BIOTERRORISM RNSG 1413 Amy C. Chavarria, RN, MSN, MBA, HCM, CCE

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BIOTERRORISMRNSG 1413 Amy C. Chavarria, RN,
MSN, MBA, HCM, CCE
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The Face of Bioterrorism
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BIOTERRORISM

• 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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HISTORY OFBIOLOGICAL WARFARE

• 14th Century Plague at Kaffa

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HISTORY OF BIOLOGICAL WARFARE

• 18th Century Smallpox Blankets

British commanding officers in the French and
Indian War resorted to the intentional use of
smallpox-infested blankets and clothing to infect
the Indians who were fighting along side the
French.
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HISTORY OFBIOLOGICAL WARFARE

• 20th Century
• 1943 USA program launched
• 1953 Defensive program established
• 1969 Offensive program
• disbanded

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BIOLOGICAL WARFARE AGREEMENTS

• 1925 Geneva Protocol
• 1972 Biological Weapons
• Convention
• 1975 Geneva Conventions
• Ratified

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BIOTERRORISM
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BioterrorismWho are 1st Responders?

• Primary Care Personnel
• Hospital ER Staff
• EMS Personnel
• Public Health Professionals
• Other Emergency Preparedness Personnel
• Laboratory Personnel
• Law Enforcement
• Firefighters

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PUBLIC HEALTH

• Effective planning and response to a biological
  terrorist incident will require collaboration
  with federal, state, and local groups and
  agencies including

-public health organizations -medical research
centers -health-care providers and their
networks -professional societies -medical
examiners
-emergency response units and
organizations -safety and medical equipment
manufacturers -US Office of Emergency
Management -other federal agencies
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ISSUES

• Existing local, regional, and national
  surveillance systems
• Adequate to detect traditional agents
• Inadequate to detect potential biowarfare agents
• Specific training for health care professionals
• clinical personnel will be first responders

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ISSUES

• Civilian biodefense plans are usually based on
  HAZMAT models
• Assumes responders enter a high exposure
  environment near the source
• Assumes site of exposure is separate from the
  health care facility
• Assumes no time pressure for decontamination
• Maximum protection is provided for a minimum
  number of workers / rescuers

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ISSUES

• HAZMAT
• OSHA mandates use of PPE based on site hazard,
  but site hazards are more easily defined at the
  point of release
• Traditional HAZMAT products are expensive, take
  time to set up, and are inadequate for large
  numbers of patients
• Difficult to train and maintain proficiency in a
  civilian work force with high turnover

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Key Problems

• Managing an outbreak
• The hard problem
• Investigating the attack if it is bioterrorism
• Does not require any special laws
• Demands effective public health infrastructure
• Preventing bioterrorism
• Laws on control of agents and personnel

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Minimal Threat

• Limited and non-communicable
• Anthrax Letters
• Scary, but very small risk to a small number of
  people
• Gross Overreaction in Government Office Buildings
• Huge Costs dealing with copycats
• No special legal problems

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Significant Threat, Not Destabilizing

• Broad and non-communicable
• Anthrax from a crop duster over a major city
• Could be managed with massive, immediate
  antibiotic administration and management of
  causalities
• Panic will quickly become the core problem

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Significant Threat, Potentially Destabilizing

• Limited and communicable
• A few cases of smallpox in one place
• Demands fast action
• If it spreads it can undermine public order
• Probably controllable, but with significant
  vaccine related causalities

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Imminent Threat of Governmental Destabilization

• Broad and communicable
• Multiple cases of smallpox, multiple locations
• Would demand complete shutdown on transportation
• Would quickly require military intervention
• Local vaccination plans are mostly unworkable

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POTENTIAL BIOTERRORISM AGENTS

• Viruses
• Smallpox
• VEE
• VHF-viral hemorrhagic fever

• Bacterial Agents
• Anthrax
• Brucellosis
• Cholera
• Plague, Pneumonic
• Tularemia
• Q Fever
• Source U.S. A.M.R.I.I.D.

• Biological Toxins
• Botulinum
• Staph Entero-B
• Ricin
• T-2 Mycotoxins

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CRITICAL BIOLOGICAL AGENTSCATEGORY A

• High priority agents that pose a threat to
  national security because they
• can be easily disseminated or transmitted
  person-to-person
• cause high mortality, with potential for major
  public health impact
• might cause panic and social disruption
• require special public health preparedness

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CRITICAL BIOLOGICAL AGENTS CATEGORY A

• Variola major (smallpox)
• Bacillus anthracis (anthrax)
• Yersinia pestis (plague)
• Clostridium botulinum toxin (botulism)
• Francisella tularensis (tularemia)
• Filoviruses
• Ebola hemorrhagic fever
• Marburg hemorrhagic fever
• Arenaviruses
• Lassa (Lassa fever)
• Junin (Argentine hemorrhagic fever) and related
  viruses

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Smallpox
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Parapox
Anthrax
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CRITICAL BIOLOGICAL AGENTSCATEGORY B

• Second highest priority agents that include those
  that
• are moderately easy to disseminate
• cause moderate morbidity and low mortality
• require specific enhancements of CDCs diagnostic
  capacity and enhanced disease surveillance

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CRITICAL BIOLOGICAL AGENTSCATEGORY B

• Coxiella burnetti (Q fever)
• Brucella species (brucellosis)
• Burkholderia mallei (glanders)
• Alphaviruses
• Venezuelan encephalomyelitis
• eastern / western equine encephalomyelitis
• Ricin toxin from Ricinus communis (castor bean)
• Epsilon toxin of Clostridium perfringens
• Staphylococcus enterotoxin B

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CRITICAL BIOLOGICAL AGENTSCATEGORY B

• Subset of Category B agents that include
  pathogens that are food- or waterborne
• Salmonella species
• Shigella dysenteriae
• Escherichia coli O157H7
• Vibrio cholerae
• Cryptosporidium parvum

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CRITICAL BIOLOGICAL AGENTSCATEGORY C

• Third highest priority agents 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 and
  major health impact
• Preparedness for Category C agents requires
  ongoing research to improve detection, diagnosis,
  treatment, and prevention

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CRITICAL BIOLOGICAL AGENTSCATEGORY C

• Nipah virus
• Hantaviruses
• Tickborne hemorrhagic fever viruses
• Tickborne encephalitis viruses
• Yellow fever
• Multidrug-resistant tuberculosis

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Parapox
Anthrax
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ADVANTAGES OF BIOLOGICS AS WEAPONS

• Infectious via aerosol
• Organisms fairly stable in environment
• Susceptible civilian populations
• High morbidity and mortality
• Person-to-person transmission (smallpox,
  plague, VHF)
• Difficult to diagnose and/or treat
• Previous development for BW

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ADVANTAGES OF BIOLOGICS AS WEAPONS

• Easy to obtain
• Inexpensive to produce
• Potential for dissemination over large geographic
  area
• Creates panic
• Can overwhelm medical services
• Perpetrators escape easily

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BIOTERRORISMHOW REAL IS THE THREAT?

• Hoax vs. Actual BT Event

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ANTHRAX BIOTERRORISM
San Francisco Chronicle, 20 December 1998
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ISSUES

• Existing local, regional, and national
  surveillance systems
• Adequate to detect traditional agents
• Inadequate to detect potential biowarfare agents
• Specific training for health care professionals
• clinical personnel will be first responders

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ISSUES

• Civilian biodefense plans are usually based on
  HAZMAT models
• Assumes responders enter a high exposure
  environment near the source
• Assumes site of exposure is separate from the
  health care facility
• Assumes no time pressure for decontamination
• Maximum protection is provided for a minimum
  number of workers / rescuers

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Threats reported to FBI
Source FBI personal communication
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CHEMICAL BIOLOGICAL TERRORISM

• 1984 The Dalles, Oregon, Salmonella (salad
  bar)
• 1991 Minnesota, ricin toxin (hoax)
• 1994 Tokyo, Sarin and biological attacks
• 1995 Arkansas, ricin toxin (hoax)
• 1995 Ohio, Yersinia pestis (sent in mail)
• 1997 Washington DC, Anthrax (hoax)
• 1998 Nevada , non-lethal strain of B. anthracis
• 1998 Multiple Anthrax hoaxes

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SALMONELLOSIS CAUSED BY INTENTIONAL CONTAMINATION

• The Dalles, Oregon in Fall of 1984
• 751 cases of Salmonella
• Eating at salad bars in 10 restaurants
• Criminal investigation identified perpetrators as
  followers of Bhagwan Shree Rajneesh

SOURCE Torok et al. JAMA 1997278389
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Source ASAHI SHIMBUN SIPA
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CLINICAL STATUS OF PATIENTS EXPOSED TO SARIN ON
MARCH 21, 1995
Dead 8 Critical 17 Severe
37 Moderate 984 Outpatient 4,073 Unknown
391 Total 5,510
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SHIGELLOSIS CAUSED BY INTENTIONAL CONTAMINATION

• Dallas, Texas in Fall of 1996
• 12 (27) of 45 laboratory workers in a large
  medical center had severe diarrheal illness
• 8 (67) had positive stool cultures for S.
  dysenteriae type 2
• Eating muffins or donuts in staff break room
  implicated
• PFGE patterns indistinguishable for stool,
  muffin, and laboratory stock isolates
• Criminal investigation in progress

SOURCE Kolavic et al. JAMA 1997278396
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FEDERAL AGENCIES INVOLVED IN BIOTERRORISM

• NSC
• DOD
• FEMA
• DOJ
• DHHS
• Treasury
• EPA
• FBI

• PHS
• CDC
• Secret Service
• USDA
• FDA
• SBCCOM
• USAMRIID
• OEP

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COST OF BIOTERRORISM
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AGENT TRANSMISSION
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ROUTES OF INFECTION

• Skin
• Cuts
• Abrasions
• Mucosal membranes

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ROUTES OF INFECTION

• Gastrointestinal
• Food
• Potentially significant route of delivery
• Secondary to either purposeful or accidental
  exposure to aerosol
• Water
• Capacity to affect large numbers of people
• Dilution factor
• Water treatment may be effective in removal of
  agents

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ROUTES OF INFECTION

• Respiratory
• Inhalation of spores, droplets aerosols
• Aerosols most effective delivery method
• 1-5F droplet most effective

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MEDICAL RESPONSE TO BIOTERRORISM
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MEDICAL RESPONSE

• Pre-exposure
• active immunization
• prophylaxis
• identification of threat/use

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MEDICAL RESPONSE

• Incubation period
• diagnosis
• active and passive immunization
• antimicrobial or supportive therapy

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MEDICAL RESPONSE

• Overt disease
• diagnosis
• treatment
• may not be available
• may overwhelm system
• may be less effective
• direct patient care will predominate

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PUBLIC HEALTH RESPONSE TO BIOTERRORISM
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PRIORITIES FOR PUBLIC HEALTH PREPAREDNESS

• Emergency Preparedness and Response
• Enhance Surveillance and Epidemiology
• Enhance Laboratory Capacity
• Enhance Information Technology
• Stockpile

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COMPONENTS OF PUBLIC HEALTH RESPONSE TO
BIOTERRORISM

• Detection - Health Surveillance
• Rapid Laboratory Diagnosis
• Epidemiologic Investigation
• Implementation of Control
  Measures

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LABORATORY RESPONSE NETWORK FOR BIOTERRORISM
D - Highest level characterization (Federal)
Level D Lab BSL-4
C - Molecular assays, reference capacity
Level C Lab BSL-3
B - Limited confirmation and Transport
Level B Lab BSL-2 facility BSL-3 Safety
Practices
A - Rule-out and forward organisms
Level-A Lab Use Class II Biosafety Cabinet
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CDC BT RAPID RESPONSE AND ADVANCED TECHNOLOGY LAB

• BSL -3
• Agent Identification and Specimen Triage
• Refer to and Assist Specialty Lab Confirmation
• Evaluate Rapid Detection Technology
• Rapid Response Team

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BIOTERRORISMWhat Can Be Done?

• Awareness
• Laboratory Preparedness
• Plan in place
• Individual collective protection
• Detection characterization

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BIOTERRORISMWhat Can Be Done?

• Emergency response
• Measures to Protect the Publics Health and
  Safety
• Treatment
• Safe practices

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BIOTERRORISM AND THE PUBLIC HEALTH SECTOR

• CONCLUSIONS
• Preparation for a biological mass disaster
  requires coordination of diverse groups of
  medical and non-medical personnel
• Preparation can not occur without support and
  participation by all levels of government
• Preparation must be a sustained and evolutionary
  process

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Bioterrorism Preparedness and Response
ProgramCenters for Disease Control and
Prevention
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