Chapter 61

• Unlike other mass casualty events, mass exposure to a biological agent is unlikely to be realized until cases start presenting and a high degree of suspicion is needed to realize this.
• Specific knowledge of the various types of agents is required to help in the diagnosis and management.
• Victims of class A agents such as plague, anthrax, botulinum toxin, smallpox, and viral hemorrhagic fever are likely to be critically ill and in need of the expertise of intensivists.
• Preparedness for a mass casualty event is key in dealing with effective care of patients in the hospital setting, containment of spread of particularly virulent organisms, and controlling public hysteria.

Since the terrorist attacks of September 11, 2001, and the distribution of mail containing anthrax spores that led to seven deaths in the U.S., the threat of a large-scale bioterrorist attack has become very real.1 A recent report by the Monterey Institute for International Studies found a total of 121 biocrimes were committed since 1960, with a reported sharp rise since 1995.2 Reports of biological agent stockpiles and their weaponization by Iraq and the former Soviet Union, as well as the use of various biological agents by cult organizations such as the Rajneesh cult, Aum Shinrikyo, and Minnesota Patriots make the possibility of their use by a rogue nation or nonmilitary organization a very real one.

Attack of a civilian target would cause a large number of casualties, panic, and civil disruption. There would be a rapid overwhelming of public health facilities and capabilities.3–5 It is highly likely that many if not the majority of patients would need some degree of critical care such as a ventilator or hemodynamic support. Thus the critical care physician's role could be a central one that depends on specific knowledge of the various agents, and preattack preparedness, the two cornerstones in dealing with such a catastrophe. The main objectives of this chapter are to provide a concise review of individual agents likely to be used in a bioterrorist attack, and focus on key issues related to the intensivist in preparing to deal with such an event.

The Centers for Disease Control and Prevention's strategic planning workgroup categorizes biological warfare agents into groups A, B, and C, based on capability to cause illness or death, stability of the agent, ease of delivery, ease of mass production, person-to-person transmissibility, potential for creating public fear and civil disruption, and the ability of the public health systems to deal with such an attack.6 Category A agents would have the greatest impact on public health and its infrastructure. Category B agents would have less impact on the public health and its infrastructure. Category C agents are least likely to impact on the public health and include various emerging infectious agents.6,7 This list is not definitive and serves only as a guideline for preparation for a bioterrorist attack (Table 61-1).

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