Weapons of Mass Destruction

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• Weapons of Mass Destruction

Akram Sadaka, MD, MPH, FACPM
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Provider Assumptions

• This wont happen near my home
• Theyll die before I see them
• Specialists will be called in for any such events

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Provider Assumptions

• Theyll be decontaminated before they get to me
• They will not have any problems that apply to my
  field
• Ill have time to ask the experts for help
• There is no risk to me as a provider

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The Chem/Bio Threat

• Use in Conventional War
• Use in Operations Other Than War and Use by
  Terrorists
• Accidents in Manufacturing and Transportation

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The Chem/Bio Threat

• Healthcare Providers must
• be ready to deal with military and civilian
  casualties
• be aware of what constitutes a biological or
  chemical threat
• be fully knowledgeable in diagnosis and treatment
  
• understand they may be the first to recognize use
  of an agent and will be responsible for reporting
  this to the appropriate leaders

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Cost per square kilometer
JAMA 262644-648, 1989
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Lethality Comparison
Office of Technology Assessment, 1993
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Education About the Threat
Industrial accident
Hypothermia
Nuclear Attack
Chem/Bio Attack
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The Threat List

• Biological Agents
• Bacteria, Viruses, Toxins
• Chemical Agents
• Nerve Agents
• Vesicants
• Blood Agents,
• Lung Damaging Agents

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Recognizing a Biological Attack

• 1) Unusual disease in an area
• 2) Multiple diseases in one patient
• 3) Large number of casualties in both civilian
  and military population
• 4) Evidence of a mass point source outbreak
• 5) Illness is limited to localized geographic
  area

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Recognizing a Biological Attack

• 6) Low attack rates in people who are
  protected
• 7) Dead animals of multiple species in the
  area
• 8) Apparent aerosol route of infection
• 9) Evidence of munitions
• 10) Claims by aggressors

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Biological Threats

• Anthrax
• Plague
• Q Fever
• Tularemia
• Brucellosis

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Sverdlovsk Incident

• Sverdlovsk, (1.2 Million people) 1400 km east of
  Moscow, site of military microbiology facility
• Working on an B. Anthracis vaccine
• 2 April 1979 unplanned release of spores
• 96 Official cases of Human Anthrax with 66 dead
• Over 1000 unofficial cases plus livestock (50 km)

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Sverdlovsk Incident

• Outbreak in a plume shaped pattern starting from
  the military facility along prevailing winds

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Bacterial Biological Threats

• Anthrax
• Bacillus Anthracis
• aerosolized form is the biological threat
• incubation period of 1-6 days
• early-nonspecific flu like symptoms including
  headache, malaise, fever
• late-respiratory distress with cyanosis, dyspnea,
  stridor, shock

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Bacterial Biological Threats

• Anthrax
• Diagnosis - high index of suspicion, sputum for
  gram stain, CXR may show widened mediastinum
• Treatment - supportive care
• Penicillin 2 mil units q 2 hr IV
• Ciprofloxin 400 mg IV q 8-12 hr IV
• Doxycycline 200 mg loading then 100 mg IV q 12 hr

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Bacterial Biological Threats

• Anthrax Prevention
• There is essentially no person to person
  transmission so standard universal precautions
  are adequate.
• Vaccine
• Prophylaxis
• Ciprofloxin 500 mg po q 12 hr
• Doxycycline 100 mg po q 12 hr

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Bacterial Biological Threats

• Plague
• Yersinia pestis
• aerosolized form leading to pneumonic plague
• incubation period from 1-3 days
• early - malaise, fever, lymphadenopathy
• late - productive bloody cough, pneumonia,
  sepsis, coagulopathy

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Bacterial Biological Threats

• Plague
• Diagnosis - clinical suspicion with bloody
  sputum, elevated WBC, LFTs, FSPs, sputum gram
  stain, IFA, ELISA
• Treatment - supportive care
• Streptomycin 30mg/kg/d IM BID x 10 days
• Gentamicin 3-5mg/kg/d IV x 14 days
• Doxycycline 200mg loading then 100mg q 12hr x 14
  days

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Bacterial Biological Threats

• Plague Prevention
• THIS PATIENT NEEDS ISOLATION as person to person
  transmission is very high
• Vaccine - only prevents bubonic plague not
  pneumonic plague
• Prophylaxis - high risk individuals or anyone
  exposed to a patient with this diagnosis should
  take oral ciprofoxin or doxycycline

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Bacterial Biological Threats

• Q Fever
• Coxiella burnetii
• aerosolized form causes infection
• incubation period from 10-40 days
• early - fever, headache, myalgias, cough
• late - pneumonia, nonspecific neurologic
  symptoms, rarely endocarditis or hepatitis
• INCAPACITATING

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Bacterial Biological Threats

• Q Fever
• Diagnosis - clinical suspicion, detection of
  antibodies in bloodstream, complement fixation
  test, ELISA
• Prevention - no current effective vaccine or
  prophylaxis, no known person to person
  transmission
• Treatment - supportive care
• Tetracycline or Azithromax

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Biological Threats

• Viruses
• Smallpox
• Venezuelan Equine Encephalitis (VEE)
• Viral Hemorrhagic Fever Agents
• Ebola, Dengue, Hantan, Lassa, Congo Crimean

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Viral Biological Threats

• Smallpox
• hardy virus, high infectivity in aerosolized
  form, person to person transmission high
• incubation period from 7-17 days
• early - malaise, fever, headache
• late - centrifugal pustule formation with skin
  desquamation, diarrhea

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Viral Biological Threats

• Smallpox
• Diagnosis - clinically obvious
• Vaccine - currently available
• Treatment for an outbreak
• Supportive Care
• Vaccinia Immune Globulin 0.6mL/kg IM within 3
  days of exposure
• Vaccine within one week of exposure
• Quarantine Patients
• Decontaminate Items with bleach, steam, fire or
  soap and water

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Viral Biological Threats

• Venezuelan Equine Encephalitis (VEE)
• mosquito borne disease but aersolization possible
• incubation period 2-6 days
• early - acute febrile illness with myalgias, sore
  throat, photophobia
• late - weakness and lethargy, fulminant
  encephalitis usually only in children

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Viral Biological Threats

• Venezuelan Equine Encephalitis (VEE)
• Diagnosis - clinical suspicion, leukopenia, CSF
  will demonstrate elevated WBCs and protein,
  serologic tests are available
• Treatment - only supportive with analgesics
• Prevention - vaccine only currently available to
  lab workers, no person to person transmission
  known
• INCAPACITATING AGENT

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Viral Biological Threats

• Viral Hemorrhagic Fever Agents
• Ebola, Dengue, Hantan, Lassa, Congo Crimean,
  Yellow Fever
• animal reservoirs, aerosolization possible
• early - fever, myalgias, flushing
• late - hemorrhage, renal failure
• treatment - supportive, avoid ASA or NSAIDs,
  ribavirin
• prevention - yellow fever is the only vaccine
  available

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Biological Threats

• Toxins
• come from living agents
• skin contact not dangerous
• aerosols or ingestions are dangerous
• large amounts are required to cause injury or
  death
• botulinin, ricin, staphylococcal enterotoxin B

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Toxin Biological Threats

• Botulinin Toxin (BOT)
• Clostridia botulinin
• blocks Acetylcholine release
• incubation is 24-36 hrs
• early - bulbar palsy, ptosis, diplopia,
  photophobia, dry mouth
• late - symmetrical descending flaccid paralysis
  with respiratory arrest
• diagnosis - clinical
• treatment - equine antitoxin, vaccine

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Toxin Biological Threats

• Staphylococcal Enterotoxin B (SEB)
• 1-6 hr incubation period
• early - fever, headache, chills, myalgias,
  nonproductive cough, diarrhea, vomiting
• late - pulmonary edema and potentially ARDS
• diagnosis - clinical and serum test
• treatment - supportive

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Toxin Biological Threats

• Ricin
• source is Castro Bean
• large quantity necessary
• symptoms -weakness, fever, cough, hypothermia,
  cardiovascular collapse, type of exposure results
  in necrosis of organs
• diagnosis - ELISA
• treatment - supportive

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Decontamination for Biological Agents

• Inanimate Objects
• Bleach (5 sodium hypochlorite)
• People
• Bleach 110 dilution (0.5 sodium hypochlorite)

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Chemical Considerations

• Chemical agent categories
• nerve agents inhibit acetylcholinesterase
• GA (tabun), GB (sarin), GD (soman), and VX
• vesicants
• sulfur mustard, Lewisite, phosgene oxime
• cyanide (blood agents)
• hydrocyanic acid, cyanogen chloride
• lung damaging (choking) agents
• phosgene,

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Chemical Considerations

• Agents exist as solid, liquid or gas
• Persistent vs non-persistent
• Effect of weather conditions
• Volatility

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Chemical Considerations

• Protective Gear
• Detection
• Decontamination
• Symptomatology
• Treatment

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Terrorist AttackTokyo Subway Attack March 20,
1995

• Sarin was placed in 11 sealed plastic bags
• Bags were placed in 5 Tokyo subway cars during
  rush hour, and pierced with sharp umbrella tips
  allowing gas to escape
• 12 Dead, 5500 Exposed to Sarin

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Risk to Providers - Tokyo

• Tokyo Womens Medical College received 74
  patients, 23 hospitalized and 1 died
• In transporting and treating the one patient who
  died, 6 health care workers were exposed and
  became patients
• Keio University, Tokyo
• 113 patients (85 treated as outpatients, 15 adm)
• 13 of 15 Doctors working in the ER had symptoms,
  6 needed atropine
• Decontamination and Ventilation needed

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Decontamination

• Most effective if done 1-2 minutes after exposure
• Decontamination
• Set up a station
• Remove clothing and place in a sealed bag
• Wash exposed contaminated areas with dilute
  sodium hypochlorite
• Personnel must wear protective gear

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Nerve Agents

• GA-Tabun, GB-Sarin, GD-Soman, GF, VX
• irreversibly bind to acetylcholinesterase
• subsequent overstimulation of cholinergic
  receptors by Acetylcholine

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Nerve Agents

• Symptomatology
• Eyes - miosis, dim vision, headache, pain
• Nose - rhinorrhea
• Lungs - dyspnea, cessation of respiration
• GI - nausea, vomiting, diarrhea
• Skin - sweating
• Muscle - generalized twitching, weakness or
  paralysis
• CNS - syncope, seizures

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Nerve Agent Treatment

• Treatment - detection, terminate exposure,
  decontamination, supportive care, antidote
• Atropine
• treatment of choice
• blocks the effects of excess ACh
• starting dose 2 mg
• titrate to drying of secretions and ease of
  ventilation

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Nerve Agent Treatment

• Pralidoxime (2 PAM CL)
• enhances activity of atropine
• can remove agent from enzyme in some cases
• 15-25 mcg/kg over 20-30 minutes
• only effective if aging has not occurred

• Antiseizure Medication

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Vesicants

• Sulfur mustard
• oily liquid (brown-yellow)
• odor - onion, garlic or mustard
• enters body via skin, mucus membranes, or
  enterally
• DNA alkylating agent

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Sulfur Mustard

• Symptomatology
• Eyes - irritant with edema
• Skin - erythema with vesicles and bullae
• Lungs - pneumonitis, necrosis of airways,
  pulmonary edema, bacterial pneumonia
• GI - nausea and vomiting
• Hematologic - pancytopenia

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Sulfur Mustard

• Treatment
• Topical antibiotics for eyes
• Burn care for skin
• Supportive care including intubation for severe
  pulmonary disease
• NO ANTIDOTE AVAILABLE

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Industrial AccidentBhopal, India1984

• Densely populated city in central India
• Large chemical plant released cloud of gases used
  in the production of pesticides (methyl
  isocyanate and phosgene) - covered 25 square
  miles
• At least 2000 people dead, thousands more
  severely injured

Eckert, W. Am J Forensic Path 12(2) 119-25, 1991
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Cyanide

• concern is industrial accidents
• interferes with cellular respiration by
  complexing with enzymes
• respiratory, percutaneous or oral exposure
  hazardous
• rapidly acting but non-persistent agent

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Cyanide

• Symptomatology
• CV - HTN and bradycardia, hypotension and
  tachycardia, terminal bradycardia
• CNS - anxiety, agitation, weakness, syncope,
  muscle rigidity, seizures
• Skin - sweating, flushing
• GI - salivation, nausea and vomiting
• Lungs - tachypnea, dyspnea, pulmonary edema and
  cessation of respiration

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Cyanide

• Treatment
• Amyl nitirite perles
• sodium nitrite 300 mg IV
• sodium thiosulfate 12.5 g IV
• avoid MetHb levels gt 30
• administer oxygen with ventilation if required

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Phosgene

• Symptoms develop between 10 min and 24 hrs
• nasal irritation
• chest tightness
• cough
• lacrimation
• severe cough
• laryngospasm
• pulmonary edema

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Phosgene

• Treatment
• remove from exposure
• supportive care
• observe for at least 4 hours (CXR, ABG and
  physical exam)
• antibiotics only for complicating pneumonias
• steroids of no known benefit

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Treatment Considerations

• Stress on patients and providers will cause
  further confusion
• potential for mass hysteria is high
• Physical complaints may mimic those due to
  chemical or biological agent exposure
• palpitations, GI distress, headaches, dizziness,
  inattentiveness
• Terrorism is a form of psychological warfare

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SummaryMeeting the Challenge

• Understand the threat
• Assume we will have casualties to treat
• Be able to provide leaders sound advice
• Overcome training deficiencies
• treatment and diagnosis
• protection and decontamination
• Be aware of new technologies and developments in
  the threat
• Become the experts that others may perceive us to
  be

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ANY

• QUESTION?