Bioterrorism: The Biologic Agents: Part I

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Bioterrorism The Biologic Agents Part I
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Stevan Cordas DO MPH

• Committee on Bioterrorism Texas Department of
  Health
• Med TaskForce, Committee of the Tarrant County
  Medical Society
• Consultant in clinical toxicology and
  occupational medicine.
• Certified in allergy, immunology, internal
  medicine and occupational medicine.

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Biologic Agents

• Biologic agents are being used as terror weapons
  in this country and their clinical features must
  be reviewed.
• This presentation will review the clinical
  presentations and treatment of these agents.
• More information is available at www.bt.cdc.gov,
  www.hhs.gov and www.fbi.gov.

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Biological Agents and Their Byproducts

• Anthrax
• Smallpox
• Tularemia
• Brucellosis
• Dengue Fever
• Plague
• Ebola virus
• Other hemorrhagic viruses

• Q fever
• Glanders and Meloidosis
• Trichothecenes
• Ricin
• Staphylococcus endotoxin B
• VEE and other encephalitis

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Anthrax

• Anthrax is caused by a gram positive, spore
  forming organism, Bacillus anthracis.
• It is ubiquitous in soil in Africa and Asia. In
  the United states, these spores are common in
  rural Texas, Oklahoma and the Mississippi Valley.
  
• Anthrax is usually is a epizootic or enzootic
  disease of herbivores such as deer, goats, sheep
  or cows with man being a secondary host. The
  animals acquire the disease from ingesting
  infected soil.

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Types of Anthrax

• Cutaneous the bacillus enters via a cut or
  abrasion.
• Gastrointestinal No reported cases in the
  United States.
• Inhalation Most deadly form. 97 mortality if
  untreated.

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CDC Regimen for the Treatment of Anthrax

• Post exposure - Adults
• Ciprofloxacin 500mg bid for 60 days.
• Doxycycline 100mg bid for 60 days.
• Children
• Ciprofloxacin 15 mg/kg po q 12 h.
• Doxycycline 100mg bid if gt8 yrs and gt45 kg or 2.2
  mg/kg if lt8 yrs or under 45 kg.
• Penicillin can be used in children if the
  organism was shown to be sensitive to it.

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Further Considerations

• Do not send anthrax specimen or blood testing to
  state or local health lab if there is no exposure
  shown. These labs are overloaded.
• Do not prescribe ciprofloxacin without a good
  reason for doing so. Especially not for
  prophylaxis in non-exposed patients.
• Be vigilant bioterrorism is a new kind of war
  and you are a soldier in this war along with the
  rest of us.

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Summary on Anthrax

• Anthrax is a rare infectious disease that has
  reemerged though acts of terrorism. It is
  treatable in most cases but vigilance is
  required.
• Awareness of the epidemiology, disease
  characteristics and treatment is essential for
  the practicing physician.

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Smallpox

• Edward Jenner made history on May 14th 1796 when
  he transferred cowpox from the hand of Sarah
  Nelms to the arm of James Phipps. Immunization
  was born on that day.
• The last known case of smallpox occurred on
  October 26 1977 in Somalia

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Clinical Characteristics of Smallpox

• Smallpox is a human to human transmitted disease
  without any other known intermediary host.
• 12 to14 days after exposure fever, myalgia and
  prostration occur.
• 2 or 3 days later a papular eruption starts on
  the face and spreads to the extremities.
• The eruption changes to vesicles, pustules, scabs
  and later scars.

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Treatment of Smallpox

• Quarantine and isolation.
• Vaccination. Effective even if started 1 to 2
  days after the onset of the rash. After that it
  may reduce mortality. It is best performed as a
  preventive modality.
• Supportive care with appropriate protection of
  the health care worker.

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Summary

• Smallpox is a highly infectious disease spread by
  aerosol.
• It is physically disfiguring and carries a case
  mortality rate of 30 or more.
• It is largely preventable by vaccination though
  no one has been vaccinated in the United States
  in the past 25 years.
• There are no proven drug treatments that have
  released at this time.

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Plague

• A Potential Time Bomb

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Bubonic Plague

• 2-8 day incubation period
• Bubonic plague is the most common form
• Fever, chills, headache, exhaustion, myalgias
• Lymphadenopathy. Bubos often in groin but may be
  in axilla or cervical area.
• Typically goes from bubonic to septicemia to
  pneumonic form.

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Pneumonic Plague

• May begin with this form after aerosol inhalation
  and is the most likely form with bioterrorism
  attacks.
• Sudden onset of cough, chest pain, dyspnea,
  hemoptysis, high fever death within 24 hours
• Nearly 100 mortality if untreated. Timely
  treatment with Streptomyciin or Gentamycin can
  reduce the mortality rate but treatment must
  start within 18 hours.

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Treatment of Pneumonic Plague

• Streptomycin 30 mg/kg IM in two doses
• Gentamycin 5 mg/kg daily IV or IM divided
• Ciprofloxacin 400 mg IV bid
• Doxycycline 200 mg loading then 100 mg bid
• If meningitis is present use chloramphenicol 25
  mg/kg loading then 15 mg/kg qid.
• All treatments should be for 10 to 14 days.

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Summary

• If a cluster of previously healthy individuals
  demonstrated a sudden appearance of pneumonia,
  the first thing to think about is plague in this
  day of bioterrorism.
• Start therapy as soon as possible. Obtain proper
  samples and contact public health authorities and
  law enforcement.