American College of Physicians: Internal Medicine — Doctors for Adults ®


ACP Guide to Bioterrorism Identification

Epidemiological Clues of a Bioterroristic Attack

  1. Unusual temporal or geographic clustering of illness.
  2. Unusual age distribution of common disease (e.g., an illness that appears to be chickenpox in adults but is really smallpox).
  3. Large epidemic, with greater case loads than expected, especially in a discrete population.
  4. More severe disease than expected.
  5. Unusual route of exposure.
  6. A disease that is outside its normal transmission season, or is impossible to transmit naturally in the absence of its normal vector.
  7. Multiple simultaneous epidemics of different diseases.
  8. A disease outbreak with health consequences to humans and animals.
  9. Unusual strains or variants of organisms or antimicrobial resistance patterns.

None of these clues alone are pathognomonic of a bioterrorist attack, but several taken together provide support for further investigation.

Sentinel Clues for Category A Biological Agents

These agents are easily disseminated, may be transmitted from person to person, and can cause high mortality.

Pneumonia or Influenza-like Syndromes

  • Chest pain, dry cough, possible nausea and abdominal pain, followed by sepsis, shock, widened mediastinum, hemorrhagic pleural effusions, and respiratory failure. A Gram-positive bacillus may be isolated. Consider inhalation anthrax.
  • Gram-negative bacillus pneumonia associated with muco-purulent sputum, chest pain, and hemoptysis, particularly in an otherwise normal host. Consider pneumonic plague.
  • A Gram-negative coccobacillus broncho-pneumonia associated with pleuritis, and hilar lymphadenopathy, particularly in an otherwise normal host. Consider tularemia.

Cutaneous Ulcer or Ulceroglandular Syndromes

  • A painless ulcer covered by a black eschar, surrounded by extensive non-pitting edema that is out of proportion to the size of the ulcer. Fever and regional lymphadenopathy may be present. Consider cutaneous anthrax.

Fever and Rash Syndromes

  • An abrupt, influenza-like illness with fever, dizziness, myalgias, headache, nausea, abdominal pain, diarrhea and prostration. Evidence of "leaky capillary syndrome" with edema or signs of bleeding ranging from conjunctival hemorrhage, mild hypotension, flushing, petechiae, and ecchymoses to shock and generalized mucous membrane hemorrhage and evidence of pulmonary, hematopoietic, renal, and neurological dysfunction. Consider viral hemorrhagic fevers.
  • A febrile illness with myalgias followed in two to three days by a generalized macular or papular-vesicular-pustular eruption, with greatest concentration of lesions on the face and distal extremities, including the palms. On any one part of the body (face, arms, chest) all lesions are the same stage of development (all papules, vesicles, pustules, or scabs). Consider smallpox.

Paralytic Syndromes

  • A paralytic illness characterized by symmetric, descending flaccid paralysis of motor and autonomic nerves, usually beginning with the cranial nerves. Consider botulism.

Further information (including images) on Category A biological agents and diseases may be found online at the ACP Bioterrorism Resource Center

Reporting Protocols & Resources

If you suspect bioterrorism is responsible for an illness, contact your local public health department immediately! Do not wait for confirmation.

Office Setting: Suspicious case > record data and order tests > report to local public health dept. > alert clinical lab > arrange for consultations > discuss findings with all involved parties.

Hospital Setting: Suspicious case > record data and order tests > alert clinical lab > arrange for consultations > follow hospital protocols > notify hospital epidemiologist/infection control specialist > discuss findings with all involved parties.

More information may be found online at:

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Produced by the American College of Physicians.
2004 ACP


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