Chemical and Biological Terrorism Phillip L. Coule, M.D. Medical College of Georgia Assist. Professor of Emergency Medicine Director, EMS and ECC An Overview of the Threat

Phillip L. Coule, M.D.2 Expert??? After September 11?

Phillip L. Coule, M.D.3 Objectives Review history and define Nuclear, Chemical and Biological Terrorism Review history and define Nuclear, Chemical and Biological Terrorism Review previous ChemBio events Review previous ChemBio events Overview of CDC Class A bioterrorism agents Overview of CDC Class A bioterrorism agents Overview of chemical agents and toxins Overview of chemical agents and toxins Types of nuclear terrorist events Types of nuclear terrorist events Specific information on agents Specific information on agents

Phillip L. Coule, M.D.4 Definitions Nuclear, Biological or Chemical agents to terrorize attack or terrorize a population Nuclear, Biological or Chemical agents to terrorize attack or terrorize a population  NBC – nuclear, biological, chemical  “Biochem”  “Chembio”  WMD – Weapons of Mass Destruction

Phillip L. Coule, M.D.5 Other Terms NBC – nuclear, biological, chemical NBC – nuclear, biological, chemical “Biochem” “Biochem” “Chembio” “Chembio” WMD – Weapons of Mass Destruction WMD – Weapons of Mass Destruction

Phillip L. Coule, M.D.6 Biological terrorism Dispersal of microbes or their toxins to produce illness, death and terror Dispersal of microbes or their toxins to produce illness, death and terror Microbes Microbes  Bacteria  Viruses  Toxins

Phillip L. Coule, M.D.7 Is this something new? 14th Century – Kaffa 14th Century – Kaffa  City on Crimean Peninsula  Strategic to Silk trade routes between China and Europe  Rival trade groups captured city  Multiple unsuccessful attempts to retake city Hurled plague infested corpses over walls of city to infest it Hurled plague infested corpses over walls of city to infest it

Phillip L. Coule, M.D.8 Is this something new? 18 th Century French and Indian War 18 th Century French and Indian War  British Officers gave blankets from smallpox victims to indians aligned with French  Caused an epidemic in tribes  Effective means of incapacitating group

Phillip L. Coule, M.D.9 Bioterroism- the 20 th Century  US Biological Warfare program  Defensive program established  Offensive program disbanded

Phillip L. Coule, M.D.10 NBC Events since Typhoid March 1995 Sarin 12 Dead, 5500 Affected November 1995 Radioactive Cesium December 1995 Ricin June 1996 Uranium 1992 Cyanide March 1995 Ricin April 1995 Sarin April-June 1995 Cyanide, Phosgene, Pepper Spray February 1997 Chlorine 14 Injured, 500 Evacuated June 1994 Sarin 7 Dead, 200 Injured May 1995 Plague April 1997 U Salmonella 200 Injured 1985 Cyanide 1984 Botulinum 2001 Anthrax 5 dead ??? Injured San Diego Medical Society

Phillip L. Coule, M.D “Order of the Rising Sun” Possession of kg of Typhoid Cultures Possession of kg of Typhoid Cultures Were going to poison water supplies of Chicago, St Louis, and other large Midwestern cities Were going to poison water supplies of Chicago, St Louis, and other large Midwestern cities Thwarted by FBI Thwarted by FBI

Phillip L. Coule, M.D – Bhagwan Shree Rajneesh The Dalles, Oregon fall 1984 The Dalles, Oregon fall 1984 Sprayed Salmonella on salad bars at 10 restaurants Sprayed Salmonella on salad bars at 10 restaurants Attempt to sway local election by decreasing turnout of voters Attempt to sway local election by decreasing turnout of voters 751 Ill 751 Ill 45 Hospitalized 45 Hospitalized 0 fatalities 0 fatalities

Phillip L. Coule, M.D ’sAum Shinrinkyo Cult Attempted release of Anthrax on at least 8 occasions- no illness Attempted release of Anthrax on at least 8 occasions- no illness Sarin Subway Attack ,510 affected Sarin Subway Attack ,510 affected  Dead 8  Critical 17  Severe 37  Moderate 984  Outpatient 4,073  Unknown 391

Phillip L. Coule, M.D.14 Today? – Questions?

Phillip L. Coule, M.D.15 Ideal Biological Weapon Easy to manufacture/obtain Easy to manufacture/obtain Lethality / Incapacitation Lethality / Incapacitation Easy to store Easy to store Easy to deliver to target in large quantities large population – particle size Easy to deliver to target in large quantities large population – particle size Highly infective / contagious Highly infective / contagious Incubation period Incubation period Fear factor - untreatable Fear factor - untreatable

Phillip L. Coule, M.D (bronchioles) 1-5 (alveoli) Infection Severity Particle Size (Micron, Mass Median Diameter) The ideal aerosol contains a homogeneous population of 2 or 3 micron particulates that contain one or more viable organisms Maximum human respiratory infection is a particle that falls within the 1 to 5 micron size Less Severe More Severe Aerosol / Infectivity Relationship Source: San Diego Medical Society

Phillip L. Coule, M.D.17 CDC Threat Classification Category A Category A Agents that pose a threat to National Security Agents that pose a threat to National Security  Easily disseminated or transmitted from person to person  Cause high mortality – public health impact  Public panic / Social disruption  Require special action for PH preparedness

Phillip L. Coule, M.D.18 CDC Threat Classification Category B Category B Moderately easy to disseminate Moderately easy to disseminate Moderate morbidity and low mortality Moderate morbidity and low mortality Require specific enhancement of CDC and PH surveillance Require specific enhancement of CDC and PH surveillance

Phillip L. Coule, M.D.19 CDC Threat Classification Emerging pathogens that could be engineered for mass dessemination Emerging pathogens that could be engineered for mass dessemination Availability Availability Ease of production and dissemination Ease of production and dissemination Potential for high morbidity and mortality and major health impact Potential for high morbidity and mortality and major health impact

Phillip L. Coule, M.D.20 CDC Critical Biological Agents “Category A”- Viruses Viral Agents Disease Arenaviruses - Lassa, Junin, Machupo Viral Hemorrhagic Fevers Filoviruses – Ebola, Marburg Viral Hemorrhagic Fevers Variola Major Smallpox

Phillip L. Coule, M.D.21 CDC Critical Biological Agents “Category A”- Bacteria Bacterial Agent Disease Bacillus anthracis Anthrax Franscisella tularensis Tularemia Yersinia pestis Plague

Phillip L. Coule, M.D.22 CDC Critical Biological Agents “Category A” - Toxins Toxin Name Disease Clostridium botulinum toxin Botulism

Phillip L. Coule, M.D.23 CDC Threat Classification – Category B AgentsDisease Coxiella burnetti Q fever Brucella species Brucellosis Burkholderia mallei Glanders Ricinus communis (castor beans) Ricin Toxin Clostridium perfringens Epsilon toxin Staphylococcus Enterotoxin B

Phillip L. Coule, M.D.24 CDC Classification – Category C Agents Nipah virus Hantaviruses Tickborne hemorrhagic fever

Phillip L. Coule, M.D.25 Chemical Agents Blister / vesicants Blister / vesicants Cellular Respiration poisons Cellular Respiration poisons Choking/ Pulmonary agents Choking/ Pulmonary agents Incapacitating Agents Incapacitating Agents Nerve Agents Nerve Agents Riot Control / Tear Gases Riot Control / Tear Gases Emetic agents Emetic agents

Phillip L. Coule, M.D.26 Comparison of Bioterrorism Toxins and Chemical Agents ToxinsChemical Natural origin Man-made Generally more toxic Generally less toxic Difficult, small-scale production Large-scale, industrial production None volatile Many volatile Aerosol delivery Vapor or aerosol delivery Source: AHLS

Phillip L. Coule, M.D.27 Comparison of Bioterrorism Toxins and Chemical Agents-2 ToxinsChemical Odorless and taste less Noticeable order or taste Not dermally active* Dermally active Legitimate medical uses No legitimate medical use Many effective immunogens Poor immunogens * Exceptions, trichothecene (T-2) mycotoxins Source: AHLS

Phillip L. Coule, M.D.28 Chemical Terrorism Agents ClassNamesEffectsAntidotes Nerve agents Tabun, Sarin, Soman, VX Cholinergic crisis, parlysis, vent failure, coma 2-PAM, atropine Vesicants Lewisite, sulfur, mustard, phosegene oxime Vesiculation, chemical burns of skin and mucous membranes British-Anti- Lewisite (BAL) for Lewisite only Cyanides Hydrogen cyanide, cyanogen chloride Cellular asphyxia, anaerobic metabolism, cardiovascular collapse, shock, CNS dysfunction, seizures, coma Amyl nitrite, Sodium nitrite, Sodium thiosulfate Source: AHLS

Phillip L. Coule, M.D.29 Chemical Terrorism Agents – 2ClassNamesEffectsAntidotes Pulmonary Agents Phosegene Noncardiac pulmonary edema, hypoxemia, Respiratory failure None Riot Control Agents CN, CS (Mace) Mucous membrane & skin irritation lacrimation None Source: AHLS

Phillip L. Coule, M.D.30 Nuclear TerrorismNameExample Simple Radiological Device Dispersal of plutonium through bldg ventilation system Radiological Dispersal Device Spreading radioactive Material w/ conventional explosion Nuclear Reactor Sabotage Disabling nuclear reactors cooling system Nuclear Weapon Detonating a 1 kiloton, suitcase size, nuclear weapon obtained from one of worlds nuclear powers More likely Less Likely Source: AHLS

Phillip L. Coule, M.D.31 Anthrax Gram positive bacillus Spore Forming 1 micron spore size Spores are persistent in soil >100 yrs

Phillip L. Coule, M.D.32 Botulism Toxin produced by Clostridium botulinum Toxin produced by Clostridium botulinum Lethal dose is 1 ng/kg Lethal dose is 1 ng/kg Neurotoxin Neurotoxin Incubation 1-5 D (foodborne), blocks cholinergic synapses Incubation 1-5 D (foodborne), blocks cholinergic synapses Diplopia, weakness, paralysis Diplopia, weakness, paralysis Death from respiratory failure Death from respiratory failure Tx: ventilatory support, trivelant antitoxin Tx: ventilatory support, trivelant antitoxin

Phillip L. Coule, M.D.33 Plague – Yersinia pestis Gram negative coccobacillus (rods) Gram negative coccobacillus (rods) Two forms: Two forms:  Bubonic plague  Pneumonic plague Can occur naturally, but usually as bubonic Can occur naturally, but usually as bubonic Sx’s Sx’s  fever, cough with mucopurulent sputum, hemoptysis, chest pain

Phillip L. Coule, M.D.34 Plague - Pathogenesis Consumed by macrophages transported to regional lymph nodes Consumed by macrophages transported to regional lymph nodes  regional adenitis Bacteremia – spread Bacteremia – spread  Lungs  Spleen  Liver  Brain

Phillip L. Coule, M.D.35 Pneumonic Plague Prevention of Secondary Infection Secondary transmission is possible and likely Secondary transmission is possible and likely Standard, contact, and aerosol   Until sputum cultures are negative   pneumonic plague is excluded

Phillip L. Coule, M.D.36 Pneumonic Plague Signs and Symptoms 2 to 3 day incubation 2 to 3 day incubation High fever, myalgias, chills, HA, and cough and bloody sputum High fever, myalgias, chills, HA, and cough and bloody sputum Pneumonia and sepsis develop acutely Pneumonia and sepsis develop acutely Dyspnea, stridor, cyanosis, circulatory collapse Dyspnea, stridor, cyanosis, circulatory collapse Patchy infiltrates or consolidation CXR Patchy infiltrates or consolidation CXR Suspicion for lobar pneumonia out of season Suspicion for lobar pneumonia out of season

Phillip L. Coule, M.D.37 Bubonic Plague Signs and Symptoms Erythema, fever, rigors Erythema, fever, rigors Bubo formation in regional lymph nodes Bubo formation in regional lymph nodes Bubo aspiration and gram stain is diagnostic Bubo aspiration and gram stain is diagnostic  Differentiate from  Tularemia  Cat-scratch fever  Staph-strep lymphadenitis

Phillip L. Coule, M.D.38 Acral Gangrene Acral gangrene Acral gangrene  Late complication of pneumonic or septicemic plague Fingers Fingers Toes Toes Earlobes Earlobes Nose Nose Penis. Penis.

Phillip L. Coule, M.D.39 Plague - Treatment Care is otherwise supportive Care is otherwise supportive Vaccine effective only for bubonic plague Vaccine effective only for bubonic plague Prophylaxis - tetracycline or doxycycline Prophylaxis - tetracycline or doxycycline Antibiotics must be started within 24 hours of symptoms to impact survival Antibiotics must be started within 24 hours of symptoms to impact survival Streptomycin (30 mg/kg/day IM divided BID for 10 days) Streptomycin (30 mg/kg/day IM divided BID for 10 days) Doxycycline (100 mg IV BID for 10 days) Doxycycline (100 mg IV BID for 10 days) Chloramphenicol for plague meningitis Chloramphenicol for plague meningitis Respiratory isolation mandatory for the first 48 hours of treatment

Phillip L. Coule, M.D.40 Smallpox - Microbiology Variola (Var-ï-óla) virus, an Orthopox virus, both minor and major forms of smallpox exist Variola (Var-ï-óla) virus, an Orthopox virus, both minor and major forms of smallpox exist Structure is a large DNA virus Structure is a large DNA virus Declared eradicated in 1980 and the U.S. stopped its civilian vaccination in 1981, U.S. military stopped in 1985 Declared eradicated in 1980 and the U.S. stopped its civilian vaccination in 1981, U.S. military stopped in 1985

Phillip L. Coule, M.D.41 Close-up Smallpox rash CDC/Public domain

Phillip L. Coule, M.D.42 VHF Pathogenesis Fever, myalgias, prostration Fever, myalgias, prostration Shock, mucous membrane hemorrhage Shock, mucous membrane hemorrhage Conjunctival injection, petechial hemorrhage, and hypotension Conjunctival injection, petechial hemorrhage, and hypotension Abnormal renal and LFT - poor prognosis Abnormal renal and LFT - poor prognosis Mortality varies; % Ebola Zaire Mortality varies; % Ebola Zaire Disease severity and survival Disease severity and survival  host factors  target organ is the vascular bed.

Phillip L. Coule, M.D.43 VHF Treatment Hemodynamic resuscitation and monitoring Hemodynamic resuscitation and monitoring  Invasive Swan Ganz catheter as feasible Careful fluid management Careful fluid management  use of colloid Vasopressors and cardiotonic drugs Vasopressors and cardiotonic drugs Cautious sedation and analgesia Cautious sedation and analgesia No anti-platelet drugs or IM injections No anti-platelet drugs or IM injections Coagulation studies and replacement of clotting factors / platelet transfusions Coagulation studies and replacement of clotting factors / platelet transfusions

Phillip L. Coule, M.D.44 Prevention of Secondary VHF Transmission No vaccine is available at this time No vaccine is available at this time Single room w/ adjoining anteroom as only entrance Single room w/ adjoining anteroom as only entrance  handwashing facility with decontamination solution Negative air pressure if possible Negative air pressure if possible Strict barrier precautions Strict barrier precautions  gloves, gown, mask. shoe covers, protective eyeware/faceshield  consider HEPA respirator for prominent hemorrhage, vomiting, diarrhea, cough

Phillip L. Coule, M.D.45 Isolation Precautions Anthrax: Standard Anthrax: Standard Plague: Respiratory (X 48 hrs) then droplet Plague: Respiratory (X 48 hrs) then droplet Smallpox: Respiratory Smallpox: Respiratory Tularemia: Standard Tularemia: Standard Brucellosis: Standard Brucellosis: Standard

Phillip L. Coule, M.D.46 Summary Bioterrorism is not new, just more prevalent Bioterrorism is not new, just more prevalent Diseases of greatest concern Diseases of greatest concern  Anthrax  Botulism  Tularemia  Plague  Smallpox  VHF’s Disaster preparedness should focus on all threats Disaster preparedness should focus on all threats  Chemical Agents  Nuclear Threats

Phillip L. Coule, M.D.47 Questions?