Table 6.6 Epidemiologic Clues to Bioterrorism
1. Single case of disease caused by an uncommon agent (e.g., glanders, smallpox, viral hemorrhagic fever, inhalational or cutaneous anthrax) without adequate epidemiologic explanation
2. Unusual, atypical, genetically engineered, or antiquated strain of an agent (or antibiotic-resistance pattern)
3. Higher morbidity and mortality in association with a common disease or syndrome or failure of such patients to respond to usual therapy
4. Unusual disease presentation (e.g., inhalational anthrax or pneumonic plague)
5. Disease with an unusual geographic or seasonal distribution (e.g., tularemia in a non-endemic area, influenza in the summer)
6. Stable endemic disease with an unexplained increase in incidence (e.g., tularemia, plague)
7. Atypical disease transmission through aerosols, food, or water, in a mode suggesting deliberate sabotage (i.e., no other physical explanation)
8. No illness in persons who are not exposed to common ventilation systems (have separate closed ventilation systems) when illness is seen in persons in close proximity who have a common ventilation system
9. Several unusual or unexplained diseases coexisting in the same patient without any other explanation
10. Unusual illness that affects a large, disparate population (e.g., respiratory disease in a large population may suggest exposure to an inhalational pathogen or chemical agent)
11. Illness that is unusual (or atypical) for a given population or age group (e.g., outbreak of measles-like rash in adults)
12. Unusual pattern of death or illness among animals (which may be unexplained or attributed to an agent of bioterrorism) that precedes or accompanies illness or death in humans
13. Unusual pattern of death or illness among humans (which may be unexplained or attributed to an agent of bioterrorism) that precedes or accompanies illness or death in animals
14. Ill persons who seek treatment at about the same time (point source with compressed epidemic curve)
15. Similar genetic type among agents isolated from temporally or spatially distinct sources
16. Simultaneous clusters of similar illness in noncontiguous areas, domestic or foreign
17. Large number of cases of unexplained diseases or deaths