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Thoughts on Bioterrorism

Excerpted from
Update in Infectious Diseases
Annals of Internal Medicine, 17 August 1999. 131:273-280.

John G. Bartlett, MD

The key aspects of bioterrorism as a clear and present danger in the United States have been discussed by Henderson. (1) The first question is whether it is likely to occur in this country, and most of those concerned now seem to believe that it is. Nevertheless, it is proving difficult to get the attention of U.S. physicians, despite the manifest importance of doing so. Many probably would acknowledge that an act of bioterrorism is going to happen somewhere in the United States, "but not in Cincinnati." In fact, the likelihood of an attack in some city is high, but in any particular city, low. Certainly, logic would dictate that New York City and Washington, D.C., are the most tempting targets, but terrorist acts of all kinds have occurred at unpredictable places and times. The next question about bioterrorism is which agents will be launched. The consensus is that the "big two" are smallpox and anthrax.

The key question is whether we in the United States are ready to deal effectively with bioterrorism. The tendency has been to approach the problem in the manner used for chemical warfare, which in fact is a different challenge. Chemical exposures occur in a matter of minutes and affect those near the point of release, and the site of origin is readily detected. Biological assault, in contrast, takes place over a period of days and affects a widespread population. Its point of origin is difficult to detect. The rules and regulations for dealing with chemical exposure are intended largely for fire fighters, police officers, and paramedics as the first responders. But in the event of a bioterrorism attack, the initial responders will include physicians, other care providers, and emergency department staff. Physicians will administer antibiotic prophylaxis to many thousands of people if an anthrax attack is launched, and it is physicians as well who will have to deal with smallpox or other biological agents.

Just how likely is a bioterrorism attack in the United States? It is estimated that at least 10 nations and possibly 17 possess biological warfare agents. In 1991, Iraq produced large amounts of anthrax, botulinum toxin, and other agents, deliverable by SCUD missiles or drones. The facility itself was destroyed in 1996, but it seems likely that the biological materials reside elsewhere. The Japanese man who led the sarin gas attack in 1995 is to be released from prison and, with thousands of followers and abundant assets, remains a substantial threat. The same group attempted an anthrax attack in Tokyo that was foiled only by climatic conditions. The former Soviet Union's highly sophisticated biological weapons program employed 60 000 workers in eight cities before its political demise. Today, Russian experts in bioterrorism are being recruited by many nations that wish to develop a biological warfare capacity. These include Iraq, Iran, Libya, Syria, and North Korea. Organized efforts by some nations aside, the FBI reports that, at least once a day, a politician, school, abortion clinic, or other controversial person or institution receives an envelope from a dissident containing a powder and a note announcing exposure to a lethal dose of, say, anthrax. That they have so far been hoaxes does not mean that dissidents in the future will not be sending the real thing.

The U.S. Congress has allocated more than $130 million to deal with bioterrorism, but the all-important element of an effective response–the civilian response–has not been adequately funded. Limited hospital facilities, a consequence of the downsizing that accompanies managed care, are also a potential problem. Antibiotics can probably be readily stockpiled regionally so that several million doses will be on hand if needed, but vaccines are a problem. Industry estimates are that, if we start now, a smallpox vaccine probably would not be available to civilians until about 2002.


  1. Henderson DA. The looming threat of bioterrorism. Science. 1999; 283: 1279-82.
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