The domestic approach to potential terrorist attacks using chemical, biological, or toxinweapons attempts to balance a "post-event" consequence management approach with a "pre-event,"preventative approach. Legislation and plans have been developed to address the casualties fromchemical, biological, or toxin weapons, generally focused on the physical consequences of suchweapon use and methods to provide prompt consequence management. Further efforts regardingpublic outreach, enhancing treatment and prophylaxis through federal initiatives, or additionalregulation of materials used in developing chemical, biological, and toxin weapons are areaspolicymakers may revisit as preventative approaches to reduce the enhanced terror aspect of theseweapons This report provides a general overview of chemical, biological, and toxin weapons and their treatment; a summary of why some of these weapons may be more attractive to terrorist groups thanconventional weapons; select aspects of the current response against chemical, biological and toxinterrorism; and potential options towards lessening these weapons' impact. The widespread public unease following the anthrax mailings and the continued concernregarding possible terrorist use of weapons of mass destruction - nuclear, chemical, biological, orradiological - have highlighted the potential these weapons may have to a terrorist group. (1) Thisreport focuses on chemical, biological, and toxin weapons, whose impact and nature differ from eachother and from nuclear or radiological weapons. Chemical weapons are chemical compounds that have a strong, deleterious effect on the human body, even when encountered in small doses. The different types of chemical weapons includevesicants, which blister and burn on contact; choking agents, which cause lung damage; and nerveagents, which interfere with the nervous system and may lead to death. The effects from chemicalweapons may occur very quickly after exposure, on the order of minutes to hours. (2) Biological weapons are pathogens that cause disease and illness in infected humans. Because the pathogens multiply within the victim, a small initial amount of pathogen is sufficient to causeinfection. As a consequence, biological weapons require much less material than chemical weaponsto produce equivalent casualties and generally take longer to produce effects. Biological weaponsinclude diseases that are primarily incapacitating, such as Q fever, as well as those that are lethal,such as smallpox. Some biological weapons are contagious pathogens, such as smallpox, and havethe potential to spread the effects of an attack by traveling from victim to victim. The symptomsfrom a biological weapon attack would require some time to develop, so a covert biological attackmight not be recognized for several days. (3) Toxin weapons are primarily illness-inducing chemicals formed from living creatures, such as bacteria, fungi, plants, and animals. Toxins range in effect from disabling to acutely toxic. The mostdeadly compound currently known, botulinum toxin, is a bacterial toxin. Toxins are more potentthan chemical weapons, requiring less material to produce equivalent casualties, but they are notself-reproducing, so more material is required than for a biological weapon. Symptoms from toxinexposure typically occur on a timescale intermediate between chemical and biological weapons,generally appearing over the course of several hours. (4) The difficulty of obtaining or developing chemical, biological, or toxin weapons has made their use very rare, but these weapons have been used for terror purposes. Sarin, a chemical nerve agent,was used in the Tokyo subway system in 1995 by the Aum Shinrikyo cult. (5) Anthrax bacteria, abiological agent, was used in 2001, infecting individuals in Connecticut, New York, Florida, and theDistrict of Columbia. Also, salmonella bacteria was used by the Rajneeshee cult in 1984 in anattempt to influence local election turnout. Ricin, a toxin, was mailed to the White House in 2003and Congress in 2004. Additionally, there have been arrests and news reports of individuals and terrorist organizations that have tried to develop and use chemical and toxin weapons. Videotapes acquired and broadcastby CNN have shown the effects of a chemical agent on test animals. (6) In 2003, Britishlaw-enforcement officials arrested several people accused of manufacturing ricin in a Londonapartment. (7) Previously, it was thought that the difficulties of developing, weaponizing, and disseminating chemical, biological, and toxin weapons provided high barriers to their use by non-state actors. (8) Advances in molecular biology, chemistry, and engineering have increased the ease by whichbiological and chemical compounds can be manufactured. Purchasable civilian technologies maybe applicable to manufacture of chemical, biological, and toxin weapons. (9) The Defense ThreatReduction Agency was able to assemble the requisite equipment from civilian sources. UnderProject BACUS, a biological agent production facility was successfully built in Nevada fromdual-use technology without drawing regulatory attention. (10) Some experts maintain that thetechnological barriers to chemical, biological, and toxin use have significantly decreased. Chemical, biological, and toxin weapons also differ in their medical treatment and theavailability of effective prophylaxis. (11) Chemicalweapons, with their quick-acting effects, must betreated as promptly as possible. Because of the large range of potential effects caused by chemicalweapons, there is no universal treatment for chemical weapon exposure. (12) Exposure to nerve agentscan be directly treated with medication to prevent or reduce symptoms. Exposure to vesicants, suchas mustard gas, is generally untreatable; most people exposed will exhibit the agent's effects. Theeffects from vesicant exposure, primarily blisters and lesions, can be treated. In addition, injury fromexposure to choking agents, such as chlorine, can be ameliorated by prompt medical treatment tolimit permanent lung damage. Many biological agents either respond to medical treatment or have effective prophylaxis. Single or combination antibiotic regimens, if employed early in the course of the disease, areeffective against many bacteria that might be used as biological weapons. Such timely treatmentmay be difficult if recognition of a bioterror event is delayed. Some viruses targeted as biologicalweapons have effective prophylaxis in the form of vaccines, while others reportedly respond toantiviral drugs. (13) However, some potentialbiological weapons lack prophylaxis, treatment, or cure. Additionally, biological weapons can be engineered, with some effort, in a laboratory to be resistantto specific countermeasures. Treatment of injuries sustained from toxin weapons may be more complicated. Anti-toxins and toxoid vaccines can be developed against toxin weapons, but the process for doing so is involvedand time-consuming. Consequently, stores of these medicines are limited in scope, (14) and a largenumber of toxin weapon casualties could exhaust local supplies. Some toxins, such as botulinumtoxin, cause death by paralyzing the muscles used for breathing. These toxins can be treated withsupportive care, through artificial ventilation and other means, until the patients recover. For bioterror events, it is difficult to project the likely treatment success rate. Treatment of chemical, biological, and toxin weapons relies on providing medication within a relatively narrowtime window. If medication is not provided fairly quickly after exposure or the development ofsymptoms, depending on the weapon, full recovery is unlikely. By their nature, terrorist events are unexpected, shocking, and often perceived as random, andthey evoke a sense of fear and uncertainty. Chemical, biological, and toxin weapons use maycontribute additional considerations. In part, this is because chemical, biological, and toxin weaponshave the potential to cause mass casualties. Effectively disseminated, a single release of a chemicalor biological weapon could cause tens of thousands of casualties. (15) This ability to inflict greatnumbers of casualties may cause terrorists to view chemical or biological weapons as a viable meansfor promoting an agenda of terror and destruction. The impact of these weapons may be magnifiedby other factors. The use of chemical, biological, or toxin weapons in terror attacks could complicate emergency response due to the need to establish special care facilities for the victims, such as decontaminationareas, and the need to protect first responders from the weapon's effects. If first responders becamevictims through inadequate personal protective equipment or contamination of emergency vehicles,increased casualties and greater social disruption could result. Furthermore, chemical, biological, and toxin weapons may produce a wide array of effects. Terrorists may believe they can select chemical, biological, or toxin weapons to produce specificresults for certain situations. They may believe that these weapons increase their operationalflexibility. (16) Since for some chemical, biological,and toxin weapons there exists a delay beforesymptoms develop, terrorists may feel that their use will increase the chances of successfullyavoiding arrest. The variety of potential effects and timing can complicate medical treatment andpreparedness, as it might not be readily apparent what chemical or pathogen has caused thesymptoms, nor what antidote will prove most effective. (17) The use of chemical or toxin weapons could generate a disproportionate public response because of a broad public perception that their use is akin to poisoning. According to experts, therehas long been fear of and antipathy towards the use of poison. It is especially frightening to thevictim, as the symptoms may seem to appear from nowhere. Poisons lacking an antidote may raiseconcerns further, as the victim perceives that there is no recourse or cure available. The dreadgenerated from the inability to control the situation, and oftentimes one's own bodily safety, iscommon to victims of chemical weapons, and multiplies anxieties related to these weapons' use. (18) Biological weapon use may evoke deep-seated concerns regarding epidemic disease and sickness. (19) Plagues have historical and religiousassociations, (20) and more recent epidemics havelefttheir mark on society. (21) Furthermore, victims ofdiseases that manifest symptoms externally, suchas smallpox, may enhance concerns with respect to contagion. Individuals infected by biologicalweapons may develop marked anxieties in response to the uncertainty of their medical treatmentoptions, health condition, and prognosis. (22) Trauma associated with being a victim of a biologicalattack may itself inhibit understanding and recovery from the illness. (23) Dread may also arise in thosewho have not been exposed, but fear that they may have. These anxieties may cause common eventsto take on new negative meanings. For example, during the anthrax mailings, there were manyreports regarding white powders found at people's workplaces which were forwarded to lawenforcement authorities; the vast majority were not anthrax related. (24) Because of heightened individual health anxieties about chemical, biological and toxin weapons, some have suggested that their use could have the potential to result, at the extreme, inpanic. When sarin was introduced into the Tokyo subway system in 1995, over 5,500 people arrivedat hospitals requesting medical treatment, but only 1,051 people had medical symptoms indicativeof sarin exposure. (25) In the case of a widespreaddissemination of chemical or biological weapons,the number of people requesting treatment, and the difficulties involved in separating those withactual illness from those with panic-induced symptoms, could greatly complicate effective healthcareand possibly lead to greater public hysteria. Public panic might have weighty ramifications. If a chemical or biological weapon was disseminated widely, especially in the case of a contagious pathogen, there might be governmentintervention to quarantine individuals or groups of individuals. (26) Panicked flight from areas ofperceived danger could complicate response efforts. Additionally, due to the newsworthy aspectsof a chemical, biological, and toxin weapon attack, public panic could propagate through mediareports to locations not affected by the attack. (27) While hysterical, widespread panic is cited as a potential public response to mass dissemination of a chemical, biological, or toxin weapon, it is not clear if this is a likely outcome. The loss ofpublic confidence and angry, perhaps violent, competition for medical treatment have been suggestedas possible results from a chemical or biological weapon attack. (28) On the other hand, public responseafter natural disasters has not generally led to public hysteria or unreasoned aggression, even whenthere has been significant anger directed towards government officials. (29) In previous crises, publicanxiety has been successfully reduced by government response. Federal policymakers have addressed reducing terrorist use of chemical, biological, and toxin weapons through programs ameliorating these weapons' destructive aspects and through increasedvigilance in detecting and preventing terror attacks in general. Local response to terrorist attack hasbeen further developed through federal programs providing state health departments grant-basedfunding in order to address vulnerable aspects of their response system. (30) These improvementsinclude further development of hospital and laboratory capacity; development of response networksfor timely communication during a bioterror event; development of protocols for communicatingbetween local, state, and federal responders; and improved education of physicians and health careproviders. A concerted federal effort is underway to develop emergency reserves of medicines tocombat chemical, biological, and toxin casualties. Additionally, research proposals have beenfunded in the areas of detection systems and enhanced epidemiological surveillance, to detectchemical, biological, or toxin use as early as possible. (31) Federal law enforcement agencies now have greater power to gather intelligence on terror groups and their members. (32) Increasedinformation about terrorist groups, combined withapprehension of any who have chemical, biological, or toxin weapons, may provide further barriersto terrorist acquisition and use of these weapons. (33) A registration system for researchers andfacilities possessing select agents (34) has beendeveloped by the Department of Health and HumanServices, and additional restrictions regarding access to these agents have been made law. (35) On November 25, 2002, President Bush signed into law the Homeland Security Act of 2002 ( P.L. 107-296 ). This act created the Department of Homeland Security (DHS), which has theprimary mission of preventing terrorist attacks in the United States, reducing national terrorismvulnerability, and minimizing damage and aiding in recovery from attacks. DHS coordinates federalpreparedness and response to chemical and biological terrorism, the latter in conjunction with theDepartment of Health and Human Services. DHS has extended grants to local first responders toincrease local preparedness against chemical or biological weapons use, (36) and also has established,through the Science and Technology directorate, its own programs for funding research into chemicaland biological defense. (37) The DHS has alsodeveloped and deployed the Bio-Watch program, whichaims to detect releases of biological weapons in urban areas. (38) Professional societies and non-governmental organizations are also involved in exploring ways to lessen the likelihood of chemical, biological, and toxin weapon use. Selected examples showingthe range of activities addressing chemical, biological, and toxin weapons are provided here. The National Academy of Sciences has completed projects related to chemical, biological, and toxin based terrorism. In addition to convening a Committee on Science and Technology forCountering Terrorism and publishing a document outlining its recommendations, (39) the Institute ofMedicine's Board on Neuroscience and Behavioral Health has issued a report on the psychologicalconsequences of terrorism. (40) Projects include anad hoc committee studying advanced biotechnologystandards and practices (41) and the developmentof a robust, "adaptive" methodology for prioritizingvulnerabilities to terrorism by the National Academy of Engineering. The American Association for the Advancement of Science haveaddressed the issues of risk analysis and communication and public health preparedness in a bioterror context. The AmericanPsychological Association has established a Subcommittee on Psychology's Response to Terrorismto aid in coordinating psychology's multifaceted response to terrorism, including coping with thethreat of terrorism. These efforts attempt to develop strategies to prepare for or deter the use of terrorweapons. Many think tanks have addressed the concerns that chemical, biological, and toxin weapons present to civilians. The Brookings Institution has held a series of forums on America's responseto terrorism. (42) The Cato Institute has heldbriefings and provided policy suggestions on bioterrorism,with an emphasis on the debate surrounding smallpox vaccination policy. (43) The Heritage Foundationhas held briefings and provided policy suggestions on weapons of mass destruction. (44) Below are some policy options which may reduce the impact of a chemical, biological, or toxinterrorist attack. These include preventing terrorist attacks by increasing the difficulty of chemical,biological, and toxin weapon production; developing countermeasures through directed public healthfunding' reducing public concern by enhancing public preparedness through outreach efforts; andaddressing how the media reports on acts of chemical, biological, and toxin terrorism. Barriers to chemical, biological, and toxin-related terrorism within the United States may be strengthened by further legislation. One option to increase such barriers would be to address thedevelopment and production of chemical, biological, and toxin weapons. This might entailincreasing the difficulty of obtaining these weapons by decreasing the ease with which "dual-use"equipment is acquired, either by regulating its domestic sale or through registering owners of suchequipment, through a mechanism similar to that for select agents. However, this may have anadverse economic impact on those industries with legitimate need for this equipment, such as thechemical, pharmaceutical, and health industries. (45) One suggestion would be to continue increased funding to the public health system and law enforcement, in order to provide greater hospital capacity, trained medical and mental healthpersonnel, increased screening and surveillance, and sufficient equipment in the case of a chemical,biological, or toxin terrorist attack. It has been suggested that continued spending on the order of$10 to $30 billion per year would provide sufficient depth of response to reduce a chemical,biological, or toxin attack's effectiveness. (46) Onthe other hand, some contend that the risk of terroristattack is so small that money would be better spent on other safety programs, such as highwaysafety. (47) Another option to address the threat of chemical, biological, and toxin weapons is through the development of new antibiotic, antiviral, or antitoxin medicines. While many agents of concern havean acknowledged treatment, many can be improved to have higher efficacy. Alternately, furtherinvestment in new vaccines or other methods to induce immunity might provide significantdeterrence to terrorist groups planning to use such a weapon. Critics of this approach have suggestedthat developing treatments for specific agents does not lower the overall threat of chemical,biological, or toxin attacks, but would rather force a terrorist to choose a different agent. Someexperts urge that new, broad-based methods to develop resistance against a wide variety of agentsmust be developed. (48) In the 2003 State of the Union address, President Bush announced a new program designed to increase the availability of countermeasures against terror agents. This program, called ProjectBioShield, would provide a government-guaranteed market for manufacturers of countermeasureswhich lack broader applicability. (49) The ProjectBioshield Act of 2004 ( P.L. 108-276 ) was signedinto law on July 21, 2004. It provides expedited procedures for bioterrorism-related procurement,hiring, and awarding of research grants, and authorizes the appropriation of up to $5.593 billion totalfor FY2004 to FY2013 to purchase countermeasures against terror agents. Project Bioshieldappropriations of $5.593 billion total for FY2004 to FY2013 were provided in the Department ofHomeland Security (DHS) Appropriations Act, 2004 ( P.L. 108-90 ). By addressing specific aspects of chemical, biological, and toxin weapons that exacerbate public fears, the federal government may also decrease the usefulness of these weapons to terrorists. The enhanced impact, relative to conventional weapons, of chemical, biological, and toxin weaponsmight be decreased if the dread felt when considering their effects could be reduced. (50) If thisenhanced impact could be successfully reduced, there might be less advantage to using theseweapons rather than conventional weapons. One possible approach for reducing the terror impact of these weapons is public outreach to convey the likely risks and relative dangers chemical, biological, and toxin weapons pose comparedto other commonly encountered threats. Further outreach by public health agencies, on either thestate or federal level, providing practical information regarding the emergency measures andtreatments available in the case of such an attack might further reduce public concerns that mayexist. (51) People facing potential chemical orbiological weapon exposure might feel that they hadsufficient understanding prior to exposure, and therefore could make rational choices regarding theirsituation. For example, treatment options and regimens might already be known to victims, andthose victims might feel greater control over events, lessening their personal anxiety. As part of theCenters for Disease Control and Prevention's efforts in bioterrorism preparedness, communicationsuch as community outreach and educational efforts are supported. Some contend that open debate and flow of information regarding chemical and biological terrorism threats lessens the terror aspects of these weapons. (52) Advocates of such information flowsuggest that pre-event preparation and education will likely reduce casualties and minimize anxietyor panic following an attack. On the other hand, some have argued that an informational campaign,while decreasing the psychological effect post-exposure, may increase general, day-to-day anxiety. (53) These critics argue that information not presented in the proper context may be counter-productiveto attempts to reassure the public. For example, the efforts of the Federal Civil DefenseAdministration campaign of public relations and educational programs to prepare the population forthe possibility of nuclear war in the 1950s may have increased daily anxiety levels while preparingthe population. Also, the success of public outreach plans may be difficult to gauge. TheGovernment Accountability Office has recently reviewed several programs containing publicoutreach components and highlighted the difficulties in assessing outreach effectiveness. (54) The DHS began a public outreach campaign in February 2003, focusing on civilian preparedness in the case of terrorist attack, including the use of weapons of mass destruction. (55) Thiscampaign includes print and broadcast public-service announcements, a website (www.ready.gov),and a toll-free advice number (1-800-BE READY), as well as mailed information and billboards. (56) The initial outreach efforts of this campaign, called the "Ready Campaign," included advice forpreparing homes in case of a chemical or biological attack. This advice, which included suggestedpurchases of duct tape and plastic, garnered a mixed reception, with some suggesting that otheractions might have a higher priority (57) and othersbeing dismissive of the advice provided. (58) Theseefforts were criticized for heightening anxiety and providing disaster information without context, (59) and for presenting a mixed message of higher public awareness coupled with suggestions that thepublic should not take specific actions. (60) Others,while acknowledging that a greater effort to clearlypresent such advice might be required, maintained the value of such public informationdissemination. (61) DHS, in cooperation with theAlfred P. Sloan Foundation and the Ad Council, havedeveloped a series of television and print advertisements, in addition to their other outreach efforts. The success of this outreach program will be evaluated by the Ad Council through surveying publicresponse, but initial use of the website and toll-free number have been high. (62) Other privately fundedstudies have indicated that the outreach program had not provided a clear conceptual message. (63) The U.S. Department of Education has recommended to local school systems that a crisis plan be developed in order to prepare for potential terrorist events, including those using chemical orbiological agents. The Department of Education has published a guide to aid communities indeveloping their plan (64) and, in conjunction withDHS, has launched a new section of the Departmentof Education website dedicated to providing a central location for school emergency planning. (65) Some local school systems have developed "shelter-in-place" plans in case of large-scale biologicalor chemical attack. (66) Another proposal for lessening the impact of chemical, biological, and toxin weapons' terror aspect considers the presentation of information during a chemical, biological, and toxin weaponevent. By providing accurate, reliable information during a terror event, public confidence may bebolstered, significantly reducing the terror impact. Some media sources were criticized forpresenting the public with incorrect, contradictory, or incomplete information during the anthraxmailings. (67) Some have voiced concern that themedia reporting of events provides a confusingmixture of opinion and fact, potentially misleading viewers as to their potential role. (68) Thecombination of potentially faulty advice and varied expert opinion may have confused the publicabout what the "right" actions to maximize safety were. (69) The National Academy of Sciencesadvocates developing a voluntary media code regarding coverage of such attacks, to ensure accuratereporting, (70) and other groups also are exploringthe role of media reporting and terrorism. (71) Someeditors additionally advocate a more restrained approach to reporting on homeland security andterrorism related news. (72) In the108th Congress, the House Select Committee on Homeland Securityheld a hearing exploring the different approaches and efforts developed by media organizations toprovide a balance between protecting homeland security and providing necessary information to thepublic. (73) In an effort to provide accurate and timely expert information, the Centers for Disease Control and Prevention has established a website providing information to those interested in likelybiological, chemical, and radiological weapons. (74) In addition to providing information for thegeneral public, they also provide more detailed information for public health, clinical, and laboratoryworkers. Some have questioned what mechanism will be used to provide the public withauthoritative, official information after a biological or chemical attack. (75) Policymakers may wishto further review how to best disseminate information before, during, and after a terrorist attack. (76)

Summary:
The catastrophic terrorist attack of September 11, 2001 and the subsequent anthrax mailings have sensitized the nation to acts of domestic terror. The confirmation of terrorist interest inweapons of mass destruction and the vulnerability of the United States to such attack havehighlighted the potential that these weapons may be used as weapons of terror. The framework ofweapons of mass destruction (WMD) includes chemical, biological, and toxin weapons. Chemical, biological, and toxin weapons can produce mass casualties if effectively disseminated, but have varying and different effects. Chemical weapons, predominantly man-madechemicals, require the largest amounts of material to be effective and cause their effects in minutesto hours. Biological weapons made of naturally occurring pathogens require the least material to beeffective, but generally have an incubation period of several days before symptoms show themselves. Toxin weapons, such as ricin, chemical agents formed by biological processes, are intermediatebetween the two in both amount and timescale. Treatment protocols for chemical, biological, andtoxin weapons vary by agent, ranging from weapons with effective treatment and prophylaxis toweapons which have no known cure nor protection. Chemical, biological, and toxin weapons pose additional concerns beyond mass casualties. These weapons may contaminate the area in which they are used, emergency vehicles, and firstresponders. The wide array of potential symptoms from chemical, biological, and toxin weaponsmakes identification of the causal agent difficult and complicates treatment. Additionally, publicfears relating to disease and poisoning could increase the effect of a chemical, biological, or toxinattack, as worried, unexposed people request treatment from medical facilities. In extreme cases,public hysteria has been postulated as an outcome from mass dissemination. Several initiatives are underway to reduce the potential value of chemical, biological, and toxin weapons. One approach has been through funding significant increases in the public health system'spreparedness and response capacity. Additionally, facilities and researchers possessing "selectagents" have been registered in a national database. Non-governmental agencies, such as theNational Academy of Sciences, and professional societies have also been active in developingpolicies and options to lower the threat of terrorist attack. Potential options to further decrease the odds of chemical, biological, and toxin terrorism include regulating and registering domestic purchase of "dual-use" equipment; further developmentof the public health system; federal incentives for research and development into chemical,biological, and toxin medicines, vaccines, countermeasures and detectors; informational publicoutreach programs to properly inform the public about the risks involved; and voluntary mediacodes. This report will be updated as circumstances warrant.