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BIO-TERRORISM A Threat or Trifle for Global Public Health? Ulrich Laaser & Ibrahim Khan Section of International Public Health Faculty of Health Sciences University of Bielefeld 1 Outline of the Presentation Definition & Introduction (Public Health Perspectives) Historical Perspectives Key Biological Agents & Modes of Bio-terrorism Anthrax: Epidemiology and Dynamics of Infection Impact & Magnitude of Infectious Emergency Clinical Management & Public Health Preparedness ? Conclusions Recommendations Recommended Sources of Literature 2 Definition of Bio-Terrorism? It can be described as "the use, or threatened use, of biological agents to promote or spread fear or intimidation upon an individual, a specific group, or the population as a whole for religious, political, ideological, financial, or personal purposes" CDC, 2002. 3 Silent Biological Killers Dispersal of microbes or their toxins to produce illness, death and terror The paths of infection can be contaminated water, food, air and packages. Microbes – Bacteria – Viruses – Toxins 4 The Nature of Biological hazards Biologoical Agents & Weapons represent a unique ” Environmental ” Hazard. The pathogens involved are natural in a sense the way they occur naturally in our environment, However they are unnatural in the way in which they are inflicted upon us or society. Dr.E. Noji (CDC) 5 The Motive Behind Bioterrorism ? •Fears, scares, disruption in social life •Inducing Human sufferings and damage •Endorsing political, religious & others motives 6 Bioterrorism: Early History BW used for thousands of years back. In the 18th Century French and Indian War One of the most notorious example, when British Officers gave blankets from smallpox victims to Indians aligned with French, Caused an epidemic in tribes and was thought an effective means of incapacitating group 7 Bioterrorism: History 1940s: BW techniques refined – Aerosol methods developed • Particles suspended in a mist or spray • Additives included to prevent decay – Mass production facilities – Mass delivery systems • Bombs, bomblets 8 Bioterrorism History: Japan Japan: First modern BW program – Unit 731: Japanese-occupied Manchuria, 1932-45 • Ping Fan: “Death Factory” – 3,000 doctors, technicians and soldiers – Biological experiments on prisoners – Annual budget $2.5 million • Biowarfare weaponization – Plague, Anthrax, Cholera • Performed crude field tests 9 Bioterrorism History: Japan Japan: World War II – BW attacks launched: • Salmonella, typhoid placed in rivers • Porcelain bombs with plague-infected fleas • Populations inoculated with cholera – Planned attacks: • Anthrax placed in fragmentation bombs • “Cherry Blossoms at Night” – Kamikaze pilots to spread plague over S. California 10 Bioterrorism History: U.S. United States: – Last of world powers to start BW program • British: Anthrax bomb tested on sheep, 1942 – 1944: US bomb loaded with Anthrax • Plans to drop on 6 German cities – War ended before bombs sent to Europe – 1952: Pine Bluff site opened • 1958: Missile with BW warhead 11 Biological Weapons Convention: The First Step Biological Weapons Convention in 1972 in USA & other countries pledged to ban the Development, Production & Stockpiling of Bacteriological (Biological) & toxin Weapons. Some historical events disclosed the intentions of some countries that development is still underway Despite this convention. – The anthrax incident in Sverdlovsk in USSR in April, 1979 affected 200-1000 people – Gulf War Syndrome & 1991 UN announcement on Iraq,s Capability (B.Anthrax & the toxin of C. Perfringens) Source: CDC, 2001 12 Special Features Related to Bio-terrorism Potential for Mass Casualties Short Window for Effective Intervention Use of Rare or unusual Organisms: – Variola Major, Burkholderia Psuedomallei – Genetically manipulated organisms – Anti-biotic resistant organisms Requires different agency coordination & integration (e.g., Law enforcement) Physicians, Public Health and paramedics have limited knowledge, practical Experiences on the subject and resources Source: CDC, 2001 13 Bioterrorism: Cost-effectiveness Weapon of Mass Destruction Cost of casualties ($ per square km) Conventional 2,000 Nuclear 800 Nerve gas 600 Biological weapon 1 14 Chemical-Biological Expert Panel, U.N., 1969 The Threats of Bio-Disasters Current Depots of lethal Viruses & Bacteria can go into wrong hands (anthrax in USA after Sep, 11 ) Use on large Scale is difficult but small Scale attacks Availability of Vaccines & Anti-Biotic for Massive Use No Proper Public Awareness exists on the subject Unlike Chemical & Nuclear, BT is silent and lately detected Clinical & Public health Preparedness is non-existent or weak in many Countries (both developed & non-developed Countries) th 15 Critical Biological Agents Category A High Priority organisms Pose high risk N. Security Easily disseminated or PTP transmission Cause high mortality, Potential for major public health impact might cause public panic & social disruption & require special action for Health preparedness Category B 2nd highest Priority orgs. Moderate dissemination or PTP transmission Cause Moderate M & M, Potential for major public health impact require special action for Public Health preparedness Category C 3rd highest Priority orgs. Engineered for mass dissemination in future due to availabilityease of production & Dissemin. Potential for high M & M, Potential for major public health impact Source: WHO, 2001 16 Critical Biological Agents A Agents C Agents Variola major C. Burnetti (Q fever) Nipha Virus (Smallpox) Brucella Sp. Antaviruses B. Antrhacis (Anthrax) (Brucellosis) Tickborne Yersinia Pestis (Plague) Venezuelan Homm.FV Encephalitis C. Botulinum toxin (Botulism) Staphylococcus T.Encephalitis V Enterotoxin B F.Tularensis Yellow Fever V (tularemia) Epsilon Toxin of C. MDRPerffringens Ebola H. fever virus Tuberculosis Food, waterborn Marburg HFV Lassa Fever V Argentine HFV B Agents pathogens Salmonella Sp. Shigella Dysent. E.Coli V.Cholerae Source: WHO, 2001 17 Anthrax is a Preferred Biological Warfare Agent because • It is highly lethal. • 100 million lethal doses per gram of anthrax material (100,000 times deadlier than the deadliest chemical warfare agent). • Silent, invisible killer. • Inhalational anthrax is virtually always fatal 18 The Impact of Bio-terrorism: The Case of Anthrax 19 Evaluation of Organisms as Bio-terrorist Tools Organism Property Anthrax Smallpox Plague Available, easy to grow ? Easy to disperse to many people Person to person to spread Causes serious/ fatal disease No Proven Treatment 20 BIOLOGICAL WARFARE: IMPACT [release of 50 kg agent by aircraft along a 2 km line upwind of a population center of 500,000 – Christopher et al., JAMA 278;1997:412] Agent Rift Valley fever Tick-borne encephalitis Typhus Brucellosis Q fever Tularemia Anthrax Downwin No. dead No. d reach, incapacitat km ed 1 400 35,000 1 9,500 35,000 5 10 >20 19,000 500 150 85,000 125,000 125,000 >20 >20 30,000 95,000 125,000 125,000 21 History of Anthrax as Biological Weapon 22 Epidemiology of Anthrax (2001) USA 17 confirmed infections 3 deaths (2 in Washington DC, 1 in Florida) 7 ill with inhalation anthrax 7 cases skin anthrax 23 13,300 postal workers taking antibiotics as protective measure Anthrax: Less barriers to production. Low cost of producing the anthrax material. Not high-technology. Knowledge is widely available. Easy to produce in large quantities. It is easy to weaponize. It is extremely stable. It can be stored almost indefinitely as a dry powder. It can be loaded, in a freeze-dried condition, in munitions or disseminated as an aerosol with crude sprayers. Currently, we have a limited detection capability 24 Key Points of Pulmonary Anthrax 25 26 The Use of Bio-Agents Site: The Dalles, Oregon, 1984 Agent: Salmonella typhimurium Method of transmission: Restaurant salad bars Number ill: 751 Responsible party: Members of a religious community had deliberately contaminated the salad bars on multiple occasions (goal to incapacitate voters to prevent them from voting and thus influence the outcome of the election) Source: Torok TJ, et al. JAMA 1997;278:389-395 27 Type of Disease Transmission Direct Projection Large Droplets 1 meter spread Pertussis Smallpox Indirect spread Vehicle Born Drinking Water Cholera Indirect spread Droplets Nuclei 1-5 Microns airborne Tuberculosis Anthrax 28 PERSON-TO-PERSON ACQUISITION Disease Transmission Risk Andes virus Undefined Low Anthrax Contact with skin lesions Rare Ebola, Lassa, Marburg, CongoCrimean, AHF, BHF Smallpox Contact with infective fluid, droplet? High Contact, droplet, airborne High Plague (pneumonic) Droplet High Q fever Contact with infected placenta Rare 29 STEPS IN MANAGEMENT 1. Maintain an index of suspicion 2. Protect thyself 3. Assess the patient 4. Decontaminate as appropriate 5. Establish a diagnosis 6. Render prompt therapy 7. Practice good infection control 30 STEPS IN MANAGEMENT 8. Alert the proper authorities 9. Assist in the epidemiologic investigation 10. Maintain proficiency and spread the gospel US Army, Biologic Casualties Handbook, 2001 31 The Triangle of Infectious Diseases Emergency Infectious Person Transmission Susceptible Person Organism Time Place 32 DETECTING A BIO-TERROR EVENT? Epidemiologic features – A rapidly increasing disease incidence – An unusual increase in the number of people seeking care, esp. with fever, respiratory, or gastrointestinal symptoms – An endemic disease rapidly emerging at an uncharacteristic time or in an usual pattern – Lower attack rate among persons who had been indoors – Clusters of patients arriving from a single local – Large numbers of rapidly fatal cases – Any patient presenting with a disease that is relatively uncommon and has bio-terrorism potential 33 DETECTION OF OUTBREAKS Recognition – Syndrome criteria – Epidemiologic features Communication Medical – Triage, psychological aspects, lab support, public information – Patient isolation (Follow UNC guidelines), decontamination – Post-exposure prophylaxis, treatment of infected persons 34 What constitutes Preparedness for Bio-terrorism? To upgrade the capacities and readiness of the State and local public health institutions & jurisdictions’ to be prepared for dealing with the Public health threats & Emergencies in the communities. 35 ARE WE WELL PREPARED ? Do we have a common comprehensive Policy (protocols, guidelines, manuals) on Is it likely that early recognition (clinical identification) of a biological attack would occur? Are communication lines established? Do we have sufficient medications for postexposure prophylaxis and therapy? Are there sufficient medical facilities to manage exposure and infection? THE ANSWER TO ALL OF THE ABOVE IS NO!!! 36 STEPS IN MANAGEMENT 1. Maintain an index of suspicion 2. Protect thyself 3. Assess the patient 4. Decontaminate as appropriate 5. Establish a diagnosis 6. Render prompt therapy 7. Practice good infection control 37 STEPS IN MANAGEMENT 8. Alert the proper authorities 9. Assist in the epidemiologic investigation 10. Maintain proficiency and spread the gospel US Army, Biologic Casualties Handbook, 2001 38 What makes Stringent Public Health Measures in the event of an Attacks? 39 Measures to Protect Public Health Identification of the Source, Immediate Removal of The Source if known Established surveillance & Monitoring System for prompt detection & Response Infection Control & assessment of extent of contamination of Environment and identification of risk management Deployment of material from the National Drug Stockpiles Mass Fatality Management to provide respectful & safe disposition 40 Public Health Measures for Emergency Situation Networks of Information exchange among laboratories, Pharmacies, Research medical and Public Health institutions to identify unusual pattern of diseases in the community Mass Patient Care, Auxiliary & Treatment Facilities Massive Immunization or Prophylactic Drug Treatment Emergency measures to save lives, alert Hospitals & Health Care Centers to provide facilities for early detection Management & Prevention of secondary contamination and those who are exposed 41 Post Exposure Infection Control Stringent Public health Safety Measures of – Isolation and adequate Quarantine Measures – Keep patients in homes, not hospitals • forcible quarantine if necessary – Vaccinate the contacts 42 Adding to the Responsiveness Good Media Coverage & updates on the event, safety information Law enforcement agencies, Federal authorities supplement local activities Coordinating medical & Public Health Response to Mass Causality Events Security in Food Protection, supply and Hygiene control Strengthening targeted education & Training Massive Public education campaign on vital agents used in such attacks 43 Conclusion Due to increase security measures large scale bioterrorism is less likely to occur but Preparedness is essential It require specific Public Health Policy & and integrated action for which Prior Readiness & Preparedness is essential Develop competency standards for physicians, nurses & Paramedics that focus on emergency care of & definitive treatment of mass causalities from nuclear, biological or chemical disasters. Increased Security of research institutions where lethal viral are kept 44 Recommended Literature Resources in German & English Robert Koch InstituteBerlin(http://www.rki.de/GESUND/GESUND-BT.HTM) Arztblatt (http://www.aerzteblatt.de/archiv/artikel.asp?id=29063 ) Arztkammer (http://www.aerztekammersaarland.de/85/20011023Biowaffen/) Book: http://www.baxter.de/fachkreise/bioterrorismus/Baxter_Ellipse_S mallpox.pdf WHO (http://www.who.int) CDC (http://www.cdc.gov/) 45