Because early symptoms of most biological agent illnesses are nonspecific, the first clue might be that there is a similar case from the same building, event, neighborhood, etc. This is a signal to call infection control and the local public health department immediately. You should contact the local health department any time there is an unusual or suspicious illness, particularly if there is a cluster of patients presenting with the same symptoms. Vigilant surveillance is the key to detecting outbreaks early.

There are several epidemiological clues to a bioterrorist attack. They include: geographical pattern, sudden cluster of illness, occurrence outside of endemic area, and/or sick or dead animals.

If a patient reports a suspected exposure to a biological agent, then law enforcement should be contacted to evaluate the credibility of the threat. Although patients may request nasal swabs or other tests for anthrax, it is important to understand that the reliability of this test is very limited. Nasal swab for anthrax cannot be used to rule out exposure for a particular individual. It is used as an epidemiologic tool to determine if people may have been exposed in an area in which anthrax spores are found. Nasal swab testing should only be done if recommended by public health officials as part of an epidemiologic investigation.

If patients present with illness that may be due to a biological agent, then testing for these agents may be indicated. Anthrax can be identified on blood culture or culture of skin lesions. Special testing may be required to identify anthrax or other agents. The lab should be notified if a biological terrorism agent is suspected.

While no one knows for sure exactly what agents a terrorist will use, several agents have been identified as having the greatest potential for use as a biological weapon. These agents are classified as Category A agents and include Anthrax, Smallpox, Plague, Botulism, Tularemia, and Viral Hemorrhagic Fever. Category A agents are relatively easily disseminated or transmitted and can cause high mortality and social disruption. Special preparation by the health care community is required to prepare for a bioterrorist attack at this level. Although virtually any micro-organism has the potential to be used as a biological weapon, most would be difficult to weaponize and disseminate effectively. (Lillibridge SR, Bell AJ, and Roman RS. Centers for Disease Control and Prevention Bioterrorism Preparedness and Response. Am J Infect Control 1999;27:463-4.)

We have already seen that small-scale biological attacks can occur. Many people are afraid to think about a large-scale bioterrorism event. They think it is too terrible to happen. However, most experts agree that it is a possibility for which we should be prepared. Even though a major attack could be devastating, advanced preparations could minimize the consequences.

Immediately. If you suspect that a patient may have an illness related to a bioterrorist event, you should notify your local public health department without delay. In addition, you should notify the hospital infection control team, the hospital lab, hospital administrators, and other necessary personnel as mandated by your institution's disaster plan. If a patient reports a possible exposure to a biological agent, then law enforcement should be notified to evaluate the credibility of the threat.

The initial response to a bioterrorist incident will be through local public health investigation and laboratory testing and will involve public health, police, fire, and EMS. The first 24-48 hours of the response time will be primarily confined to state and local responders. This is why it is so important for your institution to have an established working relationship with the local public health officials. Prompt communication will allow these officials to activate state authorities including state public health, disaster management, and the National Guard. The federal agencies that will respond to a bioterrorist event include the CDC, FEMA, FBI, and the Department of Defense. (Guidotti TL. Bioterrorism and the Public Health Response. Am J Prev Med 2000;18:178-180.)

Notify the lab as soon as a bioterrorist agent is suspected, as some labs require special processing to improve yield. Notification is also important to ensure the safety of lab workers, because some agents pose potential risks to them. Some biological agents require a high BSL (BioSafety Level). The BSL capabilities of labs vary, so it is important to know the capabilities of your local lab before sending them a suspected bioterrorist agent. This is also important because labs also range in their ability to test for various agents, from A (clinical labs) to D (CDC).

Some important steps to take include:

1. Become familiar with likely agents and clinical syndromes
2. Discuss existing surveillance programs with the infection control team
3. Implement a hospital bioterrorism disaster plan
4. Develop security preparations to control flow of people in and out of hospital
5. Develop strategies for dealing with the media

(Atlas R. The Medical Threat for Biological Weapons. Critical Reviews in Microbiology 1998; 24(3):157-68.)

We also suggest that you develop and maintain accurate contact information and a good working relationship with your local health department.

Appropriate response to possible anthrax exposure in a letter is to call 911, place the envelope in a plastic bag or just set it down and cover it with something. Wash hands and other exposed areas of the body with soap and water. People should be removed from the immediate proximity of the letter, and the names of those who were in the immediate area should be noted. Although in most cases it is difficult for anthrax spores in a letter to become airborne, spores that are specially prepared may pose a threat of inhalation anthrax to those in the immediate area.

The state of California Public Health Lab is capable of testing for category A agents including anthrax, plague, tularemia, brucellosis, and botulism. The remaining category A agents must be sent to the CDC for testing and confirmation. The capability of local health departments to test biological agents varies by county. These differences represent little variation in the time necessary to identify a biological agent if public health response is activated early.

There are many sites that have reliable information regarding bioterrorism. They include: www.bt.cdc.gov; www.fema.gov; www.nbc-med.org; www.hopkins-biodefense.org; and www.apic.org. The information on these sites ranges from bioterrorism protocol and educational materials to developing a bioterrorism readiness plan and identifying biological agents. You should also review the BT Publications and Links pages on this site as these pages have additional information. Your local and state public health departments will also have information on bioterrorism. They are excellent resources that may be more specifically applicable to your location/setting.