EPIDEMIOLOGY OF BIOTERRORISM

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Biodefense Epidemiology Shahid Beheshti
University of medical sciences 2008 By
Hatami H. MD. MPH
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Bioterrorism Definition

• The intentional or threatened use of
  microorganisms or biological toxins to kill or
  incapacitate people, animals, or crops.
• Bioterrorism events may be unnaturally occurring
• emerging infections.

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logical warfareBiological attackBiological
weaponBiological defenseBiological
educationAgricultural bioterrorismpsychoterroris
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Historical Aspects of Bioterrorism

• Biological weapons are not new
• The technologies of production and delivery have
  been developed

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Indian Aconite Aconitum napellus
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Indian Aconite Aconitum napellus
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Indian Aconite Aconitum napellus
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Known Development to Agents by the Major powers

• Canada
• United State
• France
• Germany
• United Kingdom
• Russia
• Japan

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History of biological weapons

• 1346 Tartar siege of Kaffa (Feodossa) catapult
  plague victims over walls (662y)
• 1767 The French and Indian War the English gave
  Smallpox contaminated blankets to Indians (241 y)
• 1918 (WWI) German agents inoculated horses and
  cattle with Glanders disease (90 y)
• 1940 Japan dropped Bubonic plague infected fleas
  and grain (to attract the local rats) in China
  (68 y)

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History of biological weapons (continued)

• 1975 Biological Weapons Convention prohibiting
  the production/stockpiling biological weapons (33
  y)
• 1979 Sverdlovsk Incident accidental explosion at
  biological warfare facility killing an estimated
  200-1000 people from anthrax (29 y)

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• Bioterrorism events may be unnaturally occurring
  emerging infections.
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B.W. Agents Differ from C.W. Agents
Biological Agents Natural Production
difficult None volatile Many toxins more
toxic Infectious agents replicate Not dermally
active Legitimate medical use Odorless and
tasteless Diverse pathogenic effects Many are
effective immunogens Aerosol delivery Delayed
Onset (Days to Weeks) A few are contagious
Chemical Agents Man-made Production difficult
(industrial) Many volatile Less toxic than many
toxins Do not replicate Many are dermally
active No use other than as weapons Odor or taste
when contaminated Fewer types of effects Poor
immunogens Mist / droplet / aerosol
delivery Rapid Onset (Minutes) Not Contagious
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Critical Biological Agents Category A

• Organisms that pose a risk to national security
  because they
• Can be easily disseminate
• Transmitted person-to-person
• Cause high mortality
• Major public health impact
• Might cause public panic
• Social disruption
• Require special action for public health
  preparedness

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Critical Biological Agents Category A

• Variola major
• Bacillus anthracis
• Yersinia pestis
• Clostridium botulinum
• Francisella tularensis
• Ebola hemorrhagic fever
• Marburg hemorrhagic fever
• Lassa Junin

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Critical Biological Agents Category B

• Are moderately easy to disseminate
• Cause moderate morbidity and low mortality
• Require specific enhancements of diagnostic
  capacity and disease surveillance

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Critical Biological Agents Category B

• Coxiella burnetti
• Brucella species
• Burkholderia mallei
• Alphaviruses
• Venezuelan encephalomyelitis
• Equine encephalomyelitis
• Ricin toxin
• Toxin of C. perfringence
• Staphylococcus enterotoxin B
• SARS CoV ??

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Critical Biological Agents Category C

• Include emerging pathogens that could be
  engineered for mass dissemination in the future
  because of
• Availability
• Ease of production and dissemination
• Potential for high morbidity and mortality
• Major health impact

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Critical Biological Agents Category C

• Nipah virus
• Hantaviruses
• Tickborne hemorrhagic F
• Tickborne encephalitis
• Yellow fever
• MDR tuberculosis
• SARS CoV??

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Another classification of Agents

• Lethal or incapacitating
• Anti-personnel, anti-animal,
• anti-plant
• Replicating pathogen, toxin
• Contagious or non-contagious

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Bioweapons
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Bioagents by Probability of Use as Biological
Weapons

• Very likely to be used
• Smallpox
• Plague
• Anthrax
• Tularemia
• Marburg
• Melioidosis
• Q fever
• Typhus

• Possible use
• Brucellosis
• Japanese encephalitis
• Yellow fever
• Tetanus
• Diphtheria

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Epidemiological Pattern of Tularemia Weapon
Contaminated zone
Infected zone
Zone of initial explosion
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Epidemiological Pattern of Anthrax Weapon
Contaminated zone
Zone of initial explosion
Infected zone
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Epidemiological Pattern of Plague Weapon
New foci of secondary infection
Contaminated zone
Infected zone
Zone of initial explosion
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Outbreak or Epidemic ?
Plague
Anthrax (and most others)
Smallpox
Day 0
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Outbreak or Epidemic ?
Plague
Anthrax (and most others)
Smallpox
Day 10
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Outbreak or Epidemic ?
Plague
Anthrax (and most others)
Smallpox
Day 20
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Outbreak or Epidemic ?
Plague
Anthrax (and most others)
Smallpox
Day 30
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Outbreak or Epidemic ?
Plague
Anthrax (and most others)
Smallpox
Day 40
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Targets

• General population
• Animals
• Plants

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Host, Agent, Environment
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Host, Agent, Environment
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Typical Incubation Periods

• lt 1 day
• Staphylococcal enterotoxin B
• lt 1 week
• anthrax
• plague
• tularemia
• VEE
• botulism

• gt 1 week
• brucellosis
• Q fever
• Smallpox
• EEE/WEE
• Viral hemorrhagic fevers
• anthrax

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Epidemiological Clues to a Biological Attack

• Suspicious transmission pattern
• Unusual genetic or molecular patterns
• Multiple simultaneous epidemics
• Unusual clinical presentation
• Unexplained animal deaths
• Direct evidence of biowarfare munitions
• Claims by aggressors and/or prior intelligence

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Epidemiological Clues to a Biological Attack

• Large unexplained epidemic with similarly acute
  patients with an unusual epidemic curve
• More severe case of disease than usual with
  higher mortality, refractory to treatment and
  usually with respiratory manifestation
• Multiple diseases in the same patient
• Unusual geographic, seasonal, or patient
  distribution

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Some Indicators ofBioterrorism Events

• Point source exposure pattern.
• Compressed epidemic curve.
• Geographic correlates of exposure.
• High attack rate among exposed.
• Exotic disease for area.
• Low attack rates in protected areas.
• Animals also acquiring disease.

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Elements of Biological Defense

• Technical
• Detection
• Identification
• Physical protection
• Disinfection
• Disinsection

• Medical
• Prophylaxis
• Urgent (pre- and post-exposure) prophylaxis
• Treatment

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The Way Ahead

• Surveillance (diagnostics and communication)
• Education
• Proactive Deterrence
• Public Health Infrastructure
• HUMINT
• Biomedical Research

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• Horror / anger / panic
• Fear of contagion
• Fear of invisible agents
• Irrational thinking about viruses/microbes
• Anger at terrorists, government, or both
• Attribution of symptoms to infection
• Scapegoating/paranoia/social isolation
• Loss of faith in social/political/ governmental
  institutions

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(psychoterrorism)

• Prevention of group panic
• Rapid, careful medical evaluation
• and treatment
• Avoidance of emotion-based responses
• Control of symptoms due to hyperarousal and
  somatization
• Effective, credible communication

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