INTRODUCTION

Terrorism has been defined as premeditated, politically or religiously motivated use of violence perpetrated against noncombatant targets by sub-national groups or clandestine agents that is usually intended to coerce or influence an audience. Since the wake-up call of September 11, 2001 the dental profession has recognized that in addition to its role in the resolution of traditional forensic dental issues it can provide health care workers to triage and assist the injured and other victims of bioterrorism and chemical terrorism acts.

INTRODUCTION
This legislation states that the dentist must complete a course of instruction, within two years after initial licensure, relating to the medical consequences of an act of terrorism that involves the use of a weapon of mass destruction. The course must provide at least four hours of instruction that includes the following subjects:
An overview of acts of terrorism and weapons of mass

destruction Personal protective equipment required for acts of terrorism

INTRODUCTION

Common symptoms and methods of treatment

associated with exposure to or injuries caused by, chemical, biological, radioactive and nuclear agents
Syndromic surveillance and reporting procedures for

acts of terrorism that involve biological agents.

An overview of the information available on, and the

use of, the CDC Health Alert network.

The basis for the following material was presented as a bioterrorism-multiple fatality incident seminar by Igrid Gill, JD at the 58th Annual Meeting of the AAFS in February, 2006.

This seminar included discussion of criminal prosecutions of bioterrorism suspects and concerns for balancing the rights of the accused and national security.

History of Bioterrorism
General George Washingtons private correspondence released from the archives of the US government in 2006 revealed that he was concerned that the British might have plotted to spread smallpox among the colonial troops and citizens during the American Revolution. Indeed, this was not beyond the ken of others who settled the North American continent as they passed this particular biological agent to the Native Americans in the nineteenth century.

HISTORY OF BIOTERRORISM
Since the end of World War I international conventions held in Geneva, concerning the use of these agents by warring governments has reduced the threat of this kind of warfare. However, the government of Iraq under Saddam Hussein was not averse to using chemicals against ethnic factions (Kurds) among its own citizenry in the latter part of the twentieth century.

HISTORY OF BIOTERRORISM
The threat of chemical and biological warfare from the non-government sources or radical fringe groups with political, religious or anarchist agendas has loomed over global so chemical and biological warfare society since the end of World War II.

HISTORY OF BIOTERRORISM
In 1970 chemical and biological warfare agents were confiscated from the terrorist group known as the Weather Underground which intended to place them in urban water supplies. Eight microbial pathogens including those that caused typhoid fever, diphtheria, dysentery, and meningitis among others were intended for similar use by an organization calling itself RISE in 1972.

HISTORY OF BIOTERRORISM
By 1984, salmonella had been used to contaminate salad bars in Dalles, Oregon leaving over 751 sick and 1991 Ricin was intended for use by the Minnesota Patriots Council until the group was arrested by the FBI. In Japan the doomsday religious cult Aum Shinririkyo released sarin nerve gas into the Tokyo subway in 1995 killing twelve. NATO has designated sarin as GB (O-Isopropyl methylphosphonoflouridate) an extremely toxic agent.

HISTORY OF BIOTERRORISM
This chemical weapon is classified as a weapon of mass destruction by the United Nations according to UN Resolution 687. Its production and stockpiling was outlawed by the Chemical Weapons Convention of 1993. Bacillus anthracis was sent through the U.S mail in Florida and on October 15th of that year an envelope containing weapons grade B. anthracis was sent I through the United States Postal service to the Hart Senate Building in Washington, DC.

HISTORY OF BIOTERRORISM
Tucker noted that the terrorist incidents and hoaxes involving toxic or infectious agents have been on the rise and the preferred choice of target has also changed over time. In an analysis of 135 terrorist incidents for which the target was known he identified two types of targets that have increased in frequency. These include general civilian population targets where the apparent intent is to cause indiscriminate casualties and targeted symbolic buildings or organizations.

HISTORY OF BIOTERRORISM
Since 1990 the principal motivation for the use of chemical, biological, radiological or nuclear materials by terrorist organizations is the Retaliation or revenge taking for a real or policies and defense of animal right are also groups to use these agents

HISTORY OF BIOTERRORISM
In the United States, the Patriot Act of 2001, Title 18 U.S.C 175 (b) provides for arrest, of up to ten years for individuals convicted of knowingly possessing a biological agent, be justified by a prophylactic, protective, purpose. Title 18 U.S.C Sec. 2332(a) of use of a disease causing organism directed at humans, animals or plants is a crime regardless of whether the perpetrator actually possesses a disease causing agent. Further provisions under Public Law No. 107-40, Sec. 2 (a) 115 Stat 224 authorize the President of the United States to use military force against the nations, organizations or persons he determines planned, authorized, committed or aided the terrorist attacks or harbored such organizational persons.

The Following materials have been used as weapons of chemical or biological warfare: Chemical Agents Radiological Agents Explosive and Incendiary Devices Biological Agents (Poor Mans Nuke)

There are specific and well developed treatments for most agents, but identification team members must be aware of the significant personal risk of operating around substances. Most will linger on clothes and human remains and rubber gloves may not be adequate barrier, any oral autopsy of known chemical, radiological or biological victim should only performed when antidotes/treatments and trained personnel are present and available and with the latest protective equipment. Identification is important but not the primary concern when unknown are suspected.

Chemical agents include substances developed for non terrorist purposes by companies supplying organic and inorganic chemistry, and specific agents developed for use as weapons. Gasoline, propane and many other petrochemicals can be misused by small groups interest in anarchy. The usual well known weapons substances are:

Nerve Agents Blood Agents Choking Agents Blister Agents Riot Control

Syrin, VX Cyanide Phosgene, Chlorine Mustard, Pepper Mace, Pepper Spray, Tear Gas

Vomiting agents Incapacitating Agents Ammonia Arsine

Signs and symptoms of chemical exposure are varied, may mimic biological infection
Signs and Symptoms Agents

Nausea/ Vomiting, cholinergic effects

Decreased WBC, RBC, Platelets Erythema, small vesicles that later coalesce blisters/bulla

Mustard gas
Mustard gas Mustard gas

Epistaxis, sore throat, hacking cough, hoarseness, dyspnea, productive cough

Mild-severe conjunctivitis, eyelid inflammation damage, blepharospasm, corneal opacification, ulceration, and or perforation

Mustard gas
Mustard gas

Eye irritation, tearing, feeling of pain and sense of Vomiting fullness in the nose and sinuses, severe headache, agents burning throat, tightness and pain in the chest, violent coughing and sneezing, nausea and vomiting

Signs and symptoms of chemical exposure are varied, may mimic biological infection
Signs and Symptoms Agents

Severe irritation to eyes, skin, airways immediately Lewisite after exposure, vesicant effects similar to mustard, no bone marrow effects
Blepharospasm, tearing, redness, nasal discharge, sneezing, burning cough, SOB, chest tightness, wheezing skin burning, erythema, anxiety induced tachycardia hypertension Sunburn-like skin lesions Riot control/tear agents Radiation exposure

Burning eyes, tearing, pain, corneal injury, lens injury, ammonia cough, SOB, chest pain, Wheezing, laryngitis, hypoxia, chemical pneumonia, hemorrhage, pain, cough, abdominal pain, nausea/vomiting, edema lips, mouth, esophageal stricture, perforation

Differential Diagnosis include:

Tularemia

Botulism
Lewisite Riot Control agents Ammonia Intestinal Anthrax

Intestinal Tularemia
Hantavirus

Differential Diagnosis include:

Viral encephalitis Staphylococcal EntStaphylococcus Enterotoxin Mustard Staphylococcal Entero Toxin B Mustard Ammonia

Vomiting agents

BIOLOGICAL AGENTS
Biological agents include those of bacterial, viral or rickettsial origin and biological toxins. These agents are potentially contagious and it is often difficult to contain and track the attack when they are used. They are easily concealed and almost impossible to detect until employed. Lethal doses vary among the agents employed. Additionally, their victims may have delayed appearance of symptoms .

BIOLOGICAL AGENTS
The danger posed by delayed symptoms in victims of biological warfare is that if contagious biological agents are exposed to the general population carriers of the infection will disperse it from the attack site before the existence weapon of a biological weapon attack has been realized. Conversely, an opportunity for containment and treatment efforts that may prevent the onset of the disease or reduce its effects.

BACTERIAL AGENTS
Characteristically, bacterial agents have a long shelf life and low biological decay as aerosols. In spore form they are more resistant to cold, heat, drying, chemicals, and radiation than the bacterium itself. The following bacterial agents are the most commonly employed as biological weapons:
Anthrax
Brucellosis

Cholera

BACTERIAL AGENTS
Diphtheria

Escherichia coli serotype

Glanders Melioidosis

Plaque (Bubonic and Pneumonic)

Tularemia Typhoid Fever

Viral Agents, being the simplest type of microorganisms, require living hosts for replication. As biological agents they are attractive because they do not respond to antibiotics. Because their incubation periods are longer than bacterial than bacterial agents incapacitation of victims may be delayed, complicating the identification of an outbreak. Agents in this category include:

Congo-Crimean Hemorrhagic fever Virus Dengue Fever Virus Ebola Virus Junin Virus Marburg Virus Rift Valley Virus Smallpox Venenzuelan Equine Encephalitis Yellow Fever Virus

Rickettsiae are obligate intracellular bacteria that are intermediate in size between most bacteria and viruses. They are susceptible to a broad spectrum of antibiotics and are usually spread through bites by infected insects.

These agents include:

Endemic Typhus Epidemic Typhus

Q Fever
Rocky Mountain spotted Fever

Biological Toxins are poisons produced by living organisms. These can be genetically altered and/or synthetically manufactured into weapons grade concentrations:

Botulinum Toxin Ricin (Isolated from Castor Beans) Saxitoxin Staphylococcal enterotoxin Tricothecence mycotoxins

Identification of threats of bioterrorism requires coordination between law enforcement and public health investigate agencies. The methodologies used by these to groups, however, often are based on contrasting styles and different objectives when processing a terrorism crime scene and/or investigating a potential biological attack. This can often lead to breakdown in communication between them when investigating the causes of a biological outbreak associated with an act of bioterrorism.

Flu-like Symptoms Anthrax Smallpox

Skin Lesions Anthrax Tularemia

Abdominal Pain Intestinal Anthrax Intestinal Tularemia

Eye symptoms Tularemia Botulism

Swollen Glands Tularemia Glanders

Rash may be absent early

Plague Tularemia

Plaque
Typhus Fever Mustard

Typhoidal Tularemia
Typhoidal Tularemia Hantavirus

Staphylococcus
Enterotoxin B Mustard

Plague

Viral
Hemorrhagic fever Brucellosis

Riot control
Ammonia Radiation Exposure

Viral
Encephalitis Staphylococcus

Lewisite
Riot control Agents Ammonia

Flu-like Symptoms Nipah Virus

Skin Lesions

Abdominal Pain Enter. B

Eye symptoms Swollen Glands

Typhus Fever
Melioidosis Glanders Q Fever Viral Encephalitis Ricin Staphylococcus Enterotoxin B Hantavirus Psittacosis

Mustard
Ammonia Vomiting Agents

Law enforcement investigations are deductive in nature. Witnesses and potential suspects pursued and all available evidence is collected, identified, and tracked. The suspected perpetrator(s) is identified , arrested, and prosecuted if evidence is adequate. The ultimate goal of this approach is to gather evidence that will meet constitutional standards and withstands legal challenges to obtain a conviction. Law enforcement officials are concerned with confidentiality to protect informants, witnesses and to preserve the integrity of the case for the prosecution.

Public health investigators take an inductive approach to understanding why a biological pathogen causes an outbreak . They conduct interviews, collect data and develop hypotheses to explain transmission. Epidemiological and laboratory studies are conducted to test these hypotheses and if the studies confirm them, prevention and control strategies are developed, implemented, and evaluated. All work is held to the standard of scientific peer review, generally through presentation of data at scientific meetings and publication in scientific journals.

Patients records are confidential, therefore not subject to discovery in a court proceeding. Thus, the policy considerations of public health officials are confidentiality to protect sensitive patient medical information, and monitor and control capabalities to contain infectious disease outbreaks.

Current public health detection methodology is based on syndromic surveillance principals that detect the early manifestations of illnesses occurring during a bioterrorism related epidemic. The principals include a broad spectrum of activities utilizing information technology to track data that can red flag a bioterrorism related disease. Through an enhanced surveillance project the CDC works with hospitals and information system contractors using syndromic surveillance to monitor hospital ER visit data, physician office data, 911 calls, school and business absenteeism and over the counter drug sales.

The goal of syndromic surveillance is the early diagnosis of the initial stages of stages of disease. Information technology allows for early detection of bioterrorism related diseases through the extraction, processing and analysis of clinical data listed in Table 3-5. The effectiveness of early detection of syndromic surveillance is often dependent o the size of outbreak.

The FBIs Weapons of Mass destruction Operations Unit (WMDOU), in conjunction with other federal agencies conducts a threat/credibility assessment to determine if there is an intentional criminal act present. During 2001 anthrax field investigators, FBI investigators and epidemiologists were paired during interviews with possible case patients and exposed persons permitting the collection, processing and sharing of pertinent information to identify the source of the infection and perpetrator.

When joint investigations by the CDC and FBI are conducted the following legal and medical questions arise which may conflict: Are both agencies interviews of patients subject to discovery in a criminal proceeding? Was there a doctor/patient relationship established when a citizen is interviewed by a public health official? If so, is it waived by the presence of the FBI? Do certain public health confidentiality laws apply to the interviews conducted by the CDC.

On scene detection, identification and assessment (DIDA) of biological agents is the capability to quickly detect , locate, characterize and assess a potential or ongoing terrorist attack. Biological detection systems are currently in the research and early development stages. The paucity of biological field detection equipment can be understood by remembering that detection of biological agents requires high sensitivity due to the very low dose of biological agent required to cause infection and spread disease.

A high degree of selectivity is also required because of the scope of the large and diverse biological background material in the environment. Additionally, biological agents are more complex molecules than chemical molecules.

Currently, some commercially available devices have limited usefulness in identifying biological warfare agents. They respond to only a limited number of agents and are generally high cost items, however. It is strong recommend that first responders be cautious when considering the purchase of any device that claims to detect biological warfare agents.

The LRN was established in accordance with Presidential Decision Directive 39 and is a collaborative effort of the CDC, FBI and Association of Public Health Laboratories. The network became operational August, 1999 and is a multilevel system connecting local and state public health laboratories with the advance capacity of public health and military laboratories. Clinical specimens are referred to the LRN facilities from local and state public health laboratories for identification of potential covert bioterrorism attacks.

LRN is the result of predicting the need for validated tests that would be consistent with evidentiary requirements. A uniform set of laboratory protocols, based on established procedures and reagents, facilities the introduction of test results into a court of law, thereby limiting evidentiary challenges that may result from the use of different testing methods or analyses.

end of presentation