BIOTERRORISM

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Assault with a Chemical Weapon Its worse out
there than just Bioterrorism

• Frank Paloucek DABAT

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Biological warfare in history

• ???
• 6th Cent
• Romans
• 1346
• 1800s
• WWI
• 1933-45

• Feces-smeared arrows
• Assyrians poison wells with ergot
• Animal cadavers into well water
• Plague-dead corpses catapulted into Kaffa by
  Tartars
• British donate smallpox laden blankets
• Germans use zoonoses against livestock
• Japans Unit 731 kills 10,000 Chinese with
  plague, anthrax, dengue, tularemia

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Lord Jeffrey Amherst, July 1763re Pontiacs
rebellion
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In English

• You will do well to try to inoculate the Indians
  by means of blankets, as well as every other
  method that can serve to extirpate this execrable
  race

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Recent Biological Accidents or Terrorism

• 1978
• 1979
• 1984
• 1994
• 2000

• G. Markov killed by ricin in umbrella tip
• Leak of military anthrax spores outside of
  Sverdlosk 66 deaths
• 751 people poisoned with Salmonella in Dallas OR
  salad bars contaminated by local cult
• Aum Shinrikyu sprays botulism toxin twice and
  tries anthrax spore cloud
• 35 anthrax cases reported to FBI in US

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Anthrax History

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• 15-1700s
• 1979
• 1994
• 2001

• 5th and 6th plagues of Exodus
• Major livestock disease Europe
• Leak of military anthrax spores outside of
  Sverdlosk 66 deaths
• Aum Shinrikyu sprays botulism toxin twice and
  tries anthrax spore cloud
• 35 anthrax cases reported to FBI in US, 10,000
  receive 60 days of prophylaxis

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Anthrax

• Bacillus anthracis (Greek for coal)
• Called Black Bane in Middle Ages
• Major zoonosis ided in 1870 by R. Koch
• Ided as cause of Woolsorters Disease
  (specifically for inhalational disease )
• Successful immunization in 1880, Pasteurs
  vaccine developed in 1881
• Wild prevalent in Africa, Asia and anthrax
  belt of U.S. Midwest/Great Plains

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Human Infection

• Generally due to agricultural or industrial
  exposure
• Three forms
• Cutaneous (95) 2 in Texas 2001, 1 N.Dakota
• Gastrointestinal (lt1)
• Inhalational (5)
• 235 cases in U.S from 1955-1994, 20 fatalities.
  Since 1900, 18 inhalational, last 1978.
• Human-to-human transmission is not believed to
  occur

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Cutaneous anthrax

• Manifests 2-5 days post exposure
• Papule that over 1-2 days becomes vesicular,
  striking edema surrounding
• Vesicular fluid noteworthy for lack of
  neutrophils
• Pruritic, but not painful
• Ruptures after 5-7 days, the ulcer progress to
  black eschar that sloughs in 2-4 weeks
• Mild systemic symptoms
• Fatality if untreated 5-20

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Gastrointestinal anthrax

• Eating infected meat
• Begins 2-5 days later
• Severe abdominal pain, melena, ascites, profuse
  watery diarrhea
• Proliferation in mesenteric lymph nodes edema
  and hemorrhage usually fatal
• Oro-pharyngeal variant also, last outbreak 1982
  Thailand from contaminated water buffalo 3/24
  deaths.

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Inhalational Anthrax

• 1-6 day incubation
• Initial nonspecific flu-like syndrome fever
  nonproductive cough, myalgias, malaise
• Commonly, has transient resolution (while it has
  migrated and is proliferating in lymph nodes)
• Resumes with severe respiratory distress, shock
  and death lt 24hours
• Meninges frequently involved (50)

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Anthrax treatment

• Wild forms very sensitive to penicillin,
  ciprofloxacin, doxycycline. Evidence suggest
  streptomycin increases response to PCN
• Cutaneous treat with oral. GI and Inhalational
  with intravenous. (Cipro 400 q12 Doxy 100 q 12h
  and 1 or 2 of following Vanco, PCN, amp)
• Vaccine designed for cutaneous - 92 efficacy,
  35 reaction rate
• (in monkeys) Vaccination post-lethal aerosol
  inhalation exposure plus 30 days antibiotics
  90

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Sverdlosk

• Military grade anthrax spore aerosol leak. Cloud
  over 1.4 million inhabitant city.
• Covered-up by military, claimed GI disease.
• Post glasnost investigation 96 confirmed cases
  and 66 deaths.
• Interesting note- no cases under 24 yrs old.
• Cases followed classic air/wind spread and
  dispersion patterns.
• Aum Shinrikyo (1982) used attenuated
  (non-encapsulated) Tokyo some pet deaths only.

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Current U.S. bioterrorist event

• 22 cases that have met CDC case definition.
• No new cases since 11/7/01.
• 12 cutaneous, 10 inhalational 4 deaths
• Source is unknown for one case
• All 18 survivors have been treated and
  discharged.
• 32,000 have received prophylaxis. 490 have been
  surveyed for toxicity 95 (19) have reported
  head/neck swelling, SOB, difficulty breathing.

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National Pharmaceutical Stockpile

• Maintained by CDC
• Coordinated with selected metropolitan areas
• 12 separate 50 ton 12-hour PUSH Packages for
  anthrax, smallpox, plague, tularemia, botulinum
  toxin, and viral hemorrhagic fevers
• Followed by Vendor Managed Inventory materials

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Pharmacys Role

• Minimize hysteria
• Recognize patterns or outbreaks
• Be prepared for unexpected
• Antidotes and supportive therapies may be given
  in unusual doses or routes. Be pharmacovigilant
• Coordinate with public health officials
• Try to avoid hoarding phenomenon
• Check CDC website. Consult and interact with
  local Boards of Health

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Chemical Agents

• Vesicants
• Mustard compounds (WWI)
• Cellular Asphyxiants
• Cyanide gases
• Nerve agents
• Phosphoric acid derivative acetylcholinesterase
  inhibitors (Sarin, tabun, soman, VX)
• Organophosphates
• Pulmonary irritants unlikely for
  chemicoterrorism
• Coumarin treated shrapnel in Middle East

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Nerve agents

• None are gases liquids that vaporize or
  aerosols
• Lethal doses as low as 10 mg for organophosphorus
  compounds
• Death within 15 minutes
• Atropine and 2-PAM antidotes
• Tokyo subway attack with sarin most severe
  patients require lt8 mg atropine for systemic
  symptoms. Many require eye drops for ocular pain
• Blurred vision, cloud, underwater vision

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Most Recent ThreatRicin

• Most deadly plant derived toxin known
• From Castor Bean
• Cellular poison no known antidote
• Used by Eastern bloc espionage units in Cold
  War
• January 2003 Suspected Algerian terrorist cell
  arrested in flat (above a pharmacy) where traces
  of ricin found. Massive hunt for cache now in
  progress
• Food poisoning

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Bhopal
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Bhopal

• 12/3/84, Union Carbide pesticide plant
• Accident 40 metric tons methyl isocyanate
• 2000 deaths, 10,000 injuries 3 hours
• Gas dispersed along wind flow
• Slightly similar event in 8/85 WV hospitalized
  100 people
• EPA estimates 17/29 events in U.S. could have
  been worse

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Other forms of malicious poisoning

• Munchausen Syndrome by Proxy
• Child Abuse
• Elder Abuse
• Criminal Sedation/Disinhibition (Date-Rape)
• Homicide
• Profit
• Toxicomaniacs

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Munchausen Syndrome by Proxy

• Bleeding
• Seizures
• Respiratory arrest
• Sedation
• GI
• Fever/Infection
• Rash

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Date-Rape

• Dis-inhibitors (or Date Rape drugs)
• GHB, GBL, 1,4 BD
• Ruhypnol - flunitrazepam/ benzodiazepines
• Chloral Hydrate (history bar in Chicago)
• Scopolamine
• Ethanol
• Ketamine/PCP
• Imidazolines (Visine, Naphcon)