BIOTERRORISM

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BIOTERRORISM

• Dr. E. McNamara
• Public Health Lab. HSE, Dublin.
• St. Jamess Hospital.

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9/11 Changes

• Move to high risk
• Biological Threat, specialist public arena
• Newsworthy
• Rare/eradicated infections
• Low clinical experience

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Autumn 2001 USA

• 5 letters, finely milled anthrax spores
• 11 pulmonary anthrax (5 died)
• 7 cutaneous anthrax
• All sent from Trenton, New Jersey, 1 person
• American origin, B. anthracis
• Criminal Act Terrorist

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Lessons Learned

• No one prepared
• Easy to produce contagious material
• Easy to spread, (except aerosolization)
• Small numbers affected, major concern
• Copy cat phenomenon Hoaxes
• Lab. techniques for diagnosis
• Major disruption
• Use of prophylactic antibiotics

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Benefits

• Co-operation internationally
• WHO
• CDC
• EU
• National preparedness Plans
• Multidisciplinary
• Government
• Admininstrative
• Emergency services
• Medical
• Scientific

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History Biological Warfare

• Water wells contaminated with corpses
• Siege Caffa, Crimea 1346, used plague corpses
• British, gave Smallpox contaminated blankets as
  presents to Native Americans

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Modern History Biological Warfare

• Germany WWI
• sold anthrax infected horses
• WWI-II
• Many countries started biological programme
• WWII Not Used
• UK 5 million anthrax cattle-cakes
• USA Botulinum
• Canada Plague
• Germany Salmonella
• Japan POW/Chinese trials

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Post WWII

• USA
• 3400 people 1969, BTWC
• Allegation
• Korean War
• Cuba
• Misinformation, FBI to Soviets
• Soviets
• 1920 1969, BTWC signed
• 1975 Enlarged, Biopreparat
• 60,000 people
• 40-50 facilities
• 50 agents

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Post WWII contd.

• 1979 Sverdlovks, Anthrax, 69 died
• 1980 1990 Defections
• 1990 Yelsin cessation?
• Iraq 1974?, S. Africa 1980-1993
• 10 12 trying to acquire, evidence?

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Preparing for Biological Attacks

• Enhance surveillance
• Resource laboratories
• Communication systems
• Bioterrorism education
• Stockpile vaccines and drugs
• Molecular surveillance microbial strains
• Support development diagnostic tests
• Support research Rx. and vaccines
• CDC April 2000

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Biological Agents

• Category A
• Easily dessiminated
• High mortality
• Public panic
• Require special preparedness
• Category B
• Moderately easy to dessiminate
• Low mortality
• Need enhanced Dx./surveillance
• Category C
• Emerging pathogens

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Anthrax, B. anthracis

• Zoonotic, spore forming rod
• Soil reservoir, years
• Affects large domestic and wild herbivoires
• Worldwide
• Humans
• Contact with infected animals/products
• Skin cutaneous
• GIT/resp. inhalation
• 2000 cases, cutaneous / year
• 5 cases USA, 1 case UK
• No cases Ireland for 25 years

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Anthrax contd.

• Bioterrorist threat inhalation spores
• No person person spread ! (cutaneous?)
• Cutaneous
• Skin inoculation
• Painless swelling
• Papular vescle ulcer
• Black eschar
• Toxaemia
• Mortality with Rx., lt 1.
• GIT
• Ingest contaminated meat
• Pain, diarrhoea, haematemesis, septicaemia
• Mortality gt 50

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Anthrax contd.

• Dx. (Confirm reference laboratory)
• Hazard Group 3 CL3
• Non motile, GPB, Aerobic
• Central / Terminal spores
• Nonhaemolytic
• Sensitivity tests
• Rx. Penicillin / Ciprofloxacin
• Post exposure prophylaxis Ciprofloxacin
• Infection Contol standard precautions

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Biological Agents

• Category A
• Easily dessiminated
• High mortality
• Public panic
• Require special preparedness
• Category B
• Moderately easy to dessiminate
• Low mortality
• Need enhanced Dx./surveillance
• Category C
• Emerging pathogens

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Anthrax, B. anthracis

• Zoonotic, spore forming rod
• Soil reservoir, years
• Affects large domestic and wild herbivoires
• Worldwide
• Humans
• Contact with infected animals/products
• Skin cutaneous
• GIT/resp. inhalation
• 2000 cases, cutaneous / year
• 5 cases USA, 1 case UK
• No cases Ireland for 25 years

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Anthrax contd.

• Bioterrorist threat inhalation spores
• No person person spread ! (cutaneous?)
• Cutaneous
• Skin inoculation
• Painless swelling
• Papular vescle ulcer
• Black eschar
• Toxaemia
• Mortality with Rx., lt 1.
• GIT
• Ingest contaminated meat
• Pain, diarrhoea, haematemesis, septicaemia
• Mortality gt 50

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Anthrax contd.

• Dx. (Confirm reference laboratory)
• Hazard Group 3 CL3
• Non motile, GPB, Aerobic
• Central / Terminal spores
• Nonhaemolytic
• Sensitivity tests
• Rx. Penicillin / Ciprofloxacin
• Post exposure prophylaxis Ciprofloxacin
• Infection Contol standard precautions

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Inhalation Anthrax

• Bioterrorist agent
• Mortality 90
• Incubation 1 60 days
• Initial Phase (hrs days)
• Non-specific symptoms
• Non-specific clincial signs Dx. test
• Recover / Progress to fulminant
• Fulminant Phase
• Septicaemia / Toxaemia
• Dyspnoea with CXR mediastenal widening
• 50 haemorrhagic menigitis and death
• Mortality increased with short incubation

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Small Pox

• Human, DNA variola virus
• 2 Forms
• Variola major, mortality 30 (3 vaccinated)
• Variola minor, mortality 1
• Airborne spread, contact
• Secondary attack rate 50 (unvaccinated)
• Last death 1978 UK.
• WHO 1980, eradicated.

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Small Pox contd.

• Incubation 12-14 days, rash further 2-4 days
• Fever, headache, myalgia, abdominal pain and
  vomiting
• Delirium 15
• Rash, centrifugal, face and extremities
• Copious virus on mucosal lesions
• Secondary bacterial pneumonia (mortality gt 50)
• Haemorrhagic Small Pox (95 mortality)
• Differental Chicken Pox.

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Small Pox contd.

• Dx.
• Hazard Group 4
• EM (Herpes Pox) - CL3
• PCR (differentites Pox viruses) CL4
• Culture CL4
• Public Health Emergency International
• Case Standard, contact and airborne precautions
• Isolate negative pressure, HEPA extract
• PPE. Decontamination protocol
• Immune HCW (vaccinated)
• Rx. supportive
• Contact/Exposed
• Quarantine for 18 days - monitor temperature
• Infectious form onset of fever

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Small Pox Vaccine

• Face face contacts
• HCW (core, prepardness)
• Designated emergency personnel
• Vaccine
• Live vaccinia virus (not variola)
• Vaccine site, infectious until scab heals
• Newer vaccine development
• S/E
• Efficancy

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Small Pox Vaccine contd.

• CI atopic dermatitis, pregnant,
  immunocompromised
• S/E
• Fever headache, rigors, vastles
• Generalised vaccinia (GV)
• Eczema vaccinatum (EV)
• Progressive vaccinia (PV)
• Post vaccinial CNS (PVE)
• Incident 1968
• Life threatening 52 / million
• Deaths 1.5 / million

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Cl. Botulinum

• Botulinum neurotoxin most potent
• Contaminated food, canned products
• Wound botulism, contaminated soil, IVDA
• Bioterrorism agent
• Aerosolisation inhalation
• Contaminate food ingestion
• Large numbers with acute flaccid paralysis

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Cl. Botulinum contd.

• Incubation
• 2hrs 8 days, Foodborne
• 1hr 5 days, Aerosol
• Foodborne
• VD, diplopia, dysarthria, weakness
• Ptosis, facial palsy, ?gag Hypotonic
• Inhalation
• Dysplagia, nystagmins, ?speech, ?gait
• Terminal
• Progressive muscular paralysis
• Mortality 5 (with Rx.)

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Cl. Botulinum contd.

• Differential Dx.
• Guillain-Barré
• Myastheria gravis
• Stoke
• CNS despressants

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Cl. Botulinum contd.

• Dx.
• Detect botulinum toxin
• Culture
• Rx.
• Antitoxin
• Supportive
• Infection Control standard precautions

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Plague

• Yersinia pestis HG3
• GNCB, 02
• Aerosol, flea vector, person-person
• 3 Forms
• Bubonic 90
• Septicaemic 10
• Pneumonic 1
• Bioterrorist agent
• Aerosol pneumonic
• Fleas bubonic, septicaemic

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Bubonic Plague

• Incubation 1-8 days
• Fever, rigors, headache
• Buboes painful lymph nodes
• 15 develop pneumonic plague
• Mortality 12

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Septicaemic Plague

• Primary, or secondary to bubonic
• Rigors, abdominal pain, VD
• Purpura, DIC, necrosis
• Mortality 30

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Pneumonic Plague

• Highest bioterrorism risk
• Primary or secondary from haematogenous
• Incubation 1-3 days
• Pneumonic symptoms
• Respiratory failure and shock
• Mortality - ?with rx. 8

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Plague

• Dx.
• Culture
• Rx.
• Gentamicin, Streptomycin IV
• Ciprofloxacin, Doxycycline P.O.
• Infection Control
• Standard and droplet, single room, surgical mask
• Contacts
• Prophylaxis Ciprofloxacin 72 hrs.

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Tularaemia

• F. tularensis
• Non-motile, aerobic, GNCB, zoonosis, rabbits,
  deerfly
• HG3
• Worldwide
• Low inoculum 10 CFU
• Ulceroglandular
• Typhoidal
• Mortality 35-60 (untreated)
• Inhalation
• Infection Control standard (no person-person)
• Rx. Gentamicin/Streptomycin 10 days
• Contacts prophylaxis

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Tularaemia
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Tularaemia