Biological warfare (BW) is the use of microbiological agents for hostile purposes. Such use is contrary to international law and has rarely taken place during formal warfare in modern history, despite the extensive preparations and stockpiling of biological agents carried out during the 20th century by most major powers (including development of strains resistant to multiple drugs). The area of most concern is the use of BW agents by terrorist groups. Biological-warfare agents are thought by some to be an ideal weapon for terrorists. These agents may be delivered clandestinely, and they have delayed effects, allowing the user to remain undetected.
The US Centers for Disease Control and Prevention (CDC) has created a priority list of biological agents and toxins (see table CDC High-Priority Biological Agents and Toxins). The highest-priority are Category A.
The deliberate use of BW agents to cause mass casualties would probably entail dissemination of aerosols to create disease via inhalation, and thus inhalational anthrax and pneumonic plague are the 2 diseases most likely to occur under these circumstances.
CDC High-Priority Biological Agents and Toxins*
A: Highest priority
Bacillus anthracis, causing anthrax
Botulinum toxin from Clostridium botulinum, causing botulism
Yersinia pestis, causing plague
Francisella tularensis, causing tularemia
Variola virus, causing variola major (classic smallpox)
Viral hemorrhagic fever (VHF) viruses
B: 2nd highest priority
Brucella species, causing brucellosis
Epsilon toxin of Clostridium perfringens causing food poisoning
Burkholderia mallei, causing glanders
Burkholderia pseudomallei, causing melioidosis
Chlamydia psittaci, causing psittacosis
Coxiella burnetii, causing Q fever
Ricin toxin from Ricinus communis
Staphylococcal enterotoxin B causing staphylococcal food poisoning
Rickettsia prowazekii, causing typhus fever
Alphaviruses causing viral encephalitides (eg, Venezuelan, eastern, and western equine encephalitides)
C: 3rd highest priority
Other agents associated with emerging infectious diseases
* An alphabetical listing of bioterrorism agents and diseases can be found at Centers for Disease Control and Prevention: Emergency Preparedness and Response.
It can be difficult to distinguish use of a biological-warfare (BW) agent from a natural outbreak of disease. Clues to the deliberate rather than a natural origin of a disease outbreak include the following:
- Cases of diseases not usually seen in the geographic area
- Unusual distribution of cases among segments of the population
- Significantly different attack rates between those inside and those outside buildings
- Separate outbreaks in geographically noncontiguous areas
- Multiple simultaneous or serial outbreaks of different diseases in the same population
- Unusual routes of exposure (eg, inhalation)
- Zoonotic disease occurring in humans rather than in animals
- Zoonotic disease occurring first in humans and then in its typical vector
- Zoonotic disease arising in an area with a low prevalence of the typical vector for the disease
- Unusual severity of disease
- Unusual strains of infectious agents
- Failure to respond to standard therapy
Epidemiologic investigation of cases and cooperation with law-enforcement resources are crucial, as is risk communication to the general public.
The clinical presentation, diagnosis, and treatment of patients with disease caused by high-risk BW agents are discussed elsewhere in The Manual: anthrax, plague, smallpox, tularemia, and viral hemorrhagic fevers. Management of outbreaks due to biological warfare does not differ from that of natural outbreaks except that clinicians must be alert for unusual antibiotic resistance patterns.
Isolation (of patients) and quarantine (of contacts) may be necessary. The most communicable deliberately disseminated diseases are smallpox (for which airborne precautions are necessary) and pneumonic plague (necessitating droplet precautions).
Because of the relatively long incubation periods of diseases caused by BW agents, most lives will be saved or lost in a hospital setting. Adequate supplies of vaccines, antibiotics, and antivirals for hospitalized patients and for contacts are needed, and systems for distributing such medical countermeasures to members of the general public at high risk of exposure are crucial.
The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army, Department of Defense, or the US Government.
The following English-language resource may be useful. Please note that The Manual is not responsible for the content of this resource.
- Centers for Disease Control and Prevention: Emergency Preparedness and Response: An alphabetical listing of bioterrorism agents and diseases