| The deliberate release of anthrax in the United
States shortly after the terrorist attacks of 11 September 2001 brought
a radical change in people’s perception of the risk of bioterrorism.
These bioterrorist events, unlike others before, had a worldwide impact
not only in respect of security and public health but also in other sectors.
Governments and international entities with responsibilities related to
maintenance of peace, security, safety and health protection reviewed urgently
their political, economic, diplomatic, military and legal means to face
up to such attacks and embarked upon major efforts to increase their preparedness.
In Europe, civil protection, security and law enforcement services
were put on alert, and public health systems had to manage numerous
events relating to letters suspected to be contaminated with anthrax.
The disturbance and psychological effects of these incidents became
of great concern to European societies and decision makers alike.
On 19 October 2001, the European Council, meeting in Ghent, asked
the Council of Ministers and the European Commission to prepare
a programme to improve the cooperation between Member States in
the evaluation of risks, alerts and intervention, the storage of
means of intervention, and in the field of research. The programme
had to cover the detection and identification of infectious and
toxic agents as well as the prevention and management of chemical
and biological attacks. Shortly afterwards, the EU Council of Ministers
requested the Commission to develop an action programme of cooperation
on preparedness and response to biological and chemical agent threats.
In response, the Commission launched a series of coordinated actions
across the civil protection, health, enterprise, research, nuclear
and transport and energy fields.
On the wider international level, Health Ministers from the G7
group of countries together with the Health Minister for Mexico
and the member of the European Commission responsible for Health
and Consumer Protection, agreed at a meeting in Ottawa on 7 November
2001 to initiate concerted global health security action to strengthen
the public health response to the threat of international biological,
chemical and radio-nuclear terrorism.
In the EU, many countries set up new administrative and operational
structures and adapted their preparedness and response plans in
order to deal with the new kind of threat. Recognising the importance
of joint action and in order to complement national measures, the
Health Ministers, together with the Commission, set up a Health
Security Committee on 26 October 2001, to provide the coordination
and consultation needed in the EU. Furthermore, the Ministers agreed
to create a small task force with seconded national experts from
academic medical centres and research, public health and emergency
agencies in the EU countries, together with Commission officials,
and charged it with the implementation of a 25-action programme
on health security. Preparation and dissemination of European Union
clinical guidelines on biological agents that may be used in terrorist
attacks or threats was a key action under the programme.
Several guidelines have been published already. EU Member States
have also issued guidance to health professionals under their jurisdiction.
Most of these guidelines deal with the six agents considered as
major bioterrorist threats, namely anthrax, smallpox, plague, tularaemia,
botulism and viral haemorrhagic fevers. Moreover, these national
guidelines do not focus on describing the clinical features of
these agents; if included, the description tends to be limited.
As a result, national guidelines are not the tool that clinicans
need to be able to tackle the challenge of managing cases from
bioterrorist attacks successfully.
Furthermore, more than one hundred and fifty pathogens have been
reported to be potential agents for acts of bioterrorism. Many
are uncommon in the EU and could easily be construed to be linked
to an emerging infectious disease rather than point to, or be implicated
in, a biological attack. It would be prudent to assume that many
European Union clinicians are not familiar with the clinical features
of these pathogens. Indeed, this feature of the clinical landscape
became of great concern to Health Ministers and public health authorities.
It is against this background that action at EU level, as agreed
by the Health Ministers, was undertaken. Its objective is to develop
a set of documents that would be the basis for guidance by the
national authorities or could be directly used by clinicians, general
practitioners and specialists when confronted with patients infected
by agents due to deliberate release of biological agents.
Of the numerous agents that may be used as biological weapons,
a first set has been identified as deserving immediate attention
in the context of this EU action. Ten clinical guidelines have
been written so far, on anthrax, smallpox, botulism, tularaemia,
plague, viral hemorrhagic fevers, viral encephalitis, Q fever,
brucellosis, glanders and melioidosis [1-10]. Most of these agents
have been studied, and some of them used as biological warfare
agents. Historical data are available for most of them. All could
be used in an aerosolised form which is the most effective route
of transmission for a bioterrorist attack. Medline databases and
pertinent articles in books and on the worldwide web were scanned
for information published between 1962 to February 2003 on the
In each of the papers that follow, after a short introduction,
there is a summary of the epidemiology of the agent and its potential
use in bioterrorism. In addition, recent data are included concerning
the microbiological characteristics of the agent, the microbiological
diagnosis and the treatment. The clinical features of the disease,
the main issue of these guidelines, are then described.
These clinical guidelines were reviewed by the Task Force and
by two experts designated by each Member State of the European
Union. This review was completed at the end of February 2003. The
revised guidelines were submitted to the Health Security Committee
which approved them in April 2003 and agreed their publication
in a widely disseminated journal so as to allow access to as large
an audience as possible. The editorial process of Eurosurveillance
also introduced modifications that improved the contents of these
It is hoped that the Bichat Clinical Guidelines that are presented
here would become a useful tool in the hands of clinicians that
might be confronted by a patient infected with a bioterrorist agent.
To keep them up to date, regular revisions will be made based on
new medical knowledge and developments in science and technology.
Guidelines on other agents may also be produced in the future,
if circumstances so require.