Future Challenges

Maintaining Vigilance Against Bioterrorism roday, an unfortunate challenge in epidemiology is to maintain vigilance against biological warfare. Even as we work to control, and seek to eradicate, some diseases, we must be aware that microbes pose a threat as potent biological weapons. Experts in the field of bioterrorism list four diseases—anthrax, botulism, plague, and smallpox—as the greatest threats.

While it is hoped that a biological weapons attack will never occur again, it is crucial to be prepared for the possibility. Prompt recognition of such an event, followed by rapid and appropriate isolation and treatment procedures, can help to minimize the consequences. The CDC, in cooperation with the Association for Professionals in Infection Control and Epidemiology (APIC), has prepared a bioterrorism readiness plan to be used as a template by health care facilities. Many of the recommendations are based on the Standard Precautions already employed by hospitals to prevent the spread of infectious agents (see Perspective 20.1). Some of the most relevant characteristics of the diseases that are the most likely candidates for biological weapons include:

■ Anthrax. This was the agent used in the bioterrorism events of2001. The most severe outcome results from the inhalation of the airborne endospores of Bacillus anthracis, which can rapidly result in a fatal systemic illness. Anthrax can be prevented by vaccination, but that option is not widely available. Prophylaxis with antimicrobial medications is possible for those who might have been exposed, but this

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requires prompt recognition of exposure. Fortunately, person-to-person transmission of anthrax is not likely.

■ Botulism. Botulism is caused naturally by the ingestion of botulinum toxin, produced by Clostridium botulinum. Aerosolized toxin could also be used as a weapon, however, because any mucous membrane can absorb the toxin. Botulism can be prevented by vaccination, but that option is not widely available. An antitoxin is also available. Botulism is not contagious.

■ Plague. Pneumonic plague, caused by inhalation of Yersinia pestis, is the most likely form of plague to result from a biological weapon. Although no effective vaccine is available, post-exposure prophylaxis with antimicrobial medications is possible. Special isolation precautions must be used for patients who have pneumonic plague because the disease is easily transmitted by respiratory droplets.

■ Smallpox. Although a vaccine is available, routine immunization was stopped over 20 years ago because the natural disease has been eradicated. As is the case with nearly all infections caused by viruses, effective drug therapy is not available. Special isolation precautions must be used for smallpox patients because the virus may be acquired through droplet, airborne, or contact transmission.

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