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Chapter 26: CBR: Biological Warfare
COL Theodore Cieslak, MC, USA & COL Edward Eitzen, MC, USAIntroduction: Dozens of biological organisms and toxins are potential weapons of war or terrorism. Detailed
discussion of each of these agents is beyond the scope of this manual. This guide focuses on six agents
discerned to represent the most significant or problematic threats by a panel of military and civilian experts.
The motives of terrorists are often difficult to ascertain, and since belligerents may employ weapons of
opportunity, these six agents are not necessarily those most likely to be employed, but rather those that,
IF employed, might pose the greatest threat to health and to operations. Because agents other than those
discussed here might be encountered, and because patients may present with a nonspecific febrile illness,
empiric therapy might often be necessary. This is especially true on the battlefield where sophisticated
diagnostic tools and expert consultation are less likely to be available.
Subjective: Symptoms
Using Basic Tools: Predominantly pulmonary: neuromuscular impairment of muscles of respiration
(botulism), shortness of breath and cough; non-specific febrile illness: fever, headache, myalgias, fatigue,
malaise, and weakness.
Using Advanced Tools: Lab: CBC, nasal and throat swabs, blood and sputum for Gram stain and culture;
CXR; if possible obtain and save serum for future serologic studies, blood and/or urine for future toxin analysis
and throat swabs for viral culture.
Objective: Signs
Depend on agent but may include fever, cough, tachypnea, tachycardia, rales, dyspnea, cyanosis, diaphoresis,
hypotension, and muscular weakness.
Assessment: Use the following epidemiological clues to differentiate a potential biological attack from
naturally occurring illnesses and infectious diseases: tight clusters (in time and location) of casualties;
unusually high infection rates; unusual geography (presence of a presumed disease in an area where it
does not naturally occur); unusual or unexpected clinical presentations, unusual munitions, evidence of a
point-source for outbreak; dead or dying animals; lower illness rates in protected personnel.
Plan:
Treatment: This section deals with empiric therapy provided when biological attack is suspected but the
identity of the specific agent is unknown. In cases where a specific agent is identified or strongly suspected the
medic should refer to the appropriate section of this manual. Remember that empiric therapy is not a substitute
for the continued pursuit of a definitive diagnosis and the consequent provision of definitive therapy.
Primary: When dealing with casualties exhibiting pulmonary symptoms, or when dealing with large numbers
of casualties exhibiting significant but nonspecific febrile illness, empiric antibiotic therapy might be warranted.
This would be the case if patients were deteriorating and lives were in jeopardy, and it might also be the case
if the tactical situation would be compromised by large numbers of casualites. In this setting, oral doxycycline
100 mg q 12 hours can be prescribed. Supportive care (oxygen, intravenous fluids, antipyretics) should also
be provided as needed.
Alternative: Ciprofloxacin 500 mg po q 12 hours (primary if anthrax suspected)
Consider tetracycline or other fluoroquinolones as alternatives.
NOTE: See individual discussions below concerning vaccines, barrier protection, quarantine, evacuation and
other issues.
Biological Agents: Inhalational Anthrax
Introduction: The inhalational form of the disease would likely result from intentional aerosol delivery. It is