Download Bioterrorism

PU 430
Unit 5
Chapters 2 and 3
Bioterrorism
http://www.youtube.com/watch?v=2t_MsSO9qRk
Chapter Two
Basic Facts About
Bioterrorism Threats
 Bioterrorism is the use or threatened use of
biological agents as weapons of terror
 Current U.S. laws make the threat alone a
severe crime
 The biological material used may be lethal or
nonlethal, a common bacteria or virus, the
toxic by-product of a pathogen, a rare
organism, or even a specially engineered
organism, never before diagnosed or treated
 These acts are intended to instill fear in the
targeted population in support of terrorist goals
 Organisms or other biological materials can be
released in the air, or placed in food or water
sources
Advantages of Biologics
as Weapons
Easy to obtain
 Inexpensive to produce
 Potential dissemination over large
geographic area
 Creates panic
 Can overwhelm medical services
 Susceptible civilian populations
 High morbidity and mortality
 Difficult to diagnose and/or treat
 Some are transmitted person-to-person via
aerosol

Routes of Infection
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Skin (cuts, abrasions, mucosal membranes)
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
Respiratory
◦ Inhalation of spores, droplets & aerosols
◦ Aerosols most effective delivery method
◦ 1-5F droplet most effective
Medical Response
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Pre-exposure
◦ active immunization
◦ prophylaxis
◦ identification of threat/use
Incubation period
◦ detection and diagnosis
◦ active and passive immunization
◦ antimicrobial or supportive therapy
Overt disease
◦ diagnosis
◦ treatment
 may not be available
 may overwhelm system
 may be less effective
◦ direct patient care will predominate
Bioterrorism:
Who are 1st Responders?
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Primary Care Personnel
Hospital ER Staff
EMS Personnel
Public Health Professionals
Other Emergency Preparedness
Personnel
Laboratory Personnel
Law Enforcement
Scenarios
 Overt
Event
◦ Announced
◦ Patients Fall ill or Die
(Increased Morbidity and
Mortality)
◦ Microorganisms Unconfirmed
◦ Hoaxes Assumed to be Real
Scenarios
 Covert
Event
◦ No Prior Warning - Unannounced
◦ Patients Fall ill or Die from
Causes of Unknown or Unusual
Origin
◦ Unusual Cluster(s) of Cases May be Geographically
Distributed
◦ Undetermined Causative Agent
 Bioterrorism preparedness activities include:
◦ The development & practice of a mass emergency
distribution of pharmaceuticals
◦ Risk communication training
◦ Incident Command System training for public
health & healthcare workers
 Controversy surrounds many issues, including:
◦ Vaccinations & antibiotics
◦ The potential for increasing bioterrorism &
biocrime risks
◦ Funding of public health programs
U.S. Bioterrorism
Preparedness Controversies
 Category A pathogens - High priority
organisms & toxins posing the greatest
threat to public health
 Category B agents - Fairly easy to
disperse but have lower morbidity &
mortality than the Category A agents &
can be successfully addressed
 Category C agents - Emerging infectious
organisms that could become easily
available at some point in the future &
used as a weapon
Categorization of Threats
 Anthrax (Bacillus anthracis) – considered by many
to be the perfect biological weapon
 Botulism (Clostridium botulinum toxin) - regarded
as the most potent poison in the world
 Plague (Yersina pestis) - without quick antibiotic
treatment, can cause death in several days
 Smallpox (Variola major, Variola minor) - the most
destructive infectious disease in human history
 Tularemia (Francisella tularensis) - highly infectious
for individuals directly exposed to the organisms,
but is not spread from person to person
 Viral Hemorrhagic Fevers (Filoviruses,Arenaviruses,
Bunyaviruses, & Flavivruses) – have potential
lethality & infectiousness at low doses when
delivered as an aerosol
Health Threats:
Category A Organisms
Anthrax: Current Issues in
the U.S.
 Anthrax remains an endemic public health
threat through annual epizootics.
 B. anthracis is one of the most important
pathogens on the list of bioterrorism threats
Aerosolized stable spore form
Human LD50 8,000 to 40,000 spores, or
one deep breath at site of release
http://www.youtube.com/watch?v=4IxFU_itIUE
Exposure Situation Management:
B. anthracis in Envelope
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Antimicrobial prophylaxis for those
potentially exposed
Environmental samples
◦ Surface swabs
◦ Nasal swabs of potentially exposed
persons (if <7 days)
Refine list of potentially exposed persons
◦ Not exposed: stop treatment
◦ Likely exposed: continue treatment for
60 days total
Anthrax: PostExposure Treatment

Start oral antibiotics as soon as possible
after exposure
◦ Ciprofloxacin or Doxycycline or
Amoxicillin/Penicillin (if known PCN
sensitive)
Antibiotics for 60 days without vaccine
 Antibiotics for 30 days with 3 doses of
vaccine (animal studies)
 Long-term antibiotics necessary
because of spore persistence in
lung/lymph node tissue
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Post-Exposure Treatment
(continued)

Current U.S. vaccine (FDA Licensed) continued
◦ FDA approved for 6 dose regimen over 18
months
◦ 3 dose regimen (0, 2, and 4
weeks) may be effective for post-exposure
treatment (animal studies)
◦ Limited availability
Anthrax: Vaccine
(continued)
 Prevention of bioterrorism
 Public Health Security & Bioterrorism
Preparedness & Response act of 2002
 The Pandemic Preparedness & Response Act
Prevention
FOODBORNE
BOTULISM
Infective dose: 0.001 g/kg
Incubation period: 18 - 36 hours
Dry mouth, double vision, droopy
eyelids, dilated pupils
 Progressive descending bilateral
muscle weakness & paralysis
 Respiratory failure and death
 Mortality 5-10%, up to 25%
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Level A Procedures
for Botulism Event
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Properly collected specimens are to be
referred to designated testing
laboratories
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Prior to the shipment of any botulismassociated specimen, the designated
laboratory must be notified and
approved by the State Health
Department
Plague: Overview
Natural vector - rodent
flea
 Mammalian hosts
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◦ rats, squirrels,
chipmunks, rabbits, and
carnivores
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Enzootic or Epizootic
CDC: Wayson’s Stain of Y. pestis showing
bipolar staining
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Three Clinical Types:
◦ bubonic (infected lymph nodes)
◦ septicemic (blood-borne organisms)
◦ pneumonic (transmissible by aerosol;
deadliest)
Plague Epidemiology
Plague: Prophylaxis

Bubonic contacts
◦ If common exposure, consider oral Doxycycline,
Tetracycline, or TMP/SMX for 7 days
◦ Other close contacts, fever watch for 7 days (treat if
febrile)
 Pneumonic contacts
(respiratory/droplet exposure)
◦ Consider oral Doxycycline, Tetracycline, or
TMP/SMX
◦ Continue for 7 days after last exposure

Vaccine no longer manufactured in
U.S.
◦ Not protective against pneumonic plague
Plague: Prophylaxis
(continued)
 Limiting the impact of a bioterrorism attack
requires healthcare providers with sufficient
training & support to remain diligent
 Regular disease surveillance includes:
◦ Mandatory disease reporting by local healthcare
providers
◦ Data entry & analysis by local or regional public health
agencies
◦ Additional analysis, reporting, & allocation of needed
resources by state & federal public health agencies
 Other forms of surveillance include
environmental monitoring & standoff detection
Detection
Supportive therapy
Isolation with droplet precautions for
pneumonic plague until sputum cultures
negative
 Antibiotic resistant strains have been
documented
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Plague:
Medical Management
Plague: Clinical Forms
Bubonic
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Bubonic
◦ Inguinal, axillary, or cervical lymph nodes
most common
◦ 80% can become bacteremic
◦ 60% mortality if untreated
Plague: Bubonic
Incubation: 2-6 days
 Sudden onset headache,
malaise, myalgia, fever,
tender lymph nodes
 Regional lymphadenitis
(Buboes)
 Cutaneous findings
◦ possible papule, vesicle, or
pustule at inoculation site
◦ Purpuric lesions - late

USAMRICD:
Inguinal/femoral
buboes
Smallpox: Overview
1980 - Global
eradication
 Humans were only
known reservoir
 Person-to-person
transmission
(aerosol/contact)
 Up to 30% mortality in
unvaccinated
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CDC: Electron
micrograph of
Variola major
 Prodrome
(incubation 7-17 days)
◦ Acute onset fever, malaise,
headache, backache, vomiting
◦ Transient erythematous rash
Smallpox:
Clinical Features
Level A Procedures
Smallpox virus
Rule out chickenpox (PCR)!
 Specimen of choice is lesion material from
pustules
 Contact your State Public Health
Laboratory for guidance

Smallpox:
Current Vaccine
Made from live Vaccinia
virus
 Intradermal inoculation
with bifurcated needle
(scarification)
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◦ Pustular lesion/induration
surrounding central
scab/ulcer 6-8 days after
vaccination
WHO: Smallpox vaccine vials
Smallpox:
Medical Management
Strict respiratory/contact isolation of patient
◦ Patient infectious until all scabs have
separated
 Notify public health authorities immediately for
suspected case
 Identify contacts within 17 days of the onset of
case’s symptoms

 With quick identification of the biothreat
agent & population at risk, there is a
window of opportunity for prophylactic
treatment
 Decisions must be made rapidly & the
response needs to begin immediately
 Communication must be quickly
established with the population at risk
 Those working in healthcare, public
health, & the first response community
need to be provided with detailed
instructions on how to respond
Immediate Actions
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Awareness
Laboratory Preparedness
Plan in place
Individual & collective protection
Detection & characterization
Emergency response
Measures to Protect the Public’s Health
and Safety
Treatment
Safe practices
Bioterrorism:
What Can Be Done?
Clean-up will not be difficult for most
pathogenic organisms, with the notable
exception of anthrax
 Federal Insecticide, Fungicide, &
Rodenticide Act (FIFRA)

◦ The Environmental Protection Agency has
established a listing of “antimicrobial products”
to ensure that effective cleaning agents are
used
Recovery
Bombings and
Explosions
Chapter Three
Introduction
 Between 2006 & 2007, the death toll
related to bombs increased by 30% & the
number of suicide bombings increased by
approximately 50%
 Today’s bombers often want to generate
as many civilian casualties as possible &
are acquiring the technologies & methods
to reach that objective
 Four categories have been established to aid in the
understanding of the complex assortment of
injuries associated with explosions & provide
structure for the triage process:
◦ Primary blast injuries
◦ Secondary blast injuries
◦ Tertiary blast injuries
◦ Quaternary blast injuries
Health Threat
1.) Physical Security
2.) Threat Detection &
Identification
Prevention
 If a threat necessitates an evacuation
from a building:
◦ Everyone at risk must be evacuated
immediately to a safe distance
◦ Occupants should quickly collect personal items
so they are not among the possible threats
needing to be assessed by bomb technicians
◦ Elevators should not be used
◦ There should be a rallying point away from the
building for a head count
Immediate Actions
 The Centers for Disease Control & Prevention
have established several essential concepts that
caregivers need to keep in mind concerning
provision of care to those injured in explosions
 It is important for all the first responders to be
aware of risks when approaching a potential
bomb scene
 It is important to consider the possibility of
residual explosive material
 Local public health agencies also have an
important role in long-term monitoring & followup of survivors
Health & Medical Response