BIOLOGICAL TERRORISM

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BIOLOGICAL TERRORISM

• Edward L. Goodman, MD,
• Chief of Infectious Diseases
• Presbyterian Hospital of Dallas
• December 14, 2005

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Biological Terrorism

• Use of biological agents to intentionally produce
  disease or intoxication in susceptible
  populations to meet terrorist aims
• Has been done in the past on a limited scale
• U.S. must be prepared to respond to this threat

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History of Biological Warfare

• In 1346, Tartar army hurled corpses of plague
  victims over the walls of Caffa, a seaport on the
  Crimean coast
• In 1718, Russians used same tactic against Sweden
• During the Pontiac Rebellion in 1763, the British
  army provided the Delaware Indians with blankets
  and handkerchiefs from the Smallpox Hospital

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History of Biological Warfare (cont.)

• German program in WWI
• Japanese program in WWII
• In 1943, the U.S. began research into the
  offensive use of biological agents Program
  stopped by President Nixon in 1969

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History of Biological Warfare (cont.)

• In 1972, U.S. and many other countries signed the
  Biological Weapons Convention
• Former Soviet Union program began massive effort
  in 1970s
• Today, term warfare is outdatedterrorism of
  civilian populations major risk Anthrax in 12
  persons 2001

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Why There was a Belief Bioterrorism in the U.S.
Would Not Happen

• Biologic weapons seldom used
• Their use is morally repugnant to most
• Technologically difficult?
• Concept of nuclear winter was unthinkable and
  thus dismissed until suicide hijackers and
  anthrax appeared

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The Coming of Age and Bioterrorism

• Perpetrators
• Availability of biological agents
• Methods of dissemination

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The Spectrum of Terrorists

• State-sponsored
• Insurgent/rebel
• Doomsday/cult-type group
• Non-aligned terrorists
• Splinter groups
• Lone offenders

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Sources of Agents for Terrorism Use

• World Directory of Collections of Cultures and
  Microorganisms
• 453 worldwide repositories in 67 nations
• 54 ship/sell anthrax
• 18 ship/sell plague
• International black-market sales associated with
  governmental programs

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Methods of Dissemination of Biologic Agents

• Postal service never previously reported
• Aerosol
• Enclosed areas
• Community-wide
• Ingestion
• Mass produced food
• Water supplies

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• You have to be lucky all the time.
• We have to be lucky just once!
• Irish Republican Army

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• The only difference between
• reality and fiction is that
• fiction has to make sense.
• Tom Clancy

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Syndromes Suggesting BT

• Encephalitis
• Hemorrhagic mediastinitis
• Pneumonia with abnormal liver function
• Papulopustular rash
• Hemorrhagic fever
• Descending paralysis
• Nausea, vomiting /- diarrhea

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Biological Terrorism Likely Agents

• Bacterial Anthrax Q fever
• Brucellosis Tularemia
• Plague
• Viral Smallpox
• Viral encephalitides
• Viral hemorrhagic fever
• Toxin Botulism
• Ricin
• Staph, Enterotoxin B

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Ideal Characteristics for Potential Biological
Terrorism Agent

• Inexpensive and easy to produce
• Can be aerosolized (1-10µm)
• Survives sunlight, drying, heat
• Cause lethal or disabling disease
• Person-to-person transmission
• No effective treatment or prophylaxis

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Anthrax

• Caused by Bacillus anthracis, a rod shaped,
  sporulating organism
• Is a zoonotic disease in cattle, sheep, and
  horses
• Transmission through scratches or abrasions of
  skin, wounds, eating insufficiently cooked
  infected meat, or inhalation of spores

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Pathophysiology of Anthrax
Dixon, T. C. et al. N Engl J Med 1999341815-826
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Cutaneous Anthrax Infection of the Hand and Cheek
Dixon, T. C. et al. N Engl J Med 1999341815-826
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Anthrax (cont.)

• Case fatality in untreated inhalational disease
  is almost 100
• In recent 2001 occurrence, only 3/6 died
• Incubation 1 45 days, most within 21 days
• Initial flu-like symptoms are often followed by
  abrupt development of severe respiratory
  distress, shock, and death within 24 hours

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Anteroposterior Chest Radiograph Obtained on
Admission, Showing the Widened Mediastinum That
Is Characteristic of Anthrax
Bush, L. M. et al. N Engl J Med 20013451607-1610
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Cerebrospinal Fluid Specimen Containing Many
Polymorphonuclear White Cells and Gram-Positive
Bacilli (Gram's Stain, x1000)
Bush, L. M. et al. N Engl J Med 20013451607-1610
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Differential Diagnosis of Clinical Manifestations
of Anthrax
Dixon, T. C. et al. N Engl J Med 1999341815-826
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Anthrax (cont.)

• Medical management must be reserved for those
  with early symptoms or no symptoms
• Use of antibiotics for treatment (penicillin,
  ciprofloxacin, or IV doxycycline) and prophylaxis
  and vaccination
• No secondary transmission

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Recommendations for Postexposure Prophylaxis
Swartz, M. N. N Engl J Med 20013451621-1626
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Recommendations for Antimicrobial Therapy of
Clinical Inhalational Anthrax
Swartz, M. N. N Engl J Med 20013451621-1626
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Anthrax (cont.)

• Weaponized by the U.S. in 1950s and 60s
• Major emphasis of USSR program
• Can be delivered as aerosol

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Inhalational AnthraxSverdlovsk, USSR, 1979
Incubation-Days 0-6 7-13 14-20 21-27 28-44
Cases 6 28 9 6 11
Died 6 25 7 6 5
Days to Death 4.5 2.5 3.0 4.5 3.5
15 additional cases without an exact date of
onset all died.
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Shopping Mall Scenario - Denver

• Anthrax aerosolized into shopping mall
  ventilation system 10,000 people are present and
  9,000 people are exposed terrorist announces
  attack at 24 hours.
• 90 of exposed started on antibiotics by end of
  day 2, 10 cannot be found initially
• Total number hospitalized 4,950 total requiring
  ICU care 2,925 total deaths 855 total
  ventilators required 2601

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Shopping Mall Scenario Denver (cont.)

• The 13,000 military beds deployed for the Persian
  Gulf War would STILL not provide enough ICU beds
  (approximately 1,300)
• Even a small biological terrorism event
  completely overwhelms a citys medical care
  resources

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Smallpox

• An even worse scenario

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Smallpox

• Killed more than 500 million persons in the 20th
  century despite being eradicated in 1978
• Mortality of 30 in susceptible population
• Incubation period of 8 to 16 days

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Smallpox (cont.)

• Clinical manifestations begin acutely with
  fever, rigors, vomiting, headache and backache
• Approximately 10 of light-skinned patients
  exhibit erythematous rash during early phase
• Two to three days later, an enanthem appears on
  face, hands, and forearms

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Smallpox (cont.)

• Transmission begins with rash and lasts
  throughout convalescence
• Ongoing transmission is critical factor
• Most in the world are no longer protected by
  vaccination
• Currently vaccine and treatment limited

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Date of Onset of Smallpox Cases by Two-Day
IntervalsMeschede Hospital, 1970
4 3 2 1
Hospital Stay Case 1
Cases
13 15 17 19 21 23 25 27
29 31 2 4 6 8 10 12
14 16 18
January
February
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Plague

• Not as likely but of concern

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Botulism
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Challenges in Recognizinga Bioterrorism Attack

• Biologic agents with delayed onset
• Medical community is unfamiliar with many of
  these diseases
• Current surveillance system may not be adequate
  to detect attack

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Epidemiological Clues to BT Event

• Uncommon illness in epidemic form
• Explosive point source epidemic curve
• Unexplained high mortality
• Discordant attack rate outdoorgtindoor
• Sentinel illness even one case of anthrax or
  smallpox

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Syndromes Suggesting BT

• Encephalitis
• Hemorrhagic mediastinitis
• Pneumonia with abnormal liver function
• Papulopustular rash
• Hemorrhagic fever
• Descending paralysis
• Nausea, vomiting /- diarrhea

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Ten CommandmentsSummary

• 1. Index of Suspicion
• 2. Protect Thyself and Thy Patients
• 3. Assess the Patient
• 4. Decontaminate
• 5. Diagnosis
• 6. Treatment
• 7. Infection Control
• 8. Alert
• 9. Epidemiologic Assessment
• 10. Spread the Gospel

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Response Planning

• Federal government
• State and local government
• Healthcare systems
• Media
• Infrastructure support

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Impact on Healthcare System

• Potential for widespread illness, in
  unprecedented numbers
• Limited therapeutic stockpiles
• Need special protective measures for medical
  care, clinical lab, and autopsy
• Panic/terror among the ill, the exposed, and
  healthcare providers

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Other Critical Issues

• Legal aspects
• Criminal investigation
• Controlling civil disorder
• Quarantine
• Continued public health activities

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Planning Responses to Biological Terrorism

• Are we ready?
• Should we get ready?
• Is it possible to be effectively prepared?

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• Its not a matter of if,
• but when, which agent,
• and how bad it will be!

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• World
• Trade
• Center

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New York City