BIOTERRORISM! PROVIDING ESSENTIAL NURSING CARE TO VICTIMS

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1 BIOTERRORISM! PROVIDING ESSENTIAL NURSING CARE TO VICTIMS Contact Hours: 2 First Published: March 31, 2017 This Course Expires On: March 31, 2019 Course Objectives: Upon completion of this course, the nurse will be able to: 1) Differentiate various types of biological agents. 2) Recognize the symptoms of the numerous biological weapons. 3) Treat patients according to the type of biological agent that was used in a bioterrorist attack. A religious cult has established a base outside town. The cult has applied for a charter to start its own publicly funded school. It's already been voted down once. The charter school is again on the ballot. On Election Day, hundreds of townspeople become ill and are too sick to get out to vote. In searching the cult headquarters on another matter, a vial of Salmonella typhimurium is found. After questioning by the police, one of the cult members reveals that the salmonella was used to intentionally contaminate local restaurant salad bars with the aim of limiting the number of people who would vote against the charter school.

2 The above scenario actually occurred in Dalles, Oregon in A religious cult called the Rajneeshees decided to infect American citizens with a biological agent. The Rajneeshees used Salmonella typhimurium in order to poison the citizens of Dalles, Oregon. These terrorists planted this biological agent in salad bars in numerous restaurants across the city of Dalles. The Rajneeshees had political goals in mind behind this bioterrorist attack. The Rajneeshees wanted to influence public opinion in the upcoming election in Dalles. Fortunately, nobody was killed in this terrorist attack. However, 751 American citizens became ill due to the biological agent. The Possibilities of Bioterrorism It is very possible that a terrorist cell is currently plotting a terrorist attack with a biological weapon. In a book entitled Terrorism and Counterterrorism, Richard F. Pilch wrote a section on biological weapons. Pilch's essay was called "The Bioterrorist Threat in the United States, and he wrote about the possibilities of a terrorist unleashing a biological weapon onto the American people. According to Pilch, the term bioterrorism is defined as "the use of pathogens or toxins against human, animal, or plant populations by a terrorist group to achieve political, social, or religious aims" (Howard & Sawyer eds. 2006, p. 274). A bioterrorist has many options that are open to him/her in using a biological weapon of mass destruction. Biological Weapons of Mass Destruction A biological weapon is often categorized as a weapon of mass destruction, also known as a WMD. There are many different types of biological weapons, which are also referred to as bioweapons. Even though biological weapons are difficult to obtain and produce, a biological terrorist attack is possible. The medical field must make certain preparations in order to care for patients that are exposed to biological weapons. Biological terrorism is also referred to as bioterrorism. There are many types of biological weapons of mass destruction that a terrorist can employ against innocent people. There are also some other kinds of biological weapons that are not usually lethal. However, these biological agents can still cause damage and inflict terror into the hearts and minds of the population, if they are used by a terrorist cell.

3 EDUCATION EDGE! Everything written in green throughout this course is information you will need to know! Sources of Biological Agents There are numerous sources from where a terrorist can obtain a biological agent. According Pilch, biological agents can be acquired in the following locations: 1) "the environment, including soil, buried animals, and infected animals and humans; 2) U.S. culture collections, for example the American Type Culture Collection (ATCC); 3) Foreign culture collections; 4) BW facilities of the former Soviet Union; 5) Incubators and private culture collections housed in hospital microbiology laboratories, commercial medical laboratories, and academic laboratories; 6) Military laboratories; and 7) Vendors" (Howard & Sawyer eds. 2006, p. 274). There are many other ways in which a terrorist organization can acquire a biological weapon. One way is that a terrorist cell can steal a biological weapon of mass destruction that has already been created by another group. Another way is that a terrorist organization can build a biological weapon themselves. In order to build a biological weapon of mass destruction, certain ingredients are needed. These materials can be found in nature. They can also be stolen from a lab or a hospital. Terrorist cells can also purchase certain biological agents on the black market. Additionally, many terrorists have the potential to create a biological weapon. Terrorist cells around the globe possess members who are skilled in biology and other sciences. No matter how a biological weapon is acquired, if a terrorist organization uses a biological weapon of mass destruction against a nation, the results would be catastrophic. Types of Biological Weapons:

4 Viruses are noncomplex life forms, yet they are among the most deadly forms of life. Viruses are made up of a genetic core RNA or DNA based and a protein coat to surround it (Weintraub, 2002, p. 77). Fortunately, viruses cannot be created in a lab. So, a terrorist organization will have to rely upon obtaining or more likely stealing an actual virus. Types of Viruses: Smallpox = Smallpox is an extremely deadly virus, and it is very contagious. Delivery Smallpox can be contracted from person to person and also through aerosol. Incubation period The incubation period for this virus is about 12 days. Symptoms The symptoms of smallpox are as follows: - Sudden malaise - High fever - Blisters - Headache - Backache - Vomiting Possible misdiagnosis Smallpox can be misdiagnosed for chicken pox. Luckily, the differences between smallpox and chicken pox are quite extensive. For instance, there is a great difference in the lesions between these two illnesses. In smallpox, the lesions start to form in the patient s mouth. Then, the lesions spread to the extremities and face, where they are concentrated, and then they spread to the torso, legs, hands, and soles of the patient. More importantly, most of the lesions on an area of the body are in the same development stage (Weintraub, 2002, p. 85). Treatment The only treatment for smallpox is the vaccination, but it has to be given to a patient prior to contracting smallpox or immediately after a patient is exposed to smallpox. Also, the vaccination to smallpox does not mean that the patient will not contract this virus and ultimately die from smallpox. Unfortunately, this is the only treatment option currently available to modern science (Weintraub, 2002, p. 79).

5 Equine Encephalitides (Encephalitis) = Encephalitis means inflammation of the brain. There are three kinds of this type of virus, which are as follows: 1) Venezuelan Equine Encephalitis (VEE) --- According to Elaine Landau, who wrote the book Chemical and Biological Warfare, usually within a couple of hours of being bitten by a mosquito, VEE victims frequently experience high fever and a severe headache. Normally, these symptoms disappear, and the patient recuperates. The vast majority of victims survive. 2) Eastern Encephalitis (EEE) --- This is considered to be the most dangerous of these types of viruses. EEE kills about 50-70% of infected patients. 3) Western Encephalitis (WEE) --- About 10% of patients infected with WEE die. Delivery These viruses are delivered by being bitten by infected mosquitos. VEE, EEE, and WEE can also be delivered through aerosol. Incubation period VEE = 5 to 15 days. EEE = 1 to 6 days. WEE = 5 to 10 days. Symptoms The symptoms for VEE, EEE, and WEE are as follows: - Photophobia (early symptom) - Muscle pain (early symptom) - Headache (early symptom) - Nausea - Vomiting - Fever - Diarrhea - Sensitivity to light - Confusion - Lethargy - Sore throat - Excess salivation - Cranial nerve palsies - Impaired respiratory regulation - Seizures - Meningitis - Coma Treatment Currently, there is no vaccine available for these types of viruses. The only treatment available is general supportive medical care.

6 Hemorrhagic Fevers = There are numerous kinds of this type of virus, which are follows: 1) Yellow Fever 2) Dengue 3) Marburg 4) Lassa 5) Ebola 6) Junin 7) Hantavirus 8) Crimean-Congo Fever 9) Rift Valley Fever Delivery These fevers can be delivered through aerosol or through contact with the victim s fluids. Incubation period Since there are numerous types of hemorrhagic fevers, the incubation period is 4 to 35 days. The incubation period depends upon which fever the patient has contracted. Symptoms The symptoms of these fevers include the following: - Muscle aches - Headaches - Fatigue - Fever - Diarrhea - Vomiting - Renal failure - Liver failure - Rash - Sore throat - External and internal bleeding (after the 5 th day) Treatment Will mostly consist of supportive care: - Maintaining BP and fluids - Correcting bleeding disorders (coagulopathies) - Sedation and pain control - Ribavirin (Rebetol, Copegus)- Is an antiviral drug. It is thought to interfere with the production and/or action of viral DNA and RNA which are critical to the survival and multiplication of the virus. May be effective for some types of VHF. - Patient isolation: a) single room with adjoining anteroom if available (handwashing facility with decontamination solution) b) negative air pressure c) strict barrier precautions including protective eyewear/face shield

7 There are numerous types of toxins that a terrorist organization can employ against its enemies. According to Pamela Weintraub, who wrote the book Bioterrorism: How to Survive the 25 Most Dangerous Biological Weapons, toxins are poisonous by-products of living organisms, including microbes, plants, and animals. So, toxins cannot be created by terrorists. Characteristics of Toxins There are many characteristics that define toxins, which can be used as biological weapons. The characteristics of toxins are as follows: Types of Toxins: - Toxins are really stable - Toxins cause severe illness - Toxins can be inhaled, ingested, or introduced into a victim s body through any means - Toxins are not explosive - Toxins do not emit vapors - Toxins are not man-made - Toxins cannot be passed from person to person (Weintraub, 2002, p. 121). Ricin = Ricin is also known as Ricinus communis. This type of toxin comes from castor bean plant seeds. Delivery Ricin can be delivered through aerosol. It can also be delivered through the contamination of water or food. Incubation period Illness usually starts about 1 to 12 hours from exposure. Symptoms The symptoms of a ricin attack depend on how the ricin was delivered. The symptoms for ingestion of ricin are as follows: - Cough - Fever - Shortness of breath - Weakness - Pulmonary edema - Tightness in the chest - Eye irritation - Joint and muscle pain - Congestion of the pharynx The symptoms for an aerosol attack are as follows: - GI bleeding - Abdominal pain - Nausea - Vomiting - Diarrhea - Liver failure

8 - Kidney failure - Shock When a victim is attacked with a ricin attack through aerosol, it can result in death. Treatment Since there are different symptoms for the different delivery methods of ricin, the treatments are also different. The treatment for ricin exposure is as follows: Inhalation - Place patient in half-upright position. - Provide oxygen, and/or mechanical ventilation with positive end expiratory pressure to maintain oxygenation, if needed. - Perform cardiopulmonary resuscitation if necessary. Ingestion - Do not induce vomiting. - Administer a single dose of activated charcoal as soon as possible if the patient has suspected/known ricin ingestion, if vomiting has not begun and airway is secure. - Do not give anything by mouth. - Gastric lavage may be considered if ingestion has occurred in 1 hour. - If vomiting, lean victim forward or place on left side, head-down position, if possible, to maintain open airway and prevent aspiration. - Provide early and aggressive intravenous fluid and electrolyte replacement. - Administer blood pressure support through the use of intravenous vasopressors, if needed. Ocular Exposure - Flush eyes with large amounts of water for at least 15 minutes. Dermal Exposure - Remove clothing - Decontaminate skin by showering or washing, using soap and water, and rinsing skin with plenty of water. Systemic Symptoms - Give medication for control of seizure activity, if necessary. - Administer medication for treatment of hypotension, if necessary.

9 Staphylococcal Enterotoxin B = This toxin is also referred to as SEB. It exists in dairy, baked foods, and unrefrigerated meats. As such, it is one of the most popular causes of food poisoning. Fortunately, only a low percentage of patients die as a result of this toxin. Delivery Usually this toxin comes from contaminated food. It can also come from sabotaging a city s water supply, or through aerosol. Incubation period 4 to 10 hours (ingestion) 3 to 12 hours (inhalation) Symptoms The symptoms for SEB are the following: - Cough - Shortness of breath - Headache - Chest pain - Diarrhea - Nausea - Vomiting - Muscle pain In acute cases, even though it is rare, the symptoms can be the following: - Respiratory failure - Pulmonary edema These symptoms can result in death, but only in a low percentage of cases of SEB. Treatment The treatments for SEB patients are as follows: - Replacing the lost fluids and electrolytes and keeping up with fluid intake are important. - If diarrhea is severe, oral rehydration solution such as Ceralyte*, Pedialyte* or Oralyte*, should be drunk to replace the fluid losses and prevent dehydration. Sports drinks such as Gatorade* do not replace the losses correctly and should not be used for the treatment of diarrheal illness. - Preparations of bismuth subsalicylate (e.g., Pepto-Bismol*) can reduce the duration and severity of simple diarrhea. - If diarrhea and cramps occur, without bloody stools or fever, taking an antidiarrheal medication may provide symptomatic relief, but these medications should be avoided if there is high fever or blood in the stools because they may make the illness worse.

10 Botulism = Botulism is probably the most widely known type of toxin because most people associate botulism with contaminated food. People usually contract botulism from improperly dried meats or fish and canned foods. This is known as food-borne botulism. Another form of botulism is wound botulism. As the name implies, wound botulism is contracted through a person s wounds. Delivery Aerosol or through contaminated food or water. Incubation period 24 to 36 hours Symptoms The symptoms for botulism are as follows: - Impaired speech - Impaired swallowing - Impaired vision - Dryness of mouth - Dryness of throat - Drooping eyelids - Muscular paralysis, which results in respiratory failure Treatment The treatment for botulism is the following: - Antitoxins - Ventilator assistance and supportive care - Botulism antitoxin bivalent- for food borne and wound botulism (when diagnosed early) - Available only from CDC - Most effective if given early - Blocks the action of toxin circulating in the blood. This can prevent patients from worsening but recovery still takes many weeks. - Not routinely given for treatment of infant botulism - Removal of contaminated food in gut through induced vomiting or enemas - Surgical treatment for infected wounds (to remove source of toxin)

11 Bacteria can cause disease through the following ways: Producing poisons Invading host tissues Types of Bacteria: Plague = There are two types of plague: 1) Bubonic plague this plague can turn into pneumonic plague, and then it is very contagious. 2) Pneumonic it is very contagious. Delivery The delivery methods differ for each plague. In bubonic plague, the disease is spread through the fleas on rats. In contrast, pneumonic plague is delivered through aerosol. Incubation period The incubation period for both of these plagues are also different: Bubonic plague 2 to 6 days Pneumonic plague 1 to 6 days Symptoms The symptoms for these two kinds of plagues are the same, and these symptoms are as follows: - Major pain in lymph nodes - Fever - Headaches - Fatigue - Muscle aches - Pneumonia - Hemorrhaging in mucous membranes and skin - Inflamed glands - Septicemia Note These plagues can also cause meningitis. The death rate is very high in bubonic plague and pneumonic plague Treatment The treatment for these plagues are different. These different treatments are: Bubonic plague vaccine Pneumonic plague there is no vaccine for this plague Note Also, available treatments are as follows: - Streptomycin - Gentamicin - Ciprofloxacin - Doxycycline

12 Melioidosis = This bacterium comes from dirt and soil. Delivery This type of bacteria is delivered through aerosol. Incubation period 10 to 14 days Symptoms The symptoms for melioidosis are as follows: - Initial fever of 102 degrees F or higher - Muscle pain - Headache - Chest pain - Jaundice - Diarrhea - Sensitivity to light - Night sweats In acute cases of melioidosis, the symptoms are as follows: - Bloody nodules and ulcers form in the nasal cavities, which secrete bloody discharge and can cause toxic infection - Pneumonia - Bronchitis Treatment The treatment for melioidosis is as follows: Treatment generally starts with intravenous antimicrobial therapy for days, followed by 3-6 months of oral antimicrobial therapy. Antimicrobial agents that have been effective against melioidosis include: Intravenous therapy consisting of: - Ceftazidime administered every 6-8 hours OR - Meropenem administered every 8 hours Oral antimicrobial therapy consisting of: - Trimethoprim-sulfamethoxazole taken every 12 hours OR - Doxycycline taken every 12 hours Note Even if patients are treated, symptoms can reoccur decades later. It can also cause chronic metastatic illness and seed in the brain, heart, liver, bone, spleen, lymph nodes, and eyes (Weintraub, 2002, p. 73). On the other hand, if a patient is not treated, the likelihood of death is 100%.

13 Cholera = This bacteria can be contracted through ingestion of undercooked or raw fish. According to Weintraub, intentional use of cholera by terrorists would presumably involve contamination of food or water supplies. For those who prefer this route of delivery, cholera could be the bioweapon of choice (2002, p. 51). As a result, patients who exhibit symptoms of cholera, medical professionals must inquire if they all drank bottle water or tap water. This is so that a possible decontamination of a city s water supply can take place, or if that is not possible, to warn a city s inhabitants to not drink the water, for a bioterrorist attack is probably taking place. Healthcare workers must always be on the lookout for this potential scenario. Delivery In addition to raw or undercooked fish, cholera can be delivered through contaminated water and other contaminated food. Incubation period 12 hours to 6 days Symptoms These symptoms are as follows: - Rapid loss of bodily fluids - Chronic diarrhea - Nausea - Vomiting - Unconsciousness - Toxemia Treatment The severe cholera patient may have lost more than 10% of body weight and needs swift volume replacement. Cholera deaths can be prevented by the aggressive administration of fluids. This will correct the dehydration, shock, and acidosis Note Cholera often can result in death. For those who receive treatment, the death rate is 3% to 30%. For those who do not receive treatment, the death rate is 50% to 80%. Antibiotics can be administered as follows: Doxycycline: Adult (non-pregnant): 300 mg in a single dose, Child: 2-4 mg/kg in a single dose OR Azithromycin: Adult: 1g in a single dose, Child: 20 mg/kg in a single dose OR Tetracycline: Adult (non-pregnant): 500 mg, 4 times/day for 3 days, Child: 12.5 mg per kg, 4 times/day for 3 days OR Erythromycin, Adult: 500 mg, 4 times/day for 3 days, Child: 12 mg/kg, 4 times/day for 3 days

14 Glanders = This type of bacteria exists in infected animals, usually horses. The bacteria that cause glanders are transmitted to humans through contact with tissues or body fluids of infected animals. Glanders can exist in soil, dust, and water, so this makes this an intriguing weapon of choice for terrorists (Weintraub, 2002, p. 72). Delivery The bacteria enters the body through cuts or abrasions in the skin and through mucosal surfaces such as the eyes and nose. It may also be inhaled via infected aerosols or dust contaminated by infected animals. Incubation period 10 to 14 days Symptoms The symptoms for glanders are as follows: - Initial fever of 102 degrees F or higher - Muscle pain - Headache - Chest pain - Jaundice - Diarrhea - Sensitivity to light - Night sweats Treatment The treatments for glanders are as follows: - Oral antibiotics for patients with localized disease, for 60 to 150 days - Intramuscular therapy and intravenous therapy for more seriously infected patients - Sulfadiazine has been found to be an effective in experimental animals and in humans. - In addition, the bacterium that causes glanders is usually susceptible to: a) Tetracyclines b) Ciprofloxacin c) Streptomycin d) Novobiocin e) Gentamicin f) Imipenem g) Ceftrazidime h) Sulfonamides

15 Tularemia = This type of bacteria comes from animals. Tularemia is not passed from person to person. In the past, it was also referred to as deer fly fever or rabbit fly fever (Weintraub, 2002, p. 39). Delivery It can be delivered through aerosol. A person can also contract tularemia through a tick bite or through another animal that is infected with tularemia. Incubation period 2 to 10 days Symptoms The symptoms of tularemia are as follows: - Sudden flulike illness - Shivering - Fever - Headaches - Muscle aches - Deep cutaneous ulcers - Loss of bodily fluids - Swollen lymph nodes Treatment The treatments for this illness include the following: - Streptomycin is the drug of choice based on experience, efficacy and FDA approval. Gentamicin is considered an acceptable alternative, but some series have reported a lower primary success rate. Treatment with aminoglycosides should be continued for 10 days. - Tetracyclines may be a suitable alternative to aminoglycosides for patients who are less severely ill. Tetracyclines are static agents and should be given for at least 14 days to avoid relapse. - Ciprofloxacin and other fluoroquinolones are not FDA-approved for treatment of tularemia but have shown good efficacy in vitro, in animals, and in humans.

16 Anthrax = This bacterium has been used by terrorists before. After the terrorist attack against the United States on September 11, 2001, terrorists targeted a handful of Americans and sent a powder form of anthrax through the mail. Anthrax is deadly when it is in powder form. In this bioterror attack, five innocent people died (Dudley ed. 2004, p. 53). In a book entitled Biological Warfare: Opposing Viewpoints, Sallie Baliunas wrote a section on this biological weapon. Baliunas essay on anthrax was called Anthrax is a Serious Threat, and she claimed that anthrax is a great option for a bioterrorist attack due to its resoluteness (Dudley ed. 2004, p. 53). Baliunas wrote that this bioweapon is a disease caused by a bacteria that exists naturally in livestock animals; it is nearly always fatal to humans if it is caught by inhalation and left untreated (Dudley ed. 2004, p. 53). Anthrax has the potential to be extremely lethal. Also in the book Biological Warfare: Opposing Viewpoints, another author, named Steven Milloy, also wrote about anthrax. Milloy s essay was entitled The Threat of Anthrax Has Been Exaggerated. This writer claimed that the anthrax threat has been exaggerated because anthrax must be turned into a powder in order to inflict the most damage and be extremely lethal. According to Milloy, anthrax spores are easy enough to obtain. But before spores can be made into a mass inhalation threat, they need to be converted to a powdered form (Dudley ed. 2004, p. 60). If anthrax is in a liquid form, it would be useless as a biological weapon as soon as it hits the floor (Dudley ed. 2004, p. 60). However, the possibility that a terrorist organization could use powdered anthrax in the future should be taken seriously. Therefore, healthcare workers need to ensure that they are prepared to deal with patients that have been infected with anthrax. Delivery Delivery is through inhalation or ingestion, usually in powder form. Anthrax can also be delivered through aerosol and through a victim s broken skin. Note Anthrax is not passed from person to person. Incubation period The incubation period differs, depending on how anthrax has infected the victim: Inhalation/ingestion = 1 to 7 days Aerosol = 1 to 7 days Broken skin = 1 to 12 days Symptoms The following symptoms of anthrax are possible: - Blisters or sores - Flulike illness - Chest pain - Shock - Respiratory failure - Fever - Fatigue - Pains

17 - Headaches - Meningitis - Lower intestinal infection - Stomach pain - Nausea - Sores or blisters on tongue - Bloody diarrhea - Lymph gland infections Treatment There are several options for treating patients with anthrax, including antibiotics and antitoxin. Patients with serious cases of anthrax will need to be hospitalized. They may require aggressive treatment, such as continuous fluid drainage and help breathing through mechanical ventilation. All types of anthrax infection can be treated with antibiotics, including intravenous antibiotics. If someone has symptoms of anthrax, it s important to get medical care as quickly as possible to have the best chances of a full recovery. Doctors will select antibiotics that are best for treating anthrax and that are best for the patient based on their medical history. The antibiotic treatment for anthrax includes the following: - Ciprofloxacin - Doxycycline - Penicillin When anthrax spores get inside the body, they can be activated. When they become active, anthrax bacteria can multiply, spread out in the body, and produce toxins or poisons. Anthrax toxins in the body cause severe illness. After anthrax toxins have been released in the body, one possible treatment is antitoxin. Antitoxins target anthrax toxins in the body. Doctors must use antitoxin together with other treatment options.

18 Q Fever = This type of bacteria is normally not lethal, so it is usually categorized as an incapacitating biological agent. Q fever is a disease caused by the bacteria Coxiella burnetii which is found worldwide. The bacteria naturally infects some animals, such as goats, sheep and cattle. C. burnetii bacteria are found in the birth products (i.e. placenta, amniotic fluid), urine, feces, and milk of infected animals. People can get infected by breathing in dust that has been contaminated by infected animal feces, urine, milk, and birth products. Some people never get sick; however, those that do usually develop flu-like symptoms. Delivery Q Fever can be contracted by eating contaminated food or through aerosol Incubation period 2 to 3 weeks Symptoms The symptoms for Q Fever are as follows: - Headache - Chills - Fever - Sweating - Respiratory irritation - Fatigue - Chest pain - Muscle pain - Joint pain Treatment Most cases of acute Q fever will recover without antibiotic treatment. Those that do require treatment can be effectively treated with the antibiotic doxycycline. Unfortunately, there is no vaccine available for Q Fever. Multiple biological agents could be used against innocent citizens. Among these biological agents, experts have claimed that certain biological agents are more probable to be used by terrorists than other biological agents. The Centers for Disease Control (CDC) and Prevention s Strategic Planning Workgroup devised lists of the most likely biological weapons for terrorists to obtain and to use. Among these lists of biological agents, this group of experts claimed that certain agents pose the greatest threat to mankind. These biological agents are as follows: 1) Smallpox 2) Anthrax 3) Plague 4) Botulism 5) Tularemia An outbreak of one of these biological weapons could cause mass hysteria throughout the entire world. In addition to murdering a vast number of innocent people, terrorists are yearning to instill even more fear within democratic societies. Unleashing a biological weapon onto the global population could achieve both of a terrorists' goals. As a

19 result of a biological terrorist attack, many lives would be lost, and fear would grip the entire world. The medical field must be ready to save as many lives as possible.

20 REFERENCES Baliunas, Sallie. (2004). Anthrax is a Serious Threat. In Dudley, William (Ed.), Biological Warfare: Opposing Viewpoints (pp ). Farmington Hills, MI: Greenhaven Press. Bioterrorism Agents/Diseases. (n.d.). Retrieved October 6, 2015, from Bioterrorism and Public Health Preparedness. (n.d.). Retrieved October 6, 2015, from Bioterrorism Surveillance. (n.d.). Retrieved October 6, 2015, from General Fact Sheets on Specific Bioterrorism Agents. (n.d.). Retrieved October 6, 2015, from Landau, Elaine. (1991). Chemical and Biological Warfare. New York, NY: Lodestar Books.

21 Medhurst, Paul. (2002). Global Terrorism. New York, NY: United Nations Institute for Training and Research Programme of Correspondence Instruction UNITAR Programme of Correspondence Instruction. Milloy, Steven. (2004). The Threat of Anthrax Has Been Exaggerated. In Dudley, William (Ed.), Biological Warfare: Opposing Viewpoints (pp ). Farmington Hills, MI: Greenhaven Press. Pilch, Richard F. (2002). The Bioterrorist Threat in the United States. In Howard, Russell D. & Sawyer, Reid L. (Eds.), Terrorism and Counterterrorism (pp ). Dubuque, IA: McGraw-Hill/Contemporary Learning Series. Weintraub, Pamela. (2002). Bioterrorism: How to Survive the 25 Most Dangerous Biological Weapons. New York, NY: Kensington Publishing Corp.