Biological warfare (BW) is the use of microbiological agents for hostile purposes. Such use is contrary to international law and has rarely taken place during formal warfare in modern history, despite the extensive preparations and stockpiling of biological agents carried out during the 20th century by most major powers (including development of strains resistant to multiple drugs). The area of most concern is the use of BW agents by terrorist groups. Biological-warfare agents are thought by some to be an ideal weapon for terrorists. These agents may be delivered clandestinely, and they have delayed effects, allowing the user to remain undetected.
The U.S. Centers for Disease Control and Prevention (CDC) has prioritized biological agents and toxins into 3 groups: A (highest priority), B, and C (see table CDC High-Priority Biological Agents and Toxins) (1).
The deliberate use of BW agents to cause mass casualties would probably entail dissemination of aerosols to create disease via inhalation, and thus inhalational anthrax and pneumonic plague are the 2 diseases most likely to occur under these circumstances.
CDC High-Priority Biological Agents and Toxins*
Category | Agent |
|---|---|
A: Highest priority | Bacillus anthracis, causing anthrax Botulinum toxin from Clostridium botulinum, causing botulism Yersinia pestis, causing plague Francisella tularensis, causing tularemia Variola virus, causing variola major (classic smallpox) Viral hemorrhagic fever (VHF) viruses:
|
B: Second highest priority | Brucella species, causing brucellosis Epsilon toxin of Clostridium perfringens causing food poisoning Salmonella causing food poisoning; Escherichia coli O157:H7 ; and Shigella, causing shigellosis Burkholderia mallei, causing glanders Burkholderia pseudomallei, causing melioidosis Chlamydia psittaci, causing psittacosis Coxiella burnetii, causing Q fever Ricin toxin from Ricinus communis Staphylococcal enterotoxin B causing staphylococcal food poisoning Rickettsia prowazekii, causing typhus fever Alphaviruses causing viral encephalitides (eg, Venezuelan, eastern, and western equine encephalitides) Vibrio cholerae, Cryptosporidium parvum, and other agents, causing waterborne diseases (eg, cholera, cryptosporidiosis) |
C: Third highest priority | Nipah virus, hantavirus, coronaviruses, and influenza viruses capable of causing pandemic influenza Other agents associated with emerging infectious diseases |
* An alphabetical listing of bioterrorism agents and diseases can be found at Centers for Disease Control and Prevention: Emergency Preparedness and Response. | |
(See also Overview of Incidents Involving Mass-Casualty Weapons.)
General reference
1. Bioterrorism Agents/Diseases. Emergency Preparedness and Response. Centers for Disease Control and Prevention (CDC). Available at https://emergency.cdc.gov/agent/agentlist-category.asp. Accessed October 3, 2024.
Recognition of Biological Weapon Injuries
It can be difficult to distinguish use of a biological-warfare (BW) agent from a natural outbreak of disease. Clues to the deliberate rather than a natural origin of a disease outbreak include the following (1):
Cases of diseases not usually seen in the geographic area
Unusual distribution of cases among segments of the population
Significantly different attack rates between those inside and those outside buildings
Separate outbreaks in geographically noncontiguous areas
Multiple simultaneous or serial outbreaks of different diseases in the same population
Unusual routes of exposure (eg, inhalation)
Zoonotic disease occurring in humans rather than in animals
Zoonotic disease occurring first in humans and then in its typical vector
Zoonotic disease arising in an area with a low prevalence of the typical vector for the disease
Unusual severity of disease
Unusual strains of infectious agents
Failure to respond to standard therapy
Epidemiologic investigation of cases and cooperation with law-enforcement resources are crucial, as is risk communication to the general public.
The clinical presentation, diagnosis, and treatment of patients with disease caused by high-risk BW agents are discussed elsewhere in The Manual: anthrax, plague, smallpox, tularemia, and viral hemorrhagic fevers. Management of outbreaks due to biological warfare does not differ from that of natural outbreaks except that clinicians must be alert for unusual antibiotic resistance patterns.
Isolation (of patients) and quarantine (of contacts) may be necessary. The most communicable deliberately disseminated diseases are smallpox (for which airborne precautions are necessary) and pneumonic plague (necessitating droplet precautions).
Recognition reference
1. Artenstein AW, Haessler S. Biological attack. In Ciottone's Disaster Medicine. 2024 Jan 1:511-519.
Response to Biological Weapon Injuries
Because of the relatively long incubation periods of diseases caused by BW agents, most lives will be saved or lost in a hospital setting. Adequate supplies of vaccines, antibiotics, and antivirals for hospitalized patients and for contacts are needed, and systems for distributing such medical countermeasures to members of the general public at high risk of exposure are crucial (1).
Response reference
1. Powers S, Escajeda J, Glauser J. Updates to Disaster Management Strategies for CDC Category A Bioterrorism Agents. Current Emergency and Hospital Medicine Reports. 2024 Apr 22:1-7
More Information
The following English-language resource may be useful. Please note that The Manual is not responsible for the content of this resource.
Centers for Disease Control and Prevention: Emergency Preparedness and Response: An alphabetical listing of bioterrorism agents and diseases. Accessed September 5, 2024.
