Terrorism

Chemical, Biological and Other Weapons of Mass Destruction and the implications to medical response personnel

1978 Bonn Summit

Called as a result of increased Airline hijacking

Terrorism is the act of kidnapping, hostage-taking, bomb attacks on innocents, hijacking or the assassination while being a political tool

Terrorism

The intentional use of threat of politically, socially, economically, or religiously-motivated violence initiated by a non-state or state-sponsored organization in whichthe Proximate Target is exploited, injured, or destroyed so as to influence a separate, distinct Principal Target

Title 22 of the United States Code, Section 2656f(d)

terrorism: premeditated, politically motivated violence perpetrated against noncombatant targets by sub-national groups or clandestine agents, usually intended to influence an audience

international terrorism: terrorism involving citizens or the territory of more than one country

terrorist group: any group practicing, or that has significant subgroups that practice terrorism

FBI definition of terrorism

the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives

Dept of Defense Definition of Terrorism

the calculated use of violence or the threat of violence to inculcate fear; intended to coerce or to intimidate governments or societies in the pursuit of goals that are generally political, religious, or ideological

Other Forms of Terrorism

Religious Terrorism based on intolerance or racial,

ethnic and religious differences EcoTerrorism

any crime committed in the name of saving natureTree spiking, Tire studs, etc.

Computer / Electronic Terrorism Any crime committed against a

computer / information system with the intent to cause havoc

Weapons of Mass Destruction

The weaponization of nuclear, biological or chemical (NBC) agents and the manipulation of computers or other technological devices so as to cause death, destruction, and infrastructure disruption of a principal target

History of terrorism

Before the 19th Century Frequently, terrorism was incidental to other forms of

violence, such as war or insurgency terrorists usually granted certain categories of people

immunity from attack. Like other warriors, terrorists recognized innocents radicals planning the assassination of Tsar Alexander II aborted several

planned attacks because they risked harming innocent people

Early Chem/Bio terrorist acts 423 B.C.: allies of Sparta in the Peloponnesian War took an Athenian-

held fort by directing smoke from lighted coals, sulfur, and pitch through a hollowed-out beam into the fort

Catapulting of bodies infected with plague into cities under siege British colonialists giving the American Indians blankets infected with

Smallpox

Traditional terrorism (pre-1990’s)

Constrained or modulated violence, usually against a political leader

Committed to gain attentionTerrorists unwilling to cause mass casualties.

Could backfire by losing popular support and by unleashing governmental forces that could wipe out the group

The act itself is a means to gain attention to spotlight grievances so terrorists usually identify themselves

Post-Modern Terrorist (1990s +)

Oftentimes with a religious foundation. Could lead to copy-cat secular terrorism

No distinction between proximate and principal targets

To kill en-masse to please God and comrades becomes an end in itself

Usually silent, anonymous Easy access to material, funds,

and technical expertise to develop a WMD

The sophisticated terrorist knows:

the death of a single individual, even a monarch, doesn’t necessarily produce policy changes

attack people previously considered innocents to generate political pressure

indirect attacks create a public atmosphere of anxiety and undermine confidence in government. Their unpredictability and apparent randomness make it virtually impossible for governments to protect all potential victims. The public demands protection that the state cannot give. Frustrated and fearful, the people then demand that the government make concessions to stop the attacks

Facilitators for significant acts of Terrorism

Break-up of the USSR and the resulting imbalance of world power as well as the termination of the usual checks and balances existing during the Cold War

Mushrooming of a weapons black market throughout the world

Desire for and unwillingness to modify individual and societal freedoms. Augments terrorist’s ability to learn, travel, act, and escape

Urbanization-Industrialization: A plethora of random targets all within reach of terrorists and with limited security measures

Diffusion of Technology: The terrorist has access to media and other educational modalities that can enhance the development and utilization of tactical and strategic weapons

Theories of Terrorism

Political: To advance a group’s vision of a better world in timely manner

Individual Psychological: Terrorists suffer from incomplete psychosocial identities which lead them to affiliate with similar sociopath and to blame their own inadequacies on society

Group Psychological: The longer a group is in existence, the need to keep and maintain its solidarity will supercede the initial primary mission

More acute now- why?

Media proliferation and trying to “make news”

Knowledge of foreign threats in other countries

Awareness of a lack of protection and vulnerability

Greater ability to cause mass casualties: population density

American psyche unprepared

Examples of some Foreign and Domestic Terrorism

Aum Shinrikyo Cult

Worldwide cult responsible for the 3/20/95 sarin attack in Tokyo, Japan. Also known to have been working on weaponizing anthrax and botulinum toxin. Once tried to disseminate anthrax spores from the roof of a building but wind currents rendered the operation useless. Tested Sarin on a sheep farm in Australia. Also attacked Matsumoto 6/27/94, Yokohama (3/6/96) and leak in SATAYAM 7 - Kamakuishiki (7/14/94) and suspected of the Tokyo briefcase duds on 3/15/95

Hizballah

A Lebanese Shi’ite group created in 1983 whose main objective is the creation of an independent, Islamic Lebanon. Its military wing, The Islamic Resistance Movement, has been implicated in a series of bombings (e.g. U.S. Marine barracks, 1983) as well as rocket attacks on Jewish settlements. Synonyms: Party of God, Islamic Jihad.

Conventional Weapons Chemicals

Blood agents (Poisons / Toxins) - Cyanide, Ricin

Blistering / Choking Agents - WWI - Chlorine gas, sulphur mustard (HD), nitrogen mustard (HN), the arsenical vesicants such as lewisite

Nerve Agents - Tabun, Sarin, VX, Pesticides (malathione)

Terrorist Weapons

Biologicals Anthrax, Brucellosis,

Botulism, Plague, Q-fever, Tularemia

Closer to home

World Trade CenterOklahoma City (Murrah Building)Anthrax Scare in Las Vegas

Chemical Weapons Classifications

Lethal The dose causes death

Incapacitating less than 1/100 of

the lethal dose causes incapacitation

through nausea, visual or GI problems

Chemical weapon classifications (cont.)

Harassing - Tear gas in schools & movie theaters

Also classified as Volatile(evaporate and contaminate the air) and Persistent (cover surfaces) Volatile / Non-Persistent: disperse

rapidly and short duration - airborne particles absorbed through inhalation

Persistent: Slowly vaporize due to thickening agents - contact hazard

To be considered for a weapon:

The agent must not only be highly toxic but also "suitably highly toxic" so that it is not too difficult to handle

The substance must be capable of being stored for long periods in containers without degradation and without corroding the packaging material It must be relatively

resistant to atmospheric water and oxygen so that it does not lose effect when dispersed

It must also withstand the heat developed when dispersed (ie: explosive dispersal: rides the shock wave, not burned up in the explosion as commonly thought

Factors that alter a chemical weapon’s effectiveness

Effectiveness Effectiveness is the

capacity of an agent to produce the maximum number of casualties or amount of disruption of operations with the least amount of agent

Physical & chemical properties of the agent as well as meteorological conditions

Gaseous molecules are well behaved and have a high rate of diffusion Rate of droplet

evaporation dependent on particle size, number density, heat of vaporization

Winds, Temperature, Rain, Atmospheric Stability (inversion layer)

Outside: winds, solar heating and a large volume to diffuse to - therefore, not as effective

Inside: barriers, forced air currents, finite source of air, little dilution concentration remains lethal longer,

accumulated dosage increases, lethality efficiency increases

Poor man’s atomic bomb

for a large-scale operation against a civilian population, casualties might cost $2,000 per square kilometer with conventional

weapons $800 with nuclear weapons $600 with nerve-gas weapons $1 with biological weapons

CIA report "concluded that 'clandestine production of [chemical and biological weapons] for multiple casualty attacks raises no greater technical obstacles than does the clandestine production of chemical narcotics or heroin"

Dispersal of chemical weapon

droplets must be sufficiently large to ensure that they fall within the target area and do not get transported elsewhere by the wind increase; thus

complicates decontamination.

achieved by dissolving polymers (e.g., polystyrene or rubber products) in the CW agent to make the product highly-viscous or thickened

persistence time and adhesive ability

Poisons / Toxins

Cyanide, Hydrogen Cyanide, Cyanogen, Ricin

Ricin

Ricin is a protein toxin which acts as a cellular poison and is readily produced from castor beans (Ricinus communis), which are ubiquitous throughout the world

Waste from the commercial production of castor oil contains 5% ricin, making it easy for such a substance to fall into the hands of terrorists

6000 times more toxic than cyanide and with no antidote

Ricin (cont.)

toxic by numerous exposure routes its use by belligerents

might involve poisoning of water or foodstuffs, inoculation via ricin-laced projectiles, or aerosolization of liquid ricin or lyophilized powder.

History of Ricin

This toxin has been used in the past to assassinate political enemies and is considered a useful weapon for terrorists

In Minnesota, 1992, 4 members of the Minnesota Patriots Council militia mixed ricin and a solvent with the intent of smearing the concoction on doors and steering wheels in order to assassinate a deputy U.S. marshall and a sheriff who had served tax violation papers on 1 of them. They had enough of the toxic agent to kill 125 people. The 4 members were the first to be convicted under the Biological Weapons Antiterrorism Act (1989)

Clinical features of Ricin exposure

When inhaled as a small particle aerosol, ricin would likely produce symptoms within 8 hours

Fever, cough, dyspnea, nausea, and chest tightness are followed by profuse sweating, the development of pulmonary edema, cyanosis, hypotension, and finally respiratory failure and circulatory collapse

Time to death would likely be 36-72 hours, depending on the dose received

Diagnosis of Ricin exposure

Naturally-occurring cases of ricin intoxication involve ingestion of castor beans, and are marked by severe gastrointestinal symptoms, vascular collapse, and death

The diagnosis of ricin intoxication is largely clinical and should be suspected in a setting of mass casualties with a similar and appropriate clinical picture

Failure to respond to antibiotics helps to differentiate ricin exposure from pulmonary infections produced by bacterial agents

An ELISA exists and may be performed on paired acute and convalescent sera

Treatment of Ricin Exposure

No specific treatment exists, and care is thus supportive. In cases of gastrointestinal exposure, gut decontamination via lavage, activated charcoal, and cathartics is warranted

Large amounts of volume replacement may be necessary

Ricin Treatment (Cont.)

Prophylaxis: A protective mask offers protection from aerosol exposure, but no specific vaccine or antitoxin exists

Decontamination and Isolation: Ricin may be inactivated with 0.5% hypochlorite. Since it is not dermally active and is involatile, decontamination may not be as critical as with certain other biological and chemical agents

Outbreak Control: Ricin does not, in general, pose a risk of secondary aerosolization

Cyanide

A poison that rapidly deactivates the cellular metabolism throughout the body. Within 30 seconds of inhalation, a victim loses consciousness, seizes, becomes apneic, and within 8 minutes is in cardiac arrest. Treatment must be prompt and consists of inhalation of amyl nitrite and i.v. administration of sodium nitrite and sodium thiosulfate

Hydrogen cyanide

A highly toxic agent that causes general poisoning and rapid death. It is a colorless, odorless liquid that is highly volatile. It can be absorbed by the skin or by inhalation. Treatment is based on hastening the body’s ability to excrete it.

Vesicant / Blistering Agents / Choking Agents

Lewisite, Mustard, Phosgene, Chlorine, Chloropricin

Mustard

Chemicals that are characterized by the blistering that occurs on exposed skin, eyes, respiratory membranes, and internal organs. The onset of symptoms may be delayed up to 2-24 hours from exposure. Treatment is symptomatic.

Used during WWI & IIUsed during the 1978 Iranian War

Effects of Blister Agents

Vesicants burn and blister the skin or any other part of the body they contact. They act on the eyes, mucous membranes, lungs, skin and blood-forming organs. They damage the respiratory tract when inhaled and cause vomiting and diarrhea when ingested

Exposure to mustard is not always noticed immediately because of the latent and sign-free period that may occur after skin exposure. This may result in delayed decontamination or failure to decontaminate at all

Within 2 minutes contact time, a drop of mustard on the skin can cause serious damage

Protection

Ordinary clothing gives little or no protection against mustard agents

Special equipment including a respirator, NBC suit, gloves and over-boots are required

Due to slow absorption of mustard by many materials, protective equipment must be changed regularly

No drug is available for the prevention of the effects of mustard on the skin and the mucous membranes

It is possible to protect the skin against very low doses of mustard by covering it with a paste containing a chlorinating agent, e.g., chloramine

The only practical prophylactic method is physical protection such as is given by the protective respirator and special clothing

Blistering Agent Decontamination

Decontamination

The importance of early decontamination can not be over emphasized. Decontamination of the skin should be accomplished quickly if it is to be fully effective. Liquid agent may be removed by `fullers’ earth or chemically inactivated by the use of reactive decontaminants.

Decontamination personnel should use a respirator and full protective equipment whilst decontamination is performed

Once a casualty has been decontaminated, or the agent fully absorbed, no further risk of contamination exists. The casualty's body fluids, urine or feces do not present

a chemical warfare (CW) hazard

Decontamination of the Skin

Absorbent powders to pull agent from the skin

Chemical inactivation by chlorinating compounds incorporated into adsorbing powders, ointments, solutions or organic solvents

Mustards should not be decontaminated with water, except for the eyes, as this may spread the agent

Decontamination of Mucous Membranes and Eyes

The substances used for skin decontamination are generally too strongly irritant to be used on mucous membranes and the eyes. In this case the affected tissues should be flushed immediately with water. The eyes can be flushed with copious amounts of water, or, if available, isotonic sodium bicarbonate (1.26%) or 0.9% saline

Decontamination of Wounds

Mustard may be carried into wounds on fragments of cloth. These wounds should be carefully explored using a no-touch technique. Fragments of cloth should be removed and placed in a bleach solution. This removes the hazard from mustard vapor off-gassing

Wounds should be irrigated using a solution containing 3000-5000 ppm (parts per million) free chlorine (dilute "milton" solution) with a dwell time of approximately 2 minutes. The wound should then be irrigated with saline. Irrigation of the contaminated wound should not be used in the abdominal, or thoracic cavities, nor with intracranial head injuries.

Additional Procedures

Whatever means is used has to be efficient and quick acting. Chemical inactivation using chlorination is effective against mustard and Lewisite, less so against HN3, and is ineffective against phosgene oxime. In the case of thickened mustard, where the usual procedure is inadequate, the agent may be scraped off with a knife or similar hard object. This may be followed by wetting the surface with a cloth drenched in an organic solvent, e.g.,petrol (unleaded gasoline) and subsequent application of the usual decontaminating procedure. If water is available in abundant amounts these procedures should be followed by copious washing

Nerve Agents

GA (Tabun), GB (Sarin), GD (Soman), GF and VX (methylphosphonothioic acid).

The nerve agents

Developed just before and during World War II as German scientists were developing insecticides thus are related chemically to the organophosphorus insecticides.

produce toxicity due to cholinergic overdive at Muscarinic, Nicotinic and CNS cholinergic sites. to inhibition of the acetylcholinesterase enzyme with accumulation of acetylcholine and excessive stimulation In the pure state nerve agents are colorless and mobile liquids. In an impure state nerve agents may be encountered as yellowish to brown liquids. Some nerve agents have a faint fruity odor

OTC agents used as pesticides: malathion, parathion (distilled to make stronger)

Effects of Nerve Agents

MUSCARINIC EFFECTS: Sweating, salivation, increased bronchial secretions, miosis, bradycardia, hypotension, vomiting and diarrhea, bronchoconstriction, and urinary and fecal incontinence

NICOTINIC EFFECTS: Fasciculations and weakness of muscles (including the diaphragm), tachycardia, hypertension, and mydriasis

CNS EFFECTS: Restlessness, anxiety, headaches, seizures and coma

Symptoms of mild exposure

Unexplained runny nose / Unexplained sudden headache / Sudden drooling

Difficulty in seeing (dimness of vision and miosis)

Tightness in the chest or difficulty in breathing

Localized sweating and muscular twitching in the area of the contaminated skin

Stomach cramps / Nausea / Bradycardia or tachycardia

Symptoms of a moderate exposure

most or all of the mild symptoms

increase in fatigue, weakness and muscle fasciculation

The progress of symptoms from mild to moderate indicates either inadequate treatment or continuing exposure to agent

Symptoms of severe exposure

May experience most or all of the mild symptoms

Strange or confused behavior Wheezing, dyspnea (severe

difficulty in breathing), and coughing

Severely pin-pointed pupils / red eyes with tearing

Vomiting / severe muscular twitching and general weakness

Involuntary urination and defecation / convulsions

Unconsciousness / respiratory failure / bradycardia

Protection

To prevent inhalation of an incapacitating or lethal dose it is essential that the breath is held and the respirator put on at the first warning of the presence, or suspected presence, of a nerve agent. The respirator protects the eyes, mouth and respiratory tract against nerve agent spray vapor and aerosol.

Normal clothing s penetrated by these agents whether contact is with liquid or vapor and specialized clothing including a respirator, nuclear, biological, and chemical (NBC) suit, gloves and overboots are required for protection when liquid agent is present.

Nerve agent vapor in field concentrations is absorbed through the skin very slowly, if at all, so that where a vapor hazard exists alone, the respirator may provide adequate protection without the use of an NBC suit.

Decontamination

Wash exposed surfaces with water at least 3 times. 1:10 Bleach solution or Ethanol more effective. Eyes rinsed with water for 15-20 minutes.

Towelettes carried by military personnel contain an alkaline chloramine and phenol mixture which can break down nerve agents

Potential for Secondary Contamination: HIGH before decontamination. LOW after decontamination if all nerve agent has been removed from the skin

Treatment

The lethal effects of nerve agent poisoning may be combated by a combination of pretreatment and post exposure therapy

Pre-exposure treatment

Carbamate anticholinesterases by virtue of their capacity to bind

acetylcholinesterase reversibly, preventing the organophosphate (OP) binding to the enzyme

However, the carbamate-acetylcholinesterase complex breaks down fairly rapidly, while organophosphate-acetylcholinesterase complexes break down very slowly. The aged soman-acetylcholinesterase complex breaks down virtually not at all

carbamate pyridostigmine, given in a dose of 30 mg every 8 hours

Post-exposure treatment (self treatment)

The rapid action of nerve agents call for immediate self treatment

IM/IV injection of 2-5 mg (child: 0.05mg/kg) of atropine (1mg for diagnostic dose) - Repeat doses every 10-30 minutes as needed. Continues infusions of 0.02 to 0.08 mg/kg/hr

Pralidoxime (2-PAM CL, Protopam) 1 to 2 g IV at 0.5 g/min, or mixed in 250 ml of NS and infused over 30 min. (CHILD: 25 to 50 mg/kg, diluted to a 5% concentration in NS and infused over 5 to 30 min.) Repeat dose once in 1 hour and then every 6-12 hours as required [or continuous 500mg/hr iv no more than 12 g /24hr]

Military Auto-Injectors

US military personnel carry 3 atropine (2 mg) and 3 pralidoxime chloride (600 mg) autoinjectors to be used concomitantly for initial field self- or buddy-treatment of nerve agent poisoning. A single diazepam autoinjector (10 mg) is also carried and used after the last atropine autoinjection to prevent seizures.

Biological Weapons

Intelligence experts believe that China, Libya, N. Korea and 13 other countries maintain biological weapon programs

Anthrax

A bacterial disease caused by B anthracis and considered a potent Biological weapon of Mass destruction

Transmitted to humans and animals through skin lesions, wounds, inhalation of its spores, or by ingestion of meat infected with the contagion. The anthrax spore which is the usual infective form can survive for decades even in an hostile environment ( heat, dryness, disinfectants)

There are 3 clinical presentations in humans: cutaneous, gastrointestinal, and inhalation (the most likely manifestation in a biological attack)

Infective Dose: 8,000-50,000 spores aerosolized

History of Anthrax

During the Midwest Floods of 1996, anthrax exposed cattle / horses which had been buried in the 1800’s were unearthed by the flood erosion

Weaponized by the US in the 1950s and 60s. Iraq admitted to the UN in 1995 it had weaponized anthrax. Over 8000 L of anthrax in 1980. Other countries are currently suspected of doing the same thing. For example, in the former Soviet Union, an accidental release of anthrax spores resulted in the deaths of 66 people

Clinical Features of Anthrax Exposure

Incubation period: 1-5 daysBiphasic pattern: Fever, weakness,

cough, dyspnea. Possible 2-3 day period of improvement followed by respiratory distress, stridor, cyanosis, bacteremia, hemorrhagic mediastinitis, sub-Q edema of neck and chest, septic shock, meningitis in ½ of cases leading to shock & death within 3 days

Diagnosis

Suspect in presence of rapidly developing mediastinitis with absence of pain, marked leukocytosis, and history of exposure; identification of B anthracis in pleural fluid confirms diagnosis

Treatment of Anthrax

Chemotherapy Ciprofloxin 400-750mg IV q 8-12h.

Doxycycline 100-200 mg IV then 100 mg IV q 8-12 h.

Penicillin 2 million units IV q 2h. + Streptomycin 30mg/kg IM qday.

Penicillin G: 50 mg/kg continuous IV drip in first hour, followed by 200 mg/kg/day or Erythromycin 1 to 4 g/day continuous IV drip.

Chemoprophylaxis

Ciprofloxacin 500mg bid x 4 wk. + initial doses of vaccine. Doxycycline 100mg bid x 4 wk. + vaccination

Vaccine: Michigan Biological Products Institute vaccine: 0.5mL SC @ 0,2,4 wk & 6, 12, 18 mos. & annually thereafter

Brucellosis

A bacterial disease of which 4 species, Brucella melitensis, B suis, B abortus, and B canis, are pathologic to man and have the potential of being a Biological Weapon of Mass Destruction

Infective Dose: 10-100 organisms by aerosol. Brucellae do not produce toxins or form spores. They are susceptible to heat and disinfectants, but they can survive up to 10 weeks in soil or water

Incubation Period: 5-60 days These macrophage parasites localize in organs with large

numbers of macrophages such as lung, liver, spleen, CNS, bone marrow, synovium. This distribution dictates the clinical manifestations

History of Brucellosis

The US weaponized B. suis in the 1940s and 50s; stopped in the 1960s. It is suspected that other countries currently have weaponized this bacterium. It can be delivered as a slurry in bomblets or as a dry aerosol

Clinical Features of Brucellosis

Fever, chills, malaise, Cough, pleuritic chest pain (20% of infected) Sacroiliitis, joint infections, vertebral osteomyelitis Genito-urinary infections, hepatitis, anemia, neutropenia, thrombocytopenia, Endocarditis & CNS infections (both rare, but account for most of the fatalities which is less than 5% of untreated patients. Systemic symptoms can last for months

Brucellosis Diagnosed by

Serum tube agglutination test, blood cultures, bone marrow cultures

Treatment of Brucellosis

Chemotherapy: Doxycycline 200mg/day + rifampin 600-900 mg/day for 6 weeks

Chemoprophylaxis: Doxycycline + rifampin x 3 weeks

No Vaccine

Botulism

A neurological disorder caused by any of 7 toxins produced by the bacterium, Clostridium botulinum which has the potential of becoming a Weapon of Mass Destruction

Infective dose: 0.001micrograms/kg aerosolized (Type A neurotoxin); 15,000 times more toxic than VX and 100,000 times more toxic than sarin

Incubation period: 1-5 daysActs by interruption of neurotransmission

History of Botulism

Iraq admitted to the UN in 1991 that it had performed research using botulinum toxin as an offensive weapon. It was revealed in 1995 that Iraq had filled and deployed over 100 munitions containing the toxin and had over 20,000 L. It is feasible that any or all of the 7 neurotoxins can be delivered in an aerosol attack or by sabotaging food supplies

Clinical features of Botulism

Blurred vision, diplopia, ptosis, photophobia, dysarthria, dysphonia, dysphagia (bulbar palsies) leading to symmetrical, descending, progressive weakness of the skeletal muscles leading to respiratory paralysis. Patient remains without fever and alert until the stage of respiratory failure begins

Treatment of Botulism

Chemotherapy: DOD heptavalent antitoxin (A-G)- investigational CDC Trivalent equine antitoxin (A, B, E)- licensed

No Chemoprophylaxis availableVaccine: DOD has a pentavalent

toxoid (A-E) that is investigational

Defense Against Weapons of Mass Destruction Act of 1997

A Federal law enacted by the US Congress which directs the President to enhance the Federal capabilities to mitigate, prepare for, and respond to terrorist incidents associated with weapons of mass destruction

Future Terrorism?

Future terrorism is likely to include higher than ever levels of violence. Hijackings, kidnappings, and drive-by shootings will continue, but their shock effect has decreased with familiarity. Since terrorists need publicity to inspire fear, familiarity causes them to seek more unusual events that capture and hold public attention.

While no one will challenge the United States on the conventional battlefield in the foreseeable future, terrorist acts are likely to be the preferred form for expressing hostility toward the remaining superpower.

Terrorism Research Center