Biologic Weapons in War

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Biologic Weaponsin War

• The use of germs to kill, immobilize or
  demoralize the Enemy.
• It WILL happen.
• Again.
• Vicken Y. Totten MD, MS
• FACEP

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Warfare agents

• Projectiles and explosives physical injuries
  incompatible with life
• Chemical and nuclear poisoning incompatible
  with life
• Eco devastation the environment will no longer
  sustain human life
• Carthage
• Genetic imperialism
• Rape and forced impregnation change a genome
• Germ Warfare

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Purpose of bioterrorism

• To instill fear, change lifestyles
• Immobilize populations
• Waste resources
• Occupy trained personnel
• Weaken the Enemy

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Germ Warfare (BioWar)

• Different agents have different infectious dose,
  germ survival in the environment, effectiveness,
  availability LD-50, but all should be feared.
• Psychological impact almost as lethal as their
  physical effects.
• Hot zones where contracting these germs means
  sure but slow! and contagious! death.
• 1 to 2 weeks turn your body into liquefied, virus
  - infected tissue culture. You
• Hemorrhage virus infected blood potential to
  wipe out 20-99 of population

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• The Salt Lake Tribune (5/12, May)
• if "a killer flu strikes, with several thousand
  sick or injured and no room to spare in
  understaffed hospitals, care will be denied to
  the sickest adults and children."
• Individuals "who are severely burned, have
  incurable and spreading cancer, fatal genetic
  diseases, end-stage multiple sclerosis or severe
  dementia will be turned away.
• They can be sent elsewhere for comfort care, such
  as painkillers, but they will not be treated for
  the flu, according to the guidelines.

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BioWeapons Germ Warfare

• Not new used for thousands of years
• Whats new is Weaponizing
• increases virulence
• Assists in spread by technology
• Biologic capability is relatively inexpensive and
  widespread.
• Risk of a serious bioterrorism incident.

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Serendipitous and deliberate

• Zoonoses in the New World
• Deliberate small pox in the New World
• Actual infection is not even required post
  attack, US anthrax hoaxes had many of the effects
  hoped-for from actual infections Disrupting
  business, life styles and demoralizing the Enemy.

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Ashdod of the Philistines1320-1000 BC

• I Samuel The Philistines stole the Israelites
  Ark of the Covenant.
• Rats (mice) appeared, then the Lords hand on
  the people of Ashdod and its vicinity, throwing
  the city into a great panic. He afflicted the
  people of the city, both young and old, with an
  outbreak of tumors (emerods) in the groin.
• As a result, the Philistines returned the Ark of
  the Covenant with five golden emerods and five
  golden mice.

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Plague of Athens (430-426 BCE)

• Thucydides The Peloponnesian War attributed
  the success of the war to the plague.
• The plague arrived in the first days of summer,
  during the second year of the war, at the same
  time as Archidamus, son of the king of
  Lacedaemon.

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Plague of Athens

• Spartans besieging the city were not affected by
  the disease.
• Many Athenians died, and eventually capitulated.
• Plague probably came by boat with the alleys up
  from Egypt, with immune soldiers.

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14th and 15th century Europe.

• Armies would fling diseased and decaying cadavers
  (especially of slaughtered enemy soldiers) over
  protective town walls to demoralize and sicken
  the besieged cities.
• 1346 -1347. Tartars defeated Genoese army by
  catapulting plague-dead soldiers over the walls
  into Kaffa (Caffa), by the Black Sea
• 1422. Lithuanians flung dead soldiers and 2000
  cart loads of excrement into Carolstein.
• These battles contributed to the 25 million
  victims of the European Black Plague

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THE BLACK DEATH PANDEMIC

• Worst from 1346 and 1352 with outbreaks till
  1800s
• Killed 25 million people(1/3 of the worlds
  population at that time)
• 30-60 of the populations of large cities died
  from the disease
• final foray occurred in Marseilles in 1720.
• Still around

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World War II British

• tested anthrax in Gruinard Island off the coasts
  of Scotland.
• Anthrax can live decades in soil.
• Cleaning the Island years later was very costly.

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United States, Post WWII

• 1950, Germany accuses US of releasing Colorado
  beetles over German crops.
• China, North Korea, and the Soviet Union accused
  the US of using biological weapons during the
  Korean War.

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Second Sino-Japanese War

• The Imperial Japanese Army bombed Ningbo with
  fleas carrying bubonic plague.
• 1941. More plague-contaminated fleas airdropped
  by 40 planes onto Changde.
• These operations caused epidemic plague outbreaks.

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United States 1980s

• September 1984, The Dalles, OR, dozens got food
  poisoning Salmonella enterica typhimurium.
• 1st Shakeys Pizza. Later, 10 more restaurants.
• More than 700 ill the only hospital ran out of
  beds. 
• CDC involved. Deliberate contamination was
  proved the Rajneesh cult was suspected but never
  convicted.

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Weaponized Super-Germs vs common organisms

• Small inoculums will infect large populations
  (highly infectious)
• Easily transmitted from person to person
  airborne better than contact.
• Either lethal or prolonged illness with lasting
  morbidity (ties up Enemy resources and diverts
  them from War Effort demoralizes)
• Treatment none

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Properties for Maximum Credible Threat

• highly lethal toxic
• easily produced in large quantities.
• environmental aerosol stability
• Dispersal capability to (1 mm to 5 mm particle
  size)
• person to person communication
• no treatment or vaccine.

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Potential human biological pathogens.

• NATO handbook lists 39 agents including bacteria,
  viruses, rickettsiae, and toxins.
• Biologic agents spread on their own therefore,
  the dose needed is less.
• Highly toxic poision, Ricin 8 metric tons vs 1
  kg anthrax for same number casualties

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Comparison
Agent   Type Untreated Mortality  Relative Infectivity Dose  Incubation Period  Treatment
Anthrax Bact-eria 80 1000 Spores 1-4 Days Pre Exposure Antibiotics
Botulism Virus 40-90 Moderate 2-7 Days Some Antibiotics
Plague Bact-eria 90 10 Organisms 2-3 Days Antibiotics
Smallpox Virus 75 High 7-14 Days Vaccine
Tular-emia Bact-eria 30 25 Organisms 2-4 Days Antibiotics
V.H.F. Virus 50-90 High 2-7 Days Antibiotics
Not effective after symptoms develop
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Anthrax, Plague and Smallpox best candidates

• Highly lethal
• Anthrax, untreated anthrax gt 80 die Variola
  Major 30 of unvaccinated patients die
  Septicemic Plague 100
• All can be produced in quantity
• Plague available world wide no need to raid
  containment facilities
• Anthrax Smallpox stable for aerosol
  transmission
• Anthrax spores survive for decades
• smallpox can be freeze-dried.

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All Weaponized.

• Iraq produced anthrax for use in Scud missiles
• former Soviet Union produced smallpox virus by
  the ton
• Japanese weaponized plague
• All uncommon diseases with non-specific initial
  presentation
• Delayed recognition will allow for secondary
  spread
• Vaccines poor or limited in availability.

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Treaties honored in the breach

• 1972 Biological Weapons Convention
• Soviet Union in 1979 accidentally released
  anthrax
• Iraq in 1995 had anthrax, botulinum toxin, and
  aflatoxin

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United States 1969 stockpile

• Bacillus anthracis,
• botulinum toxin,
• Francisella tularensis,
• Brucella suis,
• Venezuelan equine encephalitis virus,
• staphylococcal enterotoxin B
• Coxiella burnetti (9).

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Soviet Union stockpile

• smallpox,
• plague,
• anthrax,
• botulinum toxin,
• equine encephalitis viruses,

• tularemia,
• Q fever
• Marburg
• melioidosis
• Typhus

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More details about

• Plague (Yersinia pestis),
• Smallpox (Variola major and minor)
• Anthrax (Bacillus anthracis),
• Tularemia (Francisella tularensis)
• Influenza is seldom mentioned but would be an
  excellent BioWeapon
• Many diseases have been accused of being
  BioWeapons, including SARS, Swine Flu and HIV

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Plague
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Plague (Yersinia pestis),

• gram-negative, anaerobic coccobacillus.
• transmitted to humans through fleas, rodents, or
  droplet infection.
• Human-to-human transmission quick
• Called Black death because the septic shock
  causes cyanosis, peripheral gangrene
• Blackening

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Rodents and fleas

• Endemic in rodents fleas transmit but dont
  sicken.
• The next mammal is the next victim.
• 10,000 years of human garbage attracting
  flea-ridden rats. Less a disease of nomads.

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Plague mode of transmission

• Natural Fleas from infected rodents
• BioWar aerosolized
• Large aerosol droplets contain 100-500 organisms
• Person-to-person transmission

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Plague

• Worldwide one of most feared diseases throughout
  history
• As many as 200 million deaths in last 1000 years.
  
• Not gone! India had outbreak in 1994.
• Endemic in US Southwest in rodents

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Plague Clinical Manifestations
Cervical bubo
Ecchymosis, septicemia
Gangrene, septicemia
Inglesby T, et al. JAMA 20003832281
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Plague

• 3 forms bubonic, pneumonic and septicemic
  Bubonic is classic.
• infected individuals die within 2 -3 days
• Bubonic has a mortality of 30 - 75 pneumonic
  septicemic forms have mortality of 90 - 100
  respectively
• Septicemic plague usually occurs secondary to
  bubonic or pneumonic plague.

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Plague Black lesions bubos(fingers toes,
penis nose)
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Symptoms Bubonic Plague

• AMS Hallucinations, headache, fever, chills.
• semiconscious to lethargic.
• " Madness (agitated delirium)
• Hematemesis, bloody diarrhea

• Lymphadenopathy swollen, tender lymph nodes
  (buboes) in armpits, groin even supra-clavicular
  and cervical buboes rupture suppurate
• Black blisters and hematemesis
• Recovered victims disabled muscular tremors,
  withered thighs and tongues

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Plague bubo
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Plague Septicemia

• Non-specific gram-negative septicemic symptoms
• Flu-like illness rapidly progresses to pneumonia,
  hemoptysis.
• Blood cultures , but no lymphadenopathy
  respiratory contagion at 2 to 5 feet.
• Pneumonic plague is 100 fatal unless treatment
  is given with 24 hours of the onset of symptoms.

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Pneumonic Plague

• Most contagious and deadly pneumonic plague
• Airborne person-to-person airborne spread.
• Y. pestis is not spore forming, and is viable for
  only 60 minutes as an aerosol.
• Doesnt live long on surfaces.

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Pneumonic Plague CXR
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Plague Diagnosis and Treatment

• CXR nonspecific
• Suspicion, setting, environment
• Standard treatment of bubonic, septicemic, or
  pneumonic plague is streptomycin, 30mg/kg IM q
  12 h x 10 days.
• alternatives chloramphenicol, gentamicin, or
  doxycycline.
• Chemoprophylaxis includes treatment with
  tetracycline or doxycycline.

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Plague Vaccine

• Not a generally viable option
• The Greer vaccine is an inactivated form of the
  disease, and requires a course of injections over
  6 months.
• A recombinant sub-unit vaccine is being
  investigated.
• Outbreak would spur vaccine development too late

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Smallpox
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Smallpox Communicability

• Contact fomites, person to person
• Aerosol communicability by aerosol requires
  negative-pressure isolation.
• One single case -gt 10 to 20 others.
• No more than 20 of the population has any
  immunity from prior vaccination
• No acceptable treatment

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Smallpox Mode of transmission

• Patient-to-patient transmission likely
• Droplets, Large Small
• More infectious if coughing or bleeding

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Smallpox the Virus

• 2 Wild types
• Variola major
• Variola minor
• Variola called "smallpox" to distinguish it from
  Syphilis, the "great pox"
• Smallpox is believed to have emerged in human
  populations about 10,000 BC.

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Pustules up close. Note thick covering of skin.
not like typical blisters.
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Small Pox Symptoms

• Maculopapular rash, then
• Raised fluid-filled blisters
• characteristic scars, commonly on the face, which
  occur in 6585 of survivors.
• Blindness resulting from corneal ulceration and
  scarring Limb deformities due to arthritis and
  osteomyelitis are less common complications,
  25 of cases.

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Variola Diseases

• V. major produces a more serious disease than V.
  minor
• V. major mortality 3035
• V. minor causes a milder form of disease (also
  known as alastrim, cottonpox, milkpox, whitepox,
  and Cuban itch kills about 1 of its victims.
• ?Protective immunity?

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Smallpox versus chicken pox
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Smallpox

• Lesions progress simultan-eously in Chicken pox
  they come in crops

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Biological Warfare Using Smallpox

• Ravaged Europe surviving population relatively
  immune
• Frequently used against American Indians
• The British June 24 1763, William Trent, a local
  trader, wrote, we gave them two Blankets and an
  Handkerchief out of the Small Pox Hospital. I
  hope it will have the desired effect.

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Diagnosis

• Clinical setting classic syndrome rash is
  enough to make the diagnosis
• Electron Microscopy of vesicle see Orthopox
  virus does not prove variola
• Culture definitive but SLOW. Chick membrane or
  cell culture
• PCR (ref lab) is faster

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Treatment

• Isolation!!
• Supportive care
• Fluid balance
• Electrolytes
• Hemodynamic support
• Respiratory support if needed
• No proven effective antivirals
• Antibiotics for secondary infections

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Smallpox Infection Control

• Strict Universal Precautions
• Prevent inhalation of particles 5µ or smaller
• Transfer to appropriate isolation room
• In large epidemic, may cohort patients
• Limit transportation (but use mask on patient if
  necessary)

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Post-Exposure Prophylaxis

• Vaccine
• Partially effective up to 3 days s/p exposure
• Reduces incidence 2-3 fold
• Decreases mortality by 50
• Plus Vaccinia immune globulin (VIG)
• 3 fold decrease in incidence and mortality
• Passive immunity for 2 weeks
• (?) Cidofovir antiviral agent is effective in
  animals against other poxviruses

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Smallpox prevention

• No more wild smallpox Vaccine available
• Last case 20 years ago
• Immunization may NOT confer lifelong immunity.
• CDC has 10-15M doses of vaccine, can produce more
  fairly quickly

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Reactions to Smallpox Vaccine
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More reactions
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Anthrax and tularemia (rabbit fever)

• Most infectious in aerosol
• cause the highest number of dead and
  incapacitated
• greatest downwind spread

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Anthrax Tularemia (rabbit fever)

• These are the most infectious aerosols
• Aerosols cause the highest number of dead and
  incapacitated
• Spread downwind person to person
• Available in the wild
• Weaponized versions are Abx resistant

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Anthrax
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Anthrax history

• Biblical Egyptian plague.
• Bacillus anthracis, a gram-positive, spore
  forming bacillus.
• Transmission by inhalation, ingestion, or skin
  breaks from infected animals or their products,
  or from terror attack.
• Often associated with sheep and wool

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Cutaneous lesions are black
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Anthrax as BioWeapon

• Anthrax as a Biological Weapon, 2002 Updated
  recommendations for management
• JAMA. 2002287(17)2236-2252 (doi10.1001/jama.287
  .17.2236)
• Thomas V. Inglesby Tara O'Toole Donald A.
  Henderson et al.
• http//jama.ama-assn.org/cgi/content/full/287/17/2
  236

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Lesion of Cutaneous Anthrax Associated With
Microangiopathic Hemolytic Anemia and
Coagulopathy in a 7-Month-Old Infant
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Infant w Cutaneous Anthrax

• Previous slide photo was from hospital day 12,
  when 2-cm black eschar was present in the center
  of the cutaneous lesion.
• Reprinted from Freedman et al.

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BioWar Anthrax not new

• Aerosol technologies for large-scale
  dissemination are developed and tested
• Brits weaponized Anthrax pre-WWII
• 1995, Iraq acknowledged producing weaponized
  Anthrax
• Soviet Union at least 13 other countries Clear
  evidence of offensive biological weapons programs.

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US 2001 Anthrax Attacks

• Powder containing Anthrax spores in at least 5
  letters to Florida, New York City, and
  Washington, DC.
• 22 confirmed or suspected Anthrax cases
• B anthracis spores in all the letters were Ames
  strain a research strain
• Aerosol release of B anthracis would be odorless
  and invisible and would have the potential to
  travel many kilometers before dissipating.

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Types of Anthrax

• cutaneous, (Woolsorter's disease),
• gastrointestinal
• inhalational
• CNS (meningitis)
• Anthrax invades the lymphatic system and causes
  hemorrhages, sepsis, produces necrotizing toxins
  death

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Cutaneous anthrax stemming from wearing
contaminated wool scarf
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Cutaneous anthrax

• inoculation of spores through open skin lesions.
• Painless, pruritic papules appear w/i 5 d.
• Papules develop into vesicles
• By 7 days, central necrosis develops
• Necrosis progresses to black eschar that
  eventually sloughs off.
• Cutaneous Not usually fatal
• Half the victims of mailed powdered anthrax 2001
  got cutaneous anthrax.

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Cutaneous Anthrax EscharRaised, vesiculated
edge, inflamed, and with a black base to the ulcer
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Cutaneous anthrax ulcer

• Antibiotics reduce systemic symptoms
• Antibiotics dont alter lesion course

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Gastrointestinal Anthrax

• Seen in poor, developing countries with food
  shortages or inadequate food inspection.
  Sub-Saharan Africa, Central Asia, Russia, India,
  and Thailand
• Usually have concurrent cutaneous cases from
  butchering the affected animal or handling the
  infected meat
• Probable frequency one outbreak per 64 infected
  animals eaten.

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Gastrointestinal anthrax

• From eating contaminated meat
• Starts with pharyngeal ulcers and edema.
• Hemorrhagic mesenteric adenitis, ascites,
  hematemesis, and melena may occur.
• Morbidity from loss of blood, fluids,
  electrolytes. Subsequent shock.
• Death from intestinal perforation or anthrax
  toxemia.
• Symptoms subside in 10 to 14 days in survivors

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Inhalational Anthrax

• Sudden, severe, acute febrile illness in persons
  at risk following a specific attack
• Fulminant course and death or acute febrile
  illness
• Example from 2001 attacks postal workers,
  members of the news media, and politicians and
  their staff
• Half got inhalational anthrax

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Inhalation anthrax

• Usually fatal. Infective dose is 8,000-15,000
  spores.
• Flu-like symptoms for 4 days.
• Primary pulmonary infection rare.
• Endospores are engulfed by alveolar macrophages,
  get transported to the mediastinal and hilar
  lymph nodes, germinate and multiply in lymph
  nodes.
• Hemorrhagic mediastinitis, peribronchial
  hemorrhagic lymphadenitis, Lymphatic drainage
  blocked.
• Pulmonary edema.
• Toxin released into circulation.
• Death from septicemia, toxemia, or pulmonary
  bleeding/edema.

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Anthrax CXR

• CXR widened mediastinum (classic but not so
  common), infiltrates, pleural effusion
• Chest CT hyperdense hilar and mediastinal nodes,
  mediastinal edema, infiltrates, pleural effusion
• Hemorrhagic mediastinitis, hemorrhagic thoracic
  lymphadenitis, hemorrhagic meningitis

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Diagnostic tests

• Toxin ELISA
• Peripheral blood smear culture gram-positive
  bacilli
• CXR classically, widened mediastinum pleural
  effusion, mediastinal edema (boards question)
• Chest CT scan hyper-dense mediastinal and hilar
  lymph nodes
• Thoracocentesis hemorrhagic pleural effusions

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Diagnosis

• DFA stain of infected tissues
• Thoracentesis hemorrhagic pleural effusions
• Peripheral blood smear gram-positive bacilli on
  blood smear
• Blood culture large gram-positive bacilli with
  preliminary identification of Bacillus species

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Treatment

• Natural strains sensitive to penicillin
• Doxycycline (preferred) of tetracyclines
• Fluroquinolones should have equivalent efficacy
  Penicillin, doxycycline, ciprofloxacin are FDA
  approved for inhalational anthrax.
• Other drugs clindamycin, rifampin, imipenem,
  aminoglycosides, chloramphenicol, vancomycin,
  cefazolin, tetracycline, linezolid, and the
  macrolides.

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Anthrax Prophylaxis

• Natural anthrax is PCN TCN sensitive
  weaponized Anthrax is resistant.
• CDC recommends
• Oral ciprofloxacin 500 mg q 12 hours.
• Prophylaxis for 60 days (unless exposure has been
  excluded) because disease can present 50 days or
  more after exposure.

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Anthrax Vaccine

• Poor, many side effects limited availability.
• 1997 all U.S. military personnel are required to
  receive it.
• Anthrax vaccine adsorbed (AVA) inactivated
  cell-free product, produced by Bioport Corp,
  Lansing, Mich.
• 6-dose SC series 0, 2, 4 weeks then 6, 12,
  18 months annual boosters.
• Peacetime / civilian safety has been questioned.

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Weaponizing Anthrax

• B anthracis engineered to resist tetracycline and
  penicillin. 1999 study induced in vitro Ofloxacin
  resistance
• Assume PCN TCN resistance if terrorist attack
• Fluroquinolones 1st choice. Maybe.
• Once susceptibility known, use most widely
  available, efficacious, and least toxic
  antibiotic

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Francisella tularensis

• aerobic, gram-negative, intracellular
  coccobacillus
• found in the water, soil, and vegetation.
• Natural reservoir small mammals such as rabbits,
  squirrels, and mice
• In many ways, similar to Plague

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Tularemia Disease

• 3 types Ulcero-glandular, Oro-glandular,
  Pneumonic.
• Usual humans infections from insect bites,
  contact with (skinning) infected rabbits or other
  small mammals, inhalation, contact with
  contaminated environments
• The last 2 modes of transmission are what makes
  F. tularensis an ideal agent for BioWar.

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Ulceroglandular Tularemia

• Most common. It occurs after a bite from an
  infected arthropod or from handling an infected
  mammal.
• Symptoms begin as flu-like and an ulcer appears
  at the site of infection.
• Regional lymph nodes enlarge and may resemble
  buboes.
• The patient may become bacteremic.
• Low mortality rate, but may take quite a long
  time for recovery.

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Oro-glandular Tularemia

• Usually after ingestion of contaminated raw meat,
  contaminated water occasionally from inhalation.
  
• Symptoms stomatitis, exudative Pharyngitis or
  tonsillitis.
• Cervical or retropharyngeal lymphadenopathy will
  occur and also may resemble buboes.
• Bacteremic possible low mortality rate, but long
  recovery.
• Immunity ?

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Pneumonic Tularemia

• Most severe form
• Inhalation of aerosolized bacteria. Or secondary
  to hematogenous spread from cutaneous or oral
  lesions.
• Symptoms fever, non-productive cough, pleuritic
  chest pain, chills, headache, and malaise. It may
  resemble community-acquired pneumonia.
• No person to person spread no isolation needed.
  
• Mortality rate of 30-60.

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Tularemia Chest x-ray

• May show infiltrates, hilar adenopathy, or
  pleural effusion.
• Can have TB-like miliary infiltrates.
• Sometimes caseating granulomas found on lung
  biopsy.
• Culture of F. tularensis will grow in about
  24-48 hours, and can make the definitive
  diagnosis
• PCR or ELISA may also be used to aid in the
  diagnosis.

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Treatment of Tularemia

• Streptomycin 30mg/kg IM q 12 h x 10-14 days.
• Alternative gentamicin 5mg/kg IM or IV q day x
  10-14 days.
• Vaccination is not recommended as a post-exposure
  prophylaxis.
• No live attenuated vaccine against tularemia yet.
  
• Weaponised Tularemia oral doxycycline or
  ciprofloxacin are recommended as post-exposure
  prophylaxis.

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Viral Hemorrhagic Fevers

• RNA viruses highly lethal, high infectivity by
  aerosol route. 90- 100 mortality
• Sx febrile illness, liver failure, DIC,
  hypotension, death. Highly contagious.
• Dx Setting, environment, HP
• Confirm viral serologies or culture (difficult)
• Available in the wild hard to handle.
• Weaponizable when techniques for tissue culture
  mature.

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The Viral Hemorrhagic Fevers

• Ebola Hemorrhagic Fever and Marburg Disease from
  the Filoviridae family.
• Lassa Fever from the Arenaviridae family
• Rift Valley Fever Crimean Congo Hemorrhagic
  Fever, from the Bunyaviridae family

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Clinical Hallmarks of Ebola

• Bleeding everywhere
• DIC,
• capillary leaks,
• bleeding eyes
• Nose, GI tract
• Highly Infective

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VHR Patient Isolator
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Treating in Isolator Difficult
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VHF - Treatment

• Mostly supportive and ineffective
• In a mass casualty situation, Triage (in the
  harshest sense of the word)
• For lesser numbers, consider antivirals
• Ribavirin for Lassa, CCHF, Rift Valley

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Personal Protective Equipment (PPE)

• No universal standard of PPE for health care
  providers in BioWar.
• Health Care workers will be among the first
  infected secondarily
• Fear of contamination or infection may prevent
  some physicians from going to work
• At a minimum mask, gown, gloves. Complete change
  of clothes and shower BEFORE LEAVING FACILITY.
• HCW may be isolated into workplace

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Decontamination in hospital

• Decontamination PRIOR TO patient arrival, and
  AWAY from hospital ventilation ducts.
• Do you know where the UH decon room is?
• BioAgent undress, mask the patient. For most
  agents, this would be enough.
• Anthrax washing the patient with soap and water
  reduces the likelihood of secondary
  aerosolization of the spores.

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Mass Casualty

• Wet decontamination (undress completely, shower
  with soap/detergent, contain effluent.)
• Isolate decontaminate all clothing patient
  goods
• Dilute bleach solution hypochlorite can render a
  biological agent harmless, is safe for equipment
  and most fabrics
• (hypochlorite is contraindicated for open wounds)
  
• Heat and radiation for durable equipment
• Autoclaving and dry heat at 100 C x 2 hours
• Solar UV radiation and desiccation to inactivate
  biological agents.

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