CHAPTER 1
INTRODUCTION
Bioterrorism - An Overview
Bioterrorism is terrorism by intentional release or dissemination of biological
agents (bacteria, viruses or toxins) these may be in a naturally occurring or in human
modified form. 1 In biological warfare there is a silent release of catastrophic
biological agents, resulting in unrest in population due to large scale sufferings from
diseases and disabilities and this may lead to collapse of administration and
governance. 2
A bioterrorism attack is the deliberate release of viruses, bacteria or other
germs (agents) used to cause illness or death in people, animals or plants3. These
agents are typically found in nature but it is possible that they could be changed to
increase their ability to cause disease. They are normally resistant to current
medicines and can increase their ability to be spread into the environment. Biological
agents can be spread through the air, water or in food. Terrorists may use biological
agents because they can extremely difficult to detect and do not cause illness for
several hours to several days. Some bioterrorism agents, like the smallpox virus, can
spread from person to person and some, like anthrax, cannot.4
1 A.L. Bhatia and S.K Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 70.2 Sudhir Syal, Bioterrorism: time to wake up,Vol. 95, No.12, Jaypee,Current Science, 2008, p.1665.3 A.L. Bhatia , Bioterrorism and Biological Warfare, pp. 70.4 Ibid.
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Therefore, bioterrorism is the use or threatened use of biologic agents against a
person, group, or larger population to create fear or illnesses for purposes of
intimidation, gaining an advantage, interruption of normal activities, or ideologic
objectives. The resultant reaction is dependent upon the actual event and the
population involved and can vary from a minimal effect to disruption of ongoing
activities and emotional reaction, illness, or death. Bioterrorism is distinct from
biologic warfare. Although there may be similarities in agents considered for use in
the desired effect or the method of dispersion, the anticipated results are different.5
Once a largely hypothetical threat became a harsh reality in the fall of 2001
when letters containing a fine powder of dried anthrax spores were sent through the
United States mail, infecting twenty two people and killing five. Despite the fact that
the attacks involved only about ten grams of powdered anthrax, the ripple effects
temporarily disrupted all three branches of the federal government, closed down
congressional offices and mail processing stations and the incidence had frightened
millions of Americans. 6 Recent evidence suggests that the threat of bioterrorism is
real and growing. Documents and computer hard drives seized during the March 1,
2003 had captured of Khalid Shaik Mohammed a key operational planner for Al
Qaeda, revealed that the organisation had recruited a Pakistani microbiologist and
aqquired materials to manufacture botulinum toxin and developed a workable plan for
anthrax production. 7
5 Philip S. Brachman, Bioterrorism: An Update with a Focus on Anthrax, American Journal of Epidemiology, Volume 155, No.11, 1 June 2002.6 Jonathan B.Tucker, Biosecurity: Limiting Terrorist Access to Deadly Pathogens, www.usip.org/files/resources/pwks52.pdf, p. 11, access on 17 March at 2308H.7 Ibid.
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The Malaysia’s experience of natural phenomenon bioterrorism by the
outbreak of viral encephalitis invoked scenes of widespread panic for many months
before the virus was identified to be Nipah Virus a recently emerging deadly
paramyxovirus. This outbreak could have been a scenario of bioterrorism because it
produced fear, disease disabilities death, social disruption and severe economic loss to
this country. 8
Global Incident of Bioterrorism
Biological weapons represent a unique “environmental hazards. The
pathogens involved are natural in the sense that they are risks that naturally occur in
our environment. However, they are unnatural in the way in which they are inflicted
upon society. 9 The two of the earliest uses of biological weapons reported occurred
in the 6th century B.C, when the Assyrians poisioned enemy wells with rye ergot and
Solon used the purgative herb hellebore during the siege of Krissa. In 1346, plague
broke out in the Tartar army during its siege of Kaffa in the Crimea. The attackers
hurled the corpses of those who died over the city walls. Some of the infected people
who left Kaffa may have started the Balck Death pandemic that spread throughout
Europe, killing one third of the population. 10 The first idenfied attack of bioterrorism
in the United States was in 1984, when followers of Bagwan Shree Rajneesh, Indian
terrorist group contaminated salad bars in Oregon. This incident resulted the cases of
Salmonella infection from 10 restaurants sickened 751 people with no fatalities. 11
8 Sai Kit Lim, Nipah Virus a potential agent of Bioterrorism, Antiviral Research Vol 57, 2003, p. 113-119.9 Eric K .Noji, Bioterrorism: a new global environmental health threat, Global Change & Human Helath, Volume 2 No. 1, Kluwer Academic Publishers, 2001, p.2.10 Ibid.11 Micheal B. Phillips, Bioterrorism: A brief History, Focus on Bioterrorism 2005, www.DCMSonline.org access on 19 March 2011 at 2008H.
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After the Gulf War, Iraq was discovered to have a large biological weapons program.
In 1995, Iraq confirmed that it had produced, filled and deployed bombs, rockets and
aircraft spray tanks containing Bacillus Anthracis and botulinum toxin and its work
force and technologic infrastructure are still wholly intact.
Another attack by terrorist that took place in Japan by the Japanese terrorist
group Aum Shinrikyo. The Cult members released sarin, a neurotoxin in the Tokyo
subway system in March 1995 resulted in thousands of injured civilians with eight
deaths had highlightened the potential impact of dissemination of a small amount of
bioweapon in public areas. 12 The recent global threat of Bioterrorism happened in
2001 when the letters containing a fine powder of dried anthrax spores were sent
through the U.S. mail, infecting twenty two people and killing five.13
Overview of Anthrax Outbreak
For centuries, anthrax has caused disease in animals and serious illness in
humans. 14 The disease most commonly occurs in herbivoures which are infected by
ingesting spores from the soil. Large anthrax epizootics in herbivores have been
reported during a 1945 outbreak in Iran, 1 million sheep dead. 15
In human, 3 types of anthrax infection occur which is inhalation, cutaneous
and gastrointestinal. Naturally occurring inhalational anthrax is now a rare cause of
human disease. Only 18 cases were reported in the United States from 1900 to 1978
12 D.A. Henderson, Bioterrorism as a Public Health Threat, Emerging Infectious Disease, Vol. 4, No.3, John Hopkins Univesity, Baltimore July-September 1998, p.488.13 Jonathan B.Tucker, Biosecurity: Limiting Terrorist Access to Deadly Pathogens, www.usip.org/files/resources/pwks52.pdf, p. 11, access on 17 March at 2308H.14 Thomas V.I et all, Anthrax as a Biological Weapon Medical and Public Health Management, JAMA, Vol. 281, N0.18, May 12 1999, p.1736.15 Ibid 1736.
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with the majority occurring in special risk group, including goat hair mill or goatskin
workers. However, the anthrax inhalation caused by biological weapon gives big
number of outbreaks. The accidental aerosolized release of anthrax spores from
military microbiology facility in Sverdlovsk in the former Soviet Union in 1979
resulted in at least 79 cases of anthrax infection and 68 deaths demonstrated the lethal
potential of anthrax aerosols.16 Residents living downwind from this compound
developed high fever and difficulty breathing and large number died, estimated to be
200 to 1,000. 17 In September 2001, four letters sent through United States mail were
found to contain anthrax with cause 22 people were infected and five of them died.
The anthrax showed that bioterrorism has potential to cause not only dead and
disability but also huge social and economic disruption at international levels.
Cutaneous anthrax is the most common naturally occurring form, with an
estimated 2000 cases reported annually. In the United States, 224 cases of cutaneous
anthrax were reported between 1944-1994. 18 The largest report epidemic occured in
Zimbabwe between 1979 and 1985 when more than 10,000 human cases of anthrax
were reported, all of them cutaneous. Gastrointestinal anthrax is uncommonly
reported. In 1982, the gastrointestinal outbreaks have been reported with 24 cases of
oral pharyngeal anthrax in rural northern Thailand following the consumption of
contaminated buffalo meat. 19
Problem Statement
16 Giorgos Stamkos, Bioterrorism: The New Invisible Threat, www.e-telescope.gr/en/international -isssues/79-bioterrorism access on 21 March 2011 at 1208H.17 Eric K .Noji, Bioterrorism: a new global environmental health threat, Global Change & Human Helath, Volume 2 No. 1, Kluwer Academic Publishers, 2001, p.2.18 Thomas V.I et all, Anthrax as a Biological Weapon Medical and Public Health Management, JAMA, Vol. 281, N0.18, May 12 1999, p.1736.19 Ibid 1737.
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Anthrax is a potential biological threat because the spores are resistant to
destruction and can easily spread by release in the air. It is also most likely to be
encountered because it is easy to produce in large quantities, highly lethal, relatively
easy to develop as a weapon, easily spread over a large area and easily stored and
dangerous for a long time. 20 Anthrax is an especially favoured biological weapon.
Research on anthrax as a biological weapon began more than 80 years ago. A few
kilograms of the organism can kill as many people as a Hiroshima sized nuclear
weapon. 21
The anthrax attacks of 2001 in United States heightened concern about the
feasibility of large scale aerosol bioweapons attacks by terrorist groups. 22 The
deliberate dissemination of potentially lethal anthrax spores in letters sent through the
U.S Postal Service caused a total of 22 persons infected and five people died. 23 This
Anthrax attack caused a huge public health and medical alarming because it caused
health threat by massive disruption of postal services in many countries around the
world and huge economic, public health and security consequences.
Another historical fatal incidence happened involved the inhalation anthrax
occurred after the accidental release of aerosolized anthrax spores in 1979 at a military
biology facility in Sverdlovsk, Russia involving 79 cases of inhalation anthrax which
68 were fatal. According to the study done worldwide, inhalation Anthrax is the most
serious and breathing in airborne spores may lead to inhalation anthrax. Inhalation
20 Md Radzi Johari, Anthrax-Biological Threat in the 21st Century, Malaysian Journal of Medical Sciences, Vol. 9, No. 1, Jan 2002, pp. 1-2.21 Alasdair Geddes, Infection in the twenty first century: predictions and postulates, Journal of Antimicrobial Chemotherapy, Vol. 46, pp. 873.22 Thomas V.I et all, Anthrax as a Biological Weapon, 2002 Updated Recommendations for Management, JAMA, Vol. 287, No.17 (Reprinted), May 1 2002, pp. 2237.23 A.L. Bhatia and S.K Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 162.
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anthrax has a fatality rate that is 80% or higher. 24 A 1979 analysis by World Health
Organization concluded that the release of aerolized anthrax upwind to a population of
5,000,000 could lead to an estimated 250,000 casualities of whom as many as 100,000
could be expected to die.
Some nations continued offensive bioweapons development programs despite
ratification of the Biological Weapons Convention (BWC). In 1995, Iraq
acknowledged producing and weaponizing Basilus anthracis to the United Nations
Special Commission. The former Soviet Union is also known to have had a large
Basilus anthracis production program as part of its offensive bioweapons program. A
recent analysis reports that there is clear evidence of or widespread assertions from
nongovernmental sources alleging the existence of offensive biological weapons
programs in at least 13 countries. 25
By looking the global incidence of Bioterrorism and the threat of anthrax as
biological weapon used by terrorists, Malaysia should develope the strategy to prevent
and response in times of crisis especially when facing this emergence threat or the
outbreak emerging infectious diseases. Steps taken by Malaysian Ministry of Health
to joint venture with Emergent BioSolutions firm to built 52,000 square feet of
vaccine “development and manufacturing infrastructure” in on a 62 acre site in an
industrial park outside Kuala Lumpur is one of the strategies to build defences against
germ attacks.
Furthermore, Malaysia already has three Biosafety Level 3 Labs which are
managing for disease causing organisms that cause death in human, such as anthrax, 24 Md Radzi Johari, Anthrax-Biological Threat in the 21st Century, Malaysian Journal of Medical Sciences, Vol. 9, No. 1, Jan 2002, pp. 1.25 Thomas V.I et all, Anthrax as a Biological Weapon, 2002 Updated Recommendations for Management, JAMA, Vol. 287, No.17 (Reprinted), May 1 2002, pp. 2237.
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plague and SARS. This study also wants to see the public health response to
bioterrorism with the collaboration between Malaysian Ministry of Health (MOH),
Malaysian Armed Forces (MAF) and Private Sector in term of strategic plan of
preparedness in protecting Malaysia’s national security.
The past experience such as the outbreak of viral encephalitis then identified to
be Nipah Virus a recently emerging deadly paramyxovirus had become the Malaysia’s
agenda in strengthening bioterrorism management and prevention. By taking example
of the anthrax attack in United States in 2001, the program should be stressed on the
instruction and prevention strategy of bioterrorism and or outbreak disease such as
anthrax to Malaysia’s national security.
Research Importance
This study reflects to the global incidence of Bioterrorism worldwide
especially the anthrax attack in United States in 2001 to pursuing the Malaysia’s
strategies prevention of the unexpected emergence anthrax threat to Malaysia’s
national security. This studies also taking into account the magnitude of problem
from the recent pandemic such as SARS and H1N1. By developing the strategy of
prevention will increase the awareness of the relevant government and MAF to
strengthening the biosecurity level and crisis management in response to the possible
emergence athrax attack.
Literature Review
8
The Journal titled Anthrax as a Biological Weapon, 2002 Updated
Recommendations for Management by Thomas V. Inglesby et al. 26 was focus on the
study of consensus-based recommendations for medical and public health
professionals following a Bacillus anthracis attack against a civilian’s population.
From this research, the working group had identified a limited of organisms that in
worst case scenarios could cause disease and deaths in sufficient numbers to gravely
impact a city or region. Bacilus anthracis, the bacterium that causes anthrax is one
othe most serious cases.
This study more on the 2001 anthrax attack in United States and do
comparison with the previous incidences such as experiences with inhalational anthrax
in Sverdlovsk, Russia in 1979 by unintentional release of Basilus anthracis
sporesfrom Soviet bioweapons and Aum Shinrikyo, the cult responsible for 1995
release of sarin gas in a Tokyo subway station, dispersed aerosols of an anthrax and
butolism throughout Tokyo for at least 8 times.
The research recommendations include diagnosis of anthrax infection,
indications for vaccination, recommendations for antibiotic and vaccine use in the
setting of an aerosolized Basillus anthracis, postexposure prophylaxis to prevent
inhalational anthrax following the release of a Basilus anthracis aerosol as a
biological weapon, decontamination of environment and additional research by
26 Thomas V. Inglesby, Tara O’Toole, Donald A. Henderson, et al. Anthrax as a Biological Weapon, 2002 Updated Recommendations for Management, JAMA, Vol.287, No.17(Reprinted) May 1 2002, pp. 2236-2251
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develop a recombinant anthrax vaccine and rapid diagnostic assays to identify early
anthrax infection.
Specific recommendation and steps to be taken in an epidemic by the working
group will permit the comparison to Malaysian response plan. This study will
recommend a focused response plan and selective vaccination program for the
Malaysian Healthcare Provider such as Ministry of Health, Malaysian Armed Forces
Health Services (MAFHS) and Public Health Provider.
The other Journal titled Anthrax-Biological Threat in the 21 Century 27 by Md
Radzi Johari mentioned about the anthrax is a potential biological terrorism threat as
biological agents. As biological agents it most likely to be encountered because it is
easy to produce in large quantities, highly lethal, relatively easy to develop as a
weapon, easily spread over a large area and easily stored and dangerous for a long
time. The mortality rate for anthrax varies, depending on exposure and are
approximately 20% for cutanous anthrax without antibiotics and 25-75% for
gastrointestinal anthrax, inhalation anthrax has fatality rate that is 80% or higher.
The only known effective prevention treatment is the anthrax vaccine,
although anti-toxins have long been considered an essential ‘adjunctive’ therapy.
Researcher also suggests that the biomedical scientists should consider biological
weapon as a serious ‘emerging new pathogens’ to controlled and prevented for the
good huminity. New revolution in biology could be misused in offensive biological
27 Md Radzi Johari, Anthrax-Biological Threat in the 21 Century, Malaysian Journal of Medical Sciences, Vol. 9, No. 1, January 2002, pp.1-2.
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programs directed against human beings and their staple crops or livestock which
prohibited in the 1975 Biological and Toxin Weapons Convention (BTWC).
Among the latest book is Bioterrorism and Biological Warfare 28 by A.L.
Bhatia and S.K. Kulshrestha. This book tells us about the two massive threat,
Bioterrorism and Biological Warfare as the greatest challenges faced by the 21 st
century. Bioterrorism is the use of lethal biological agents which wage a war against a
civilian population. The threat of bioterrorism, long ignored and denied has
heightened over the past few years. The two agents that used by most terrorist and
bring catasthrophic to human life are smallpox and anthrax. The author had
highlighted the magnitude of the problems and the gravity of the scenarios associated
with this release of these organisms by vividly potrayed by two epidemics of smallpox
in Europe during the 1970s and by accidental release of aerosolized anthrax from a
Russian bioweapons facility in 1979.
The most recent anthrax epidemic mentioned in this book is the anthrax attack
(also known as Amerithrax by FBI case name) occurred in U.S in 2001. Letters
containing anthrax spores were mailed to several news media offices and two
Democratic U.S Senators, killing five people and infecting 17 others. The primary
threat from Biological Warefare agents today is from terrorists, civilians in densely
populated regions would like be the targets. Therefore, civilian medical personnel
need to be aware of how a Biological Warfare attack would present to minimize its
effects. There are various ways by which bioterrorism can be prevented and be shared
28 A.L. Bhatia and S.K Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009.
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with Malaysia’s National Response Team and MAFHS such as Intellengence to
prevent biowar, open sources by sharing information between country, border
security, Foriegn disease eradication, global surveillance, vaccine stockpiles, rapid
response options and crisis simulation developed and public education and awareness
campaign.
The journal entitled Bioterrorism: a ‘new’ global environment health threat 29
by Eric K. Noji, looking the issues of biological weapon proliferation by the countrys
such as former Soviet Union and Iraq although these countrys had signed the
Convention on Prohibition of the Development, Production and Stockpiling of
Bacteriological and Toxin Weapons and on Their Destruction, called the Biological
Weapons Convention. The violation of this Covention had brought massive disaster
such as an incident in Sverdlovsk in former Soviet Union by accidental release of
anthrax in aerosol form from Soviet Military microbiology facility. Estimated 200 to
1000 civillian around this compound developed high fever, difficulty breathing and
large number died.
The same situation happened in Iraq where the aftermath of Gulf War, the
Iraqi announced to United Nations Special Commission that they had conducted
research into offensive use of Bacillus anthracis, Clostridium perfingens and
botulinum toxins. The smallpox virus eradicated in late 1970’s primarily through the
enormous efforts of the U.S Centers for Disease Control and Prevention (CDC) in
Atlanta and WHO and now stored in only two laboratories at CDC Atlanta and the
29 Eric K .Noji, Bioterrorism: a new global environmental health threat, Global Change & Human Helath, Volume 2 No. 1, Kluwer Academic Publishers, 2001.
12
Institute for Viral Precautions in Moscow, Russia. The worry is the “bargained” away
by desperate Russians Scientists in seeking money.
Research Objectives
The general objective of this research paper is to study the bioterrorism with
the related agent of anthrax and the application of prevention strategy from selected
agencies to be Malaysia’s prevention strategy. The specific objectives of this study
are as follows:
a. The objective is to study the Bioterrorism related anthrax, the clinical
features and pathogenesis of anthrax.
b. To identify the prevention strategy in training and strategic plan of
preparedness for possible bioterrorism anthrax attack in Malaysia. This study
will take into consideration of prevention strategy from the previous country
with anthrax attack such as United States.
c. To study the public health awareness and identify the bio defence
capabilities in Malaysia.
d. Finally, the study is to influence the relevant agencies to undertake
corrective measures through this study by government commitment and
international collaboration.
Research Hypotheses
13
Bioterrorism - Anthrax attack as the possible emergence threat to the
Malaysia’s National Security and Malaysia will counter the threat by implying the
national strategy to prevent if it occurs.
Research Methodology
The research is based on qualitative and descriptive analysis and data will be
sought from the printed academics journals and books. Information also accessed
from the online material such as online medical and health journal straight from
internet Google, Google scholar and Yahoo. This study also looking into the
Malaysian Armed Forces (MAF) - Publikasi Perkhidmatan Bersama 15 (PPB 15) or
MAF Nuclear, Biological and Chemical Defence Mannual to develop the prevention
strategy of bioterrorism anthrax. Collecting data on characteristics of the Bacillus
anthrax, mode of infection and symptoms, pathogenicity and treatment of anthrax in
order to provide information for the response plan in the outbreak and prevention
strategy.
During this study, researcher makes full use of the library such as Malaysian
Armed Forces Staff College Library, Ministry of Defence Library, University Malaya
Library and National Library. All data collected based on the past study from journal,
electronic journal, books, e - book and etc. The use of website is based on the
consideration that it provides sufficient materials which are accessible, reliable,
essential and current to complete this research.
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Limitations of Study
The limitation of this research is primarily because of time constraint. The
study will not be able to cover the bioterrorism fully with the restriction of time frame
and the limited of the documents on Malaysian biological warfare. The Malaysia’s
experience for Bioterrorism is so slim and not many study done on Bioterrorism in
Malaysia. For this study, most of the references taken from United States and several
other country as a main guide to complete the bioterrorism caused by anthrax attack.
Chapter Outline
The research paper will be divided into five chapters in constructive manners
from basic understanding of bioterrorism and anthrax as a biological agent used in
terrorism. The threat of bioterrorism to Malaysia’s national security. The clinical
features and characteristic of anthrax until the discussion and analysing prevention
strategy and the application as preparedness plan for bioterrorism in Malaysia.
The detail chapters are as follows:
Chapter 1 - Introduction
This chapter will consists of the background, problem statement, objectives and the
significance of the study as well as literature review and research methodology. This
15
chapter will guide the layout of the framework of the research and will be the basis for
the outlines of research.
Chapter 2 - Bioterrorism Related Anthrax
This chapter will define anthrax as Biological Weapons and Bioterrorism, the current
threat of anthrax to human population, the possible emergence threat to Malaysia’s
national security and the management bioterrorism from Malaysian perspective.
Chapter 3 - The Clinical Presentation and Manifestation of Anthrax Infection
This chapter will outline and explain the background, clinical characteristic, clinical
and epidemiologic features, mode of infection and symptoms, vaccination of anthrax
infection, treatment and prevention of anthrax infection; and decontamination of site
in anthrax infection.
Chapter 4 - Analysis of Prevention Strategy from Anthrax Infection
This chapter will discuss the prevention strategy in term of training and education to
the first reponser team and strategic plan for bioterrorism preparedness and response.
This prevention strategy will be adopted from the previous country with experience in
bioterrorism anthrax such as United States.
Chapter 5 - Conclusion
This chapter will conclude on the bioterrorism as the possible emergence threat to
Malaysia’s national security in the case of anthrax as biological threat and the
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prevention strategy. End of this is the conclusion will mentioned the best national
prevention strategy on bioterrorism anthrax.
CHAPTER 2
BIOTERRORISM RELATED ANTHRAX
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Background of Biological Warfare and Bioterrorism
During the 16th century B.C, the Assyrians poisoned enemy wells with Ergot, a
fungus that would make enemy delusional and Solon of Athens used the poisonous
herb Veratrum to poison water supply of Phocaea during his siege of the city. During
the 4th century B.C Scythian archers used arrows with tips covered with animal faeces
to cause wounds to become infected. In 2004 B.C, Hanibal of Carthage had clay pots
filled vith venomous snakes and instructed his soldiers to throw the pots on to the
decks of Pergamene ships. 30
In 1346 the bodies of Mongol warriors of the Golden Horde who died of
plague were thrown over the walls of besieged Crimean city of Kaffa (now
Theodosia). It has been speculated that this operation may have been responsible for
the advent of the Black Death in Europe. 31
Another attempted use of biological warfare occurred between 1754 and 1767
when the British infiltered small pox infested blankets to unsuspecting American
Indians during the French and Indian war. Small pox decimated the Indians, but it is
unclear if the contaminated blankets or endemic disease brought by the Europeans
caused these epidemics. In 1932, the Japanese began a series of horrific experiments
on human beings at outside Harbin Manchuria China. At least 11 Chinese cities were
30 A.L Bhatia, S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 363.31 Ibid.
18
attacked with agents of anthrax, cholera, shigellosis, salmonellas and plague and at
least 10,000 died during their gruesome experiments. 32
The United States started an offensive biological warfare program at Camp
Detrick (today Fort Detrick) in Frederick, Maryland in 1943. By 1969, the U.S had
weaponized the agents causing tularaemia, butolism, anthrax and botulinum toxin.
These were soon destroyed after President Nixon unilaterally ended the U.S offensive
biological warfare program that year. In 1972, U.S signed the Biological Weapons
Convention (BWC) stating that it would ban their production of their biological
program. 33
Despite this convention, the development of Biological weapons has
continued. In late April 1979, an incident in Sverdlovsk (now Yekaterinburg), a city
of 1.2 million people in the former Soviet Union appeared to be an accidental release
of anthrax in aerosol form from Soviet Military Compound 19, a microbiology
facility. Residents downwind from this compound developed high fever and difficulty
breathing and large number died, the final toll was estimated to be 200 to 1000. 34
By 1991, the Iraqis had weaponized anthrax, botulinum toxin and aflatoxin
and fortunately these were not used during Desert Storm Operation. The United
Nations destroyed the final remains of the Iraqi offensive programs in 1996. Between
1990 and 1995, the well financed Japanesed apocalyptic cult Aum Shinrikyo launched
a repeated series of attacks on civilian using both biology and chemical weapons.
32 A.L Bhatia, S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 363.33 Ibid.34 Eric K.Noji, Bioterrorism: a ‘new’ global environmental health threat, Global Change &Human Health, Volume 2, No. 1, Kluwer Academic Publishers, 2001, pp. 2.
19
The release strain nerve gas in Japanese subway, was found to possess rudimentary
biological weapons including anthrax, botulism and Q fever. 35 On September 18,
2001, Basillus anthracis spores were sent to several locations via the US postal
Service. Twenty two confirmed or suspect cases of anthrax infection with 5 were died
from this incident. 36 This anthrax attack giving us the situation that the disasters still
exist although many countries had signed the BWC.
Anthrax Bacterium as Biological Weapons and Bioterrorism
Anthrax (Scientific name Bacillus anthracis) was the first microorganism
identified as the cause of a specific disease by Dr. Robert Koch in 1876. 37 The word
anthrax is the Greek word for anthracite in reference to the black skin lesions victims
develop in a cutaneous skin infection. Anthrax cannot spread directly from human to
human but spores can be transported by human clothing, shoes and if a person dies of
anthrax their body can be a very dangerous source of anthrax spores. 38
It is a potential biological terrorism threat because it easy to produce in large
quantities, highly lethal, relatively easy to develop as a weapon, easily spread over a
large area and easily stored and dangerous for a long time. The fatality rate in
halation for anthrax is 80% or higher. 39 All of this suggests why Bacillus anthracis
35 Ibid, pp.364.36 Thomas V.Inglesby, Anthrax as a Bilogical Weapon 2002, Updated Recommendations for Management, JAMA, Vol 287, No. 17 (Reprinted), May 1 2002, pp. 2236.37 Md Radzi Johari, Anthrax - Biological Threat in The 21st Century, Malaysian Journal of Medical Sciences, Vol. 9, No. 1, Januari 2002, pp. 1-2.38 A.L Bhatia & S.K Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher,Jaipur, 2009, pp. 83.39 Ibid.
20
became the agent of choice for most biological warfare programs. 40 There are 89
known strains of anthrax; the most widely recognized being the virulent Ames strain
used in the 2001 anthrax attacks in the United States. The Ames strain is extremely
dangerous, though not quite as virulent as the Vollum strain which was successfully
developed as biological weapon during the Second World War. 41
Anthrax, smallpox, plague, botulism, tularaemia and viral haemorrhagic
fevers are categorised ‘Category A’ biological agents by the Centers for Disease
Control and Prevention (CDC). These are biological agents with both a high potential
for adverse public health impact and that also have a serious potential for large scale
dissemination. 42 Aerosol exposure to anthrax spores could cause symptoms as soon
as 2 days after exposure. However, illness could also develop as late as 6-8 weeks
after exposure. Once symptoms begin, death follows 1-3 days later for most people. 43
The aerosol could would be colourless, odourless and invisible following its release.
Given the small size of the spores, people indoors would receive the same amount of
exposure as on the street. There are currently no atmospheric warning systems to
detect an aerosol cloud of anthrax spores. The first sign of a bioterrorist attack would
most likely be patients presenting with symptoms of inhalation anthrax. 44
40 Steven M. Block, The Growing Threat of Biological Weapons, American Scientist, Vol. 89, January-February 2001, pp. 2.41 A.L Bhatia & S.K Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher,Jaipur, 2009, pp. 84.42 A.L Bhatia & S.K Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher,Jaipur, 2009, pp. 37.43 Md Radzi Johari, Anthrax - Biological Threat in The 21st Century, Malaysian Journal of Medical Sciences, Vol. 9, No. 1, Januari 2002, pp. 1-2.44 Ibid.
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The analysis performed by the Office of Technology Assessment of the U.S
Congress, estimated that 130,000 to 3 million deaths could occur following the release
of 100 kilograms of aerosolized anthrax over Washington D.C, making such an attack
as lethal as a hydrogen bomb. 45 The Centre for Disease Control and Prevention
estimated that such a bioterrorist attack would carry an economic burden of $ 26.2
billion per 100,000 people exposed to the spores. 46
Biological weapon using the anthrax with the first recorded during the World
War I where the introduction of anthrax as weapon against livestock and
transportation animals. A clandestine biological research laboratory was set up in
Baltimore by the German government in 1915. A number of suspected uses of
anthrax by the German government during the World War I were alleged, but not well
documented. Japan, Great Britain and United States all proceeded with research into
the use of Bacillus anthrax weapon in World War II. The former Soviet Union also
developed a biological research programme during the Cold War. The accidental
release of anthrax from a secret bio weapons research facility in Sverdlovsk, Union of
Soviet Socialist Republics resulted in the death of 66 from 77 Russian military and
many others civilian in downwind from this compound. 47
Research on anthrax as a biological weapon began more than 80 years ago.
Most national offensive bio weapons programs were terminated following widespread
ratification or signing of the Biological Weapons Convention (BWC) in the early
45 Ibid.46 Md Radzi Johari, Anthrax - Biological Threat in The 21st Century, Malaysian Journal of Medical Sciences, Vol. 9, No. 1, Januari 2002, pp. 2.47 Anthrax as a Weapon of Terrorism and Difficulties Presented in Response to its Use, www.defencejournal.com/dec98/anthrax.htm access on 12 March 2001 at 2016H.
22
1970’s. 48 However, some nations continued offensive bio weapons develop programs
despite ratification of the BWC. In 1995, Iraq acknowledged producing and
weaponizing Bacillus anthracis to the United Nation Special Commission. The
former Soviet Union is also known to have a large Bacillus anthracis production
program as part of its offensive bioweapons program. A recent analysis reports that
there is clear evidence of or widespread assertions from nongovernmental sources
alleging the existence of offensive biological weapons programs in at least 13
countries. 49
The Current Threat of Anthrax to Human Population
Biological agents may appeal to the new terrorist groups because they affect
people indiscriminately and unnoticed, thereby sowing panic. A pattern is emerging
that terrorists who perpetrate mass and indiscriminate attacks do not claim
responsibility. 50 The Bioterrorist attack on October 2001 in the United States by
deliberate dissemination of potentially lethal anthrax spores in letters sent through the
United States Postal Service is the recent use of anthrax as biological weapon to the
realities of life in the 21st century. This anthrax attack caused massive disruption of
postal services in many countries around the world and huge economic, public health
and security consequences. 51 In addition to biological agents as weapons of war,
there is also increasing concern over the possibility of terrorist use of biological agents
48 Thomas V.Inglesby, Anthrax as a Bilogical Weapon 2002, Updated Recommendations for Management, JAMA, Vol 287, No. 17 (Reprinted), May 1 2002, pp. 2237.49 Ibid.50 Bruce Hoffman, “Why Terrorists Don’t Claim Credit,” Terrorism and Political Violence, Vol. 9, No. 1, 1999, pp. 1-6.51 Ibid.
23
to threaten civilian populations. 52 Although a relatively new weapon in the hands of
modern potential bioterrorists, the threat of death from the inhalation of anthrax has
been part of human history since antiquity. The deliberate use of biological weapon
has significant potential for not only damaging the human health but also causing
mass panic and public hysteria. 53
An attack using biological weapons may be more sinister than an attack using
conventional, chemical or nuclear weapons, where effects are more immediate and
obvious. By the time the first casualty is recognized, the agent may have already been
ingested, in haled or absorbed by many others and more casualties may be inevitable
despite medical countermeasures. 54 In a minute the particles can silently pass through
the air supply systems of ships, vehicles, command head quarters and even hospitals.
Biological weapon such as anthrax is considered as unique in their ability to
inflict large numbers of casualties over a wide area with minimal logistical
requirements and by means that can be virtually untraceable. In 1970, the World
Health Organisation estimated that if 50 kg of anthrax spores were dispersed upwind
of a population centre of 500,000 people in optimal conditions can effected almost
half of the population of that area would be either disabled or killed in such attack. 55
52 Eric K.Noji, Bioterrorism: a ‘new’ global environmental health threat, Global Change &Human Health, Volume 2, No. 1, Kluwer Academic Publishers, 2001, pp. 3.53 Ibid.54 Edward M.Eitzen, Use of Biological Weapons, U.S. Army Medical Research Institute of Infectious Diseases, Fort Detric, Frederic, Maryland, www.dead-planet .net/med-cbw/Ch20.pdf , pp. 442-443. Access on 28 March 2011. 55 Ibid,., pp. 443.
24
Anthrax was considered by United States Army Medical Research Institutes of
Infectious Disease (USAMRIID) as the most likely bioterrorist agent and was the first
lethal bioterrorist agent used in United States. 56 It is particularly suitable because it
can cause widespread illness and death an eventually cripple a city or region. 57
Inhalational or pulmonary anthrax results most commonly from inhalation of anthrax
spore containing dust and is highly fatal with nearly 100% mortality. A lethal dose of
anthrax is reported to result from inhalation of about 10,000 - 20,000 of spores.
Patients with anthrax inhalational cases characterized by fever, dyspnoea, stridor,
hypoxia and hypotension leading to death within 24 hours. This disease can rarely be
treated, even if caught in early stages of infection. 58
The statement above was supported by the evident from the incident in
Sverdlovsk in 1979 caused by inhalational of anthrax aerosol caused 66 patient died in
the Soviet Military Compound and estimated 200 - 1000 residents died of high fever
and difficulty breathing. The recent incidence was the inhalational of anthrax spores in
United States in 2001, caused 5 people died.
The Emergence Threat to Malaysia’s National Security
56 R Gregory Evans et al, The Threat of Bioterrorism in the U.S, A report Current Healthcare Issues Bioterrorism, Business Briefing : Global Healthcare Issues, pp. 29.57 Stefan Riedel, Anthrax: a continuing concern in the era of bioterrorism, BUMC PROCEEDINGS No. 18, 2005, pp. 234.58 D.A. Henderson, Bioterrorism as a Public Health Threat, Emerging Infectious Diseases, Vol. 4, No. 3, July – September 1998, pp. 491.
25
The emergence threats of disease outbreak to the security of Malaysia can be
resulted from the deliberate use of pathogens as biological weapons, the accidental
release from research laboratories (such as the accidental release of anthrax from a
military testing facility in Sverdlosk in the former Soviet Union in 1979) or the
naturally occurring outbreaks of particular infectious disease caused by traveller
disease or brought migrating animal, birds or insect from other country to Malaysia.
For example, the migrating of the water fowls is a significant source of this
Avian Influenza virus carried in their intestinal tract and shedding it in their faeces. 59
This is one of the good reasons of the cause of the outbreak of Avian Influenza in
Malaysia for sometimes ago. The disease outbreak as a result of bioterrorism and
pandemic affects international security, regional stability and military readiness in the
nation. The exposure to naturally occurring or resulted from the deliberate use of
pathogens as biological weapons by the bioterrorist poses a global risk to Malaysia’s
national security.
As public health histories record, infectious diseases outbreak whether causes
naturally occurring or intentionally release by terrorist have had a devastating impact
on the quality of life of individuals in most nations. In fact, infectious diseases
morbidity and mortality far exceed war related death and disability in human history.
Given the nature of pathogenic microbes, Malaysia has to cooperate to mitigate the
threat to individuals in their territories from the biological threats. The long history of
59 Christopher Lee, Alert, Enhanced Surveillance and Management of Avian Influenza in Human, 6 Feb 2004, pp. 1-2.
26
international cooperation on infectious diseases control then becomes relevant as a
foreign policy but also a security issue.
The emergence of the biological threats to Malaysia will effected many
aspects such as the human security, economic and global trade security, social security
and delivery of health security. All of these aspects will become the agenda that will
threaten of individual, communities, tourist, traders and governments.
a. Human Security Threat.
In many countries in the world, the pandemic and the endemic of the infectious
diseases caused the bad impact to the public health or the human security. The
outbreak of the disease such as pandemic Influenza, SARS, H1N1, smallpox and
plague could pose threats to large populations because of the potential for person to
person transmission, enabling spread to other cities and states and become a
nationwide emergency.
In the situation of bioterrorism, the disaster caused by from the intentional
release of virulent biological agents would be very different from other natural or
technological disasters, conventional military strikes or even attacks with other
weapons of mass destruction (e.g., nuclear, chemical, or explosive). For example,
when people are exposed to a pathogen such as plague or smallpox they may not be
aware of their exposure and they may not feel sick for some time, although they would
be contagious. The incubation period may range several hours to a few weeks and
27
consequently an attack would not become obvious for a similar period. By the time,
modern transportation could have widely dispersed the pathogen and greatly expanded
the population of victims. 60
In Malaysian medical preparedness, the initial responders to a biological
disaster will most likely include county and city health officers, hospital staff, and
members of the outpatient medical community and wide range of response personnel
in the public health system, military health services and also including the traditional
first responders such as police, fire brigade, rescue team and ambulance services.
A bioterrorist attack has occurred and could occur again at any time, under any
circumstances and a magnitude far greater than we have thus far witnessed. 61 The
use of microorganisms as agents of bio weapons is considered inevitable for several
reasons, including ease of production and dispersion, delayed onset, ability to cause
high rates of morbidity and mortality and difficulty in diagnosis. Unfortunately, in
most cases, few physician and doctors in Malaysia have ever seen a case caused by
biological weapons such as anthrax, smallpox or plague and diagnosis of an epidemic
is certain to be delayed. Laboratory capabilities for diagnosis and measuring
antibiotic sensitivity of organisms are similarly limited and caused further delays. The
weakness of the medical response and preparedness would become a fear to the
communities and big challenges to the human security. 62 Malaysia should take the
60 Eric K.Noji, Bioterrorism: a ‘new’ global environmental health threat, Global Change &Human Health, Volume 2, No. 1, Kluwer Academic Publishers, 2001, pp. 3- 4.61 Stacy L. Knobler, Adel A.F, Biological Threats and Terrorism, Accessing the Science and Response Capabilities, Workshop Summary, National Academy of Science, pp. 2. Available at http://www.nap.edu/catalog/10290.html. Access on 30 March 2011.62 Zalini Yunus, Combating and Reducing The Risk of Biological Threats, The Journal of Defence and Security, Vol.1, No. 1, Science & Technology Research Institute for Defence, MINDEF, 2010, pp. 3.
28
great efforts in establish a national outbreak preparedness plan to meet any
eventualities as a result of infectious diseases outbreaks, including bioterrorist attacks.
b. Economy and Global Trade Security Threat.
The infectious diseases outbreak or the terrorism biological attack could pose
bad impact to the Malaysia’s economic and global trade. Through the Malaysian
experience of diseases outbreak had affected the industry of tourism. In the year
2003, Malaysia too appears most susceptible to damages wrought by Systemic Acute
Respiratory Syndrome (SARS) because this health disaster had given the bad impact
to tourisms which plays important role in Malaysia’s economy. The tourism sector
accounts for 8 percent of real gross domestic product (GDP) and 17 percent of real
private consumption and is the country’s second largest foreign exchange earner. 63
Most of the tourists come to Malaysia are from China, Hong Kong, Singapore,
Thailand, Indonesia, Japan, Taiwan and Vietnam accounted for 80 per cent of total
inbound tourists arrivals to Malaysia. According to the Culture, Arts and Tourism
Ministry, tourist arrivals from China, Hong Kong and Taiwan have fallen some 80 per
cent following the outbreaks of SARS. An economist expects tourist arrivals to
decline by 14 per cent to 11.5 million visitors this year. This means that the local
economy stands to lose an income of some RM 3.4 billion, which is equivalent to 0.8
per cent of real GDP. 64
63 Darshini M. Nathan, SARS impact on industries, The Star (BizNews), Saturday, 19 April 2003. Available at netinc.net.my/health/s/011.htm. Access on 6 April 2011.64 Ibid.
29
The other sector that facing the bad impact of the SARS is the Malaysian
Airlines System Bhd (MAS). The outbreak of the deadly virus has sent airlines
scrambling to cancel flights to those countries most affected by the disease. Because
of SARS, MAS has thus far cancelled a total of 716 flights to Asian destinations such
as China, Hong Kong, Taiwan, Thailand, Indonesia and Singapore. Slower
international tourist arrivals are expected to impact negatively on Malaysia Airports
Holdings Bhd’s international volume. According to the Transport Ministry, the Kuala
Lumpur International Airport has already seen a 28 per cent drop in its passenger
traffic over the six weeks of outbreak as travellers cancel their trips due to deadly
virus. The government’s move temporarily restricted the issuance of visas to tourists
from China and Hong Kong. 65
In the scenario of bioterrorism, whether real or perceived, can have a
tremendous negative impact on society. By taking the example of the small scale
2001 anthrax attacks in the United States resulted in a cost of over $200 million to
decontaminate anthrax infected facilities. A study by the Centre for Disease Control
(CDC) in Atlanta estimates that the economic impact of a bioterrorist attack could
range from estimated $ 477.7 million per 100,000 persons exposed in the scenario of
brucellosis attack and to $ 26.2 billion per 100,000 persons exposed in the scenario of
anthrax attack. 66
65 Ibid.66 Arnold F. Kaufmann, Martin I. Meltzer and George P.Schmid, The Economic Impact of Bioterrorist Attack: Are Prevention and Postattack Intervention Program Justifiable? Emerging Infecrtious Diseases, Vol. 3, No. 2, CDC, Atlanta, April-June 1997. pp. 91- 92. Available at http://www.cdc.gov/ncidod/EID/vol3no2 / kaufman.htm. Access on 6 April 2011.
30
c. Social Security Threat.
The exposure to the naturally occurring or the release of virulent biological
agents by terrorists which highly transmissible infectious diseases poses a global risk
to the certain institution, industries or social organisation. For certain industries which
involved the society gathering and communication such as retail, wholesale, consumer
packaged goods, aviation, hospitality, gaming, sports, media and entertainment may
indirectly suffer severe economic losses due to a decrease in public gatherings, travel
and tourism. Industrial companies may experience reduced attendance due to
infection, fear of infection or absenteeism of workers caring for their families.
Broader economic problems caused by reduced workforces may then initiate
economic downturn and further unemployment. 67
In Malaysian experience, the education sector had to reel from the effects
wrought by the deadly pneumonia type virus in the outbreak of Pandemic Influenza,
SARS and H1N1. During the outbreak, many school in Malaysia had to close for
public in order to control for the further spread caused many school program had to be
cancelled and give the bad impact to Malaysian education. The temporary freeze on
students from SARS affected countries, had given the bad economic impact to the
University and private colleges with student intakes from China. In 2003, foreign
students comprise 17 percent of total student population of 14,300 where 800 consist
of Chinese students that already studying at Inti’s campuses. 68
67 The Economic and Social Impact of Emerging Infectious Diseases: Mitigation Through Detection, Research and Response. Available at www. healthcare.philips.com /main/shared/ assets/documents/ ... Access on 6 April 2011, pp. 13.68 Darshini M. Nathan, SARS impact on industries, The Star (BizNews), Saturday, 19 April 2003. Available at netinc.net.my/health/s/011.htm. Access on 6 April 2011.
31
d. Delivery of Health Care Security Threat.
The concern continues to mount that a pandemic, bioterrorism or serious
epidemic like SARS will have an enormous and potentially incapacitating impact on
the health care industry. Health care providers are considering and planning for how
to deal with unprecedented numbers of patients in emergency rooms and hospitals,
while coping with severe supply constraints. Quality of health care might further be
compromised as employees on the front line of infectious exposure must deal with
large numbers of patients and uninfected people seeking medical reassurance. These
same workers must also bear the mental burden of the risk they may pose in spreading
the disease to their families. Furthermore, if fears of contamination drive health care
professionals, staff and elective patients away from health care facilities, for profit
ones in particular which rely on patient flow and professional delivery of services on a
daily basis may find themselves unable to maintain operations. 69
Management of Bioterrorim from Malaysian Perspective
The Malaysia’s plan for bioterrorism envisages the setting up of rapid response
teams at district, state and national levels. The rapid response experience and
assembled by matching expertise and incident needs in order to provide rapid response
69 The Economic and Social Impact of Emerging Infectious Diseases: Mitigation Through Detection, Research and Response. Available at www. healthcare.philips.com /main/shared/ assets/documents/ ... Access on 6 April 2011, pp. 13.
32
to manage such outbreak effectively. Clear lines of authority and communications
have to be established in such an event. A crucial element of the outbreak
preparedness plan is with regard to surveillance and early detection of outbreak. A
bioterrorism attack is often an insidious and unnoticed event. The classical
bioterrorist weapons like anthrax, plague and smallpox are infections that are no
longer happen in Malaysia. So, it is crucial to build up the Malaysia’s plan for
bioterrorism preparedness to include that health care workers be trained to recognized
such diseases, especially those in the front line such as casualty doctors, outpatient
doctors and general practitioners.
The investigation and management of these outbreaks and bioterrorism
activities also require much planning, coordination of activities and resource
allocation. Public health practitioners are required to investigate and control these
outbreaks and they need to understand the nature of bioterrorism and how to prevent
the spread of disease if an attack occurs. Laboratories have to be prepared to handle
the specimens and make the necessary identifications. Some of the agents involved
are highly pathogenic and would require special high containment facilities for their
processing. For this purpose, Malaysia had established a Bio safety Level 3 facility at
the Institute for Medical Research and the other one at the National Public Health
Laboratory in Sungai Buloh. 70
Clinical facilities must also be prepared for bioterrorist attacks. Hospitals need
to have adequate decontamination and isolation facilities for patients and appropriate
personal protective equipment for health care workers. Infection control measures
70 Anthrax War - the Malaysian Connection. Available at www.propublica.org/.../antrax-war-the-malaysian-connection. Access on 12 March 2011.
33
have to be put in place and all health care workers have to be appropriately trained.
Sufficient supplies of critical items like essential antibiotics, vaccines, disinfectants
and personal protective equipments must be stockpiled and distributed in a timely and
efficient manner in times of crises.
In this regard, Ministry of Health (MOH) is planning to set up an Institute of
Natural Products Research and Vaccinology with the assistance of the Ministry of
Science, Technology and the Environment (MOSTE) as part of the Bio valley
initiative. It is clear that managing bioterrorist attacks is no easy task and a lot of
thought and planning is required to achieve the necessary level of preparedness.
Training of personnel is crucial and the need to draw up such a training programme
must be put into the plan of bioterrorism preparedness. The need also in upgrading
our infrastructure in the public health sector, laboratories as well as hospitals.
CHAPTER 3
CLINICAL PRESENTATION AND MANIFESTATION
OF ANTHRAX INFECTION
Background
34
Anthrax infection was described in ancient literature and religious writings
that struck Egypt around 1500 B.C as anthrax epidemics. 71 The disease is also very
well described in texts of antiquity and it has been suggested that the famous Plague
of Athens in 430 - 427 B.C was an epidemic of inhalational anthrax. 72 Periodically,
over the following millennia, there were outbreaks of anthrax worldwide. For
example, there was a substantial outbreak in Germany in the 14th century. During the
17th century, there were large outbreaks in Russia and one in Europe that killed more
than 60,000 head of cattle.
Although the disease anthrax dates back thousands of years, it was recognized
until the 1800s by several scientists who make blood testing from animals that had
died of anthrax. 73 However, the researcher at that time generally agreed that anthrax
was an infectious disease, but they did not agree on the cause of diseases and
continued to debate the cause of anthrax. The disease continued to kill large
numbers of animals and peoples. In 1864, more than 72,000 horses died of anthrax in
Russia. Between 1867 and 1870, 528 men as well as 56,000 horses, head cattle and
sheep died in Novgorod, Russia.74
Finally, in 1876, Robert Koch, a German physician discovered that the cause
of the disease was from the blood of infected animals and very infectious. Koch also
discovered that Bacillus anthracis develop protective spores that enabled them to
71 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, Springer Science, United States, 2005, pp.1 72 Stefan Riedel, Anthrax: a continuing concern in the era of bioterrorism, BUMC Proceedings, Vol.18,No. 3, July 2005, pp. 234. 73 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, pp. 2.74 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, pp. 2.
35
withstand unfavorable conditions to reemerge later when condition improved. In
1881, French scientist, Louis Pasteur who developed a vaccine of anthrax had
contributed to the decline of thousands of dead animals and thousands of people dying
each year in Europe, Asia and North America through vaccination program of animals
and anthrax eradication program. This had also contributed the number of cases of
industry related infections in human decreased dramatically. 75
China has also been affected by persistent anthrax outbreak. In 1989, 509
people were infected during the outbreak in Tibet caused 162 died. The Chinese
government had made significant attempts to reduce the incidence of outbreak. The
latest of anthrax outbreaks was the bioterrorist attack involving the use of anthrax
occurred in United States in 2001 caused in total 22 people were infected with 5
died.76
Clinical Characteristics of the Anthrax Bacterium
Anthrax is an acute disease in humans and animals that is caused by the
bacterium Bacillus anthracis and is highly lethal in some forms. 77 Bacillus anthracis
is a gram-positive, non motile, facultative anaerobic, spore forming, rode shape
bacterium. Each bacterium is the rectangular shape of the individual cell, in the chain
form gives rise to boxcar like. It is about 1 to 1.5 micron in width and 4-10 micron in
75 Ibid., pp. 3.76 Ibid., pp. 7.77 A.L Bhatia and S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 83.
36
length. 78 Since sporulation requires the presence of free oxygen and organisms shed
by the dying or dead animal will sporulate on contact with air. Anthrax spores are
highly resistant to heat, ultraviolet and ionizing radiation, pressure and chemical
agents. They are able to survive in the soil for long periods of time even up to
decades or perhaps longer. In suitable environment (e.g., various tissues or organs),
spores start vegetating and multiplying. However, the Bacillus anthracis are poor
survivors and it is unlikely that germination, propagation with further resporulation
will occur outside the host in natural conditions. 79
There are 89 known strains of anthrax, the most widely recognized being the
virulent, Ames strain used in the 2001 anthrax attacks in the United States. The Ames
strain is extremely dangerous, though not quite as virulent as the Vollum strain
(isolated in 1935 from a cow in Oxfordshire, United Kingdom) was successfully
developed as biological weapon during the Second World War. 80 Anthrax is
classified as a Category A agents with recognized bioterrorism potential priority by
the Centers for Disease Control and Prevention (CDC). 81 Even though anthrax is not
contagious disease, there are certain characteristics of the pathogen that make it
ideally suited for development into a biological weapon. The first characteristic is
that anthrax is relatively easy to produce. Anthrax also has a long shelf life and is
stable in the environment. It spores have a very high survival rate and can be used in
an explosive device. Anthrax has a high mortality rate approaching 100% in the case
78Ibid., pp. 84.? Ibid., pp. 60.79 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, pp.8.80 A.L Bhatia and S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 84.81 A.L Bhatia and S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 60.
37
of untreated inhalational anthrax. Even with treatment, the mortality rate is still high
because there is no effective treatment for advanced forms of inhalational anthrax. 82
Clinical and Epidemiologic Features.
Human anthrax is a disease acquired following contact with infected animals.
Anthrax is not contagious; the illness cannot be transmitted from person to person. 83
The key to anthrax infection is that there must be contact with spores, either through
natural or intentional circumstances. The disease is initiated by the entry of spores
into the host body. This can occur via a minor abrasion, by eating contaminated meat
or inhaling airborne spores. There are three recognized types of human infection,
determined by where spores germinate, inhalational, cutaneous and gastrointestional.
Each form can progress to fatal systemic anthrax. 84
Inhalational anthrax, which is the most likely form to be seen in bioterrorism
event. The mortality is high ranging from 45% in the 2001 anthrax attacks cases in
United States to 89 % in the 20th century of cases. Cutaneous disease is the most
common form of natural disease comprising 95% of all cases. Mortality is less than
1% in treated cases but up to 20% in cases that are left untreated. Gastrointestinal
82 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, pp.4.83 Md Radzi Johari, Anthrax – Biological Threat in The 21st Century, Malaysian Journal of Medical Sciences, Vol. 9, No. 1, Jan 2002, pp. 1-2.84 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, pp.10.
38
disease is rare, comprising less than 5% of all cases worldwide and has never been
reported in the United States. Mortality numbers is estimated to at least 50%. 85
The clinical features of inhalational anthrax have been fairly well described in
the past and have been further validated by the 2001 outbreak. The incubation period
of inhalational anthrax according to current literature may last from 1 to 9 days and
the average incubation period for the patients infected in the United States in 2001
was for 4 - 6 days. 86 Symptoms and physical findings are nonspecific in the
beginning of infection. The occasional longer incubation periods are thought to be
related to delayed spore germination which in animal studies occurred up to 98 days
after exposure. 87
After the incubation period, a non specific flulike illness ensues, characterized
by fever, myalgia, headache, a nonproductive cough and mild chest discomfort. A
brief intervening period of improvement sometimes follows 1 to 3 days of these
prodormal symptoms, but rapid deterioration follows; this second phase marked by
high fever, dyspnea, stridor, cyanosis and shock. In many cases, chest wall edema
and hemorharrhagic meningitis (present in up to 50% of cases) may be seen late in the
course of disease. Chest radiographs may show pleural effusions and a widened
mediastinum, although true pneumonitis is not typically present. Death is universal in
85 Biological Terrorism Primary Care Preparedness, Anthrax September 2003. www.bioterrorism.sku.edu/....ahec_bio/scripts/Anthrax.pdf accessed on 17Apr 2011 at 2244H.86 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, pp. 14.87 Biological Terrorism Primary Care Preparedness, Anthrax September 2003. www.bioterrorism.sku.edu/....ahec_bio/scripts/Anthrax.pdf accessed on 17Apr 2011 at 2244H.
39
untreated cases and may occur in as many as 95% of treated cases if therapy is begun
more than 48 hours after the onset of symptoms. 88
Mode of Infection and Symptoms
Anthrax is not contagious; the illness cannot be transmitted from person to
person. 89 The usual pathway of anthrax exposure for humans through the
occupational exposure to infected animals or their products such as skin, wool and
meat. Workers who are exposed to dead animals and animal products are the highest
risk, especially in countries where anthrax is more common. Anthrax does not
usually spread from an infected human to a non infected human. However, if the
disease is fatal the person’s body and its mass of anthrax bacilli becomes a potential
source of infection to others. Anthrax can enter the human body through the intestine
(ingestion), lungs (inhalation), or skin (cutaneous) and causes distinct clinical
symptoms based on its side of entry. 90
Inhalational or pulmonary anthrax results most commonly from inhalation of
spore containing dust where animal hair or hides are being handled. It is
characterized by fever, dyspnoea, stridor, hypoxia and hypotension leading to death
within 24 hours. This disease can rarely be treated, even if detected in early stages of
infection. Inhalational anthrax is highly fatal, with nearly 100% mortality. A lethal
88 Theodore J. Cieslak and Edward M. Eitzen, Clinical and Epidemiologic Principles of Anthrax, Emerging Infectious Diseases, Vol. 5, No. 4, Jul-Aug 1999, pp. 553.89 Md Radzi Johari, Anthrax – Biological Threat in The 21st Century, Malaysian Journal of Medical Sciences, Vol. 9, No. 1, Jan 2002, pp. 1-2.90 A.L Bhatia and S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 252.
40
dose of anthrax is reported to result from inhalational of about 10,000 – 20,000
spores. 91
Cutaneous anthrax is usually acquired through injured skin or mucous
membranes. A minor scratch or abrasion, usually on an exposed area of the face or
neck or arms, is inoculated by spores from the soil or a contaminated animals or
carcass. The spores germinate, vegetative cells multiply, and a characteristic
gelatinous edema develops at the side. This develops into a papule within 12 - 36
hours after infection. The papule changes rapidly to a vesicle, then a pustule
(malignant pustule), and finally into a necrotic ulcer from which infection may
disseminate, giving rise to septicemia. Lymphatic swellings also occur within seven
days. In severe cases, where the blood stream is eventually invaded the disease is
frequently fatal. 92
Gastrointestinal anthrax is analogous to cutaneous anthrax but occurs on the
intestinal mucosa. The bacteria spread from the mucosa lesion to the lymphatic
system. Intestinal anthrax results from the ingestion of poorly cooked meat from
infected animals. Gastro-intestinal anthrax is characterized by serious gastrointestinal
difficulty, vomiting of blood, severe diarrhea, acute inflammation of intestinal tract
and loss of appetite. It can be treated but usually results in fatality rate of 25% to
60% depending upon how soon treatment commences. 93
91 A.L Bhatia and S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp.253.92 Ibid., 252.93 Ibid., 253.
41
Vaccination of Anthrax Infection
Anthrax and other biological agents which categorized in categories A by
Centre of Control Disease (CDC) are posed the greatest risk for causing large
numbers of casualties in the event of an effective release by a terrorist group, are at
the top of the list of threat agents. Vaccination has been the single most cost effective
public health intervention. The U.S armed forces have recognized the military value
of vaccines against biological threats and have a long standing research and
development program for a series of vaccines to protect service members from hostile
use of a biological agent. 94
Providing the exposed population with antibiotics followed by vaccination
could be lifesaving for exposed persons who would otherwise become ill with
untreatable inhalation anthrax in the subsequent few weeks. Prophylactic antibiotics
alone will prevent disease in persons exposed to antibiotic susceptible organisms, but
incorporating vaccination into the treatment regime can greatly reduce the length of
treatment with antibiotics. Without vaccination, antibiotics must be continued for 60
days; if effective vaccination can be provided this can be reduced to 30 days.
Stockpiling a vaccine capable of inducing protective immunity with two doses could
be extremely valuable in reducing the impact of a terrorist release of anthrax. 95
Anthrax depends on two toxins (lethal factor and edema factor) for virulence.
A protein called protective factor is an essential component of both toxins. The
94 Philip K. Russell, Vaccines in Civilian Defense Against Bioterrorism, Emerging Infectious Diseases, Vol. 5, No.4, July-August 1999, pp. 53195Philip K. Russell, Vaccines in Civilian Defense Against Bioterrorism, Emerging Infectious Diseases, Vol. 5, No.4, July-August 1999, pp. 532.
42
protective factor content is the basis for the effectiveness of the current vaccine. A
vaccine based on purified protective factor made by recombinant technology has been
protective in animals. Use of a modern adjuvant with purified recombinant protective
factor should make it possible to have a very effective two - dose vaccine. 96
The current anthrax vaccine, produced from one non-virulent strain of the
anthrax bacterium is manufactured by BioPort Corporation, subsidiary of Emergence
Bio Solutions. 97 This is the U.S Food and Drug Administration licensed vaccine
derived from the supernatant fluid of an attenuated, none capsulated Bacillus
anthracis strain (Sterne) is available and has been used in hundreds of thousands of
military troops and at risk civilians. The trade name is Bio Thrax, although it is
commonly called “Anthrax Vaccine Adsorbed” (AVA). The vaccination series, as
currently licensed, consists of six doses (0, 2 and 4 weeks and 6, 12 and 18 months)
followed by annual boosters. AVA is administered subcutaneously as a 0.5-mL
dose.98
Recently, there is not enough data from exposure of humans to determine
protective efficacy of the vaccine against anthrax aerosol challenge in bioterrorism
cases, but studies in rhesus monkeys indicate the vaccine is effective, even when as
few as two doses administered. Although, there is no reason to believe that the new
vaccine will be more protective, it will be more easily produced in available
production facilities and may be slightly less reactogenic and possibly lest costly if
large lots are needed. The U.S Institute of Medicine recently published a report that
96 Ibid., 533.97 A.L Bhatia and S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 89.98 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, pp. 24.
43
concluded that Anthrax Vaccine Adsorbed (AVA) is effective against inhalational
anthrax and may help prevent onset of disease post exposure if given with appropriate
antibiotics. 99
Treatment and Prevention of Anthrax Infection
Direct person to person spread of anthrax is extremely unlikely; but a patient’s
clothing and body may be contaminated with anthrax spores. Effective
decontamination of people can be accomplished by a thorough wash down with anti-
microbe effective soap and water. Waste water should be treated with bleach or other
anti-microbial agent. Effective decontamination of particles can be accomplished by
boiling contaminated particles in water for 30 minutes or longer and using common
disinfectants. Chlorine is effective in destroying spores and vegetative cells on
surfaces. 100
After decontamination, there is no need to immunize, treat or isolate contacts
of person’s ill with anthrax unless they were also exposed to the same source of
infection. Early antibiotic treatment of anthrax is essential to delay seriously lessens
chances for survival. Antibiotic prophylaxis for inhalational anthrax appears to be
most effective before respiratory symptoms develop, but it is difficult in naturally
occurring cases to begin therapy early because the nonspecific prodrome is virtually
impossible to distinguish from flu or other less serious diseases. 101 The Centers for
99 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, pp. 25.100 A.L Bhatia and S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 87.101 Steven M.Gordon, The threat of bioterrorism : A reason to learn more about anthrax and smallpox, Cleveland Clinic Journal of Medicine, Vol. 66, No.10, Nov/Dec 1999, pp. 595.
44
Disease Control and Prevention (CDC) recommends post exposure prophylaxis with
ciprofloxacin or another fluoroquinolone twice daily, with doxycycline the second
agent of choice.102 CDC also recommended that cutaneous anthrax associated with a
bioterrorism attack should be treated with ciprofloxacin or doxycycline as the first
line therapy. 103 Cutaneous anthrax with signs of systemic involvement, extensive
edema or lesions on the head and neck require intravenous therapy and a multidrug
approach is recommended.
Although natural anthrax is very susceptible to penicillin, military experts
decided in 1991 that Iraq and Russia both had technology to develop penicillin -
resistant strains. Antibiotics would have to be taken for at least 8 weeks after
exposure, because the spores can lie dormant in the hilar lymph nodes for up to 6
weeks before germinating. 104 Alternately, antibiotics could be given for 4 weeks
while the first 3 doses of vaccine are administered. In either case, these procedures
would clearly strain local supplies of antibiotics as well as vaccine in the event of a
large scale exposure. In possible cases of inhalational anthrax exposure to
unvaccinated personnel early antibiotic prophylaxis treatment is crucial to prevent
possible death. If death occurs from anthrax the body should be isolated to prevent
possible spread of anthrax germs. Burial does not kill anthrax spores. Cremating
victims is the preferred way of handling body disposal. 105
102 Ibid.103 I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, pp. 25.104 Steven M.Gordon, The threat of bioterrorism : A reason to learn more about anthrax and smallpox, Cleveland Clinic Journal of Medicine, Vol. 66, No. 10, Cleveland, Nov/Dec 1999 pp. 595.105 A.L. Bhatia and S.K. Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009, pp. 87.
45
Decontamination of Site in Anthrax Infection
In the incidence of anthrax outbreak or intentionally anthrax released in
bioterrorism event, the decontamination of site contaminated with anthrax spores is
more crucial. Anthrax spores can survive for long periods of time in the environment
after release. Methods for cleaning anthrax-contaminated sites commonly use
oxidizing agents such as peroxides, ethylene oxide, Sandia Foam, chlorine dioxide
(used in Hart Senate office building in anthrax attack in 2001, in USA) and liquid
bleach products containing sodium hypochlorite. 106 These agents slowly destroy
bacterial spores. Chlorine dioxide has emerged as the preferred biocide against
anthrax contaminated sites, having been employed in the treatment of numerous
government building over the past decade.
The process can be speed with trace amounts of a non-toxic catalyst composed
of iron and tetro-amido macro cyclic ligands are combined with sodium carbonate and
bicarbonate and converted into spray. The spray formula is applied to an infested area
and is followed by another spray containing tertiary-butyl hydro peroxide. Using the
catalyst method, a complete destruction of all anthrax spores takes 30 minutes. A
standard catalyst-free spray destroys fewer than half the spores in the same amount of
time.
106 Ibid., pp. 89.
46
CHAPTER 4
ANALYSIS OF PREVENTION STRATEGY
FROM ANTHRAX INFECTION
Even though the threats of bioterrorism are minimal in Malaysia, the risk does
exist. One way or another, national security is vulnerable and can be threatened by
47
the easy availability of biological agents to terrorists and disgruntled individuals who
have no qualms about using them. The problem of many country in facing of
bioterrorism is the time and place of such attacks is difficult to predict. As known that
biological agents have been used for biological warfare and terrorism and their
potential for future use is a major concern. Therefore, Malaysia must be prepared to
respond appropriately to face the unpredictable attack from bioterrorist.
In Malaysia, we are still facing the nation’s bio defense science and response
capabilities is still lagging, with the striking insufficiency of vaccines and
therapeutics, and local public health departments struggling with limited resources.
The Malaysian experience of the natural phenomenon of the bioterrorism is the
outbreak of the Nipah virus, emerging deadly paramyxovirus which invoked scenes of
widespread panic because it produced fear, disease, disabilities, death, social
disruption and severe economic loss to the country. The pandemic of the Influenza
H1N1 and SARS that affect this country a few years ago could be the bench mark of
the nation’s to strategist the level of preparedness towards combating the actual
bioterrorism threat in the future.
There are various strategy of prevention that was produced by various agencies
around the world in order to prepare the nation’s preparedness and response towards
the bioterrorism anthrax threat. This paper will seek to examine the program of
preparedness, response and training aspect in the subsequent sections in order to
provide the best strategy of prevention to the bioterrorism anthrax threat.
STRATEGY OF PREVENTION
48
United States Experience and Response to Anthrax Incidents of 2001
In October 2001, an employee of American Media Inc. (AMI) in Florida was
diagnosed with inhalational anthrax, the first case in the United States in over two
decades. By the end of November 2001, 21 more people had contracted the disease
and 5 people including the original victim had died as a result. Although the FBI
confirmed the existence of only four letters containing anthrax spores, the
Environmental Protection Agency (EPA), United States had confirmed that over 60
sites about one third of which were United States postal facilities had been
contaminated with anthrax spores. 107
The cases of inhalational anthrax in Florida, the first epidemic center
(epicenter) were thought to have resulted from proximity to opened letters containing
anthrax spores. The initial cases of anthrax detected in New York, the second
epicenter, were all cutaneous and were also thought to have been associated with
opened anthrax letters. The cases detected initially in New Jersey, the third epicenter
were cutaneous and were in postal workers who presumably had not been exposed to
opened anthrax letters. The incident on Capitol Hill, the fourth epicenter began with
the opening of a letter containing anthrax spores and resulting exposure. The
discovery of inhalational anthrax in a postal worker in the Washington, D.C., the fifth
epicenter and Connecticut the sixth epicenter revealed that even individuals who had
been exposed only to sealed anthrax letters could contract the inhalational form of the
107 Bioterrorism: Public Health Response to Anthrax Incidents of 2001, Report to the Honorable Bill First, Majority Leader, U.S. Senate, Oct 2003, pp. 9.
49
disease. 108 The incidents of the anthrax attack in United States had national
implications although were limited to six epicenters on the East Coast of U.S. This is
because mail processed at contaminated postal facilities could be cross-contaminated
and end up anywhere in the country.
The U.S. local and state public health officials had identified strengths in their
responses to the anthrax incidents of 2001 as well as areas for improvement. The
planning efforts had helped to promote a rapid and coordinated response that would be
needed across both public and private entities involved in the response to the anthrax
incidents. The response of the public health officials also benefited from previous
experiences, whether gained through exercising their plans or by responding to
emergency of various kinds. One of the key successes in the plan was the effective
communication among response agencies but the responder team still had difficulty
reaching clinicians to provide them with needed guidance.109
The Centers of Disease Control and Prevention (CDC) had served as the focal
point for communicating critical information during the response to the anthrax
incidents and experienced difficulty in managing the voluminous amount of
information coming into the agency and in communicating with public health
officials, media and public. The anthrax incidents also highlighted both shortcomings
in the clinical tools available for responding to anthrax such as vaccines and drugs and
a lack of training for clinicians on how to recognize and response to anthrax. 110
108 Bioterrorism: Public Health Response to Anthrax Incidents of 2001, Report to the Honorable Bill First, Majority Leader, U.S. Senate, Oct 2003, pp. 9.109 Ibid., pp. 4-5.110 Bioterrorism: Public Health Response to Anthrax Incidents of 2001, Report to the Honorable Bill First, Majority Leader, U.S. Senate, Oct 2003, pp. 4-5.
50
CDC also identified areas for improvement and taken steps to implement those
improvements. These include restructuring the Office of the Director, building and
staffing an emergency operations center, enhancing the agency’s communication
infrastructure and developing and maintaining databases of information on and
expertise in biological agents considered most likely to be used in a terrorist attack.
CDC has also been working with other federal agencies as well as private
organizations to support the development of better clinical tools, including new
vaccines and treatments for anthrax and increased training for medical care
professionals. 111
Training for Preparedness and Response
The ability to screen and identify potential biological agents related threats in
bioterrorism have tremendous effect in terms of reduced likelihood of biological harm
to the society. In order to be effective the first responders must be trained and skillful
to identify the potential biological agents that pose fear and devastating to the society.
Training and application are essential to the success of the bioterrorism preparedness,
deterrence and response plan. Each constituency group including law enforcement,
emergency services, hospital personnel, primary care providers, decontamination team
members and medical distribution teams must have ample training and the necessary
equipment for training, practice exercises and simulations. The goal is to enable these
professionals to perform quickly, effectively and efficiently their important roles when
111 Ibid.
51
called upon in time of community catastrophe. 112 In preparing the training
procedure, local civilian medical systems both out of hospital and hospital, comprise a
critical human infrastructure that will be integral in providing the early response
necessary for minimizing the devastation of a Weapon Mass Destruction (WMD)
incident.
Training and application also are concerned with using emergency equipment
and feeling trust and respect for this equipment. Each response group must be
thoroughly familiar with the equipment that it will utilize during an actual terrorism
incident. Once plans are developed at the community level and key groups are
identified with specific tasks to perform, training should be conducted with a
systematic approach. Existing structures such as the emergency management system,
law enforcement and the like should be integrated into the plan and they should
participate in training, practice and simulation exercises with newly formed groups
such as decontamination teams. Existing equipment and procedures for responding to
a terrorist incident should be inventoried and reviewed. 113
Simulation and practice exercises are critical for finding flaws or areas of
weakness in combating bioterrorism plan. Practice exercises should be coordinated
with all local agencies. The general population should be kept informed as should
state and federal agencies. During the simulation or practice exercises, all
communication systems and the leadership command structure should be evaluated for
effectiveness. Backup systems, methods and the performance of individuals identified
112 James A. Johnson, Gerald R. Ledlow and Mark A. Cwiek, Community Preparedness and Response to Terrorism, Vol. 1 The Terrorist Threat and Community Response, Westport Connecticut, London, 2005, pp. 134-139.113 Ibid., 136.
52
for each role to access equipment failures, needs and training deficiencies should be
also evaluated. 114
Determining and providing the proper equipment for the various community
level groups, and matching equipment and people in teams together to train for
competence are vital for terrorism. 115 It is imperative that community based teams
practice with their equipment and become proficient using the appropriate equipment.
When the individual teams become proficient with their tasks, multidisciplinary teams
(EMS, decontamination, firefighting, law enforcement and etc) should work together
in simulation exercises. Federal and state authorities and agencies should be notified
of simulation exercises and invited to participate, since a bioterrorist incidence will
require a total local state and federal effort to reduce damage and to aid the
community’s recovery.
Strategic Plan for Bioterrorism Preparedness and Response - Centres For
Diseases Control and Prevention (CDC’s), Atlanta USA
The CDC was designated by the Department of Health and Human Services,
United States to prepare the United States Public Health system to respond to a
bioterrorism event. CDC’s strategic plan is based on the following five focus areas,
114James A. Johnson, Gerald R. Ledlow and Mark A. Cwiek, Community Preparedness and Response to Terrorism, Vol. 1 The Terrorist Threat and Community Response, Westport Connecticut, London, 2005, pp. 134-139. Ibid., 137.115 Ibid.
53
with each area integrating training and research concerntrated on (1) preparedness and
prevention; (2) detection and surveillance; (3) diagnosis and characterization of
biological and chemical agents; (4) response; and (5) communication. 116
Under the focus area of preparedness and prevention, CDC’s emphasized on
the detection, diagnosis and mitigation of illness and injury caused by biological and
chemical terrorism is a complex process that involves numerous partners and
activities. Meeting this challenge will require special emergency preparedness in all
cities and states. For this strategies’s effort, CDC will provide public health
guidelines, support and technical assistance to local and state public health agencies as
they develop coordinated preparedness plans and response protocols. Furthermore,
CDC also will provide self asssessment tools for terrorism preparedness, including
performance standards, attack simulations and other exercises. In addition, CDC will
encourage and support applied research to develop innovative tools and strategies to
prevent or mitigate illness and injury caused by biological and chemical terrorism. 117
The second focused area of detection and surveillance will focus on early
detection as an essential for ensuring a prompt response to a biological or chemical
attack including the provision of prophylactic medicines, chemical antidotes or
vaccines. For this effort CDC will integrate surveillance for illness and injury
resulting from biological and chemical terrorism into the United States disease
surveillance systems, while developing new mechanisms for detecting, evaluating and
116 Ali S.Khan, Alexandra M. Levitt, Biological and Chemical Terrorism : Strategic Plan for Preparedness and Response. Recommendations of the CDC Strategic Planning Workshop, Morbidity and Mortality Weekly Report, Vol.49, No.RR-4, April 2000. pp. 8. Available at www.cdc.gov/mmwr/PDF/RR/RR4904.pdf Accessed on 27/4/2011.117 Ibid., pp. 9
54
reporting suspicious events that might represent covert terrorist acts 118. As part of
this strategy, CDC , state and local health agencies will form partnerships with front
line medical personnel in hospital emergency departments, hospital care facilities,
poison control centres and other offices to enhance detection and reporting of
unexplained injuries and illnesses as part of routine surveillance mechanisms for
biological and chemical terrorism. 119
The third focused area of CDC is Diagnosis and Characterization of Biological
and Chemical Agents will emphasized on the cooperation of CDC and its partners to
create a multilavel Laboratory Reponse Network for Bioterrorism (LRNB). This
network will link clinical labs to public health agencies in all states, districts,
territories and selected cities and counties and to state of the art facilities that can
analyze biological agents. As part of this effort, CDC will transfer diagnostic
technology to state health laboratories and others who will perform initial testing. To
achieve this, CDC will also create an in-house-rapid-response and advanced
technology (RRAT) laboratory.
This laboratory will provide around-the-clock diagnostic confirmatory and
reference support for terrorism response teams. This network will include the regional
chemical laboratories for diagnosing human exposure to chemical agents and provide
links with other departments such as the United States Enviromental Protection
Agency, which is responsible for enviromental sampling. 120
118 Attacks with biological agents are more likely to be covert acts because they will not have an immediate impact because of the delay between exposure and onset illness. Chemicals terrorism acts are likely to be overt because the effects are usually immediate and obvious.119 Ali S.Khan, Alexandra M. Levitt, Biological and Chemical Terrorism : Strategic Plan for Preparedness and Response. Recommendations of the CDC Strategic Planning Workshop,. pp. 9.
120 Ali S.Khan, Alexandra M. Levitt, Biological and Chemical Terrorism : Strategic Plan for Preparedness and Response. Recommendations of the CDC Strategic Planning Workshop, Morbidity and Mortality Weekly Report, Vol.49, No.RR-4, April 2000. pp. 9.
55
The area of Response will focus a comprehensive public health response to a
biological or chemical terrorist event involves epidemiologic investigation, medical
treatment and prophylaxis for affected persons and the initiation of disease prevention
or environmental decontamination measures. For resources and expertise for
investigating unusual events and unexplained illnesses. In the event of a confirmed
terrorist attack, CDC will coordinate with other federal agencies in accord with
Presidential Decision Directive (PDD) 39. PDD 39 designates the Federal Bureau of
Investigation as the lead agency for the crisis plan and charges the Federal Emergency
Management Agency with ensuring that the federal response management is adequate
to response to the consequences of terrorism. If resquested by a state health agency,
CDC will deploy response teams to investigate unexplained or suspicious illnesses or
unsual etiologic agents and provide on-site consultation regarding medical
management and disease control. To ensure the availability, procurement and
delivery of medical supplies, devices and equipment that might be needed to response
to terrorist caused illnesses or injury, CDC will maintain a national pharmaceutical
stockpile. 121
The fourth strategic plan is the communication systems which concentrated on
the preparedness to mitigate the public health consequences of biological and
chemical terrorism depends on the coordinated activities of well trained health care
and public health personnel. Effective communication with the public through the
news media will be essential to limit terrorists’ ability to induce public panic. To
achieve this, CDC will work with state and local health agencies to develop; (1) a state
of the art communication system that will support disease surveillance; (2) rapid
121 Ibid., pp. 10-11.
56
notification and information exchange regarding disease outbreaks that are possibly
related to bioterrorism; (3) dissemination of diagnostic results and emergency health
information and; (4) coordination of emergency response activities. Through this
network, CDC will provide terrorism related training to epidemiologists and
laboratorians, emergency responders, emergency department personnel and other front
line health care providers and health and safety personnel. 122
World Health Organisation (WHO) Guidance of Public Health Response to
Biological and Chemical Weapons
The development, production and use of biological and chemical weapons are
prohibited by international treaties to which most WHO Member states have
subscribed namely the 1925 Geneva Protocol, the 1972 Biological and Toxin
Weapons Convention, and the 1993 Chemical Weapons Convention. However, not all
country follows the treaties and valid concerns remain that some may yet use such
weapons. Moreover, non-state entities may try to obtain the biological weapons for
terrorist or other criminal purposes.
For the efforts of to prepare the preparedness and response plan as integral part
of existing national emergency and public-health plans, the specific guidance that
WHO provided in strengthening public health measures and response activities with
emphasis on:
122 Ali S.Khan, Alexandra M. Levitt, Biological and Chemical Terrorism : Strategic Plan for Preparedness and Response. Recommendations of the CDC Strategic Planning Workshop, Morbidity and Mortality Weekly Report, Vol.49, No.RR-4, April 2000. pp. 11.
57
a. Threat analysis - multidisciplinary activity with inputs from the
country’s law enforcement, intelligence and medical and scientific
communities. It is aimed at identifying biological or chemical weapons against
the populations, the agents and circumstances under which they may be used.
This is an exercise that is broad in its scope and requires active liaison between
law-enforcement, security and health agencies with local authorities. It will
only rarely be possible to identify the likelihood or precise nature of the threat
and general preparedness measures will therefore usually be required.
Judgements may need to be made on the basis of a general appraisal of
national or local circumstances. 123
b. Pre-emption of attack - The establishment of a biological and
chemical response system in itself a pre-emptive risk reduction strategy. Pre-
emption of terrorist use of biological or chemical agents presupposes, first and
foremost, accurate and up to date intelligence about terrorist groups and their
activities. An important prerequisite for pre-emption is the existence of
national legislation that renders the development, production, possession,
transfer or use of biological or chemical weapons a crime and that empowers
law-enforcement agencies to act where such activities are suspected before an
actual event occurs.
c. Preparing to respond - Most civilian health-care providers have little
or no experience of illnesses caused by biological weapons especially in the
123 Public health response to biological and chemical weapons - WHO guidance, Health aspects of chemical and biological weapons : report of a WHO Group of Consultants, WHO, Geneva, 2004, pp. 58 Available at: whqlibdoc.who.int/publications/2004/9241546158.pdf. Access on 2/5/11.
58
early phases of an incident. There is a need to train health-care workers in the
recognition and initial management of biological causalities and for rapid
communication system that allows sharing of information immediately an
unusual incident suspected. Education and training must cover the general
characteristics of biological agents, the clinical presentation, diagnosis,
prophylaxis and treatment of diseases that may be caused by deliberate agents
release and sampling handling, decontamination and barrier nursing. Training,
planning and drills should be directed at physicians and staff for the
management of mass causalities. Early diagnosis of biological and chemical
exposure will be important in choice of treatment and response; preparation
should include the establishment of a reference laboratory in which potential
agents can be identified. 124
d. Preparing Public Information and Communication Packages -
A plan for providing information to the public about the biological weapons
and their risk and impact needs to be drawn up well before an incident occurs.
The public needs to know how they are expected to act if an attack takes place,
long before any such attack occurs. The communication plan may include
radio and television broadcasts, or the distribution of brochures to the public
describing the potential threat in plain, unemotional language. A well
constructed media plan is essential, both part of the pre incident education
process and to avoid overreaction after an incident. It must contain explicit
and exhaustive instructions on channels of communication and clearance
124 Public health response to biological and chemical weapons - WHO guidance, Health aspects of chemical and biological weapons : report of a WHO Group of Consultants, WHO, Geneva, 2004, pp.60-62.
59
procedures for potentially sensitive information. 125 Public health preparedness
or information programme needs to be evaluated in the context of the specific
local circumstances.
e. Response to Biological Incidents.
1) Determination that a release has occurred or an outbreak is taking
place. Initiating a response to an intentional outbreak requires prior
confirmation that a release has actually occurred or the suspicion that an
outbreak has been caused deliberately. Many factors will influence the
decision to initiate such response, particularly whether the release was overt or
covert. A covert release, just like any other outbreak of disease, will be
detected only when patients begin to present at medical facilities.126
2) Identification of the agent involved. Prompt identification of the
agent involved is required to ensure that the appropriate preventive and
medical measures are taken. One proven method is to establish a small on call
committee of experts include a biologist, physician who are familiar with the
threat agents, law enforcement agencies, the military, forensic psychologist,
representative of public health community and the on-scene authorities. Once
125 Public health response to biological and chemical weapons - WHO guidance, Health aspects of chemical and biological weapons : report of a WHO Group of Consultants, WHO, Geneva, 2004, pp. 62.126 Ibid.
60
the agent is identified, it is important to develop an initial hypothesis as to the
exposure that is causing disease. 127
3) Evaluation of potential spread. The incidents involves the release of
an anthrax agents by aerosol form can be detected by computer modelling to
predict the aerosol particles. The first steps to gather information on the wind
direction and speed and on possible sources of the aerosol. With an ongoing
outbreak, retrospective analysis may indicate that cases originate from specific
areas.128
4) Protection of Responders and health-care workers. The protection
of responders and health-care workers is obviously essential. Respiratory
protection is the most important component of physical protection. Vaccination
or prophylactic antibiotic treatment of those involved in response may have to
be considered. Pre-attack vaccination of healthcare providers may be
considered if appropriate vaccines are wide available for the cases of anthrax,
smallpox and plague.129
5) Infection Control. If agents are contagious diseases are releases, basic
hygiene and infection control measures must be taken by keeping exposed
persons away from public places, isolating suspected or symptomatic cases may
be essential in limiting secondary spread. Movement of patients should be
127 Public health response to biological and chemical weapons - WHO guidance, Health aspects of chemical and biological weapons : report of a WHO Group of Consultants, WHO, Geneva, 2004, pp. 69.128 Ibid., pp.69-70.129 Public health response to biological and chemical weapons - WHO guidance, Health aspects of chemical and biological weapons : report of a WHO Group of Consultants, WHO, Geneva, 2004, pp. 60-70.
61
restricted to the minimum necessary to provide treatment and care. The
population should be told what signs and symptoms to watch out for whom to
call or where to go if they appear. 130
6) International Assistance. The management of a large-scale outbreak,
natural accidental or intentional origin, will beyond the resources of many
countries. Early decision to enlist the assistance of international aid may save
many lives. WHO is able to offer public health assistance to countries
experiencing outbreaks of infectious disease and such aid will be available
regardless of the source of the outbreak.
Application of the Selected Strategies to Malaysia and Malaysian Armed Forces
towards the Preparedness of Bioterrorism
Malaysia have never been experienced a bioterrorism perceived attack by the
bioterrorist like the scenario of bioterrorist attack in United States, Russia, United
Kingdom, Japan and etc. The ongoing handling SARS in 2003 has proved that
Malaysia to be highly successful even though dealing with new infectious disease
caused by a novel virus. This is to a great extent due to prompt and proactive
measures taken by Ministry of Health (MOH) and the close co-operation with various
130 Ibid., pp. 71.
62
ministries and agencies in the National Committee for SARS Control, members of
media and public.
Ministry of Health (MOH) and Malaysian Armed Forces (MAF) in particular
the Malaysian Armed Forces Health Services (MAFHS) are to be considered as the
lead agency in the nation’s response towards the preparedness plan of infectious
diseases outbreak or the bioterrorism. In view of the large numbers of bioterrorism
incidents around the world which are caused by dangerous biological agents such as
anthrax, MOH and MAFHS should adopt the strategic plan for bioterrorism
preparedness and response from various agencies as the integrated national prevention
strategy of bioterrorism.
In order to be effective in the preparedness of bioterrorism, Malaysia should
conducting training, educating health professionals and others in the community and
strengthening knowledge and skills for thorough outbreak investigations, clinical
diagnosis and treatment of anthrax. These can be done by adopting the training and
application of the United States bioterrorism preparedness, deterrence and response
plan. The goal is to enable these professional to perform quickly, effectively their
importance roles when called upon in time bioterrorism attack in this country.
Training and application are also crucial in order to each response group must be
familiar to identify potential biological agents related threats in bioterrorism and the
protective equipment that it will utilize during an actual bioterrorism incident.
Simulation and practices exercises should be coordinated with all local
agencies to find the flaws or areas of weakness in combating bioterrorism plan.
63
During the simulation or practice exercises, all communication systems and the
leadership command structure should be evaluated for effectiveness. Malaysia
believed that both Anthrax attack in US and SARS outbreak have been a useful
exercise for the Ministry of Health (MOH) in preparing itself and handling possible
bioterrorist acts in the future. It has also provided an opportunity to closely
collaborate with other key agencies in an area of national security.
Learning from the experience of the anthrax attacks in 2001 in United States,
better preparation for recognizing and responding to attacks are needed. For this
effort, Malaysia should adopt the CDC’s strategic plan which concentrates on
integrating training research on respective focused areas of preparedness and
prevention, detection and surveillance, diagnosis and characterization of biological
agents, response and communication.
For the preparedness and prevention efforts, Ministry of Health (MOH) should
provide public health guidelines; support and technical assistance to state and district
public health agencies for them develop coordinated preparedness plans and response
protocols of bioterrorism anthrax. In detection and surveillance, MOH had established
a laboratory-based surveillance system and a syndromic surveillance system. The
next efforts are all these surveillance systems of bioterrorism must be integrated to
Disease Control Division at MOH, Putrajaya. In this strategy, CDC also emphasized
the importance of partnership between state and local health agencies with front line
medical personnel in hospital emergency departments, hospital care facilities and
poison control centers to enhance detection and reporting of unexplained injuries and
illnesses for biological terrorism.
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In the strategy of diagnosis and characterization of biological agents, Malaysia
should create a multilevel Laboratory Response Network for Bioterrorism (LRNB)
which network link to clinical labs to public health agencies in all states, cities and
districts that can analyze biological agents. To achieve this, an in-house-rapid-
response and advance technology laboratory should be created to provide around the
clock diagnostic confirmatory and reference support for bioterrorism response teams.
For this moment, Malaysia has three Biosafety Level 3 Labs which are managing for
disease causing organisms that cause that in human, such anthrax, plague and SARS.
The response strategy will focus a comprehensive public health response in
providing medical and health services which are the collaboration of MOH, National
Security Council, MAFHS and Private Health Agency to respond to biological
terrorist event involves epidemiologic investigation, medical treatment and
prophylaxis for affected person and the initiation of disease prevention or
environmental decontamination measures. National Security Council as the Federal
Emergency Management Agency will coordinate the needs of information and the
deployment of rapid response team to the affected area. MOH in collaboration with
MAFHS and Private Health Agency will deploy response team to investigate the
unexplained or unusual etiologic agents and provide onsite consultation of medical
management and disease control.
Malaysia also should adopt the CDS’s communication systems which
concentrated on the preparedness to mitigate the public health consequences of
biological terrorism on the coordinated activities of well trained health care and public
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health personnel. Through this efforts, it hope that MOH will work with state and
local health agencies to develop (1) a state of the art communication system that will
support disease surveillance; (2) rapid notification and information exchange
regarding disease outbreaks that are possibly related to bioterrorism; (3) dissemination
of diagnostic results and emergency health information and; (4) coordination of
emergency response activities.
Malaysian Armed Forces (MAF), specifically MAFHS plays a major role in
providing the field medical services during in time of crisis or disaster in Malaysia. In
planning for medical support in Bioterrorism event, there are several measures to be
taken in to consideration. MAF have own training doctrine such as Publikasi
Perkhidmatan Bersama (Malaysia) 15, or Nuclear, Biological and Chemical Defence
Training Doctrine or PBB(MAL) 15 which the aim of this training doctrine to enable
forces to successfully operate and complete their mission in Nuclear, Biological and
Chemical (NBC) environment. This training doctrine provides guidance to
commanders and staff officer on the impact of an NBC environment on planning and
conduct of operations, decontamination, medical support, logistics support and
training in the NBC environment.
In NBC attacks, the MAF Nuclear, Biological and Chemical Defence (NBCD)
must be able to; (a) Minimise their effects; (b) Maintain the extent of operational and
logistic capability; (c) provide for rapid recovery of operational and logistic
efficiency; (d) Deter attacks by demonstrating a sound defensive capability; and (e)
Actively target the enemy’s offensive biological capability by executing conventional
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attacks on their command and control systems, operational stockpiles and delivery
systems.
The principles for MAF Nuclear, Biological and Chemical Defence (NBCD)
are (a) Hazard avoidance; (b) Protection; and (c) Contamination Control. Hazards
avoidance refers to those actions taken to detect avoid and minimize immediate and
residual NBC hazards and considered the primary defensive measure. Hazard
avoidance is achieved by (1) Hazard prediction, (2) Warning and reporting, (3)
Monitoring and Survey. In the principles of protection does not only apply to
personnel, but also to vehicles, equipment and supplies. Total protection is not always
achievable but measures can still be taken to provide protection.
Contamination control includes all the factors which cover the monitoring,
surveying, plotting, recording and management of hazards in contaminated areas. The
effects of NBC weapons produce immediate and delayed causalities. Causalities can
be minimized by the rapid application of decontamination measures which is a
progressive operation removes residual contamination from personnel and material
with the aim of restoring combat power by allowing a reduction in protection levels.
PPB (MAL) 15 also has particular details in medical support in NBC
environment which in Chapter 6 of this mannual. Medical defensive measures
mentioned were vaccination, prophylaxis or some other method to protect personnel at
risk against exposure or intoxication. Physical measures mentioned were personnel
protective equipment, breathing apparatus and other physical method to be employed
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to reduce the risk of personnel inhaling the aerosolized biological and chemical agents
that may impose during an attack.
By looking into PBB (MAL) 15 training doctrine, it was suggested for MAF to
adopting the international guidance that provided by WHO as a guide to prepare
military strategic preparedness plan in combating the bioterrorism anthrax.
First, WHO guidance is threat analysis whereby military surveillance is
considered as one of the key measures to deter any adversarial attempts in
disseminating chemical or biological agents. There are numbers or role played by
MAF to make sure surveillance effective such as military intelligence to prevent
biowar, military border security, and open sources by sharing information with
military counterpart in other country, military global surveillance and etc. Medical
intellingence at MAF Joint Forces Headquarters is responsible in assessing the
biological threat by evaluating the state of potential adversary’s biological warfare
efforts. The investigations of disease resulting from suspected any biological agent
can be conducted by gathering data from various units in MAF.
Second, WHO guidance that can adopt in military is to establish the pre-
emption of attack. Gathering the operational relevant military information of
bioterrorist attack is crucial in establishment of an accurate and specific identification
of agent. This response is the pre-emptive risk reduction strategy. Timely
idenfication, communication and information sharing of the threat essential in
reducing the impact of the attack. The existence of national legislation is an
important pre-requisite for the military to empower the act to suspected activities
before an actual event occurs.
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Third, guidance is preparing to respond. Preparing to respond means to train
military staff in the recognition and initial management of biological casualities and
for rapid communication. Education and training must cover the general
characteristics of biological agents, the clinical presentation, diagnosis, prophylaxis
and treatment of diseases that may be caused by deliberate agents release and
sampling handling decontamination and barrier nursing. All personnel must be trained
in the use of personal protective equipment, able to detect, monitor and do
surveillance on the contaminants effectively using NBC equipment.
Fourth, Preparing Public Information and Communication Packages.
Providing the information to the public about the biological weapons and their risk
and impact is crucial. During the bioterrorist attack, the people get panic and tend to
move away from the infected area to seek for medical treatment or unifected person
try to free themselves from the disaster. This situation will increased both the spread
of infection and the number of secondary outbreak. So, to prevent this, military with
collaboration of MOH and media should provide information through the radio and
television broadcasts or distribution of brochures to the public describing the potential
threat and the dangerous of diseases. Military should enforce the curfew to restricted
the movement of people and provide necessary treatment and care.
Fifth, Response to biological Incidents by determination the release has
occurred or and outbreak is taking place, identification of the agent involved,
evalution of potential threat, protection of responders and healthcare workers,
Infection control and seeks international assistance such as from WHO in the
management of large scale outbreak.
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CHAPTER 5
CONCLUSIONS
Even though bioterrorism has of late attracted the attention world, it is not a
new phenomenon. History is abounding with examples of bioterrorist acts throughout
the world since ancient time. Bioterrorism, whether real or perceived can have a
tremendous negative impact on society. The classical bioterrorist weapons like
anthrax, plague and smallpox are infections that are no longer seen in Malaysia. The
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Malaysia’s experience of natural phenomenon bioterrorism by the outbreak of viral
encephalitis invoked scenes of widespread panic for many months before the virus
was identified to be Nipah Virus a recently emerging deadly paramyxovirus. The
recent pandemic such as SARS and Influenza and H1N1 will give the good exposure
to this country in preparedness for future infectious disease outbreak whether from
naturally occurring or as a result from bioterrorist attack.
The anthrax attack of 2001 in the United States resulted in 22 cases of anthrax
with 5 died. The United States government had spend over 33,000 antibiotic
prescription, over 1 million anthrax laboratory assay and over $USD 23 million to
decontaminate the germ from incidence location. Malaysia in fact gained useful
experience from the anthrax scare in 2001 and the Severe Acute Respiratory
Syndrome (SARS) outbreak. From these two incidents, we could learn about how the
United States managing the rapid response and crisis management and proactive
collaboration between internal agency and international agency such as WHO to
handle the bioterrorism anthrax. SARS also give valuable experience to Malaysia
dealing with new infectious disease caused by a novel virus.
When the potential agents for bioterrorism are reviewed, anthrax has the
greatest potential for mass casualties and civil disruption. Basillus anthracis
(Anthrax’s germ) has the ability to form resistant spores, which can remain viable for
over a hundred years. Anthrax is the biological weapon most likely to be encountered
because it easy to produce in large quantities, highly lethal, relatively easy to develop
as a weapon. Anthrax spores have a very high survival rate and can be used in an
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explosive device. Anthrax has a high mortality rate, approaching 100% in the case of
untreated inhalational anthrax. Even with treatment, the mortality rate is still high
because there is no effective treatment for advanced forms of inhalational anthrax.
The fear of Malaysia and other nations is this biological agent is still
developed and proliferates from time to time for country such as Russia, United
States, Iraq, Japan and China. The release of this biological agents to the terrorist is
become disaster to the worldwide. The anthrax attack caused massive disruption in
many countries around the world and huge economic, public health and security
consequences. Although a relatively new weapon in the hands of modern potential
bioterrorists, the threat of death from the inhalation of anthrax has been part of human
history since antiquity. The deliberate use of biological weapon has significant
potential for not only damaging the human health but also causing mass panic and
public hysteria.
Malaysia is not excluded to this bioterrorist anthrax attack in the future. In
conclusion, Malaysia should find the best strategy prevention from the bioterrorist
attack or natural anthrax attack. From the research, I found that many agencies
especially United States had experience and had been established the training and
response; and strategic preparedness plan towards bioterrorism anthrax. Since
Malaysia still doesn’t have any strategy of prevention against bioterrorism, MOH and
MAFHS should adopt the strategic preparedness plan from these agencies to be
integrated into national strategy against bioterrorism anthrax.
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As a nation, Malaysia should adjust our current position on the time risk
continuum from reaction, response and recovery to anticipation, dissuasion,
interdiction, disruption and containment. Sustained preventive systems are needed
and should be designed to identify and resolve problems. The health care system in
the country which consisted of the public, the military and the private should be
integrated, strengthen and efforts to develop our own protocols for bioterrorism
preparedness plan in facing the future bioterrorist attack and gaining the public
confidence. The continuous efforts of improving the systems for surveillance,
monitoring health risks detection and improvement on the management of health
services, emergency rapid reaction and decontamination units for preparedness in
outbreak should be our country agenda towards the preparedness against bioterrorism.
Vaccination has been the single most cost effective public health intervention
and have recognized as the military value of vaccines against biological threats to
protect service members from hostile use of a biological agent. The current anthrax
vaccine was known as “Anthrax Vaccine Adsorbed” (AVA) is effective against
inhalational anthrax and may help prevent onset of disease post exposure if given
with appropriate antibiotics. This is the U.S Food and Drug Administration licensed
vaccine derived from the supernatant fluid of an attenuated, none capsulated Bacillus
anthracis strain (Sterne) is available and has been used in hundreds of thousands of
military troops and at risk civilians.
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BIBLIOGRAPHY
Books
A.L. Bhatia and S.K Kulshrestha, Bioterrorism and Biological Warfare, Pointer Publisher, Jaipur, 2009.
I.W. Fong and Kenneth Alibek, Bioterrorism and Infectious Agents A New Dilemma for the 21st Century, Springer Science, United States, 2005.
James A. Johnson, Gerald R. Ledlow and Mark A. Cwiek, Community Preparedness and Response to Terrorism, Vol. 1 The Terrorist Threat and Community Response, Westport Connecticut, London, 2005.
74
PBB (MAL) 15 Publikasi Perkhidmatan Bersama Malaysia Nuclear, Biological and Chemical Defence 1999.
Journal and e-journals
Alasdair Geddes, Infection in the twenty first century: predictions and postulates, Journal of Antimicrobial Chemotherapy, Vol. 46, The British Society for Antimicrobial Chemotherapy, Birmingham, 2000.
Arnold F. Kaufmann, Martin I. Meltzer and George P.Schmid, The Economic Impact of Bioterrorist Attack: Are Prevention and Postattack Intervention Program Justifiable? Emerging Infecrtious Diseases, Vol. 3, No. 2, CDC, Atlanta, April-June 1997.
Bruce Hoffman, “Why Terrorists Don’t Claim Credit,” Terrorism and Political Violence, Vol. 9, No. 1, 1999.
D.A. Henderson, Bioterrorism as a Public Health Threat, Emerging Infectious Disease, Vol. 4, No.3, John Hopkins Univesity, Baltimore, July-September 1998.
Eric K .Noji, Bioterrorism: a new global environmental health threat, Global Change & Human Health, Volume 2 No. 1, Kluwer Academic Publishers, 2001.
Md Radzi Johari, Anthrax-Biological Threat in the 21st Century, Malaysian Journal of Medical Sciences, Vol. 9, No. 1, Universiti Sains Malaysia, Pulau Pinang, Jan 2002.
Philip K. Russell, Vaccines in Civilian Defense Against Bioterrorism, Emerging Infectious Diseases, Vol. 5, No.4, July-August 1999.
Philip S. Brachman, Bioterrorism: An Update with a Focus on Anthrax, American Journal of Epidemiology, Volume 155, No.11, 1 June 2002.
Sai Kit Lim, Nipah Virus a potential agent of Bioterrorism? Antiviral Research Vol 57, Elsevier Science, 2003.
Steven M. Block, The Growing Threat of Biological Weapons, American Scientist, Vol. 89, January-February 2001.
Steven M.Gordon, The threat of bioterrorism : A reason to learn more about anthrax and smallpox, Cleveland Clinic Journal of Medicine, Vol. 66, No. 10, Cleveland, Nov/Dec 1999.
Sudhir Syal, Bioterrorism: time to wake up,Vol. 95, No.12, Jaypee,Current Science, 2008.
Theodore J. Cieslak and Edward M. Eitzen, Clinical and Epidemiologic Principles of Anthrax, Emerging Infectious Diseases, Vol. 5, No. 4, Jul-Aug 1999.
75
Thomas V.I et all, Anthrax as a Biological Weapon Medical and Public Health Management, JAMA, Vol. 281, No.18, American Medical Association, Baltimore May 12 1999.
Thomas V. Inglesby, Tara O’Toole, Donald A. Henderson, et al. Anthrax as a Biological Weapon, 2002 Updated Recommendations for Management, JAMA, Vol.287, No.17(Reprinted) May 1 2002
Zalini Yunus, Combating and Reducing The Risk of Biological Threats, The Journal of Defence and Security, Vol.1, No. 1, Science & Technology Research Institute for Defence, MINDEF, 2010.
Report and Proceedings
Ali S.Khan, Alexandra M. Levitt, Biological and Chemical Terrorism : Strategic Plan for Preparedness and Response. Recommendations of the CDC Strategic Planning Workshop, Morbidity and Mortality Weekly Report, Vol.49, No.RR-4, April 2000. Available at www.cdc.gov/mmwr/PDF/RR/RR4904.pdf Accessed on 27/4/2011.
Christopher Lee, Alert, Enhanced Surveillance and Management of Avian Influenza in Human, 6 Feb 2004.
Public health response to biological and chemical weapons - WHO guidance, Health aspects of chemical and biological weapons : report of a WHO Group of Consultants, WHO, Geneva, 2004, pp. Available at: whqlibdoc.who.int/publications/2004/9241546158.pdf. Access on 2/5/11.
Stefan Riedel, Anthrax: a continuing concern in the era of bioterrorism, BUMC PROCEEDINGS No. 18, 2005.
Stacy L. Knobler, Adel A.F, Biological Threats and Terrorism, Accessing the Science and Response Capabilities, Workshop Summary, National Academy of Science, pp. 2. Available at http://www.nap.edu/catalog/10290.html. Access on 30 March 2011.
Internet Sources: Websites
Anthrax War – the Malaysian Connection. Available at www.propublica.org/.../antrax-war-the-malaysian-connection. Access on 12 March 2011.
Anthrax as a Weapon of Terrorism and Difficulties Presented in Response to its Use, Available at : www.defencejournal.com/dec98/anthrax.htm Access on 12 March 2001 at 2016H.
76
Biological Terrorism Primary Care Preparedness, Anthrax September 2003. www.bioterrorism.sku.edu/....ahec_bio/scripts/Anthrax.pdf accessed on 17Apr 2011 at 2244H.
Edward M.Eitzen, Use of Biological Weapons, U.S. Army Medical Research Institute of Infectious Diseases, Fort Detric, Frederic, Maryland. Available at : www.dead-planet.net/med-cbw/Ch20.pdf . Access on 28 March 2011. Giorgos Stamkos, Bioterrorism: The New Invisible Threat Available at : www.e-telescope.gr/en/international-isssues/79-bioterrorism Access on 21 March 2011 at 1208H.
Jonathan B.Tucker, Biosecurity: Limiting Terrorist Access to Deadly Pathogens. Available at : www.usip.org/files/resources/pwks52.pdf. Access on 17 March at 2308H
Micheal B. Phillips, Bioterrorism: A brief History, Focus on Bioterrorism 2005. Available at: www.DCMSonline.org Access on 19 March 2011 at 2008H.
R Gregory Evans et al, The Threat of Bioterrorism in the U.S, A report Current Healthcare Issues Bioterrorism, Business Briefing : Global Healthcare Issues.
The Economic and Social Impact of Emerging Infectious Diseases: Mitigation Through Detection, Research and Response. Available at www. healthcare.philips.com /main/shared/ assets/documents/ ... Access on 6 April 2011.
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