Some infectious agents have the potential to be used in acts of bioterrorism. The Centers for Disease Control and Prevention (CDC) has designated 3 categories of biological agents to stratify the risk to civilians and guide national public health bioterrorism preparedness and response.¹ The highest-priority agents are designated category A, because they can be disseminated or transmitted person-to-person easily, cause high rates of mortality with potential for major public health effects, could cause public panic and social disruption, and require special action for public health preparedness. Category A agents are transmitted easily and cause high morbidity and mortality rates. Organisms in category A cause anthrax, smallpox, plague, tularemia, botulism, and viral hemorrhagic fevers, including Ebola, Marburg, Lassa, Junin, and other related viruses. Category B agents are moderately easy to disseminate, cause moderate morbidity and low mortality rates, and require enhanced diagnostic capacity and disease surveillance. These agents include Coxiella burnetii (Q fever), Brucella species (brucellosis), Burkholderia mallei (glanders), Burkholderia pseudomallei (melioidosis), alphaviruses (Venezuelan equine, eastern equine, and western equine encephalomyelitis), Rickettsia prowazekii (typhus), Chlamydophila psittaci (psittacosis), and toxins (toxic syndromes including those caused by ricin toxin from Ricinus communis [castor beans], epsilon toxin of Clostridium perfringens , and Staphylococcus enterotoxin B). Additional category B agents that are foodborne or waterborne safety threats include, but are not limited to, Salmonella species, Shigella dysenteriae, Escherichia coli O157:H7, Vibrio cholerae , and Cryptosporidium parvum . Category C agents include emerging pathogens that could be engineered for mass dissemination in the future because of availability, ease of production and dissemination, and potential for high morbidity and mortality rates and major health effects. Examples include Nipah virus, hantavirus, tickborne hemorrhagic fever viruses, tickborne encephalitis viruses, yellow fever virus, and multidrug-resistant Mycobacterium tuberculosis .

Children may be particularly vulnerable to a bioterrorist attack, because children have a more rapid respiratory rate, increased skin permeability, higher ratio of skin surface area to mass, and less fluid reserve compared with adults. Accurate and rapid diagnosis may be more difficult in children because of their inability to describe symptoms. In addition, the adults on whom children depend for their health and safety may become ill or require quarantine during a bioterrorist event. Many preventive and therapeutic agents recommended for adults exposed or potentially exposed to agents of bioterrorism have not been studied in infants and children, and pediatric doses have not been established or approved by the US Food and Drug Administration for use in children.¹ Children also may be at risk of unique adverse effects from preventive and therapeutic agents that are recommended for treating exposure to agents of bioterrorism. Further, availability of appropriate pediatric formulations of medical countermeasures may be limited. Parents, pediatricians, and other adults should be cognizant of the psychological responses of children to a disaster or terrorist incident to reduce the possibility of long-term psychological morbidity.²

Fever, malaise, headache, vomiting, and diarrhea are common early manifestations of illness caused by many bioterrorist agents and other infectious diseases. Some bioterrorist agents can cause typical distinctive signs and symptoms and incubation periods and require unique Diagnostic Tests, isolation, and recommended Treatment and prophylaxis. Agents are discussed in Section 3 under specific pathogens, and extensive information and advice are available elsewhere. Table 2.1 lists resources, including telephone numbers and Internet sites, that provide updated information concerning clinical recognition, prevention, diagnosis, and Treatment of illness caused by potential agents of bioterrorism.

Clinicians should be familiar with the reporting requirements within their public health jurisdiction for these conditions. When clinicians suspect that illness is caused by an act of biological terrorism, they should contact their local public health authority immediately so that appropriate infection-Control Measures and outbreak investigations can begin. In the event of a biological terrorist attack, clinicians should review the CDC Emergency Preparedness and Response Web site (http://emergency.cdc.gov/bioterrorism) for current information and specific prophylaxis and Treatment guidelines. Public health authorities should be contacted before obtaining and submitting patient specimens for identification of suspected agents of bioterrorism.

The American Academy of Pediatrics and Agency for Healthcare Research and Quality have prepared a resource document outlining recommendations to pediatricians and the government to ensure that the needs of children and families are met in the event of chemical or biological terrorism.³