Bioterrorism has been around a very long time - at least dating back to the 14th century where besieging Tartar armies catapulted infected carcasses into cities to spread disease. In March 1995 a terrorist group in Japan released sarin gas (a nerve agent) into the air of Tokyo's subway system killing 12 people and affecting the health of over a thousand.

Bioterrorism has become a more tangible threat following the terrorist attacks of September 11th 2001, the release of anthrax in the US in October 2001 and the more recent discovery of traces of the toxin ricin in a London flat in January 2003.

Possible bioterrorist agents

• Infections e.g. anthrax, smallpox, plague, botulism, brucellosis, tularaemia, salmonella, monkeypox, melioidosis, glanders
• Toxins e.g. sarin, ricin

Management

Health decisions for the community in response to a terrorist event will require the involvement of local public health professionals, GPs and health care workers as well as more central resources. Good systems exist to cascade information rapidly to GPs and primary care workers. All health professionals should be aware of the main aspects of national (see links below) and local contingency plans for any bioterrorist attack. Primary health care teams have a role in bioterrorism with:

• Surveillance and detection: GPs will need to be alert to recognise unusual illnesses or patterns of infection which may suggest the deliberate release of agents.
• Diagnosis: immediate discussion with secondary/tertiary care to arrange the appropriate plan for further assessment and management. Patient may require admission on clinical grounds but further evaluation of those who do not require admission should be away from the hospital environment and in an environment suitable to prevent or limit any risk of spreading infection.
• Medical management of victims and protection of those not immediately affected: make available any recommended pharmaceutical countermeasures. Primary care will be involved in immunisation and identifying individuals in whom the risk of exposure merits prophylaxis as well as reassurance of the community where risks are small.
• Follow-up: monitor the medium and long term health of those in affected communities as part of the recovery process.

The precise nature of the required countermeasures and the role of primary care will depend on the specific nature of the deliberate release.

Internet and further reading

• Centers for Disease Control and Prevention (US); Bioterrorism.
• WHO; Bioterrorism
• Toxbase; (Registration is free for doctors who are employed by an NHS practice)
• U.S. Food and Drug Administration; Bioterrorism.

Acknowledgements