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BIOTERRORISM Dr. E. McNamara Public Health Lab., SWAHB, St. James’s Hospital ‘9/11 – Changes’ • • • • • Move to high risk Biological Threat, specialist public arena Newsworthy Rare/eradicated infections Low clinical experience ‘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 ‘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 Benefits • Co-operation internationally – WHO – CDC – EU • National preparedness Plans • Multidisciplinary – – – – – Government Admininstrative Emergency services Medical Scientific 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 Modern History – Biological Warfare • Germany WWI – sold anthrax infected horses • WWI-II – Many countries started biological programme • WWII – Not Used – – – – – UK USA Canada Germany Japan 5 million anthrax ‘cattle-cakes’ Botulinum Plague Salmonella POW/Chinese trials 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 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? Preparing for Biological Attacks • • • • • • • • Enhance surveillance Resource laboratories Communication systems Bioterrorism education Stockpile vaccines and drugs Molecular surveillance microbial strains Support development diagnostic test Support research Rx. and vaccines CDC April 2000 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 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 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., < 1%. • GIT – Ingest contaminated meat – Pain, diarrhoea, haematemesis, septicaemia – Mortality > 50% Anthrax contd. • Dx. (Confirm reference laboratory) – – – – – Hazard Group 3 – CL3 Non motile, GPB, Aerobic Central / Terminal spores Non–haemolytic Sensitivity tests • Rx. – Penicillin / Ciprofloxacin • Post exposure prophylaxis = Ciprofloxacin • Infection Contol – standard precautions 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 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. 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 > 50%) • Haemorrhagic Small Pox (95% mortality) • Differental = Chicken Pox. 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 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 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 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 Cl. Botulinum contd. • Incubation – 2hrs – 8 days, Foodborne – 1hr – 5 days, Aerosol • Foodborne – V+D, diplopia, dysarthria, weakness – Ptosis, facial palsy, ↓gag Hypotonic • Inhalation – Dysplagia, nystagmins, ↓speech, ↓gait • Terminal – Progressive muscular paralysis – Mortality 5% (with Rx.) Cl. Botulinum contd. • Differential Dx. – – – – Guillain-Barré Myastheria gravis Stoke CNS despressants Cl. Botulinum contd. • Dx.: – Detect botulinum toxin – Culture • Rx.: – Antitoxin – Supportive • Infection Control – standard precautions 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 Bubonic Plague • • • • • Incubation 1-8 days Fever, rigors, headache Buboes – painful lymph nodes 15% develop pneumonic plague Mortality = 12% Septicaemic Plague • • • • Primary, or secondary to bubonic Rigors, abdominal pain, V+D Purpura, DIC, necrosis Mortality = 30% Pneumonic Plague • • • • • • Highest bioterrorism risk Primary or secondary from haematogenous Incubation 1-3 days Pneumonic symptoms Respiratory failure and shock Mortality - ↓with rx. = 8% 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. 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