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Prevention, Response, and Management of A Bio-Terrorism (Anthrax) Crisis in Schools |
Terrorism typically is an unexpected deadly assault on, or a threat of deadly assault to, innocent civilians, orchestrated by a single individual or a group of people, either on their own, or as proxies, to achieve an objective by leveraging fear and panic among the public. As painful and unbelievable as it may sound, schools and school children remain one of the targets for potential terrorist attacks. Long before the tragedies and the threats related to Anthrax following September 11, 2001 woke the entire nation as well as the world to the realities of bio-terrorism, schools became the targets of such attacks, not once but twice. Thankfully both the incidences were mere hoaxes. On November 9, 1998, a letter claiming to contain Anthrax bacteria was opened at a catholic parish in Indianapolis IN, prompting about 481 elementary students and teachers to flee the parish school. Then again, on January 11, 2000, scares after receiving a letter purportedly contaminated with Anthrax caused a shut down and evacuation of Bullen Middle School in Kenosha WI. The archival data about how these threats occurred or were handled are a testimony to how well or otherwise these situations/crises were handled, and a reference for making appropriate progressive changes to those strategies, tactics, or operations. In the wake of recently heightened sense of vulnerability as well as enhanced sense of awareness related to bio-terrorism (Anthrax or other agents) threats or attacks, it has become essential to take every suspicious incidence seriously and that it is necessary for school systems to have a better understanding of these issues. School systems need to be equipped with the knowledge and expertise to prevent, respond, and manage bio-terrorism crises. The following paper is an attempt to address this need with regard to the use of Anthrax as a specific bio-weapon . Note, however, that Anthrax is only one of the biological weapons that can be used by terrorists (Others include: botulism, plague, smallpox, and tularemia). Nonetheless, the general principles of handling a bio-terror attack are similar across the board. Although the general outline of the management of bio-terrorism threats (or hoaxes) remains fairly similar, schools deserve special mention because of a high level of ignorance, innocence, and nonchalance among school children regarding this matter. Knowing this, it becomes an added responsibility of the school’s administrators to remain more vigilant and more tactful in educating their children and staff about bio-terrorism and associated issues.
One can examine the issue of Anthrax threat in the context of school setting by taking into consideration the mode of its entry, the mechanism of its spread, detection of its contamination, handling of its triage, its treatment, the response management in the aftermath of its occurrence, and the measures to prevent it from happening.
Powder and aerosol by far remain the most commonly used forms to take weapon grade Anthrax to the intended target. Aerosol dispensers and packets or letters make the most convenient delivery vehicles for the purpose. The modus operandi to bring about the contamination draws on the weaknesses of school system that comprises of youth and staff that serve schools. In general there is a greater element of trust among staff and the administrators pertaining to school related activities. On the other hand, amongst the youth, the younger ones more easily get lured while the older ones easily get into rash explorations. The Anthrax can be directly implanted by the culprit, into ventilation system of the school with the help of aerosol dispensers, or in the supplies such as the rims of stationary or the powders used in the laboratories (powder), or can be added to the food supplies stored in the cafeteria. School buses can be contaminated with the aerosol of Anthrax by breaking into them the night before. The Anthrax powder can be manipulated into schools by remote contamination through regular mail, or through contamination of gift packets that are likely to be opened in school, or through contaminating the candies wrappers (Halloween) in the neighborhood shops, or by blemishing the valentine cards in the nearby stores around valentine day.
The most consoling fact about Anthrax contamination is that mere entry of Anthrax spores inside the school premise does not automatically imply that its spread as an epidemic is inevitable or always. As a matter of fact Anthrax is ubiquitous in nature and one can always find Anthrax bacteria in the soil, grass, and grounds that make almost given components of any school environment. For a disease to occur and for it to spread many mechanisms have to come into play. Knowledge of these mechanisms can lead to effective strategies to prevent spread of the spores (disease) even when its presence has been confirmed.
For Anthrax spores to become air borne and remain so for a while so that school attendees may inhale them into their lungs, ventilation systems that have been contaminated must run, a blower of a fall leaf collector (in fall season alone) must blow the spilled Anthrax powder into air, fans must blow in or around the spilled Anthrax spore powder, the exhausts in the offices or the laboratories must keep on sucking air, dryers in the science laboratories must suck and blow the spilled powder in their surroundings.
In case of contaminated food, the food item(s) must be distributed and eaten before suspicion or detection occurs.
For skin (Cutaneous) Anthrax to spread the spilled powder must be handled by people unsuspectingly or out of panic response, or paper from the contaminated rims must change hands and get in touch with chance bruised skin before detection.
Next to prevention of an Anthrax crisis in school, the second best strategy for school safety is early detection of the contamination or infection if that has occurred. Best detection is possible with rational balanced but vigilant suspicion. There are techniques that can detect Anthrax as early as a few minutes though their sensitivity might not be high. However, these tools can come handy to raise an alarm to avert potential crisis. Generally it takes anywhere from six hours to 48 hours to confirm detection of Anthrax, though some highly sophisticated techniques that yield more accurate and detailed information may take longer time to produce reports.
When suspicion has been aroused it is necessary to collect the sample, and isolate and quarantine the affected region, material or person(s). Recurrent inspection and surveys of school premises, educating and encouraging student information system, and a vigilant watch on suspicious mail go a long way to early and successful detection of Anthrax contamination.
Usually from an allegedly affected person one or more of the following is taken for laboratory studies. 1. Nasal swab. 2. Blood. 3. Skin surface print(s) using adhesives.
Blood can be subjected to quick test strip testing on the spot. The results are available in about 15 minutes and their accuracy is 95%. Blood can be sent to laboratories to subject it to Elisa test that takes a few hours to give results, or it can be tested for antibodies directly (direct fluorescent antibody testing), or it can be used to develop culture (of Anthrax colonies) on a Petri dish, or can be subjected to phase microscopy and DNA testing of the sample.
From non-human sites of contamination, scrapings from the filters in the air ducts, or use of hand held suction machines to suck air samples from the suspected environment are the usual methods. The samples are subjected to similar laboratory tests as given above.
Anthrax is a non-contagious disease that can be cured completely if detected and treated promptly. Therefore isolation-detention-decontamination makes the key to an effective handling of an Anthrax exposure episode. In the case of a mail attack (or a hoax), those who are identified as having been exposed must be instructed not to handle the suspected material anymore (but just cover it up to avoid further spread). They must be detained and immediately isolated into a segregated area where their contact information is noted. In the quarantine they should be asked to wash hands with soap and water if nothing else is available, or with 5% Hypochlorite solution if available. Thereafter they should be asked to take shower using soap (detergent/bleach) and water. The clothes that they wore while handling the material must be taken into custody and sealed in plastic bags. Simultaneously, on the other side, arrangements must be made to call 9-1-1, who would then get state agencies, neighborhood hospitals, HAZMAT, and the FBI involved. It is important to educate appropriately all the teachers, staff, and students about what to expect once the above mentioned agencies take over the situation .
At the site of detection of material, the fans, blowers, exhausts, dryers must be turned off, if they are operational. The segment of the ventilation system to that region must be shut down. The material must be left as is where is and the area sealed until 9-1-1 and associated agencies arrive and take over.
The parents must be informed and thereafter the school should be evacuated systematically without panic or chaos. The task of informing the news agencies must be left for the government agencies.
In cases where the exposure is not localized and the entire school population is suspected to have been exposed, such as in case of contamination of school ventilation system (inhalation Anthrax) it is not advisable to evacuate the school in haste and the handling of the case must be left to the 9-1-1 and their associated team. However, school authorities must ensure that there is no panic and all efforts must be made to inform everybody about the positive side of the availability of good treatment leading to total cure.
Teachers, staff, or students who brought cars to the school must be advised to wash their cars immediately on the day of contamination.
Anthrax if treated promptly following detection is totally curable disease. There are a number of antibiotics that work effectively against Anthrax infection. The treatment must be given by and under supervision of medical professionals. Vaccination or antibiotics must not be taken unless advised.
The real time crisis created by an attack or a threat or a hoax is far less dramatic, vivid, or obvious in comparison to the effect the event has in its aftermath. The feeling of doom during the period before the test results arrive, the scare of death lurking around in spite of ongoing treatment until substantial time has passed, the fear of another attack, the painful process of dealing with police and FBI (and alike) investigating agencies, the tendency towards exaggerated response towards any minor ill health, or the phobic response to interacting with anything that is novel or unknown, summarize the picture of a prototype post traumatic stress that the victims and witnesses might suffer in the aftermath of Anthrax attack or threat incidence. Making available counseling services, handling investigations and interrogations with empathy and, preventive and after education, to all, can help tremendously to restore normalcy in life as best and as rapidly as possible.
It is advisable to:
By far, the most common method used to unleash actual bio-terrorist attacks (and those mimicked by hoaxes) is to contaminate mail with Anthrax powder, or to spread a rumor to that effect.
The best way to handle such a scenario is that one does not open or handle a suspicious letter or a packet that comes through mail. Mail coming from known contacts or vendors with clear, identifiable addresses, are unlikely to be dangerous. It is not easy to classify what a “suspicious” item might be, however, the U.S. Postal Service suggests the following criteria to consider mail item to be suspicious:
Until this past year about five new cases of Anthrax were reported in the United States, with a total of about 2,000 to 5,000 cases reported worldwide. Most of these involve the less lethal, and more easily identifiable, skin infection form of Anthrax known as “cutaneous” Anthrax. But Anthrax infections are also possible by inhaling spores (inhalation Anthrax) as well as consuming infected food. These two forms of Anthrax infection are more rarely seen, more difficult to identify, and are, as a result, more often fatal.
Historically, Anthrax had been considered a disease of cattle, sheep, goats, camels, and antelopes. Until the late 1970s, it had not been tied to human fatalities.
The earliest suggestive reference to an Anthrax epidemic seems to be from the fifth and the sixth Egyptian plague of 1500 B.C. (plague of boils). In the 1600s the “Black Bane,” probably of Anthrax origin, killed around 60,000 cattle in Europe. It was in 1876 that Robert Koch confirmed the bacterial origin of Anthrax and, subsequently, in 1880 the first successful immunization of livestock against Anthrax was carried out.
German agents were perhaps the first to conceive and use Anthrax as a biological weapon in 1915, when they deliberately injected animals (horses, mules, and cattle) with Anthrax during World War I. Between 1937 and 1969, excluding suspensions associated with World War II, several countries, including Japan, the United Kingdom and the United States, experimented with Anthrax as a potential bio-weapon. Used as a weapon, it could be devastating. An Anthrax outbreak in Iran in 1945 killed 1 million sheep.
In 1969, President Nixon ended the biological weapons program in the United States, and an international convention outlawed development or stockpiling of biological weapons in 1972. In 1970, the United States’ Food & Drug Administration (FDA) approved an Anthrax vaccine for commercial use.
The first known human epidemic of Anthrax struck Zimbabwe in 1978, infecting 6,000 and killing 100. The next year, in 1979, airborne Anthrax spores accidentally escaped from a Soviet Union military facility, killing 68 people.
In 1989, in Northern Wales, 4,492 pigs had to be slaughtered after being infected with Anthrax.
Anthrax isn’t thought to have been a bio-terrorist weapon until 1990 to 1993. During that time, a terrorist group in Tokyo, Japan called Aum Shinrikyo used Anthrax but, fortunately, without any lethal consequences. But in 1995, Iraq openly admitted having produced some 8,500 liters of concentrated Anthrax as a part of its biological weapons program.
Twenty-three years after the first reported human casualty from Anthrax in Zimbabwe, a Florida man, working in the offices of American Media Inc., died of post-inhalation Anthrax. This case, and the subsequent cases that have been detected in recent months, are in all probability a result of bio-terrorist attack.
The following steps may follow:
It is for the local, state, and federal agencies to create a state-of-the-art response team that can be activated on short notice that will contain and coordinate the appropriate agencies -- 9-1-1, police, EM clinics, HAZMAT, the FBI, testing laboratories, epidemiology research centers, information technology agencies and the communication agencies. The policies and the roles of these groups are clearly defined in advance of these crises.
The protocol followed by Biohazard Specialists is as follows:
For more technical information please read the Technical Overview of Anthrax.
A tabular overview of various attributes of other bio-terrorism agents:
| Disease Name | Botulism |
|---|---|
| Causal Agent | Bacterium Clostridium botulinum |
| Potential for use | Extremely poisonous. Spread through air or food. Non contagious |
| Symptoms | Blurring of vision, slurred speech, muscle weakness, and paralysis |
| Time Frame | 2 hours to 8 days |
| Treatment | Antitoxin |
| Fatality without treatment | Paralysis of lungs and respiration |
| Vaccine | Limited (Experimental) |
| Disease Name | Plague |
|---|---|
| Causal Agent | Bacterium Yersinia pestis |
| Potential for use | Highly contagious. Bacterium found in rodents and flea. Easily spread with Aerosol |
| Symptoms | Fever, vomiting, weakness, shortness of breath, and chest pain, pneumonia in pneumonic type |
| Time Frame | Symptoms in 1-6 days of exposure. Death in next 2-4 days |
| Treatment | Antibiotics only if given within 24 hours of first symptoms |
| Fatality without treatment | 100% |
| Vaccine | Not available |
| Disease Name | Smallpox |
|---|---|
| Causal Agent | Variola Virus |
| Potential for use | Extremely potent. Highly contagious. Can easily disseminate in any climate or season |
| Symptoms | Fever, fatigue, head and body aches, followed by rash and lesions |
| Time Frame | 7-17 days of exposure. Death after 2 weeks of exposure |
| Treatment | Vaccination- if given before or within 4 days of exposure |
| Fatality without treatment | 30% |
| Vaccine | U.S. has small emergency stockpile |
| Disease Name | Tularemia |
|---|---|
| Causal Agent | Bacterium Francisella tularensis |
| Potential for use | Extremely infective, non-contagious. Easy to disseminate. Can cause disease even with 10 organisms |
| Symptoms | Fever, fatigue, chills, swollen lymph nodes, pneumonia |
| Time Frame | 3-5 days |
| Treatment | Antibiotics |
| Fatality without treatment | 5-15% |
| Vaccine | Limited availability of vaccine for lab workers |