogens effectively (Mayo
Clinic Staff). These six main medicinal groups form the foundation of all current treatment
options available for use after a biological attack.
With a plethora of options to choose from, one may wonder why such science has not
adequately prepared the public for any and all infectious diseases. The answer lies in the fact that
the previously stated methods are still new and imperfect. In addition to that, external, nonscientific obstacles inhibit progress. Outcry, often the result of fear and gross misinformation,
hinders the widespread use of well-tested vaccines such as those for anthrax and smallpox. Such
resistance makes comprehensive defense a major challenge (Knobler, Mahmoud, and Pray 88).
Also, the vaccines that are created have inherent flaws due to the nature of vaccines. The
Department of Defense (DoD) develops vaccines to work on healthy adults, potentially
compromising the youth, the immunodeficient, and the geriatric (Knobler, Mahmoud, and Pray
85). DNA vaccines that are safe for the immunocompromised are hardly useful in the context of
infectious disease control. A Forum on Emerging Infections recommends that we “[improve] the
usefulness of DNA vaccines, which work well in rodents but not in primates” (Knobler,
Mahmoud, and Pray 87). Unfortunately, therapeutic medicine is not much better. Antibiotics are
in high demand, but take a long time to develop. The cost of large clinical trials discourages
pharmaceutical companies from researching new classes of antibiotics. As a result, new
antibiotics are developed into existing classes, making retrospective treatment alarmingly
difficult (Knobler, Mahmoud, and Pray 113). The treatment of viruses in epidemic scenarios is
even more complicated than that of bacteria. Current antiviral drugs are unsuitable for
combatting bioterrorist attacks, due to their severe side effects or unclear mass treatment
strategies (Knobler, Mahmoud, and Pray 114). When attacking the pathogen itself is not an
option, treating the symptoms is a logical solution. With many infectious diseases, antitoxins are
an invaluable tool. Antitoxins to pathogens, such as anthrax, have proven promising and have
been developed. However, most Category A agents remain without a viable antitoxin (Knobler,
Mahmoud, and Pray 114). Recombinant monoclonal antibodies have proven effective against
anthrax, smallpox, and botulinum neurotoxins. Antibodies are advantageous as they are safe and
are quick to be approved, as compared to other therapeutics. However, they are a relatively
recent development and are not as heavily stocked as antibiotics and antivirals (Knobler,
Mahmoud, and Pray 114). Simply put, the medicine needed to combat all Category A agents is
currently not sophisticated enough to be considered adequate biodefense.
One can clearly see the benefits and drawbacks to using the various methods of
preventative and therapeutic medicine. There is massive room for improvement to the arsenal of
medicine that fights Category A agents of bioterror. Although anthrax has been previously used
with great success to strike fear into the hearts of the public, the bacteria is no longer worthy of
such fear. Anthrax can currently be combatted by vaccines, antibiotics, and antitoxins (Knobler,
Mahmoud, and Pray 44). Smallpox, on the other hand, is a major concern. There is a vaccine
against smallpox but does not fully counter the pathogen and cannot be used in
immunocompromised individuals (Knobler, Mahmoud, and Pray 44-45). The infamous bubonic
plague is still relevant in bioterrorism attacks. There is currently no vaccine against plague that
comes without major side effects. However, plague can be successfully treated with antibiotics,
as long as it is caught at an early stage (Knobler, Mahmoud, and Pray 45). Tularemia was
designed to be vaccine resistant and thus has a minimally useful vaccine to fight it; though, It can
be treated with extensive antibiotics (Knobler, Mahmoud, and Pray 45-46). Lastly, botulinum
toxin requires a rapid response by a medical professional and treatment can span months. The
vaccine is only marginally effective and is reported to be quite painful (Knobler, Mahmoud, and
Pray 46). Moreover, the deficiencies in modern science dangerously complement governmental
lack of preparation against bioterrorism.
Medical preparedness is but one aspect of a large defence strategy meant to combat
bioterrorism; governmental and citizen preparedness are almost equally important factors.
Beginning in 1999, the Department of Health and Human services (DHHS) began to prepare for
bioterrorist attacks with grants from the Centers for Disease Control and Prevention (CDC) that
covers the establishment of systems for the purpose of laboratory science, surveillance, and
preemptive measures (Knobler, Mahmoud, and Pray 39). Currently, the government has made
great strides in the development of such systems, but the resulting protection is far from
comprehensive. Also, establishing communication with the public still seems like an afterthought
to most major countries, leaving the citizens in the dark, unprepared.
In the instance of the American government, certain sectors are more prepared for a
biological attack than others. This practice leaves the country as a whole unready to face
bioterror scenarios. For instance, the U.S. military has done a good job at protecting soldiers
against Category A agents, but vaccines are designed to be effective on men and women between
eighteen and forty, i.e. the majority demographic of soldiers. For understandable reasons, the
military is not overly concerned about vaccines for other demographics, such as small children or
the elderly (Knobler, Mahmoud, and Pray 23). Vaccines provide the best defense against
infection in addition to serving as a strong deterrent to terrorists. However, there is a limited
amount of resources allocated to synthesizing new vaccines. This is a problem largely due to the
fact that it takes eight to ten years to develop a vaccine that may or may not prove effective,
whereas it takes two to three years to develop an agent of bioterror (Knobler, Mahmoud, and
Pray 85). Unfortunately, these statistics have not evoked a strong enough response to actually
mend the gaps in US bioterror defence strategies. In fact, security at both naval and land borders
are remarkably easy to bypass. Irwin Redlener, Director of the National Center for Disaster
Preparedness, notes in his book, Americans at Risk, “[Ninety-nine] percent of American exports
leave by ship, and nearly 4 million people work in port related jobs. And yet only about 5.5
percent of the containers that pass through our ports are being inspected” (64). Bioterror has
further implications than mass casualties; an easy exploit of port security can promptly bring the
US economy to a halt. Although land borders are more comprehensively surveilled, they are not
impervious to a terrorist on a mission: “Large stretches of both borders remain unguarded, a fact
[...] extremists know well. With minimal creativity and intelligence, anyone can slip into the
country” (Redlener 66). Obviously, there is no perfect solution to block each and every possible
point of ingression into to a country. In fact, a major obstacle that plagues emergency
preparedness planners rests in the fact that one cannot realistically imagine all possible scenarios
and develop a contingency plan for each (Redlener 144). However, it does not take all that much
imagination to find current border inspections inadequate. Multiple branches of the government
need to share knowledge with one another, in an effort to improve everyone’s level of
preparation, as a well fortified military clearly does not mean a well fortified homeland.
Sadly, communication between governmental divisions as well as that between the
government and its citizens have proven themselves as flawed. According to Anthony S. Fauci, a
medical doctor from the National Institute of Allergy and Infectious Diseases (NIAID),
biodefense preparedness requires multiple sectors of DHHS to work together, including: the
CDC, the National Institutes of Health (NIH) for conducting general research, the Food and Drug
Administration (FDA) for approving vaccines and diagnostic devices, and the Office of
Emergency Preparedness (OEP) for allocating resources to state and county governments
(Knobler, Mahmoud, and Pray 22). With so many national agencies working towards solutions,
it is not hard to see why there might be a problem involving subpar communication. To the
detriment of interagency cooperation, the aforementioned list of agencies is but a small fraction
of the organisations involved in preparation work: “More than eighty committees and
subcommittees” are entrusted with bioterrorism preparedness funds, and they each work
independently, with little or strained communication between them (Redlener 135). While
communication within the government is essential for research and the creation of defence
resources, communication from the government to the people is important for both before and
after biological attacks. Citizen education and involvement has made Israel the “most prepared in
the world” to respond to threats of biological warfare. The Israeli public is highly trained on how
to respond to large-scale emergencies and public buildings are, by law, designed with biological
safety in mind (Redlener 205). In contrast to Israel, the United States has historically proven to
hinder the public more than it helps. Bioterrorism is inherently more threatening than a
conventional bomb because the effects are less obvious and immediate. Delayed communication
causes mass panic and chaos in countries that have not proactively set up post-attack
communication systems. Preparing for proper post-attack communications is an important step,
as the media incorrectly reported essential information in a Florida anthrax attack, mistaking
false positives for confirmed positives (Knobler, Mahmoud, and Pray 40). In summation, preestablished protocols for releasing information to both within and outside of the government are
nearly as important as vaccines or antibiotics.
Before the government can clearly communicate information about a biological attack
and before medical professionals can properly treat an incomprehensible mass of patients, there
has to be a system that alerts officials that an attack has taken place. Biological attacks don’t
necessarily make any noise, light, or smell. If desired by a terrorist, the very food that we eat
could be laced with pathogens and no one would suspect a thing until it was too late. For this
reason, there must be systems that can reliably detect these covert attacks. Prompt surveillance
and detection are vital in a bioterror situation, as delayed detection puts additional stress onto the
healthcare system (Knobler, Mahmoud, and Pray 182). Environmental and clinical detection is
difficult due to the large number of established pathogens and the possibility of bioengineered
agents. The most important factor of automated detection systems is a standardized method of
collecting samples. That way, a centralized computer system with access to “extensive sequence
databases” can not only compute what agent to treat citizens for, but can also identify where the
offending agent originated (Knobler, Mahmoud, and Pray 183). As previously stated, a
bioterrorist may create never before seen pathogens and automated environmental systems would
fail to alert the public. International surveillance systems, such as the Electronic Surveillance
System for the Early Notification of Community-Based Epidemics (ESSENCE), computationally
analyze data from medical facilities and alert officials of possible outbreaks (Knobler, Mahmoud,
and Pray 182-183). In layman’s terms, a computer analyses massive amounts of data from
healthcare providers and attempts to find patterns hinting at a possible epidemic. Not only would
such a system help with natural outbreaks, but would also detect those caused by bioterrorism.
Logically, ESSENCE can only work if it has data from almost every hospital and clinic in the
nation and / or world. Currently, that is far from the case. To summarize, environmental and
clinical surveillance systems must be established to alert governments and healthcare
professionals of biological attacks as they are happening, to minimise casualties.
Looking towards the future, all countries need to further the development of preventative
and therapeutic medicine, interagency and public communication systems, and environmental
and clinical surveillance programs. Although many valuable strides have been made in the name
of biodefense, much more must be done to ensure a well defended homeland. The world should
take note of powerful examples such as Israel, who have taken many precautions against
biological terrorism already. With current threats of bioterror coming from terrorist groups such
as ISIS, there is little question as to if an attack will take place; the real question is when it will
occur. The only thing that the public can do is prepare.
Works Cited
L. Knobler, Stacey, Adel A.F. Mahmoud, and Leslie A. Pray. Biological Threats and Terrorism:
Assessing the Science and Response Capabilities. Washington, DC: National Academy
Press, 2002. Print.
Mayo Clinic Staff. "Monoclonal Antibody Drugs for Cancer: How They Work." Mayo Clinic
2014. Web. July 13 2015.
Redlener, Irwin. Americans at Risk: Why We Are Not Prepared for Megadisasters and What We
Can Do Now. 1st ed. New York: Alfred A. Knopf, 2006. Print.
Wang, Y., et al. "Immune Responses of M-Csf-R Dna Vaccine and Its Effects on Hematopoiesis
in Mice." Experimental Hematology 28.7 (2000): 31-31. Print.