 And tell us why is there so much concern today about biological warfare and terrorism? Colonel Parker. Well Doris, the threat of biological warfare has increased, but just as importantly our appreciation and understanding of our vulnerabilities has become sharpened. When the Biological Weapons Convention was signed in 1972, it was thought that we only had a few countries out there that were developing a BW capability. Well the Gulf War was a wake-up call for us, and we learned a great deal about how biological weapons might be employed against us or against our allies. And our concept for use and our defense doctrine was based upon a battlefield scenario and a battlefield threat. We now know that there's many more countries working on biological capability, and we know that several of those countries are also supporters of international terrorism. So the BW threat is serious, and the battlefield may indeed be right on our own soil in the form of bioterrorism. Alright, Mr. Blitzer, how does the FBI view the threat? Let's just echo what Jerry mentioned. For us, we've seen a change in climate over about the last ten years. Just look at the kind of cases we've seen. Pan-I-103 World Trade Center, coal-barred towers, and the bombings recently in Africa. This is different. This is large casualties, and it's of great concern. And let's face it, with the taboo being broken in Japan by the Aum Shinrikyo, it's happened. It's actually happened. Now, that was come, but it's not far away. You know, Doris, I think for the people out there in the studio, it's useful for me to think of this threat on three levels. So I like to think of the bio threat on a strategic level, a tactical level, and a terrorist level. And what do I mean by that? Well, if you look at the strategic level, here I mean what would the enemy, and let's pick on the Soviet Union since they're not around anymore, what would the Soviet four-star general think makes a good weapon? His job is to win the war, to alter the course of global politics, and what would help him do that? Well, if you look at it that way, the news is actually pretty good because there are very few weapons systems that have the downwind drift and the widespread applicability to make them viable strategic weapons. And I think Dr. Bailey mentioned all of those. There's smallpox, there's plague, there's anthrax, but very little else would make a viable strategic weapon. And we're not there yet, but it's entirely possible that with a little bit of research, we might come up with effective medical countermeasures for everything on that very short list. Now, when you switch gears and you talk about tactical weapons, what do I mean here? Well, here I mean what would the Soviet Lieutenant Colonel think makes a good weapon? His job is to take that hill this week. What would help him do that? Well, again, the news here is still pretty good. Now the list gets a little bit longer, some of the toxins might now be included, but still there are only seven or eight agents that would be viable tactical weapons. And again, with some work, we might come up with effective medical countermeasures for everything on that very short list. I'm here to tell you though, and I'm sure Mr. Blitzer would agree with me, that when you start talking about terrorism, the task gets much, much tougher because literally anything might make a good terrorist weapon. I think you have to ask yourself, what's the average terrorist after? And often the answer to that question is publicity. And if that's all I'm after, virtually anything will get me what I want. And for a great example of that, let's look at the Benai Brith incident. For those of you who don't remember this, in April of 1997, a postal worker at the Benai Brith headquarters in downtown Washington, D.C. came upon a package in the mail room. And this package was dripping red liquid and he opened the package and inside was a blood auger plate, a petri dish. And written on there was the word anthrax, misspelled, but anthrax nonetheless. And he did exactly what he was supposed to do. He pushed the correct panic buttons. He called the FBI. They came down, retrieved the sample, and tested it for the presence of anthrax. Well, in the midst of all this, many other agencies got involved. Basically a decon station got set up on Massachusetts Avenue. They quarantined the building. They took 100 people inside that building, put their underwear, paraded them through decon in full view of the CNN cameras. And I have really mixed feelings for how things went that day. On the one hand, I think it was overkill. I think that you could have tested that. Again, biological weapons have something that other weapons don't have. They have incubation periods. In the case of anthrax, that incubation period would have been at least 24 hours. You would have had 24 hours to figure out what was going on. Well, as it turns out, there was nothing on that plate. There were no pathogens at all. And yet, here's a terrorist that everything he ever could have hoped for. He shut down the nation's capital of the United States of America at rush hour on a Friday with an empty dish. And if he could do that with nothing, imagine what you could do with anything. That's really an important example, I think, Ted, because... And here was the first, I think, major test of the first response to something like this in the United States. And it was somewhat confused to say the least. But from that, I think we learned some lessons. These hoaxes can be very serious for us. And we spend an awful lot of time on them. And unfortunately, we're getting more and more hoaxes every year. And it's resource-intensive for law enforcement and the fire community. And we have to treat every single one of them as if it's the real thing, because God knows when it will be the real thing. Kyle Pogger, is this increasing the concern that a serious biological incident could occur? Well, the simple answer to that is yes. But let me explain a little bit. There's a growing concern that there's going to be increased proliferation of weapons of mass destruction to include biological pathogens and associated delivery technology to disperse biological agents. As an example, the former Soviet Union had a large offensive biological program. Today, there's thousands of scientists, engineers, and technicians who are either out of work or have not been paid for a long time. They have families to feed, and they simply could be tempted to sell their knowledge and expertise to the highest bidder, whoever that may be. When you couple that with the fact that there seems to be an increasing trend amongst terrorists to inflict indiscriminate killing on a larger scale, well, then yes, we just simply have higher odds that a serious biological attack could occur and could come from either a regional aggressor, a rogue third world nation terrorist group, or even a religious cult. Is this an... I'm sorry, do you think that a terrorist would use a biological agent? That's a reasonable... Yeah, I do think they would. It's a simple answer, but let's face it, just looking around at the kinds of cases we've had, the trend is mass casualties, as Jerry mentioned. And what better way to do it, frankly, and particularly in a bio, which is so insidious, because by the time they do it, they're gone, and you have an incubation period, and by the time you actually know it's happened, it's too late. That's right, I think if you ask me, you know, what's the chance that somebody in Atomwa, Iowa will successfully use anthrax as a weapon this year, I'd say the chances of that are pretty slim. But if you ask me, what are the chances that somebody, somewhere will use something in the next decade, I think the chances are almost 100%, and I think Colonel Parker and Mr. Blitz would probably agree with me. Well, Mr. Blitz, what has the FBI been saying lately? Well, we've seen a tremendous upsurge in the number of cases around the nation, and it's really of concern to me, because we began a couple of years ago with maybe 20, 30 cases a year. Now we're seeing an excess of 100 cases a year, and I think that's significant, because we are actually arresting and convicting people. Now, granted, these are basically lone actors, but it's out there, and I've not seen it before. And in the whole scheme of things, I think it's an important trend, and we're following it very closely. Right, I think a great example of this trend is the case of Mr. Larry Wayne Harris, and I'm sure many of the audience members are probably familiar with Mr. Harris's case. You'll remember that he was the gentleman arrested earlier in 1998 with anthrax in his trunk, and as it turns out, it was a veterinary vaccine strain and a harmless strain, but certainly it instituted a Chinese fire drill, consumed a lot of the FBI's resources, et cetera, et cetera. You'll also remember he was the same gentleman who, in 1995, was arrested with plague in his glove compartment. And again, just a lone actor like this can certainly consume a lot of government resources. The thing about that case was that as we tested it, we kept getting hits for live anthrax, so it wasn't until the definitive tests were done some 30, 40 hours after the event that we actually knew we had a vaccine. How is the internet interacting in this? Yeah, I mean, it's out there. I mean, it's all out there. If you look around the internet, not only do you see stuff for bio, you see it for chem, arsons. It's just a panoply of information on the internet that just makes things really easy for people. All right. Carl Parker, why is it so difficult to control biological weapons proliferation? I mean, can't we just use treaties and agreements like we've done for nuclear and chemical weapons? Well, I wish we could, but it's not that simple. Biological treaties have proven to be just very, very difficult to enforce. In fact, most of the treaties have not had just the enforcement teeth. But it really comes down to biological pathogens can be produced very easily, and the same equipment that's needed to produce a biological pathogen for nefarious use has legitimate research, medical, and other applications. So that dual use nature makes it very difficult to gauge the intent of the bad guys, so to speak. And so it's that dual use equipment that makes it very easy to hide illicit activities. And that can go on even on a national scale as we now know Iraq, the former Soviet Union, had very large offensive biological capabilities, and it goes simply undetected. That's a great example of this phenomenon. It concerns this explosion of microbreweries that's occurring in the United States, and Russian inspectors come to our country for various reasons, and they're very concerned about this explosion of microbreweries, because each and every one of these breweries could, with very little work, actually be turned into a viable biological weapons production facility. Well, tell us an example of that. Just last week I was in Russia, and one day for lunch we went to a microbrewery for lunch, but took a tour of the brewery afterwards. And the story is told to us that the engineers from the biological laboratory that we had visited just the day before actually designed and installed the fermentation equipment in this microbrewery. So that dual use nature can go both ways, and dual use is also personnel. How do you keep up with what private citizens do? Where do you draw the line between what's OK and what's illegal? That's really a great question. In every country, and people have First Amendment rights, and we have to protect those. And at the same time, we have to be very vigilant whenever we see criminal activity arising. The interesting thing about some of the statutes that we have on the books is that it's not illegal to possess some of this stuff. For example, the Harris case was not illegal for him to possess the plague. It wasn't illegal for him to possess anthrax, and Congress has recognized this, and we're trying to amend the statutes to make it much more difficult for someone for nefarious purposes to have another possession, these kinds of substances. So how do we deal with the problem, or is it just too hard to do? Well, it's a very serious problem, and it's got a lot of challenges in front of us to deal with this problem, but we cannot afford to say this is too hard to do, nor can we afford to bury our head in the sand. There's many things that we can do. Just today, what we're doing today, educating everyone, and we can begin to put biological pathogens on our list of differential diagnosis will go a long way so that we can recognize and make rapid diagnosis in case an incident or an attack does occur. We have to do much more in the medical R&D role in developing the appropriate drugs and vaccines that will be needed to mount an appropriate medical response. And with that, if an attack ever were to occur, it's going to take a lot of agencies to deal with an incident. It's going to have law enforcement. It's going to have national security implications, but first and foremost, the responsibility for dealing with the initial consequences for saving life is going to fall in the medical and the public health communities. That's right, Doris. You know, Colonel Parker tells me that my job at USAMRA is to assist in the development of product strategies and countermeasures to assist in safeguarding us against these 15 or 20 infectious disease agents that our intelligence communities perceive as viable biological warfare threats. And in that context, we work on vaccinations. We work on discovering new antibiotics, et cetera. We've come a long way. We've made great strides in trying to help our country defend against these agents. But right now, we're still several years away when it comes to developing vaccines against a lot of these agents. So in 1998, one of the big cornerstones of defense is education. He's getting the word out. He's raising the sense of clinical acumen and the diagnostic capabilities of the medical providers out there. And that's exactly what we're trying to do with this course. And you know, for the last two years, we've worked awfully hard in our agency to try and prepare the domestic home front for this. And the defense has had a good program ongoing, teaching first responders the basics. And at the same time, both the White House and the Congress recognize that there has to be a lot of work done, particularly in the public health arena, and to strengthen our public health system throughout the country. Because let's face it, there are first line of defense when it comes to biological. And certainly, there are second line of defense when it comes to a camp. And the public, the health community just plays such an incredibly important role in the school arena. I agree, Bob. But I think we can, all that's worked in this community can take a lot of pride in just the accomplishments that have occurred over the last couple years. But the journey has just begun and there's a lot more work to be done, particularly in the public health and medical communities. Ted, with all the good defensive steps we've made, why would anyone choose to use a biological weapon anyway? Well, there are a lot of reasons why a terrorist might choose a biological weapon. But your question is a very good one. Certainly, history is full of examples of how terrorists can achieve their aims with conventional weapons. And Kobar Towers, World Trade Center, Oklahoma City, recent embassy bombings in Africa, all great examples of terrorists somewhat successfully employing conventional weapons. And furthermore, the gang at the Alm-Shinrikyo in the Tokyo subway certainly has demonstrated that terrorists can somewhat successfully use chemical weapons as well. So again, given that conventional and chemical weapons are readily available to terrorists, it's a good question. Why would a terrorist choose to use a biological weapon? Well, the first reason I can probably come up with is these agents are incredibly easy to produce. Anyone with two semesters of microbiology training can go out into their garden, dig up a handful of dirt, and readily culture themselves clostridium botulinum, the agent that causes botulism. In many areas of the world, you could do the same thing with Anthrax Tuva Garden. Used to. The second reason I could come up with is that these things are inexpensive to produce. And a study was done in 1970, and so this is $1970. I think you can probably triple the figures to put them into $1998. But they looked at what it would take for a terrorist to produce mass casualties, and they defined that as 50% casualties over a one square kilometer area. And to do that with conventional weapons probably would have cost in the range of $2,000. To do that with nuclear weapons would have cost about $800. Now it costs more than $800, of course, to build a nuke. But you get more than one square kilometer worth of bang for your buck. If you wanted to do that like the Tokyo subway gang did with Sarin, it would have cost $600. And if you wanted to do that with Anthrax, it would have cost a buck. So I think it's not too difficult to see why a poorly funded terrorist group might look longingly, I guess you could say, at biological warfare. The third reason I might come up with for why a terrorist would choose a biological weapon is these things can often be disseminated at great distances. And I think we have a video clip here that demonstrates this somewhat. And this video clip used Venezuelan equine encephalitis as the putative agent, but this would actually apply to anyone of a number of agents. And they assumed ideal meteorologic conditions proper time of day in an airline releasing a line source 100 kilometers long south of Washington, D.C. And you can see here that this agent cloud would affect not only Washington, but Baltimore, Philadelphia, and regions as far north as Manhattan and New York City itself. So these things again can be disseminated at great distances. The fourth reason I might offer as to why a terrorist would choose a biological weapon is that these things are odorless, colorless, tasteless, less filling. And that is when I teach defense courses, I often do so in conjunction with people from the Institute of Chemical Defense at Aberdeen. And the chemical people will tell you that if you're bopping along the battlefield and this green hazy cloud floats by and it smells like horseradish or geraniums or whatever it smells like, that you should duck or get out of the way or put your mop gear on or whatever. I fully agree with that. That's exactly what you should do. That's not going to happen with biological warfare, though. Chances are you are not going to know what hit you. You're not going to see a green hazy cloud. You're not going to hear anything. You're not going to feel anything. It's going to be invisible and undetectable. The fifth reason I would offer you is that detection is difficult. Now, we alluded already, I think, to these rapid diagnostic tickets and we'll talk a lot more about those as the course goes on. And those are great. Those are a big step forward from where we were several years ago. But in order for me to employ a rapid diagnostic test, as was done in the Larry Wayne Harris case, et cetera, I need to know that I've been hit with something in the first place or at least I need to suspect it. I've got to have the suspicion that something's going on before I know enough to pull these out of my pocket and start using them. And I'm here to tell you that if you even suspect bioterrorism, you've gone a long way towards winning the battle. The tough, tough part of this whole bioterrorism, bio warfare business is suspecting it in the first place. But where we're lacking is in standoff detection. And again, we're making great strides, but we're not there yet to where we have standoff detectors. We can go about our business confident in the knowledge that some alarm is going to go off if we're ever hit with a biological agent. The sixth reason I would offer is that the first sign that you are hit, that you have been hit by a bioterrorist agent. I feel sick. We'll get our diagnostic attention. The first sign that you're likely to have is that there are human cases walking into your emergency rooms. So for you docs and nurses and clinicians out there, you're not likely to hear bombs bursting in air. You're not likely to see crowds out there over your battlefields or your cities. What's likely to happen is a patient comes into your treatment facility and he's got flu-like symptoms. And this is a big, big problem for us as medical practitioners because the time to treat a lot of these diseases is in the incubation period before people are actually ill. For example, if I blew anthrax into this studio, and I started this all on Sipofloxacin right now, we'd all survive. We'd all live happily ever after. But if I blew anthrax into this studio until we had the first early signs, the first little bit of runny nose, headache, a little bit of fever, and then I started this on Sipofloxacin. Many of us would die. So the time to treat anthrax is before you get sick. That's true of anthrax, true of smallpox, true of plague, it's true of botulism, it's true of many of the diseases that we're going to cover in this course. So a big, big problem for us as practitioners. The seventh reason I would offer is that BW is the gift that keeps on giving. And what I mean by that is that some of the agents that we're going to talk about in this course are contagious. Now most of them are not, but a few are. Smallpox is, pneumonic plague is. So if I'm a battlefield commander, contagiousness is possibly not what I want in a weapon because I want to maintain control of the battlefield. If I throw a contagious agent out there, it goes on to affect civilian population, etc. I've kind of lost control of the battlefield in a sense. If I'm a terrorist who doesn't care what he unleashes on humanity, then perhaps this contagiousness aspect of these weapons actually looks attractive. I can unleash my weapon and it can continue to generate headlines, do dirty work, produce casualties, etc., etc. The eighth reason I would offer is that sometimes a terrorist doesn't even need to use these weapons to achieve his aims. The bani-brith incident was a good example of that. These things have brand name recognition. So if you can convince the authorities, the national command authorities, that you're the first guy on your block to have Ebola, you don't even need to have Ebola. Sometimes just the threat of having it is enough to affect policy decisions at the highest levels. So you don't even have to spell it right either? I don't have to spell it right either. The ninth reason I might offer is that perpetrators could protect themselves pretty easily against these weapons. For example, if I decided I wanted to use a chemical agent against some important government building, it would look pretty suspicious if I were sneaking around the building with a spray tank dressed in full mop gear. But on the other hand, if I wanted to use a bio agent, I could very surreptitiously vaccinate myself or start myself on antibiotics and be pretty well protected as I go around with my little spray tank in the ventilating systems, etc., etc. And the tenth and final reason that I would offer, and we'll cut it off here in the interest of time, is that the perpetrators can often escape before the effects of these weapons systems are felt. Remember, biological weapons have a very important characteristic that chemical, conventional and nuclear weapons don't have. And that's an incubation period. And for most of these weapons, this is certainly variable, but for most of these weapons, that incubation period is 24 hours or greater. Well, in 24 hours, in this day of jet travel, I can be anywhere in the world. So I can unleash my weapon, and I can be safely back in Baghdad or Damascus or anywhere I want to be before anyone knows what hit them. So all those reasons together, I think, should help you understand why a terrorist might want to choose a biological weapon. Well, based on this laundry list, Colonel Parker, I mean, it sounds so easy. So why aren't the terrorists reaching for it left and right? Well, a biological weapon is much more than just a pathogenic organism that is easy to grow and produce and relatively inexpensive. A biological weapon actually consists of a system that includes a pathogenic organism, which is readily available and inexpensive to grow and so forth. But it also consists of a munition, a delivery device, and a dispersal device. And to have that technology available that can be efficiently disseminated while maintaining the valence of the organism and be disseminated in that one to five micron respirable aerosol size does require a great deal of sophistication. It's impossible to do. It certainly is possible to do, but it would require a level of sophistication in your garden garage crazy. It does require some sophistication and resources to cause widespread distribution. Just to mention that there's a great book called The Cult at the End of the World by David Kaplan. It's a very intense study of the Aum Shinrikyo. And they actually tried to disseminate bio. And what really happened is there was so much pressure put on them by law enforcement that they just weren't ready yet. They had the technology, they had the scientists, they had it, but they couldn't get it done. So it's there. And a lot of these, this information that we know about either the limitations, whether it be or also the advantages of biological agents, we actually know a great deal from the former U.S. offensive program. You may or may not know that the U.S. had an offensive program that was disbanded by presidential directive in 1969 by President Nixon. So by studying that, studying the data in there, we've actually been able to understand quite a bit about limitations and advantages. And that helps guide us as far as our defense. Well, I'm convinced that the threat of biowarfare and terrorism is real and that we really should learn something about it in order to better protect ourselves and for medical personnel to better care for their patients. Before we go into some specific agents and what to do about them, we should discuss some basics of how these agents are distributed and how people are put at risk. We have a video interview with someone who worked in the old offensive biological warfare program and we'll look at that tape now. Today, I consider one of the greatest threats to the security of the United States is the use of biological warfare by terrorists, particularly state-supported terrorism. I've been all over the country giving lectures and I have several items that I use as visual aids to portray what a biological warfare looks like, biological warfare agent looks like. Initially, I used just one visual aid, a simulant, Bacillus glibigia powder that resembles very much Bacillus anthracis the causative agent of anthrax. Now, in going through airport security stations, I've never been stopped. I don't know exactly what heroin looks like but I would suspect it looks very much like this powder here. As time evolved, I've expanded my visual aids and I now have a lot more samples of what various BW agents look like. This could pass for VEE virus. It's a dry powder of eggs that have been taken through the same process as an infected egg. Notice that this material is pink. It's because we harvest only the embryo in preparing VEE virus. I have several liquids here. This represents liquid Bacillus glibigia. I hope you can see that this material is thickened over time and that it would be very difficult to disseminate because of increases in viscosity, increases in particulates due to coagulation. This is a sample of liquid VEE virus. Again, it's undergoing deterioration and perhaps you can see the particulates as they fall as I tilt the bottle. Now, in determining what a teres will use as a BW agent, you must consider this fact and that is liquid agents are easy to prepare but they are very difficult to disseminate in this small particle aerosol that's needed for an infection. On the other hand, dry powders are very difficult to prepare. Processes are much more complex but they can be disseminated very readily into the 1 to 5 micron particle size. I'd like to demonstrate the fact that VW terrorists can manufacture liquids very readily but in manufacturing a liquid although the process is simple, it requires a great deal of energy in order to develop an aerosol composed of small particles. The easiest way of disseminating a BW agent although it's not very effective is the use of a single fluid nozzle illustrated as follows. You notice there's a spray that's creating an aerosol for a very short period of time but the aerosol quickly falls out of the air because of large particle size and becomes not very effective in terms of giving you an infection. Single fluid nozzle. A teres can then evolve into what we refer to as a double fluid nozzle, a two fluid nozzle. Now this material is much smaller as you disseminate it. I hope you can see that this aerosol is remaining aloft for a much longer period of time. But again, even a two fluid nozzle with the amount of energy that I can generate by pushing this plunger is not very effective. You're probably getting only about 1% of your total number of organisms airborne in the right particle size. On the other hand, teres, particularly state supported teres can use small powders, small particle powders that can be disseminated very easily as demonstrated by this simple garden sprayer rose powder. Rose insecticides. Now, I've carried all these visual aids across many, many airports and I've passed security without ever being asked what is this material? What is this device? It illustrates one point I think very dramatically and that is our air support, air security points knives, your pistols and what have you. But they have not been included into what constitutes a BW agent, what it looks like and how it's disseminated. Now, state supported teres can bring into this country through diplomatic pouch in a number of bad actors like tularemia or anthrax. Today, I'm carrying about 200 grams of material that could very easily pass for tularemia, not tularemia. This amount of material would cause 50% infections in a building as large as the World Trade Center. It can be derived from as few as 500 blood auger plates and then dried. So you see, it does not take very much material of a BW agent to cover a very large area and in fact a very large population of people. There are two major ways of distributing a BW aerosol. Each has its own unique advantages and disadvantages. The first method is referred to as line source dissemination. That is, a vehicle, a plane, a person distributes the aerosol perpendicular to the wind and the wind then transports the aerosol downwind. This is the most effective way of creating large target coverage because you see you're using the energy of the wind to distribute the aerosol. The problem with aerosols that are generated as line sources is that they are very, very sensitive to meteorological conditions. You must always have an inversion or a near type of inversion in order for that aerosol to go downwind. Now inversions occur primarily early in the morning or late in the afternoon or at night. So therefore, biological warfare is a type of warfare that must be planned and advanced. The second way of distributing an aerosol of a BW agent is by point source means. That is, you release large numbers of little bomblets that perhaps are about three inches in diameter and you saturate the target. The advantage to point source release is that you can overcome to some extent bad meteorological conditions or unfavorable meteorological conditions. The drawback to point source munition distribution is the fact that the bomblet never distributes all of the material from itself. You have a residue of powder or you have a residue of liquid which can then be rushed back to the laboratories and stateside and you initiate your identification procedures. There's a third method for distributing a biological aerosol and it's referred to as a secondary aerosol. It's where you prepare a dry powder and you place the powder on a roadway or a side wall and people walking across the ribbon of powder or a vehicle traveling across the powder represent sufficient energy so that the particles are then released into the atmosphere at a height of maybe 5 to 10 feet. Now you have to build this characteristic into the powder. You simply don't dry an agent and expect it to have good secondary aerosol properties. You have to build that characteristic into it. Most people believe that firing a biological warfare attack by aerosol that secondary aerosols will be a real problem and this is not the case at all. If you look at the physics of the aerosol itself, your big particles are going to fall out during cloud equilibrium. That is, big particles are dropping out of the aerosol falling onto the rain and adhesive forces between these particles and the ground are such that it's very, very difficult to create a secondary aerosol. Now, following cloud equilibrium where you have your 1 to 5 micron particle size now in aerosol this material is now behaving as a gas. It means that you get infected because you're a pump, literally a pump and you're sucking in these particles as the aerosol passes you. Contamination of clothing is not particularly important as this aerosol passes over you. These particles behave truly as a gas. They tend to go around you as opposed to impinging on your clothes although hair and beards do represent types of material that will collect the particles as they pass around you or through you. Well, we've talked about how a terrorist might get these weapons and how they're disseminated but I think I'm still not clear on how he might actually use them. Well, Doris, let me give you an example here. I think we have an advertisement for a very legitimate peace time device known as the Ag Pilatus Porter and this device is a commercial crop dusting device meant to be strapped to the wing of your Cessna aircraft used to dust your crops. It just so happens that this device is able to generate an aerosol particle size of 1-5 microns in diameter and to show you why that's important I think we have a film clip here that will demonstrate that very well. If you have particles that are bigger than 5 microns in diameter many of those particles once they're released tend to settle out very quickly in the environment and never make it to your respiratory tract. Those that you do breathe in get stuck in your nasal mucus and never make it down to your lungs. On the other hand, particles much smaller than 1 micron in diameter are readily inhaled but are just as readily exhaled and very few of them remain entrapped in the pulmonary tissues. Particles though of 1-5 microns in diameter are perfect for settling out into the human lower respiratory tract so when those particles are breathed in, most of them do impinge on lung surfaces and stay there. So the Goldilocks analogy some are too big, some are too small and some are just right. And that pretty much this Agpilatus porter device is a great dissemination device for anthrax spores. What about what Mr. Patrick mentioned about the right meteorological conditions? Well, those are clearly very important as well. And in fact in a lot of terrorist attempts to use biological warfare that's one thing the terrorists neglect is they didn't get to demonstrate. I think we have another film clip that will demonstrate how important meteorology and weather conditions are. If you were for example to release an agent during the daytime much of this agent just drifts up into the atmosphere, doesn't settle out low over the terrain. However, as the sun goes down an inversion condition presents itself and this allows the agent to spread itself over the terrain. As the sun comes up in the morning, the inversion condition reverses itself and again particulate matter aerosol clouds tend to go up in the air as you saw in the film clip there. Okay, then basically from what we've seen it seems the most effective use of a biological weapon is through inhalation. Well, yes it is. I think this discussion is leading right to that conclusion that the inhalation route and aerosol delivery is the one that's going to be associated with a massive number of casualties. On the modern battlefield it would be just too difficult for an aggressor to contaminate our water supply in sufficient quantity to cause mass numbers of casualties. Yeah, and just think about 4th of July on the Mall in Washington with all those thousands of people. If such a dissemination occurred, just think of the casualties. That's right. The aerosol route, Doris, certainly is the preeminent route by which we would expect a biological weapon to be delivered. But the oral route of exposure is somewhat important as well. Certainly a terrorist could achieve his aims to a more limited degree with an oral weapon and the example of the Rajnishis that called out in Antelope, Oregon, back in 1984 where they poisoned the salad bars at 6 restaurants in the Dallas, Oregon would be an example of that. The dermal route of exposure is also a potential delivery route. Most of the agents that we're talking about in this course today are not dermally active and in that context a simple face mask or a gas mask would protect you when the mop gear that you would use for chemical warfare wouldn't be necessary. But there is an exception. One of the toxins is dermally active. And then related to this is this whole issue of percutaneous warfare. And there's a very famous example concerning a Bulgarian dissident named Georgi Markov. And in 1978 Markov, who was an escapee from communist Bulgaria, was standing at a bus stop on a London street corner and was assassinated using a spring loaded Maxwell smart type umbrella that fired this ricin laced pellet into his calf. On a onesie and toosie kind of scenario you're trying to assassinate one person, very viable weapon. On a larger battlefield scale probably not a very efficient way of waging warfare or terrorism. Okay, so it's important to know what routes are possible and how the agents might most likely be disseminated. And this brings us to a very important point. The public health implications of these biological agents are crucial to understanding and to helping determine that an incident in fact has taken place in the first place. And then furthermore what to do to stop the spread of disease once an incident has taken place. Alright, well before we get into that I would like to thank Colonel Parker and Mr. Blitzer for being with us today. And if you have any questions for either of them please go right ahead and fax them in and we will answer them a little later in the program. And I think we should have a quick overview with two public health professionals who were involved in a bioterrorist event who never thought they would be. On the 17th of September 1984 folks at the health department in the Dallas Oregon received calls from people who thought they might have become ill after eating a restaurant in the town over the next couple of days about the calls came in of people saying look I got gastroenteritis after eating a couple of different restaurants in the Dallas cases started to decline in number but then the next week there was a sudden increase in phone calls the local health department contacted the state the state got involved and on the 25th of September they asked CDC to participate in the investigation when it seemed as though there was an increase in the number of cases and they were unsure of how large the epidemic was likely to be. First we learned that of course there were many people who were becoming ill at the same time and that was a great concern and it was sort of puzzling to us because it implied a common source outbreak and we knew that in a community of about 10,000 people we certainly wouldn't expect to see dozens and dozens of people coming forward all at the same time with a common source and so the challenge immediately was to try to find a common source there were lots of interviews and there was lots of field work done in the restaurants in the area there were 38 restaurants in the Dallas at the time and all of them were looked at they looked of course for things like lots of lettuce or some other common ingredient to the salad bars which seemed to be implicated that might be a common source that could readily explain this we were afraid that we had some sort of interstate shipment of something that all of the restaurants had in common and that turned out negative and that was extremely puzzling because usually you can find a common source of something like this as it escalated at one point somebody suggested the possibility that it had been an intentional contamination of the salad bars but frankly that seemed pretty far fetched to us they say when you hear hoof beats you're supposed to think of horses not zebras and there had never been any report of an intentional contamination like this in the U.S. and nobody was stepping forward and claiming credit nobody seemed to have any motive it was just all of a sudden there were all these people getting salmonella typhium it looked like a common source and nobody could come up with a plausible explanation for it there was no single answer or very simple answer to explain this outbreak in retrospect I think that would be the kind of finding that would cause us to put the possibility of intentional contamination very high up on the list but on the other hand if someone had stopped after a single restaurant they could have made hundreds of people ill but then that would have looked for all intents and purposes like any other food borne outbreak the agent that they chose was salmonella typhium generally that's the most common or the second most common type of salmonella that's identified in people every year in the United States but it was unusual to see that many cases in a little community like the Dalles up to the first eight months of 1984 they had reported no salmonella islets in the entire county for that time and they typically averaged less than five a year so the fact that we were starting to see a cluster of them was of interest to us later when we were able to characterize the islet really at the end of the outbreak we learned that it did have some unique characteristics which made it in fact easier for us to track the source and the relatedness of the different salmonella typhium that we were getting this particular strain was dulcetol negative which means that it fails to ferment a particular sugar in the biochemical tests that we do and that's very uncommon only about two percent of the non-typhoid salmonellas have that characteristic and it also had an antibiotic susceptibility pattern that made it different for most of the ones that were circulating at the time because it was sort of pre-antibiotic once we found out later in the investigation where the culture came from that they used for the outbreak we understood why because this had been collected by the American-type culture collection before the use of a lot of antibiotics in humans many years ago there were really a couple of phases to this event the first one was the epidemiologic investigation and the control of the outbreak and before that was over we had spent thousands of person hours and we had cultured thousands of people and we had identified over 750 cases of salmonella typhium we got it under control and at this point the police, various police agencies the state police, the FBI the Attorney General's office the organized crime unit in fact from the state of Oregon the local law enforcement folks a number of different agencies were looking at the activities of the cult of the Rajneeshis at the time all the law enforcement agencies were investigating them for a number of different criminal acts and in fact if we had known what the law enforcement agencies knew we would have been a lot more suspicious we were public health types, innocence and the law enforcement people already knew that these folks were attempting murder they had tried to torch the office of the land use planning folks in Wasco County they had brought in homeless people from around the United States to get the register to vote they had done a number of other things inside the commune like wire tapping, the hotel at the commune had bugs in it all over the place they were already being investigated for a lot of things and so the police almost immediately believed they had been involved with this contamination event in fact the local people around the area suspected the Rajneeshis of being involved responsible for almost anything bad that happened and so of course they were suspected in this case and I have to say that personally I thought the Rajneeshis were sort of being picked on that they were probably just a bunch of folks trying to mind their own business who didn't fit in well in central Oregon and so even though I had been in the commune had seen what was going on out there and been involved with this police action I came out thinking that it probably was too far fetched I had been asked by the FBI and the Attorney General and the state police to go to the Pythagoras Medical Clinic which was part of the Rajneesh Medical Corporation and to go to their clinical laboratory and look for anything that looks suspicious to be as a microbiologist that might have been used to grow salmonella or if I found any salmonella to seize it as evidence and so that's exactly what I did I went into the laboratory I looked at the cultures that were growing in incubators I looked at their stock cultures and control cultures and I looked in freezers and refrigerators I talked to the medical technologist who worked there and then I found one of them was a salmonella typhimurium control disc and we didn't know it at the time but that almost certainly was the source of the culture that they used to contaminate the salad bars it was dulcetal negative and it was identical by restriction into nucleus cuts and plasma typing and anti biogram to the outbreak strain it's hard to imagine any other way that could have happened by coincidence we never got exact information about how they did it and the informants from the cult told the state police that they had grown the cultures and then they were instructed to put them on food and salad bars which they did they put the salmonella cultures in coffee creamer and dressing and directly onto foods in at least 10 different restaurants and they also tried this in a grocery store as well I think they put it on some vegetables then they also attempted to contaminate the city water supply they climbed up on a water tower and cut a screen that was protecting the water in there from contamination and dumped the stuff in but it didn't work apparently because there were no cases that seemed to have come from that one of the things that I was most impressed by in this entire investigation was the quality and type of response of the county health department in the small the small health department they processed the information quickly they realized that they had a potential problem and they made the link to salad bars and they closed salad bars in the town this is long before calling CDC so they quickly assessed the situation they introduced an effective intervention and probably stopped the outbreak and they didn't need the feds to tell them what to do from that standpoint it's a real public health success story well there's a pretty scary story there fortunately it all turned out pretty well the Rajneeshis didn't win the local election 750 people got sick but fortunately no one died I'm a little worried that if a more lethal agent had been used in a similar scenario the results may have been considerably worse so good for that well to help us discuss these issues are some public health experts from the Centers for Disease Control and Prevention and from the Army Dr. Brad Perkins is chief of the meningitis and special pathogens brands at CDC Colonel Pat Kelly is the director of the new department of Defense Global Emerging Infections Surveillance and Response Group and he is responsible for the DOD assisting in monitoring disease outbreaks throughout the U.S. and the world welcome gentlemen and thank you for joining us you know I've recently had the chance to take an epidemiologic investigation out at Fort Bliss, Texas and one of the questions that came up was could this have been intentional and of course it wasn't we went through the basics of an epidemiologic investigation and I have a little bit of an understanding of how that's supposed to work but I'm not sure I really understand how to approach an outbreak that may be sinister I guess for lack of a better word so Colonel Kelly I wonder if you could maybe enlighten us a little bit as to how you'd approach something like that well Ted the first challenge is recognizing that the outbreak is taking place in the first place we heard in the last clip about the Rajneesh outbreak which involved 700 people but outbreaks may be considerably smaller they may be experimental in preparation for larger events so the first challenge is really recognizing that the outbreak is taking place we heard earlier that one advantage to a terrorist is the incubation period associated with bioterrorist exposures and that may allow the terrorists to get away well similarly it may allow the affected individuals to disperse over a wide geographic area before they manifest illness and that may make it difficult to detect because unlike a nuclear or chemical event where you see a large number of casualties right in a small confined area here you might have cases spread out over many counties even many states and thus an individual clinician or even an individual hospital may not very promptly appreciate what is going on so the initial challenge with investigating these is recognizing that they take place and there are a lot of lessons to be learned from the Oregon outbreak the importance of the public health laboratory and helping to pull together a picture across a whole community or a collection of communities the importance of public health surveillance is key because again a single clinician or a single hospital or maybe even a single public health department may not be able to see the whole picture and appreciates what is going on and I think the first steps to evaluating outbreaks of this sort is to have a strong public health system of surveillance including laboratory capabilities and from that you can develop the clues necessary to start suspecting these problems. Okay well Carl for most of my career I was a blue collar pediatrician without any formal training I guess in epidemiology do you need special training to be able to work up one of these problems? Well I think the role of pediatricians is primarily to be suspicious and this course that you're leading right now is a good start in helping to equip clinicians to understand what some of the manifestations could be of these events and then the next role is to contribute to the medical surveillance system and the training necessary for that is not extensive or elaborate but in many cases it's learning what your health department currently requires of you and following those requirements. Dr. Brookins let me ask you is there some kind of surveillance system used to detect outbreaks and what triggers it? Yes Doris there's a U.S. surveillance system to report many of the diseases that we'll be talking about over the next three days those diseases are reported to state health departments and from there on to CDC as far as triggers go for some diseases like inhalation anthrax the notification of even a single case will trigger a prompt public health investigation other diseases like salmonellosis like you heard from Dr. Torek it may be a the reporting of a larger number of diseases than what would be expected when compared to background that triggers a public health investigation. One of the major concerns we have right now in the public health community is that the contemporary clinical laboratory and public health expertise for many of the high priority bioterrorism agents is ranges from non-existent to minimal primarily because these have been rare naturally occurring public health problems in the United States but to detect possible instances of bioterrorism in the United States we must develop a system where clinicians recognize these diseases where laboratories have the capacity to confirm suspected diagnoses and where the public health system is prepared to respond immediately with investigation and implementation of control measures. So again as a blue collar pediatrician I think if I saw a case of bizarro bacterium infection or something else that's in your book or my hospital laboratory would know enough to report that what about the case that I just can't figure out some weird disease and I'm not sure what's going on what do I do about that case? That's an excellent point Ted unfortunately there's no formal means that currently exist within the public health system to report such cases and formal communication about such situations this is a recognized deficiency of our current system to detect possible instances of bioterrorism there are some ongoing efforts to try to address that deficiency however one example is a project that's ongoing in several parts of the United States right now to do surveillance for unexplained deaths and critical illnesses among previously healthy people this is being done within the context of CDC's emerging infections programs projects like this and others we hope will give us a basis to fill some of these gaps on a more national level. Similarly the Department of Defense has a new emerging infections program that in many ways parallels the national effort defined by the CDC we've been trying to improve our public health laboratory capacity trying to improve reporting of laboratory confirmed conditions we're also instituting mortality surveillance for unexplained causes of death and instituting surveillance in intensive care units for serious unexplained conditions I think what we really need to do the foundation of this to a great extent is building communications networks because it's going to be hard to put in hardwired systems that anticipate every possible manifestation and thus we need flexibility and we need to have very open lines of communication between clinicians and public health authorities including the state health departments and the CDC and those military people who can help out also. So what we're saying then is that you're not constantly looking out for some abnormal disease patterns and you may miss a biological attack. That's exactly right Doris. Physicians, nurses, laboratories and scientists need to stay in contact with their local and state public health departments and communicate about these issues even though there is a formal surveillance system for many of these diseases in the United States a large majority of outbreaks are detected in fact by astute clinicians and other health care professionals and brought to the attention of the public health community. I think I have a little better understanding of the clinicians role in this whole process. My brother Paul though is a public health officer with the Oregon State Health Department how would a white collar chair born ranger public health officer like him, what would his role be in this whole system? I think there's sibling rivalry going on. The public health practitioner has a central role in this process as was alluded to by some of the previous speakers the first responders really in a biological terrorist event are from the public health community and there are many systems that are significantly underdeveloped that the development of which serves not only traditional emerging infections but also bioterrorist events because really bioterrorist events are unnaturally occurring emerging infections and the surveillance systems that we need for more traditional emerging infections are of the same nature as those that we need to recognize bioterrorist events. I think we'll see a growing role for public health practitioners in developing new surveillance systems for example real time systems looking at emergency rooms or looking at the use of certain types of antibiotic drugs I know some cities in the country are now putting in surveillance systems of this nature and I think we'll see more and more of those systems as we are better able to deal with this problem. Dr. Perkins, are there any easy clues that anyone can use that could tip them off that something unusual is going on? There are some clues not very many of them are easy and none of them take the place of a high quality epidemiologic investigation but certainly the occurrence of a disease in a population where that disease does not normally occur or is not recognized to occur is a red flag that deserves prompt investigation. Any examples? Ebola infection outside of Africa Venezuelan equine encephalitis outside of Venezuela or at least outside of Latin America those would be a couple of examples there are many others. Another example might be simultaneous outbreaks in a given population that might suggest the use of a bioterrorism cocktail a weapon containing more than one etiologic agent. Another clue as we've heard might be data suggesting a large massive point source outbreak. What kind of evidence? Well, something like what they saw on the film in the Dallas, Oregon 700 people getting 750 people getting ill within a very compressed time frame. Brad may have other examples that he can offer. I think that's an excellent one. Okay. There are in the case of aerosol exposure for example you might see illness limited to a fairly localized circumscribed geographic area disease localized to a very tight area. That might tip you off that there's been a local release of something. Low attack rates in personnel who work in areas with filtered air supplies. If you work inside a building, the air is filtered in that building and you don't get sick and everybody outside the building gets sick, that ought to tip you off. There's a problem. In fact, there's a military correlate to that. If you're out on the battlefield and soldiers who are wearing their mop gear wearing their protective masks don't get sick and yet the soldiers who aren't wearing their protective gear do get sick, that ought to tip you off that something has been aerosolized out there any others? Some of these agents, these weapon systems produce disease not only in humans but in animals as well. I already mentioned the example of Venezuelan equine encephalitis. That's a disease that certainly can affect man but affects equine species as well. If you're out there on the countryside and you see dead horses, dead mules, dead donkeys that ought to tip you off that again something has been released out there. In fact, those animals can be used as sentinel animals. What about large numbers of military and civilian casualties in a particular area? Biological warfare, biological terrorism is indiscriminate and if you were out on the battlefield for example and a battlefield commander started to see large numbers of casualties amongst his soldiers if it were a biological agent producing those casualties you would expect the civilian population that lived in that area to be similarly affected. Of course, for a biological agent that would be vector born in nature it's a occurrence in an area where that competent vector does not exist would be an indication. Okay, so Colonel Kelly, what's the take home message? I think the take home message is that all parts of the U.S. healthcare system have an important role to play here. The clinicians have to have an understanding of how these agents can possibly manifest themselves and know who to bring their concerns to promptly and then of course there's an important role for the public health practitioners in the United States in developing surveillance systems that are sensitive and timely so that we can jump on these possible problems as soon as they arise.