Biological warfare

A presentation about Biological Warfare. Includes history, concepts, threats and preparedness. Focuses on the Indian scenario.

1. BIOLOGICAL WARFARE PRESENTED BY: DR. TIMIRESH KUMAR DAS MODERATOR: DR. ANITA VERMA ASSOCIATE PROFESSOR DEPT. OF COMMUNITY MEDICINE

2. DEFINITIONS: Biological warfare (also known as germ warfare) is the use of biological toxins or infectious agents such as bacteria, viruses, and fungi with intent to kill or incapacitate humans, animals or plants as an act of war by a state or nation . 1 Entomological (insect) warfare is also considered a type of biological warfare .

3. DEFINITIONS: Biological agents (" bio-weapons ") are living organisms or replicating entities (viruses) that reproduce or replicate within their host to cause harm. 2 They are microorganisms such as viruses, bacteria or fungi that infect humans, livestock or crops and cause an incapacitating or fatal disease. Symptoms of illness do not appear immediately but only after a delay, or ‘incubation period’, that may last for days or weeks . 3

4. Mid-spectrum agents : Toxins and Psychochemical weapons. Do not reproduce in host, Shorter incubation period. Covered under both Biological weapons convention and Chemical weapons convention. Toxin : Non-living, poisonous substance produced by many types of living beings, including animals, plants and bacteria. 2 DEFINITIONS:

5. Bioterrorism : The intentional use of microorganisms, or toxins, derived from living organisms, to produce death or disease in humans, animals or plants. 3 The deliberate use or threat of use of biological agents as weapons to cause death or disease with the aim of spreading panic order to achieve ideological, religious or political goals by non state individuals or groups. 4 Usually on a smaller scale than warfare. No concern of epidemicity or controlled spread. Usually target humans, rather than animals or crops. DEFINITIONS:

6. Biological warfare vs Bioterrorism Biological warfare attack: Intent is to conquer through incapacitation or lethality Little concern about deniability Likely to involve a delivery device Dose-response optimized Self-protection is considered

7. Terrorist attacks are about: Attention to a cause Fear and Disruption Economic impact Social and political pressures to change our will and society Biological warfare vs Bioterrorism

8. HISTORY AND EVOLUTION Ancient history: 6 th century BC – Assyrians poisoned wells with decomposing rye ergot ( Claviceps purpura ) 400 BC – Scythian archers dipped arrows in decomposing bodies and faecal matter. 300 BC – Greeks and Romans – dead animals in wells. 190 BC – Battle of Eurymedon – Snakes in earthenware pots fired on ships by Hannibal.

9. Medieval period: 1155 – Battle of Tortona , Italy – Barbarossa put human corpses in enemy water supply. HISTORY AND EVOLUTION 1346 – Battle of Kaffa – Plague outbreak in Tartar army – corpses of infected soldiers hurled back –> epidemic  Christian Genoese sailors fled to Italy  Resulted in the European Plague of Black Death.

10. 1767 - French and Indian War Indians greatly outnumbered the British and were suspected of being on the side of the French Sir Jeffrey Amherst, Commander of British Forces, directs that small-pox bearing blankets be given to Indians in the Ohio River Valley. Smallpox decimated the Indians HISTORY AND EVOLUTION

11. World War 1: Germany Developed anthrax, glanders , cholera and wheat fungus. Attempted to spread Cholera in Italy and Plague in St. Petersburg. Infected horses in US ( Baltimore) with anthrax developed by Dr. Anton Dilger . France Planned biological sabotage programme against German livestock – pigs and cattle. HISTORY AND EVOLUTION

12. World War 2 : Japan – Unit 731 in Manchuria, China. Dr. Ishii Shiro . Human experiments. Used typhoid warheads against Russians in 1939. Contaminated wells with typhoid in Harbin, China (1939-40) Caused cholera outbreak in Changchun (1940). Used plague infested rats in Nanking (1941). Operation Sei -Go (Scorched Earth) (1942). HISTORY AND EVOLUTION

13. Unit 731 headquarters: The square building .

14. HISTORY AND EVOLUTION World War 2 : Germany – Suspected of producing and using biological agents Not proved. Hitler persuaded by microbiologists and doctors not to use? Soviet Union – Weaponised Bacillus anthracis,Clostridium botulinum , Yersinia pestis and foot-and-mouth disease virus. Developed missiles with biological warheads. Did not use during war.

15. HISTORY AND EVOLUTION World War 2 : United Kingdom – Paul Fildes headed Bacteriological Warfare Subcommittee. Developed cattle cakes with Anthrax. Aerosolised anti- personel agents developed. Gruinard island used for testing of Anthrax bombs. Decontaminated in 1987. US & Canada – Mostly anti animal and plant agents. Developed Anthrax and Botulinum toxin bombs. Also developed vaccines against rinderpest and botulin toxin .

16. Gruinard Island, Scotland

17. The Black Maria was the first laboratory facility built to accommodate top secret research in US. Ft. Detrick , Maryland.

18. Recent times: Biological warfare to bioterrorism 1979 – Accidental leak of Anthrax spores in Sverdlosk , USSR  66 people dead. Iraq (1985 – 1995) – Developed bombs, rockets and missiles armed with botulin , anthrax and aflatoxin . South Africa (1981-1994) – Developed toxins for political assassinations . Anti fertility vaccine against blacks. 1984 – 751 people infected with Salmonella by followers of Bhagwan Rajneesh in salad bars in Oregon, USA. 2001 – Anthrax spores through mail in US. 22 cases, 5 deaths. HISTORY AND EVOLUTION

19. BIOLOGICAL WARFARE OPERATIONS Offensive: Anti-personnel: high infectivity, high virulence, non-availability of vaccines, availability of an effective and efficient delivery system and stability of the weaponized agent. Bacteria such as B. anthracis , Brucella spp., V. cholerae , Y. pestis , etc. Viral agents such as Variola virus, JE virus, Ebola virus, Marburg virus, and Yellow fever Fungal agents like Coccidioides spp. Toxins like ricin , staphylococcal enterotoxin B, botulinum toxin.

20. Offensive: Anti livestock Foot-and-mouth disease and rinderpest against cows, African swine fever for pigs Psittacosis to kill chicken. Anthrax against cattle and draught animals Glanders in horses. Anti crop/ anti vegetation Bioherbicides (used by British & US in Vietnam) Wheat blast & Rice blast were weaponised by US & USSR BIOLOGICAL WARFARE OPERATIONS

21. Offensive: Entomological warfare Uses insects to attack the enemy Infecting insects with a pathogen and then dispersing the insects over target areas (cholera, plague) Direct insect attack against crops Uninfected insects, such as bees, to directly attack the enemy. BIOLOGICAL WARFARE OPERATIONS

22. Defensive: Disease surveillance systems Most biological warfare agents are primarily animal pathogens  animals affected earlier. Surveillance systems include public health specialists and veterinarians. Early warning helps reduce morbidity & mortality. E.g. In Anthrax infections almost 80% of exposed persons can be given antibiotics before development of symptoms if the surveillance and early warning systems are good. BIOLOGICAL WARFARE OPERATIONS

23. Defensive: Identification of bioweapons (Diagnosis) integrate the sustained efforts of the security agencies, medical, public health, intelligence, diplomatic, and law enforcement communities. Doctors & public health officers - 1 st line of defence . First Gulf War - United Nations activated a biological and chemical response team, Task Force Scorpio. Specific field tools that perform on-the-spot analysis and identification of encountered suspect materials. Multiple sandwich ELISA using gold & silver nanowires . BiosparQ developed by TNO Labs, Netherlands. BioPen by Ben Guiron Labs, Israel. BIOLOGICAL WARFARE OPERATIONS

24. AGENTS OF BIOLOGICAL WARFARE Key Features of Biologic Agents Used as Bioweapons High morbidity and mortality Potential for person-to-person spread Low infective dose and highly infectious by aerosol Lack of rapid diagnostic capability Lack of universally available effective vaccine Potential to cause anxiety Availability of pathogen and feasibility of production Environmental stability Database of prior research and development Potential to be " weaponized "

25. CDC Category A, B, and C Agents Category A: High priority agents easily disseminated or transmitted from person to person high mortality rates potential for major public health impact might cause public panic and social disruption require special action for public health preparedness   Category B: 2 nd highest priority moderately easy to disseminate, moderate morbidity rates and low mortality rates require specifically enhanced diagnostic capacity AGENTS OF BIOLOGICAL WARFARE

26. CDC Category A, B, and C Agents Category C: emerging pathogens general population lacks immunity, could be engineered for mass dissemination in the future because of availability, ease of production, ease of dissemination, potential for high morbidity and mortality, and major public health impact. AGENTS OF BIOLOGICAL WARFARE

27. CATEGORY A CATEGORY B CATEGORY C Anthrax ( Bacillus anthracis ) Psittacosis ( Ch. psittaci )  (Emerging infections) Botulism ( Cl. botulinum toxin)  Epsilon toxin of Cl. Perfringens   Hantavirus Plague ( Yersinia pestis )  Melioidosis ( B. pseudomallei ) SARS  coronavirus , Smallpox ( Variola major )  Glanders ( Burkholderia mallei ) Pandemic influenza Tularemia ( Francisella tularensis )  Food safety threats (e.g., Salmonella spp., E.coli O157:H7, Shigella ) Nipah Viral hemorrhagic f evers: Lassa, New World ( Machupo , Junin , Guanarito,Sabia ), Crimean Congo, Rift Valley, Ebola, Marburg Viral encephalitis [ alphaviruses (e.g., Venezuelan, eastern, and western equine encephalitis)] Brucellosis ( Brucella spp.)  Q fever ( Coxiella burnetii )  Ricin toxin from Ricinus communis (castor beans) Staphylococcal enterotoxin B Water safety threats (e.g., V. cholerae , Cr. parvum ) Typhus fever ( R. prowazekii ) 

28. Anthrax (Bacillus anthracis ) Infection – By cutaneous and inhalational route Signs/Symptoms- Cutaneous Pulmonary 95% cases 5% cases 1-5 days 1-6 days (60 days) Fever, tiredness, headache Fever, Headache, Cough Pustules, eschar Dyspnea , Chest pain Diagnosis : Skin biopsy for cutaneous Blood culture ELISA, PCR

29. Day 5 Day 12 2 months

30. Hilar prominence and right perihilar infiltrate widened mediastinum , perihilar infiltrates, peribronchial cuffing, air bronchograms .

31. Treatment : Ciprofloxacin, Penicillin, Doxycycline . Treated for 60 days. Prevention: Vaccination – 6 doses over 18 months, booster anually . Chemoprophylaxis – Cipro / Doxy 4 weeks before exposure. Infectious form: Spores Hardy, resistant to environmental conditions. Relatively easy to weaponise. Anthrax (Bacillus anthracis )

32. Example: September 2001, Anthrax used as bioweapon through US Postal system. 22 cases (18 confirmed) – 11 inhalational + 11 cut. (7 + 4) 5 deaths ( all among inhalational) Ames strain used. (beta lactamase + cephalosporinase ); but luckily susceptible to antibiotics. Maximum amount of spore in a letter – 2g (100 billion to 1 trillion spores) [ LD 50 = 10000] Anthrax (Bacillus anthracis )

33. Geographic location, clinical manifestation, and outcome of the 11 cases of confirmed inhalational and 11 cases of confirmed cutaneous anthrax.

34. Epidemic curve for 18 confirmed cases of inhalational and cutaneous anthrax and additional 4 cases of suspected cutaneous anthrax.

35. Letter sent to NBC anchor Tom Brokaw with cutaneous anthrax. Infected Brokaw's assistant, Erin O'Connor.

36. Plague ( Yersinia pestis ) Highly contagious. Pneumonic plague is most severe. Signs/ Symptoms: Bubonic Septicemic Pneumonic Due to infection through skin Usually from bubonic plague Due to inhalational exposure Fever, Chills, Nausea, Vomiting Fever, Chills, Nausea, Vomiting 24 hours Buboes (1-8 days) Bleeding in skin, Ischemia in limbs Cough with blood tinged sputum.

37. Bubo Ulcer

38. Diagnosis: Clinical features Microscopic examination of bubo fluid/ sputum Cultures PCR/ DFA Treatment: Gentamicin , Streptomycin, Doxycycline Prevention: Formalin fixed vaccine Flea control measures Plague ( Yersinia pestis )

39. Spread: Through bite of infected fleas. Through droplet spread from pneumonic plague patients. Through direct contact with non intact skin. Weapon potential: Labile in environment ( 1 hour) Highly contagious, person to person spread. Can be weaponised as aerosols. (10 km) Plague ( Yersinia pestis )

40. Smallpox ( Variola ) By 1980, close to whole world population was immune  not important as bioweapon then. Now susceptible population (50%). High infectivity, can spread at a factor of 10-20. 10-30% mortality in untreated. Signs/ Symptoms: Incubation period = 7 – 17 days (12-14) Fever, malaise, headache, backache, emesis Maculopapular to vesicular to pustular skin lesions Centrifugal, same stage of development Hemorrhagic & malignant forms (5- 10%)

41. Diagnosis: Culture, PCR, Electron Microscopy Treatment: Supportive treatment. Cidofovir, Antivaccinia immunoglobulin Prevention: Vaccinia immunisation Weaponisation: Infected fomites (historical use) Aerosol sprays Smallpox ( Variola )

42. Tularemia (F. tularensis ) Extremely infectious. (10-50 by inhalation) Infection through non intact skin, mucous membrane, GI tract, Respiratory tract. Rabbits, ticks, water rats, deer. Signs/ Symptoms: 1-14 days Ulceroglandular (75%) & Typhoidal (25%) Fever, chills, malaise, myalgia, headache Chest discomfort, dyspnea ,, Skin rash, Pharyngitis , conjunctivitis Hilar adenopathy on chest x-ray

43. Diagnosis: Gram stain, culture (blood, ulcer discharge, sputum) Immunohistochemistry , PCR Treatment: Streptomycin, Gentamycin , Doxycycline , Ciprofloxacin Prevention: Chemoprophylaxis - Doxycycline , 100 mg PO bid x 14 d or Ciprofloxacin, 500 mg PO bid x 14 days Weaponisation: Aerosol sprays. Tularemia (F. tularensis )

44. Hemorrhagic Fever Viruses Includes: Arenaviridae : Lassa, New World ( Machupo , Junin , Guanarito , and Sabia )      Bunyaviridae : Crimean Congo, Rift Valley      Filoviridae : Ebola, Marburg Person to person transmission through direct contact with body fluids. (Lassa, Ebola, Marburg). Aerosol sprays infectious (animal studies). Upto 90% mortality.

45. Signs/ Symptoms: Fever, myalgia, prostration, and DIC with thrombocytopenia and capillary hemorrhage Maculopapular or erythematous rashes Leukopenia, temperature-pulse dissociation, renal failure, and seizures Diagnosis should be suspected in anyone with temperature >38.3°C for <3 weeks who also exhibits at least two of the following: hemorrhagic or purpuric rash, epistaxis , hematemesis , hemoptysis , or hematochezia in the absence of any other identifiable cause. Hemorrhagic Fever Viruses

46. Diagnosis: RT-PCR Antigen isolation Treatment: Supportive therapy Ribavirin , IF , Hyperimmune Ig Prevention: No known chemoprophylaxis No vaccines Strict isolation and PPE ( N95 mask or PAPR) Hemorrhagic Fever Viruses

47. Botulinum toxin (Cl. Botulinum) One of the most potent toxins. Produced by Cl. Botulinum. Toxin is labile in atmosphere (1% per min), Organism is easily destroyed (chlorine, heat) Botulism can occur: infection in a wound or the intestine, the ingestion of contaminated food, or the inhalation of aerosolized toxin.

48. Signs/ Symptoms: 12 – 72 hours Dry mouth, blurred vision, ptosis , weakness, dysarthria , dysphagia , dizziness, respiratory failure, progressive paralysis, dilated pupils Diagnosis: Mouse bioassay Toxin immunoassay Botulinum toxin (Cl. Botulinum)

49. Treatment: Supportive ( Intubation, Mechanical ventilation, TPN) Equine antitoxin (only against A &B) Prevention: Botulinum toxoid is available for high risk workers Lab workers, military personnel Botulinum toxin (Cl. Botulinum)

50. Examples of use: Botulinum toxin was the primary focus of the pre-1991 Iraqi bioweapons program. (19000 l conc. toxin.) Aum Shrinrikyo cult unsuccessfully attempted on a least three occasions to disperse botulism toxin into the civilian population of Tokyo. 1990 - Outfitted a car to disperse botulinum toxin through an exhaust system and drove the car around Parliament. 1993 - Attempted to disrupt the wedding of Prince Naruhito by spreading botulinum in Tokyo via car. 1995 - Planted 3 briefcases designed to release botulinum in a Tokyo subway. Botulinum toxin (Cl. Botulinum)

51. Cholera ( Vibrio cholera) Causes acute, potentially severe gastroenteritis. Spread through contaminated drinking water. Signs/ Symptoms: Begins in 12-72 hrs. Watery rice water diarrhoea . Abdominal pain, cramps. Dehydration, Electrolyte imbalance Seizures and Cardiovascular collapsein children Diagnosis: Stool microscopy – dark field

52. Treatment: Fluid & electrolyte replacement Antibiotics – Doxycycline , Ciprofloxacin, Erythromycin. Prevention: Live vaccine – 50% efficacy, 2 doses + booster. Inactivated vaccine – rapid protection, 2 doses, 85% efficacy, 2-3 years. Spread: By contamination of drinking water supply. Easily destroyed by heat, boiling, chemical disinfectants. Cholera ( Vibrio cholera)

53. SAMPLES TO BE COLLECTED

54. WEAPONISATION It is the process of converting the biological agent into a usable weapon. Delivery device- Bombs Missiles Spray systems – Aerial, Aerosol based. Non traditional – food, water supplies, animals, insects.

55. ADVANTAGES Multiple Methods For Delivery Wide Utility - non-discriminating, cause sickness, death, panic, may disseminate widely, may be persistent Good Logistics - cheap to make and store Versatile - can be in small or large quantities Defence May Be Difficult Cause No Damage To Infrastructure Easy To Conceal ‘Status’ WMD - ‘poor man’s nuclear weapon’

56. DISADVANTAGES Slow onset (except toxins) Indiscriminate Difficult to control distribution ( IF contagious) Preventive and/or Treatment measures available for some. Level of technical sophistication required for effective delivery. International taboo (deterrent to state/ nations)

57. TREATIES AND CONVENTIONS Before the 20 th century, biological agents were clubbed with chemicals as ‘poisons’. Various treaties have tried to restrict or ban the use of such ‘poisons’ and asphyxiants . The Brussels convention on laws and customs of war, 1874. The Hague Declaration concerning asphyxiating gases, 1899 The Treaty of Versailles, 1919

58. Geneva Protocol, 1925 League of Nations, the “Conference for the Supervision of the International Trade in Arms and Ammunition and in Implements of War” - May 1925. Appeal by International Red Cross & Poland. “Protocol for the Prohibition of the Use of Asphyxiating, Poisonous or Other Gases, and of Bacteriological Methods of Warfare” was adopted by the international community in Geneva on 17 th June 1925 . Customary international law. A no-first-use agreement only. TREATIES AND CONVENTIONS

59. Biological Weapons Convention (BWC), 1972 Eighteen-Nation Disarmament Committee in 1969. Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on Their Destruction was signed on 10 th April, 1972 . Entered into force on 26 March, 1975 . First treaty to ban an entire class of weapons. Prohibits development, production, stockpiling and acquisition of biological weapons. Does not obstruct non-hostile use of biological agents but still covers future weaponisation of agents. TREATIES AND CONVENTIONS

60. PUBLIC HEALTH IMPORTANCE Most bio-agents are communicable diseases. Usually 1 st identification is by public health professionals and/or physicians. Biological weapons have brought together security/defense establishment and public health. Biological weapon preparedness adds some elements to public health.

61. PUBLIC HEALTH IMPORTANCE

62. USA’s BioWatch : Network of detectors across US to detect bio-agents. Also stockpiles vaccines & medicines for biological threats. WHO’s Global Outbreak Alert and Response Network (GOARN) : Works for both biological warfare agents as well as other communicable diseases. World Health Assembly (2001): Mandated the Director General to “provide technical support to Member States for developing or strengthening preparedness and response activities against risks posed by biological agents”. PUBLIC HEALTH IMPORTANCE

63. INDIAN SCENARIO Geneva protocol, 1925: Signed – 17 th June, 1925 Ratified – 9 th April, 1930 BWC, 1972: Signed – 15 th January, 1973 Ratified – 15 th July, 1974 Nodal agencies – DRDO ( MoD ), NDMA, MoHA , MoHFW . Indian Biodefence Program – started in 1973

64. INDIAN SCENARIO NDMA NCMC

65. National Disaster Management Authority: Coordinating & mandating government policies for disaster reduction/ mitigation Devising plans to counter the threat of biological disaster, both natural and man-made (bioterrorism). Ensuring preparedness at all levels Coordination of response to disaster and post disaster relief & rehabilitation. Conducts civilian biodefence and disaster management activities and drills. INDIAN SCENARIO

66. INDIAN SCENARIO

67. Ministry of Defence: Evacuation, Logistics, Control & Coordination, Clinical First responders DRDO : R&D Equipment & Materials AFMS : Command and direction Stockpiling of vaccines/ medicines Exercises and drills Immunisation of 1 st responders 25 hospitals for biological disaster management INDIAN SCENARIO

68. Indian biodefence establishments under DRDO: INDIAN SCENARIO Defence Research and Development Establishment (DRDE), Gwalior Toxicology, Immunology, Biochemical Pharmacology, Development of diagnostic kits, Decontamination equipment. NBC sensors & shelters. Defence Materials and Stores Research and Development Establishment (DMSRDE) , Kanpur Personal Protective Equipment development & Manufacture, Gloves, Boots, Protective suits, Self contained biological suit (u/d) Defense Bioengineering and Electromedical Laboratory (DEBEL), Bangalore Canisters, Face Masks, Respirators, NBC filter fitted evacuation bags Defence Food Research Laboratory (DFRL), Mysore Food supply systems for armed forces “ Anthra -check Sand-E kit” detects Anthrax

69. Ministry of Health & Family Welfare: Outbreaks & epidemics Training & deployment of RRTs EMR department : Primary 1 st responder in case of human affliction Formulation of policies & plans to handle medical problems NCDC : Investigation of outbreaks Training R & D ICMR : R & D Training INDIAN SCENARIO

70. Ministry of Home Affairs: Nodal agency in bioterrorist attacks. Threat perception & analysis Threat mitigation Policy development Law enforcement Technical support from MoHFW & MoD INDIAN SCENARIO

71. Stockpile maintenance: Vaccines – NIV, Medicines – With states, Pharmaceutical manufacturers PPE – State RRTs, Central RRT, DMSRDE Containment equipment – DMSRDE, DRDE INDIAN SCENARIO

72. Patient isolation precautions: Standard precautions Wash hands before and after patient contact Wear gloves, Wear masks/ face covers Proper handling of equipment & Linen Airborne precautions (Smallpox, Plague, Anthrax) private room with negative air pressure, a 6 air changes per hour , and appropriate filtration of air. Wear respiratory protection when dealing with patient Droplet precautions private room or group with same patients Wear mask and also use mask on patient during movt . INDIAN SCENARIO

73. Patient isolation procedure: Contact precautions (VHFs) Private room/ group patients together Gloves. Change gloves after contact. Wear gowns. Use shoe covers Dedicate non-critical equipment that requires contact (stethoscope) INDIAN SCENARIO

74. Sample collection guidelines: Early post-exposure : when it is known that an individual has been exposed to a bioagent aerosol, aggressively attempt to obtain samples as indicated . Clinical : samples from those individuals presenting with clinical symptoms. Convalescent/Terminal/Postmortem : samples taken during convalescence, the terminal stages of infection or toxicosis or postmortem during autopsy. INDIAN SCENARIO

75. Sample collection guidelines: Clean line and exit and entry strategy 3 person team is recommended, with 1 clean and 2 dirty. Personnel protective equipment Waterproof disposable cameras and waterproof notepads What to collect – Aerosol – aerosol collector required Swabs/ paper – from any contaminated site Dead animals or humans or parts Packed in double ziploc bags (Inner bag decontaminated with bleach before putting outer bag) INDIAN SCENARIO

76. REFERENCES: U.S. Army report to the Senate Committee on Human Resources, 1977. United Nations definition. Report of the secretary general titled “Chemical and Bacteriological (Biological) Weapons and the Effects of Their Possible Use,” 1969. National Disaster Management Guidelines—Management of Biological Disasters, 2008. A publication of National Disaster Management Authority, Government of India. July 2008, New Delhi. McLaughlin K., Nixdorf K.; BWPP Biological Weapons Reader: Geneva, 2009. Harrison’s Principles of Internal Medicine; 18 th ed : 2011. Edited by Fauci AS, Kasper DL, Longo DL.

77. http://www.cdc.org . Website of the Centre for Disease Control and Prevention, Dept. of Health and Human Services, USA. Hunger I. Bioweapons Monitor 2011, 1 st ed : 2011. National Strategy for Countering Biological Threats; National Security Council of USA, 2009. http://www.emedicinehealth.com/script/main/art.asp?articlekey=58836 www.mapw.org.au ; website of the Medical Association for Prevention of War Australia (MAPW). http://www.proliferationnews.org ; website of the Carnegie Endowment for International Peace. REFERENCES: