Symptoms: The incubation period for inhaled anthrax is one to six days. Fever, malaise, fatigue, cough, and chest discomfort are rapidly followed by severe respiratory distress. Shock and death occur within 24 to 36 hours of the onset of severe symptoms. In cases of cutaneous anthrax, a papule develops, then vesicates, finally developing into a black patch surrounded by moderate to severe edema. Without treatment, this disease may progress to blood poisoning and death, with a case-fatality rate of 20 percent. With treatment, fatalities are rare.

Treatment: Penicillin, ciprofloxacin, or doxycycline, though they are usually ineffective against inhaled anthrax once symptoms appear.

Protection: A licensed vaccine is available for use in those at risk of exposure.

Brucellosis
Description: An infection caused by any of four species of coccobacilli of the genus Brucella. One is normally a pathogen of cattle, while the other three are pathogens of goats, pigs, and dogs. Organisms are acquired by humans through the ingestion of unpasteurized milk and cheese, inhalation of aerosols generated on farms and in slaughterhouses, or skin lesions on persons with animal contact. Intentional exposure by belligerents would likely involve aerosolization but could involve contamination of food.

Symptoms: Symptoms of brucellosis are nonspecific and consist of irregular fever, headache, profound weakness and fatigue, chills and sweating, and generalized arthralgias and myalgias. Depression and mental status changes are noteworthy. Osteoarthritic complications, particularly involving the axial skeleton, are common. Fatalities are uncommon, even in the absence of therapy.

Treatment: Antibiotics.

Protection: No human brucellosis vaccine is available.

Cholera
Description: An incapacitating infection caused by the bacterium Vibrio cholerae, acquired by ingestion of contaminated water or food. The disease manifests itself as a watery diarrhea so profuse that supplies of IV fluids are often exhausted during epidemics. Intentional use by belligerents or terrorist groups would presumably involve contamination of food or water sources. Cholera is not itself lethal, but with heavy casualties and the breakdown in medical care often found in wartime, a large number of deaths is possible.

Symptoms: Incubation takes one to five days. While a large number of infected persons remain asymptomatic, the "classic" form of cholera is noteworthy for its severity and sudden onset. Vomiting, abdominal distention, and pain with little or no fever are followed rapidly by a profuse, watery diarrhea. Fluid losses may readily exceed 10 liters per day. Without treatment, death may result from severe dehydration and shock.

Treatment: Fluid and electrolyte replacement to prevent or overcome severe dehydration. Antibiotics.

Protection: A licensed vaccine is available but is only modestly effective, providing about 50 percent protection for six months.

Plague
Description: A lethal infectious disease caused by the bacterium Yersinia pestis. Naturally occurring plague is acquired by bite of a flea that has previously fed on infected rodents. Plague may also be transmitted via aerosol. In such instances, a pneumonic form may develop and, in the absence of prompt therapy, progress rapidly to death within three days. Intentional release by belligerents or terrorists would presumably involve aerosols.

Symptoms: Pneumonic plague begins with high fever, chills, headache, and vomiting blood, progressing rapidly to difficulty breathing and lack of oxygen. Death results from respiratory failure, circulatory collapse, and bleeding. Bubonic plague has an incubation period of two to 10 days and causes malaise, high fever, and tender lymph nodes. Bubonic plague may progress spontaneously to the septic form, with spread to the central nervous system and lungs.

Treatment: Antibiotics must be started within 24 hours of onset of symptoms.

Protection: A licensed vaccine is available but appears to offer little protection against aerosol exposure.

Tularemia
Description: An infection caused by the bacillus Francisella tularensis. Naturally acquired tularemia is contracted through bites of certain insects (notably ticks and deerflies) or contact with infected rabbits, muskrats, and squirrels. Intentional release by belligerents would presumably involve aerosolization of living organisms. Naturally acquired tularemia has a fatality rate of five percent; the pneumonic form, which would predominate in war, would likely have a greater mortality rate.

Symptoms: Incubation averages three to five days. Use of tularemia as a weapon would likely lead to preponderance of pneumonic and typhoidal cases, and large aerosolized attacks would be expected to shorten the incubation period. Victims would have tender ulcers at the site of inoculation, accompanied by tender, enlarged regional lymph nodes. Fever, chills, headache, and malaise often accompany these symptoms. Typhoidal and pneumonic forms often involve significant cough, abdominal pain, substernal discomfort, and prostration, in addition to fever, chills, and headache.

Treatment: Antibiotics, though relapses may occur.

Protection: A live, attenuated vaccine is available as an investigational product. Intramuscular streptomycin will prevent disease following documented exposure.

Q Fever
Description: An infection with the rickettsial organism Coxiella burnetii, typically spread by inadvertent aerosolization of organisms from infected animal products. Person-to-person transmission rarely occurs. Intentional release by belligerents or terrorist groups would presumably involve aerosolization, and Q fever would likely be employed as an incapacitating agent, as its mortality rate is low, only one to three percent.

Symptoms: Q fever typically starts as an undifferentiated illness with fever, chills, cough, headache, weakness, and chest pain occurring as early as 10 days after exposure. Onset may be sudden or insidious. Pneumonia is present in some cases, but pulmonary syndromes are usually not prominent. The illness lasts from two days to two weeks.

Treatment: Antibiotics. Q fever is generally a self-limited illness even without treatment.

Protection: Treatment with tetracycline or doxycycline within 12 days of exposure should prevent onset of symptoms. Vaccine is available as an investigational agent.

Viral Threats

Smallpox
Description: A lethal infection caused by the variola virus, a member of the Chordopoxvirus family. Naturally occurring smallpox has been eradicated from the globe, with the last known case occurring in Somalia in 1977. Repositories of virus are known to exist in only two laboratories. Monkeypox, cowpox, and vaccinia are closely related viruses, however, which might lend themselves to genetic manipulation and the subsequent production of smallpox-like disease.

Symptoms: The incubation period of smallpox is about 12 days. Clinical manifestations begin acutely with a period involving malaise, fevers, rigors, vomiting, headache, and backache. After two to four days, skin lesions appear and begin to progress uniformly from macules to papules to vesicles and pustules. Lesions progress centrifugally and scab in one to two weeks. In unvaccinated individuals, variola major, the classical form of the disease, is fatal in some 30 percent of cases.

Treatment: Supportive care is the mainstay of smallpox therapy. No specific antiviral therapy exists.

Protection: A licensed, live vaccinia virus vaccine is available and is administered via a bifurcated needle using a multiple puncture technique. Vaccine would only be indicated in laboratory settings or where biological warfare was a distinct possibility.

Venezuelan Equine Encephalitis
Description: A mosquito-borne disease maintained in a horsemosquitohorse cycle, though thousands of human infections also occur each year. Large outbreaks among horses typically precede appearance of human cases. Use of VEE as a weapon would presumably involve aerosolization.

Symptoms: VEE is an incapacitating agent with a mortality rate of less than one percent. Susceptibility is nearly 100 percent, however. The disease is characterized by sudden onset following a one-to-five-day incubation. Initial symptoms include malaise, severe headache, fever and rigors, photophobia, and myalgias. Cough, sore throat, and vomiting and diarrhea may follow. Only a small percentage of cases actually progress to encephalitis, which is more frequent in young children and is marked by convulsions, coma, and paralysis. In a majority of cases without neurologic complications, however, full recovery occurs in one to two weeks.

Treatment: Largely supportive.

Protection: Vaccine TC-83 is available as investigational product.

Viral Hemorrhagic Fevers
Description: A diverse group of human illnesses caused by viruses from several different families: the Filoviridae, which consists of Ebola and Marburg viruses; the Arenaviridae, including Lassa fever, Argentine, and Bolivian hemorrhagic fever viruses; the Bunyaviridae, including various members from the Hantavirus genus, CongoCrimean hemorrhagic fever virus from the Nairovirus genus, and Rift Valley fever from the Phlebovirus genus; and Flaviviridae, such as yellow fever virus, dengue hemorrhagic fever virus, and others.

Symptoms: VHFs are illnesses which can be complicated by easy bleeding, petechiae, hypotension and even shock, flushing of the face and chest, and edema. Constitutional symptoms such as malaise, myalgias, headache, vomiting, and diarrhea may occur.

Treatment: Antiviral therapy with ribavirin may be useful in several of these infections.

Protection: The only licensed VHF vaccine is yellow fever vaccine. Prophylactic ribavirin may be effective for Lassa fever, Rift Valley fever, CCHF, and possibly hemorrhagic fever with renal syndrome.

Biotoxic Threats

Botulism
Description: Lethal illness caused by any of seven related neurotoxins produced by the bacterium Clostridium botulinum. They are typically formed in canned foods and subsequently ingested, although the spore form may occasionally gain access to the body through wounds or gastrointestinal tract. Intentional release by belligerents or terrorists would likely involve aerosolization of preformed toxins, which then produce disease via inhalation.

Symptoms: Drooping eyelids, generalized weakness, dizziness, dry mouth and throat, blurred vision, slurred speech, and difficulty in swallowing are followed by symmetrical descending paralysis and the development of respiratory failure. Symptoms may begin as early as 12 to 36 hours following ingestion or inhalation but could take as long as several days.

Treatment: Supportive care is the mainstay of therapy. For respiratory failure, tracheostomy may be required. A licensed trivalent equine botulinum antitoxin is available.

Protection: Toxoid available as an investigational product.

Staphylococcal Enterotoxin B Disease
Description: An incapacitating illness caused by SEB, one of several toxins produced by the bacterium Staphylococcus aureus. SEB is a common contributor to food poisoning but could be employed by belligerents or terrorist groups as an aerosolized inhalational agent. It is incapacitating but rarely lethal.

Symptoms: Symptoms appear three to 12 hours after aerosol exposure and consist of sudden onset of fever, chills, headache, myalgia, and cough. Some patients may develop shortness of breath and retrosternal chest pain. Fever may last two to five days, and cough may persist for four weeks. Patients ingesting toxin might suffer nausea, vomiting, and diarrhea. Very high exposure levels may lead to pulmonary edema and, though rare, death.

Treatment: Treatment is limited to supportive care. No antitoxin has been developed.

Protection: Currently no human vaccine is available to prevent SEB intoxication.

Ricin Intoxication
Description: A lethal illness caused by ricin, a protein toxin which acts as a cellular poison. Ricin is readily produced from castor beans, ubiquitous throughout the world. Five percent of all waste from commercial production of castor oil is ricin. Natural cases of ricin intoxication involve ingestion of castor beans, which causes severe GI symptoms, vascular collapse, and death. Ricin use by belligerents might involve the poisoning of water or foodstuffs, use of ricin-laced projectiles, or aerosolization of ricin as a liquid or freeze-dried powder.

Symptoms: When inhaled as an aerosol, ricin would likely cause symptoms within eight hours. Fever, cough, difficulty breathing, nausea, and chest tightness are followed by profuse sweating, development of pulmonary edema, cyanosis, hypotension, and finally respiratory failure and circulatory collapse. Death would occur in 36 to 72 hours, depending on size of the dose.

Treatment: No specific antitoxin treatment exists.

Protection: A protective mask offers protection from aerosol exposure, but no specific vaccine exists.

Trichothecene Mycotoxicosis
Description: Disease caused by the trichothecene mycotoxins, poisons produced by several species of fungi. Most are potent inhibitors of protein synthesis and respiration. The toxins most frequently isolated from agricultural products, and likewise mentioned most often in the context of belligerent use, include diacetoxyscirpenol (DAS), Nivalenol, 4-Deoxynivalenol (DON), and especially T-2. T-2, one of the most stable types, is perhaps the most likely to be employed in terrorism or warfare. Intentional use of T-2 by belligerents might involve aerosolization or contamination of food.

Symptoms: Skin exposure leads to symptoms within minutes, including redness of the skin, pain, and a burning sensation. Blisters form and progress to necrosis with a leathery blackening of the skin. Inhalational exposure produces a rapid onset of nose and throat pain, with nasal discharge, cough, labored breathing, wheezing, chest pain, and coughing up of blood. Eyes are likewise affected with intense burning. GI exposure leads to loss of appetite, nausea, abdominal cramping, and watery or bloody diarrhea.

Treatment: Standard poison management techniques, such as the use of superactivated charcoal, are useful when administered early to casualties with gastrointestinal exposure.

Protection: Physical means, such as a protective mask and clothing.

Nerve Agents

Tabun (GA), Sarin (GB), Soman (GD), GF, VX
Description: The most toxic of the known chemical agents. Nerve agents are extreme hazards in their liquid and vapor states and can cause death minutes after exposure. Nerve agents inhibit certain enzymes in tissue; effects are caused by resulting excess compounds. Nerve agents are considered major military threats. They can be dispersed from missiles, rockets, bombs, howitzer shells, spray tanks, land mines, and other large munitions.

Symptoms: Small exposure to vapor brings constriction of the pupils, nasal inflammation, and mild difficulty breathing, while a large exposure to vapor causes sudden loss of consciousness, convulsions, a halt in breathing, paralysis, and death. Small to moderate exposure of liquid on skin produces localized sweating, nausea, vomiting, and a feeling of weakness, while a large exposure to liquid on skin has same effect as vapor exposure. Lethal amounts of vapor or liquid cause a rapid cascade of events culminating, within a minute or two, with loss of consciousness and convulsive activity followed by a halt in breathing within several more minutes.

Treatment: Three drugs--atropine, pralidoxime chloride, and diazepam--are used to treat nerve agent exposure.

Protection: Pyridostigmine bromide as a pretreatment. Protective masks, clothing.

Vesicant Agents

Mustard (H, HD)
Description: A major military threat agent since its introduction in World War I, mustard is an oily liquid with color ranging from a light yellow to brown and has an odor of garlic, onion, or mustard (hence its name). Mustard constitutes both a vapor and a liquid threat to exposed skin and mucous membranes. Effects are delayed, appearing hours after exposure. A vesicant, it causes vesicles (blisters) on the skin; however, these agents also damage the eyes and airways by direct contact and have other effects.

Protection: Protective mask, clothing.

Cyanide Agents

Hydrocyanic Acid (AC), Cyanogen Chloride (CK)
Description: A rapidly acting lethal agent that is limited in its military usefulness by its high volatility. However, at high concentrations, cyanide kills quickly. Cyanides are sometimes called "blood agents." Cyanides are in liquid state in munitions but rapidly vaporize upon detonation of the munitions.

Protection: Protective mask, clothing.

Pulmonary Agents

Phosgene, Others
Description: A lung-damaging liquid dispersed in a liquid-filled shell that explodes, rapidly vaporizing as a low-lying, white cloud of gas. It has a characteristic odor of sweet, newly mown hay or freshly cut grass or corn.

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