Intended for healthcare professionals

Clinical Review

Biological warfare and bioterrorism

BMJ 2002; 324 doi: (Published 09 February 2002) Cite this as: BMJ 2002;324:336

This article has a correction. Please see:

  1. Nicholas J Beeching, senior lecturer in infectious diseasesa (,
  2. David A B Dance, director and consultant microbiologistb,
  3. Alastair R O Miller, consultant physician and clinical director of medicinec,
  4. Robert C Spencer, consultant microbiologistd
  1. a Division of Tropical Medicine, Liverpool School of Tropical Medicine, Liverpool L3 5QA
  2. b Public Health Laboratory, Derriford Hospital, Plymouth PL6 8DH
  3. c Worcestershire Acute Hospitals NHS Trust, Kidderminster Hospital, Kidderminster DY11 6RJ
  4. d Bristol Public Health Laboratory, Level 8, Bristol Royal Infirmary, Bristol BS2 8HW
  1. Correspondence to: N Beeching
  • Accepted 15 January 2002

Since the terrorist attack on the United States in September 2001 attention has been focused on the threat of biological warfare. The disruptive effects of deliberate release of anthrax in civilian settings have been well documented, and several other pathogens could also be used as biological weapons. We have described the key features of such pathogens, how they might be used in biological warfare, and the clinical syndromes they cause. We also discuss the medical and logistic response to their possible use.

Summary points

Appropriate dispersion of even a small volume of biological warfare agent may cause high morbidity and mortality, which may be exacerbated by public panic and social disruption

Early symptoms of disease induced by a biological warfare agent may be non-specific or difficult to recognise

Healthcare workers should be alert for unusual single cases or clusters of illness, especially in otherwise healthy adults

Unusual illness should be notified immediately to public health authorities

Strategic responses to the deliberate release of biological warfare agents must be rehearsed locally and nationally with multiple agencies

Healthcare professionals should familiarise themselves with national and local sources of advice on deliberate release

The use of pathogens as weapons

Biological warfare agents are defined as “living organisms, whatever their nature, or infected material derived from them, which are used for hostile purposes and intended to cause disease or death in man, animals and plants, and which depend for their efforts on the ability to multiply in the person, animal or plant attacked.”1 Many such agents are zoonotic and have a considerable impact on agriculture as well as on human health. Biological warfare agents are well suited for use in bioterrorism or for attack by poorer nations against the rich (so called “asymmetric methods” of attack2) as they are cheap and easy to obtain and disperse, although full scale use …

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