During the 14^th Century, Mongol raiders catapulted plague-infested cadavers onto a European trading post on the Black Sea. Survivors of the attack retreated to Sicily, carrying a disease which would subsequently wipe out a third of the European population, nearly 25 million people. Although acts of bioterrorism have changed considerably over the years, the danger has not. Biological agents are still easy to produce and readily available. Most agents are inexpensive, easily distributed by nature’s forces, and simple to produce. Unlike most of their chemical counterparts, harmful biological agents may also be odorless and tasteless. In addition, some experts believe the threat of biological warfare may supercede that of nuclear warfare.

Biological weapons could have a greater impact than nuclear weapons as new "super terrorists" want mass casualties; agents are readily available and arms control is difficult, according to David Siegrist, of the Potomac Institute for Policy Studies. In fact, while the threat of nuclear bombs continues to diminish, the possibility of biological terrorism has assumed a stronger presence in recent months with a rash of anthrax hoaxes. Three threats occurred within a three-week period of time in Utah, including a Planned Parenthood health clinic, an LDS Church office building, and a milk delivery truck. No biological agent was found.

The increase of threats in Utah cases represents a nationwide trend. In fact, the majority of bioterrorism cases under investigation by the FBI are still anthrax hoaxes and the agency’s caseload has doubled since 1997. That year, the FBI had 71 cases, nearly a six-fold increase from the previous yearly average of 12; in 1998, the bureau investigated 146 cases. This year the number of cases has already surpassed 100. Many officials believe the hoaxes are aimed at "wearing down" the responders in preparation for an actual terrorist attack. Health experts believe that anthrax and smallpox pose the biggest threats to civilians, and are preparing accordingly by re-engineering a safer smallpox vaccine and stockpiling prophylactic antibiotics and vaccine for anthrax.

While some believe an actual attack with biological weapons is imminent, others believe the possibility of a bioterrorist act remains relatively low. "The likelihood is entirely unknown", said Donna Shalala, Secretary of Health and Human Services. "It may never occur. But we’ve seen terrorism emerge as one of the problems of the post-Cold War world. We must not be afraid, but we must be aware."

Health-care workers must be aware that, unlike fire or police personnel, they will most likely be the first responders following a bioterrorist attack. The first indication that a silent attack has occurred may be an outbreak of some unusual illness or an abrupt, significant increase in the incidence of commonly observed symptoms. In such covert attacks, how quickly the outbreak is detected, analyzed, understood, and addressed will determine the timeliness and effectiveness of the medical and public health response and, hence, the extent and severity of the impact upon the health and well-being of the affected community, according to the Centers for Disease Control and Prevention (CDC). For example, a silent release of a biological agent capable of producing a highly communicable disease could afflict hundreds, even thousands of individuals over a wide geographic area during a period of several weeks before a full medical and public health response could be initiated.

The delayed onset of symptoms is not the only problem confronting public health. Many of the biologic agents most likely to be used by terrorists are not commonly seen as clinical or public health threats in the U.S. The nation lacks the epidemiologic and laboratory expertise and capacity to adequately deal with agents/diseases such as anthrax, plague, and smallpox. "We are ill-prepared to deal with a terrorist attack that employs biological weapons," said D.A. Henderson, director of the Johns Hopkins Center for Civilian Biodefense Studies. "In countering civilian terrorism, the focus has been almost wholly on chemical and explosive weapons. A chemical release or a major explosion is far more manageable than the biological challenges posed by smallpox or anthrax. After an explosion or a chemical attack, the worst effects are quickly over, the dimensions of the catastrophe can be defined, the toll of injuries and deaths can be ascertained, and efforts can be directed to stabilization and recovery. Not so following the use of smallpox or anthrax. Day after relentless day, additional cases could be expected and in new areas."

Much of the responsibility for addressing the health aspects of various types of terrorist attacks falls on the state and local public health community. Urgent health issues, including evaluation of the threat, identification of public health response and prevention strategies, advising the public on protective actions, and delineating procedures for first responders and health care providers, must be addressed quickly. Close coordination and communication by health agencies with other relevant organizations are essential for bioterrorism preparedness.

Many of us have read articles, both in scientific and popular literature, that describe in vivid detail where germs thrive in households. If you have ever read one of these articles and thought to yourself, "Why (and how) would anyone study this?", you might gain some insight from excerpts from an article about Dr. Charles Gerba ("On Germ Patrol, at the Kitchen Sink", New York Times, February 23, 1999).

Dr. Charles Gerba is a professor of microbiology at the University of Arizona. His primary area of interest is environmental microbiology. Most of his career has been focused on uncovering how viruses and other organisms infiltrate our drinking water. He first developed the method used to test water for cryptosporidium, and serves as a consultant for cities in America and around the world on how to improve water quality. In addition to his interest in drinking water, Dr. Gerba has become most interested in what ‘germs’ lurk in our homes and where they might be hiding.

Where do you keep your toothbrush? Dr. Gerba’s obsession began in the early 1970's when he was a postgraduate student at Baylor University in Houston, studying viruses in water. "My adviser, Craig Wallace, dragged me into the bathroom. Then he flushed the toilet a few times. ‘Can you feel the aerosol?’" he kept asking. That experiment led Dr. Gerba to create what he calls a "commodograph," a method of determining patterns of droplet emission from the bowl. He also used a strobe light to shoot a time-lapse photograph of a flush, which shows droplets of water, usually invisible, each containing thousands of bacteria and viruses, being ejected from the bowl. "Keep your toothbrush in the medicine cabinet," Dr. Gerba advised.

If you think the bathroom is bad, wait until you hear about the kitchen. "In a study published last year in Applied Microbiology, Dr. Gerba sampled spots all over the house and found that in most homes, the bathroom is much cleaner than the kitchen. Because of contamination introduced by meat and vegetables, sinks harbor the most dangerous bacteria, and people who appear cleanest -- who wipe down counters regularly with their kitchen sponge -- tend to have that bacteria all over their kitchen."

And you thought your laundry was clean... "Dr. Gerba’s latest project is the laundry, a task he believes Americans regard with not nearly enough caution or diligence. He is preparing his latest paper for presentation this spring at the meeting of the American Society of Microbiology. His study, survival of microbial pathogens during laundry, examines how fecal bacteria infiltrate washing machines.

Focusing on four-person families in Tucson, Dr. Gerba’s team randomly visited 60 homes and washed a sterile washcloth in their machines. One-fifth of the machines contained Escherichia coli, while a quarter were contaminated with fecal matter. The laundry, Dr. Gerba contends, is becoming less clean. Fewer Americans wash clothes in hot water, and only 5 percent use bleach, he said. Wash cycles are only 20 minutes, while the average drying time is only 28 minutes. Dr. Gerba found that some Salmonella and hepatitis A survive through laundry -- including the dry cycle -- and remain on clothes. "We have no idea how well we clean clothes," he said.

Dr. Gerba’s own laundry machine yielded E. coli, prompting him to change his washing habits. "I always washed my underwear last, in a separate load, but I started using bleach, and now I run an empty wash, with just bleach, when I’m done. It’s mouthwash for the machine."

Although Dr. Gerba says he has covered most of what he can in the household, he has no fear that he will run out of material."

How clean are public bathrooms? Dr. Gerba also conducted studies of public restrooms. In the mid-1970s he numbered squares of toilet paper in public restrooms and checked them hourly to gauge how many were used. Twenty years later, with a grant from the Scott Paper Company, he did the same experiment, this time with microprocessors in the dispensers, and found that men used an average of two squares per visit and women used seven.

He discovered which sex had dirtier bathrooms (women, by far), and where the bacterial hot zones were in bathrooms (outside sanitary napkin disposals, the floor and the sink, in that order; the doorknob is surprisingly clean). The average employee uses the bathroom 3.3 times per working day, and women spend twice as much time in the bathroom as men."

Send comments to:  The Bureau of Epidemiology, PO Box 142104, Salt Lake City, UT 84114-2104, or call (801) 538-6191

Approval 8000008:  Appropriation 3705

Rod Betit, Executive Director, Utah Department of Health

Charles Brokopp, Dr.P.H., Division of Epidemiology and Laboratory Services

Craig R Nichols, MPA, Editor, State Epidemiologist, Director Bureau of Epidemiology

Cristie Chesler, BA, Managing Editor