Bioterrorism

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Bioterrorism
Ian Britton - FreeFoto.com
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What is bioterrorism?
The intentional or threatened use of viruses,
bacteria, fungi, or toxins from living organisms
to produce death or disease in humans, animals,
or plants.
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Why Biological Attacks?

• Easy to obtain
• Inexpensive to produce
• Environmental stability
• Aerosol distribution
• Delayed recognition/response
• Perpetrators escape easily
• Susceptible population

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The use of biological weapons through history.

• 400 B.C. Archers dipped arrows into the manure,
  blood and rotting bodies.
• 14th Century Bodies of bubonic plague victims
  were catapulted over the walls of the city of
  Kaffa.
• 15th Century Spanish contaminated French wine
  with the blood of leprosy victims.
• 17th Century A Polish General put saliva from
  rabid dogs into hollow artillery spheres.
• 18th Century Smallpox blankets were given to
  American Indians.

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U.S. Biological Warfare Program

• Geneva Protocol developed in 1925
• U.S. offensive program in 1943
• U.S. defensive program in 1953
• U.S. program abandoned in 1969
• Biological Weapons Convention in 1972
• Geneva Convention Ratified in 1975

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History of Biological Agent Use/Possession in the
U.S.
1972
College students produced 30-40 kg of Salmonella
typhi with plans to release it into the water
supplies of major Midwestern cities.
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History of Biological Agent Use/Possession in the
U.S.
1984
Members of the Rajneesh cult sprayed Salmonella
on eight local salad bars in Oregon in an attempt
to influence a local election. They caused 715
cases of illness, but didnt alter the election
results.
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History of Biological Agent Use/Possession in the
U.S.
1992
Members of the Patriots Council plotted to kill
law enforcement officers using ricin placed on
the door knobs of their vehicles. The plot failed
because an informant notified authorities, and
the conspirators were arrested.
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History of Biological Agent Use/Possession in the
U.S.
1995
Larry Wayne Harris obtained Plague cultures
from ATCC and talked openly about their potential
for biological attacks. He was arrested and the
vials were recovered unopened.
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History of Biological Agent Use/Possession in the
U.S.
1996
A disgruntled med tech brought doughnuts spiked
with Shigella for her co-workers coffee break.
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History of Biological Agent Use/Possession in the
U.S.
2001

• Multiple anthrax attacks
• 22 cases ( 1 lab-acquired case)
• 11 inhalational cases
• 11 skin cases
• 5 deaths

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Agent Selection Considerations

• Catastrophic public health consequences
• Mass casualties which overwhelm medical systems
• High morbidity or mortality
• Contagious

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What are the main bioterrorist weapons?
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Biological Agents of Highest Concern

• Bacillus anthracis (Anthrax)
• Yersinia pestis (Plague)
• Francisella tularensis (Tularemia)
• Botulinum toxin (Botulism)
• Variola major (Smallpox)
• Filoviruses and Arenaviruses (Viral hemorrhagic
  fevers)

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Most of the information on what would happen in a
Bioterrorist attack is based on what we know
about the natural disease.
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Why These Agents?

• Can cause disease via aerosol route
• Organisms fairly stable in aerosol
• Susceptible civilian populations
• High morbidity and mortality
• Some with person-to-person transmission
  (smallpox, plague, VHF)
• Difficult to diagnose and/or treat
• Previous development for Biological Warfare

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3 Categories of Bioterrorist Agents
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Category A

• Easily transmitted
• Easily disseminated
• High mortality rate
• Potential for major public health impact
• Can cause public panic and social disruption
• Requires special action for public health
  preparedness

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Bacterial Agents - Category A

• Bacillus anthracis
• Yersinia pestis
• Francisella tularensis

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Category B

• Moderate morbidity
• Low mortality
• Require specific non-standard diagnostic capacity
• Moderately easy to distribute
• Requires enhanced disease surveillance

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Bacterial Agents - Category B

• Brucellosis - Brucella species
• Q Fever - Coxiella burnetii
• Psittacosis - Chlamydia psittaci

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Bacterial Agents - Category B continued

• Glanders - Burkholderia mallei
• Meliodiosis - Burkholderia pseudomallei
• Typhus fever - Rickettsia prowazekii

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Bacterial Agents - Category B continued

• Water Threats
• Cholera -Vibrio cholerae
• Cryptosporosis - Cryptosporidium parvum (PROTOZOA)

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Bacterial Agents - Category B continued

• Food Safety Threats
• Salmonella species
• Escherichia coli O157H7
• Shigella

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Category C

• Newly discovered disease
• Easily obtained
• Easy to make and distribute
• Potential for high morbidity and mortality

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Types of Bioterrorist Events

• Announced
• (Overt)
• Unannounced
• (Covert)

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Likely Scenarios

• Overt threat
• anthrax letters
• device, e.g. aerosol bomb, Heating Air
  conditioning systems release
• Covert release
• food or water contamination, aerosol release,
  surface contamination, zoonotic attack

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Covert vs. Overt Event

• Overt Covert
• Recognition early delayed
• Response early delayed
• Treatment early delayed
• Responders Traditional Health Care
  FirstResponders Workers

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Delivery Systems

• Air
• aerosol most effective dissemination method
• droplet size lt 10 µm, 1-5 µm optimal
• Food
• Water
• Skin and mucous membranes

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Step 1 in Preparing forBioterrorism
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Recognition of Biological Attack

• Environmental detection not feasible
• Onset of symptoms is delayed
• incubation periods range from days to weeks
• Symptoms may be nonspecific
• initial presentation mimics flu
• Symptoms may be acute
• incapacitation, paralysis, coma, death

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Maintain a high level of suspicion in a number of
clinical situations

• A rapidly increasing disease incidence in a
  normally healthy population
• An epidemic curve that rises and falls during a
  short period of time
• An unusual rise in the number of people seeking
  care, especially with fever, respiratory, or
  gastrointestinal complaints
• An endemic disease rapidly emerging at an
  uncharacteristic time or in an unusual pattern

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• Lower attack rates among people who have been
  indoors, compared with people who have been
  outdoors
• Clusters of patients arriving from a single
  locale
• Large numbers of rapidly fatal cases
• Patient presenting with a disease that is
  relatively uncommon and has bioterrorism
  potential
• Concurrent reports of increased animal deaths
• Unusual age distribution
• Atypical disease presentations

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Step 2 in Preparing forBioterrorism
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Develop and use epidemiological tools

• Presence or lack of an appropriate exposure
  history
• Travel to a location that has high-consequence
  disease transmission
• Pathogens with unusual antimicrobial resistance
• Routine surveillance and disease-reporting
  mechanisms

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American Academy of Family Physician Suggestions

• Know how to contact local and state health
  departments.
• Maintain contacts with local health officials.
• Maintain reference materials on the diagnosis and
  treatment of agents of bioterrorism.

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• Develop a bioterrorism response plan for your
  office. Be prepared to use infection control
  practices.
• Know the requirements for laboratory support.
• Be aware of proper post-exposure management for
  patients and health care staff.
• Develop skills in and resources for counseling
  patients to minimize the psychologic consequences.

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Clinical and microbiological characteristics
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Fear is the enemy.

• Know which of the biological warfare agents occur
  naturally in your area.
• If a biological attack is identified, keep a calm
  face.
• Remind people not to rush to the hospital or
  Doctors office.
• Help family members understand the facts.
• Do not let the news media and sensational
  reporting distract from accurate information.

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Since the 9/11 attacks, the federal government
has spent about 50 billion to improve the way
it detects and responds to biological threats.
But progress has been limited, and some security
experts say the threat is greater than it was.
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Scenario

• On April 1, 2008 a 20 year old male student from
  the University of North Carolina comes home to
  visit his family in Cayce.
• While he is home he develops a fever. This
  rapidly progressed to shortness of breath, chest
  pain, dry cough, headache, chills and rigors,
  generalized body aches (in the low back), coryza,
  and sore throat
• On April 5th his mother takes him to the E.R.
  With sever shortness of breath, chest pain and
  dry cough.
• Findings on clinical examination -
  undifferentiated febrile illness with incipient
  pneumonia, pleuritis, and hilar lymphadenopathy.

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• This was 3 days after the NCAA basketball
  tournament sweet 16 in Charlotte.
• What do you look for? Which organisms could it
  be and what additional information would you
  need? Who do you contact?
• Unusual respiratory disease in its early stages,
  could be difficult to distinguish from a natural
  outbreak of community-acquired infection,
  especially influenza or various atypical
  pneumonias.

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• Tularemia would be expected to have a slower
  progression of illness and a lower case-fatality
  rate than either inhalational plague or anthrax.
• Plague would most likely progress very rapidly to
  severe pneumonia, with copious watery or purulent
  sputum production, hemoptysis, respiratory
  insufficiency, sepsis, and shock.
• Inhalational anthrax would be differentiated by
  its characteristic radiological findings of
  prominent symmetric mediastinal widening and
  absence of bronchopneumonia.
• Anthrax patients would be expected to develop
  fulminating, toxic, and fatal illness despite
  antibiotic treatment.
• Milder forms of inhalational tularemia could be
  clinically indistinguishable from Q fever
  establishing a diagnosis of either would be
  problematic without reference laboratory testing.
  
• Presumptive laboratory diagnoses of plague or
  anthrax would be expected to be made relatively
  quickly, although microbiological confirmation
  could take days. Isolation and identification of
  F tularensis using routine laboratory procedures
  could take several weeks.