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In the Event of Bioterrorism: Protecting Families from Deadly Diseases

The threat of bioterrorism has been on the minds of many parents, particularly since September 2001. Several infectious organisms have the potential to be used in acts of terrorism, and children are particularly vulnerable to these germs.

Children have a more rapid breathing rate and tend to be more sensitive to many infectious diseases and toxins. Additionally, a young child's inability to describe symptoms to their parents might delay appropriate treatment.

Here are some of the most common germs that could be used in a terrorist attack.


Anthrax is a serious infection caused by a bacterium called Bacillus anthracis. In 2001, 22 cases of the disease were reported in the United States after anthrax spores were sent through the mail. Because of this, most Americans are now aware of the infection and its possible use as a biological weapon.

At the same time, naturally occurring anthrax infections in humans or animals remain very rare in the United States. Both 2000 and 2001 had one such case of this form of anthrax. These natural infections in humans can be spread through contact with infected animals or contaminated animal products such as hides, wool, hair, and undercooked meat.

Signs and Symptoms

Anthrax bacteria can be contracted in 3 ways. Each type of infection has its own set of signs and symptoms. Although the skin sores are infectious, person-to-person transmission of any type of anthrax is rare.

  1. Breaks in the skin (cutaneous anthrax): anthrax spores (dry resting forms of the bacteria that can survive in soil for decades) enter the skin through a cut or abrasion, causing swollen, itchy sores or bumps on the skin. Within a day or two, the center becomes thick and black. In most cases, surprisingly, the sore is not painful.
  2. Breathed in (inhalational anthrax): Develops when a child breathes anthrax spores into his lungs. Early symptoms are similar to those of the flu, including fever, chills, cough, chest pain, headaches, muscle pain, and weakness. Two to 5 days later, the symptoms get worse as the bacteria move through the body and may include excessive sweating, bleeding, a bluish tint to the skin from not receiving enough oxygen, serious breathing difficulties, confusion, and shock.  Most children will die of disease if it gets to this stage.
  3. Swallowing (gastrointestinal anthrax): Can be caused when a child eats undercooked meat from an infected animal. Its symptoms include nausea, loss of appetite, vomiting, and fever. As the child's condition gets worse, he may have severe stomach pain, bloody diarrhea, and vomiting of blood. Some children have sores in their mouths and throats and swelling of their necks.

The incubation period for all forms of anthrax is usually less than 2 weeks, although it can be as long as 2 months for the inhalation variety.

How Is the Diagnosis Made?

If a pediatrician believes an anthrax infection may be present in a child, he may order special diagnostic laboratory tests of a child's blood, respiratory fluids (sputum), or skin lesions. If inhalational anthrax is suspected, he will likely place the child in the hospital and recommend a chest x-ray film or a computed tomography scan to look more closely at the lungs and other areas inside the chest. Pediatricians are required to report any suspected cases of anthrax to public health officials.


An anthrax infection needs to be treated right away. Naturally occurring cutaneous anthrax is typically treated with a variety of antibiotics such as penicillin or doxycycline for 7 to 10 days.

In the cases of anthrax associated with bioterrorism in 2001, doctors often prescribed the oral antibiotic ciprofloxacin or doxycycline. Although drugs such as ciprofloxacin and tetracycline are generally not recommended for use in children, they may be appropriate choices in serious infections in which the benefits of these antibiotics outweigh any real or possible side effects. However, the drugs such as ciprofloxacin or tetracycline that are usually given to adults for these anthrax infections are prescribed more cautiously in children and pregnant women because of safety concerns.

For inhalational and gastrointestinal infections, a pediatrician may first recommend that antibiotics be given intravenously in the hospital. Treatment for these more serious infections usually lasts 2 months or longer.

What Is the Prognosis?

When treatment for anthrax is provided early, it is usually effective. However, if the infection is untreated, it is very serious and can cause death. Of the 3 types of anthrax infections, inhalational anthrax is the most dangerous. This type of anthrax can prove to be deadly within days after symptoms appear in as many as half of those with the infection. By contrast, cutaneous anthrax poses a very small risk of death. In fact, deaths are rare when cutaneous and gastrointestinal anthrax infections are treated right away.


An anthrax vaccine is available in the United States. However, it is not approved for children or pregnant women because it has not been tested enough in these groups. Newer, more efficient anthrax vaccines with fewer side effects are currently being studied.

Important Message for Parents: Do not give your child antibiotics as a preventive measure because you are afraid that he might be exposed to anthrax at some time in the future. Antibiotics can lead to resistance in bacteria, which makes them less effective. They can also sometimes cause serious side effects. A pediatrician should prescribe these medicines only if a child has actually come in contact with anthrax bacteria. If your pediatrician thinks your child has been exposed to anthrax spores, he may consider prescribing preventive antibiotics against inhalation anthrax. If a terrorist attack should occur, pediatricians will decide whether antibiotics should be used as a preventive measure.


Once called "Black Death," plague killed millions of people in earlier times before the discovery of antibiotics. In the 1300s, it was responsible for the deaths of 20 to 30 million people in Europe. Although improvements in living conditions and rodent control have dramatically reduced the number of cases today, there are still 1,000 or more new cases worldwide each year, including some in the United States.

The bacteria responsible for plague are called Yersinia pestis. Cases of naturally occurring plague, usually acquired from close contact with wild animals who can carry the bacteria, have been reported in several western states in the United States. The disease occurs in rural areas and the incidence tends to be higher in the summers.

Bubonic plague is the most common form of plague, and it infects the lymph nodes. It can be spread to humans in the following ways:

  • When a person is bitten by fleas that have fed on infected rodents (most often, rats) or animals such as pet cats and dogs that have been in close contact with rodents.
  • When a person comes in contact with the tissues and body fluids of infected rodents and other animals, including pets. The germs typically enter the human body through a cut or abrasion in the skin.
  • When a person is bitten by an infected animal such as a ground squirrel or prairie dog.
  • Person-to-person transmission can occur from contact with drainage from infected lymph nodes or by breathing in tiny droplets coughed up by patients with lung infection.

Other forms of the disease can be spread to humans in the following ways:

  • Although septicemic plague, which affects the bloodstream, occurs most often as a complication of bubonic plague, it can occur from direct contact. Once bacteria invade the bloodstream, the disease can cause serious illness.
  • Primary pneumonic plague infecting the lungs is spread when an individual breathes in airborne droplets from a person or animal with the plague. It can lead to pneumonia. There have been recent concerns about the possible use of Y pestis in bioterrorism, because it can be spread through the air.

Signs and Symptoms

Common symptoms associated with bubonic plague, as well as other forms of plague, include:

  • Fever
  • Painful, swollen lymph nodes called buboes
  • Buboes (swollen, tender lymph glands) tend to develop in the groin area or regions of the armpit or neck, the lymph nodes that are designed to trap bacteria coming up the leg, or arm, or face, respectively.
  • Chills
  • Headache
  • Extreme weakness or exhaustion

When a person has plague that infects the bloodstream (septicemic) and spreads through the body, it can cause serious problems such as low blood pressure and breathing difficulties. Pneumonic plague can have serious complications as well, such as a cough, breathing difficulties, and bloody sputum. The incubation period for bubonic plague is always less than a week and possibly as little as 2 days.

Important Message for Parents: Contact your pediatrician if a wild rodent bites your child or if she develops symptoms like those described above.

How Is the Diagnosis Made?

Plague is usually diagnosed with laboratory tests that can detect Y pestis, including evaluations of samples from sputum and the lymph nodes, as well as blood specimens.


Children with plague are most often treated with very effective antibiotics, such as gentamicin, given as a shot. In some cases, other drugs like doxycycline may be chosen instead. This treatment usually continues for 7 to 10 days or until several days after the fever breaks. A pediatrician may recommend draining the pus from lymph nodes in children with bubonic plague.

What Is the Prognosis?

If treatment is given promptly, it can keep plague from getting worse. If not properly treated, however, the disease can result in death related to infections in the lungs and bloodstream.


If you live in parts of the United States where plague has been reported, such as the southwest, take steps to lower your risks for the disease.

  • Do not leave out pet food that can attract rodents.
  • Remove brush and rock piles that can serve as rodent nesting sites.
  • Use insecticides to destroy fleas.
  • Regularly treat the family pets to remove fleas.
  • Tell children to avoid any contact with sick and dead animals.

Important Message for Parents: If your child has had close contact with a person with plague, or someone who recently handled a dead animal, call your pediatrician if she develops a fever or other symptoms that may indicate that she has become infected. Antibiotics may be prescribed as a preventive (prophylactic) measure in these cases.

Although plague has not been used as a bioterrorist weapon, government officials have noted its possible use in this way. If the threat ever turns into reality, guidelines may be issued on steps to take to protect your child. There is no vaccine presently available to protect against plague.


In 1980, the World Health Organization declared that smallpox had been eliminated worldwide. In the United States, doctors stopped giving routine smallpox vaccines to children in 1971. After the terrorist attacks of September 2001, however, concern about smallpox reemerged because the disease is considered a possible weapon for use in a bioterrorist attack. As a result, even though the smallpox vaccine is not recommended for universal use, public health officials are developing recommendations for when such a vaccine should be given.

The variola virus, part of a family of viruses called Poxviridae, causes smallpox. It is highly contagious and is spread by airborne saliva droplets from an infected person. In a small number of cases, it can be spread by direct contact with a smallpox lesion, clothing, or bed linens. Only humans can get smallpox.

Signs and Symptoms

A child with smallpox will develop the illness after a 7- to 17-day incubation period. He will become so severely ill that he'll be left bedridden with symptoms such as:

  • A high fever (102°F–104°F or 38.9°C–40.0°C)
  • Severe headaches
  • Backache
  • Abdominal pain
  • Physical exhaustion
  • Vomiting
  • Seizures

After about 2 to 5 days, the child will develop blisters or ulcers in the mouth or throat. At this point, he will become contagious and able to spread the infection. In the next 24 hours, a rash will develop, usually beginning on the face and spreading rapidly to the forearms, torso, and legs. This rash will progress to raised bumps and then pus-filled blisters that soon become crusty. Rarely, the blisters will be filled with blood. Scabs will form, which will fall off approximately 3 to 4 weeks later, sometimes leaving behind pitted scars. About 3 to 4 weeks after the rash first appears, the scabs will separate. At this point, the child will no longer be contagious.

Important Message for Parents: If your child develops this illness, especially a rash with a fever, contact your pediatrician right away. Early chickenpox can be confused with smallpox, but the rashes look very different and children with chickenpox are usually not very sick-appearing. The blisters of chickenpox are more concentrated on the face and torso than the arms and legs. The rashes appear in waves rather than all at once and are in different stages of development at the same time (e.g., bumps, blisters, scabs). Chickenpox is more delicate, and appears to be on top of the skin rather than more deep in the skin.

How Is the Diagnosis Made?

A doctor will suspect smallpox if the symptoms described previously are present, particularly the characteristic rash associated with the infection. Diagnostic tests for smallpox, which include analyzing fluid from the rash and blisters, can only be conducted at the Centers for Disease Control and Prevention (CDC). If a child or adult is suspected of having smallpox, health departments will be contacted immediately, as the only way that smallpox can occur now, is from a bioterror exposure.


Currently, no effective treatment is available for smallpox. An antiviral medicine called cidofovir may be useful, but has not been tested in actual cases. Children and adults with the infection will be given supportive treatment such as intravenous fluids in the hospital, as well as medication to manage fever and other symptoms. Patients and their close contacts will immediately be placed in isolation, so they will not spread the infection to others.

What Is the Prognosis?

Before modern medicine, the reported death rate was as high as 30% in infants before their first birthdays and adults older than 30. Nevertheless, the majority of children and adults with this disease recover, although they may be left with scars associated with the rash.


Immunizations against smallpox are not presently recommended for the general public, and the vaccine is not available from a pediatrician. Military personnel and first responders such as ambulance drivers, emergency medical technicians, some nurses, and doctors have received the vaccine. In the United States, the government has stockpiled large supplies of smallpox vaccine to be used in an emergency, including a smallpox-related terrorist attack, if it should ever occur. The vaccine can reduce the seriousness of a smallpox infection or even prevent it if it is administered within 4 days after a person has been exposed to the variola virus. However, the vaccine itself has potentially serious side effects.

Hemorrhagic Fevers Caused by Arenaviruses

A family of viruses called arenaviruses is responsible for causing lymphocytic choriomeningitis and 5 hemorrhagic (bleeding) fevers—Bolivian, Argentine, Sabia-virus associated, Venezuelan, and Lassa. In some parts of the world, especially South America and the African continent, these infections are much more common, but they can be seen in the United States. Lassa fever, for example, occurs primarily in West Africa, but has been diagnosed in the United States among people who have traveled to Africa.

Arenaviruses are carried by rodents and can be spread to humans who breathe in tiny particles of the virus or have skin contact with the urine or saliva of the rodents. The virus then enters the body through a cut or scratch.

Signs and Symptoms:

Some hemorrhagic fever infections cause only mild illness, but in other cases, they can be much more serious. At times, they can be fatal.

  • An infection with an arenavirus often begins with symptoms such as fever, headache, muscle aches, eye pain, and abdominal pain.
  • Respiratory tract symptoms, including a sore throat and cough, can occur in people with Lassa fever.
  • Arenavirus infections can also cause bleeding from the mucous membranes (the nose and mouth) and red spots and blotches on the skin called petechiae and purpura that indicate bleeding under the skin.
  • In the most severe infections, patients can develop shock about 7 to 9 days after the illness begins. Other serious findings may include seizures, tremors, and changes in consciousness.

Person-to-person transmission through body fluids or respiratory secretions is uncommon, but can occur. The incubation periods for the arenavirus diseases are about 1 to 2 weeks.

How Is the Diagnosis Made?

Children and adults suspected of having hemorrhagic fever can be tested for antibodies to the virus, and a test for the virus in the bloodstream or on mucus membranes can be sent to the CDC.


Sometimes an antiviral medication called ribavirin (approved by the FDA for treatment of hepatitis B virus), given intravenously, is used to lower the death rate among people with severe Lassa fever, especially if the medicine is given during the first week of the illness. Ribavirin also may be helpful in treating other types of arenaviruses. Transfusions of plasma from patients who have recovered from arenavirus infection are sometimes given as part of the treatment.


The best way to avoid arenaviruses is to keep away from rodents that may carry the disease. Make efforts to prevent rodents from entering homes and nesting in areas near people. Argentine and possibly Bolivian hemorrhagic fever can be prevented with a vaccine that is still being studied. No vaccines are available for other hemorrhagic fevers associated with arenaviruses. Do not allow your child to be in close contact with people already infected with a hemorrhagic fever virus. In case of a bioterrorist attack involving arenaviruses, follow the instructions from public health officials to reduce your family's risk of exposure.

Talking to Children about Bioterrorism

In the event of bioterrorism, knowing how to talk to your child, along with helping your child cope, will be critical. In general, it is best to share basic information with children, not graphic details, or unnecessary information about tragic circumstances.

Additional Resources:

Last Updated
Adapted from Immunizations & Infectious Diseases: An Informed Parent's Guide (Copyright © 2006 American Academy of Pediatrics)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.
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