1. Bioterrorism

2. Goals and Objectives  What is bioterrorism?  What are the biological agents of terror?  What’s my role?

3. Bioterrorism  The use of organisms or toxins to kill or sicken people, animals, or plants  1346 Tartars catapulted corpses over the walls of Kaffa to spread plagueTartars catapulted corpses over the walls of Kaffa to spread plague  1754 Blankets used by smallpox patients distributed to Native AmericansBlankets used by smallpox patients distributed to Native Americans  1939 Japanese army accused of dropping plague- infected fleas over Manchurian ChinaJapanese army accused of dropping plague- infected fleas over Manchurian China

4. The Makings of a Biological Weapon  Infectivity  Stability  Ease of production, dissemination, and transmission  Morbidity and mortality of resultant disease(s)  Ability to cause public panic

5. Smallpox  It’s smallpox, don’t do nothing  Vaccinia immune globulin only given to high-risk populations (pregnant, immunosuppressed)  Cidofovir (used for CMV) has in vitro activity against smallpox, but clinical effectiveness unknown  Smallpox vaccine should be given within 4 days of exposure to provide partial protection  Pt should monitor BID for temp > 38˚ x 17 days

6. Smallpox  Causative agent: Variola virus dsDNA orthopoxvirus of family PoxviridaedsDNA orthopoxvirus of family Poxviridae  Host: humans  Last case: 1977  Mortality: 30%  Incubation: 7-17 days  Symptoms: High fever, malaise, vomiting, headache, backache, abdominal painHigh fever, malaise, vomiting, headache, backache, abdominal pain

7. Smallpox  The Rash: Face and extremitiesFace and extremities Same stageSame stage Macules  papules Macules  papules  pustules  scabs (8 days) pustules  scabs (8 days)  Other forms: HemorrhagicHemorrhagic MalignantMalignant  Differentiate from: Chickenpox (varying stages, favors trunk)Chickenpox (varying stages, favors trunk) Human monkeypox (lymphadenopathy)Human monkeypox (lymphadenopathy)

8. Smallpox Vaccine  Live vaccinia virus  Partial protection if given within 4 days  Lots of complications  Lots of contraindications  Immune globulin available

9. Anthrax  Causative agent: Bacillus anthracis Gram positive aerobic spore-forming bacillusGram positive aerobic spore-forming bacillus Inhalational form most likely to be usedInhalational form most likely to be used  Mortality: up to 100%  Incubation: 1-7 days Up to 43 daysUp to 43 days  Symptoms: phase-dependent

10. Anthrax  Prodrome Flu-like, without coryzaFlu-like, without coryza  Second phase Severe dyspnea, respiratory distress, shockSevere dyspnea, respiratory distress, shock Meningitis (50%)Meningitis (50%) Enlarged hilar/mediastinal nodesEnlarged hilar/mediastinal nodes  Widened mediastinum Pleural effusionsPleural effusions

11. Anthrax  Other forms CutaneousCutaneous GastrointestinalGastrointestinal  Treatment Fluoroquinolone/Doxycycline x 60 days, plusFluoroquinolone/Doxycycline x 60 days, plus One or two additional agents until sensitivitiesOne or two additional agents until sensitivities  Vaccination  Isolation: none

12. Plague  Causative agent: Yersinia pestis Gram negative rodGram negative rod  Forms: Bubonic plagueBubonic plague Septicemic plagueSepticemic plague Pneumonic plaguePneumonic plague  Mortality: 100% If not treated within 24 hrs of symptom onsetIf not treated within 24 hrs of symptom onset

13. Bubonic Plague  Inoculation: flea bite  Incubation: 2-7 days  Symptoms: Fever, chills, weakness, headacheFever, chills, weakness, headache  Findings: Buboes, papules, vesiclesBuboes, papules, vesicles DICDIC

14. Pneumonic Plague  Inoculation: aerosolized Y.pestis  Incubation: 2-4 days  Symptoms: High fevers, headache, myalgias, dyspnea, hemoptysis, sepsisHigh fevers, headache, myalgias, dyspnea, hemoptysis, sepsis  Findings: “Watery,” blood-tinged sputum, patchy bronchopneumonia on CXR“Watery,” blood-tinged sputum, patchy bronchopneumonia on CXR Stridor, cyanosis, deathStridor, cyanosis, death

15. Plague  Treatment: Streptomycin x 7-10 daysStreptomycin x 7-10 days Alternatives – Gentamicin, DoxycyclineAlternatives – Gentamicin, Doxycycline  Prophylaxis: Fluoroquinolone/DoxycyclineFluoroquinolone/Doxycycline  Isolation: Bubonic – standard precautionsBubonic – standard precautions Pneumonic – droplet/airbornePneumonic – droplet/airborne

16. Botulism  Causative agent: Clostridium botulinum Gram positive spore-forming rodGram positive spore-forming rod 8 different toxins – A and B in US8 different toxins – A and B in US  Types: FoodborneFoodborne WoundWound GastrointestinalGastrointestinal AerosolizedAerosolized Dr. 90210Dr. 90210

17. Botulism  Incubation: 12-72 hours  Symptoms: DiplopiaDiplopia DysphoniaDysphonia DysarthriaDysarthria DysphagiaDysphagia Descending, symmetric, flaccid paralysisDescending, symmetric, flaccid paralysis  Findings: EMG – normal conduction with reduced amplitudeEMG – normal conduction with reduced amplitude

18. Botulism  Treatment: antitoxin  Isolation: none

19. Tularemia  Causative agent: Francisella tularensis Gram negative, intracellular coccobacillusGram negative, intracellular coccobacillus Most likely pneumonic form from aerosolizationMost likely pneumonic form from aerosolization  Incubation: 3-5 days Up to 21 daysUp to 21 days  Symptoms: Fever, headache, malaise, chest pain, sore throat, abd pain, dry cough, coryzaFever, headache, malaise, chest pain, sore throat, abd pain, dry cough, coryza Fever may be relapsing and remittingFever may be relapsing and remitting

20. Tularemia  Treatment: Streptomycin/Gentamicin  Vaccination:  Prophylaxis: ???  Isolation: Standard

21. Viral Hemorrhagic Fevers  Causative agents: small RNA viruses  Category A: Ebola feverEbola fever Marburg feverMarburg fever Lassa feverLassa fever Argentine hemorrhagic feverArgentine hemorrhagic fever Bolivian hemorrhagic feverBolivian hemorrhagic fever

22. Viral Hemorrhagic Fevers  Symptoms: Fever, myalgias, headache, vomiting, diarrhea (~4 d)Fever, myalgias, headache, vomiting, diarrhea (~4 d) Severe prostration, nondependent edema, hypotension, mental status changes, shockSevere prostration, nondependent edema, hypotension, mental status changes, shock Petechial hemorrhage, hemorrhage of mucous membranes, DICPetechial hemorrhage, hemorrhage of mucous membranes, DIC  Treatment: SupportiveSupportive RibavirinRibavirin  Isolation: Standard, plusStandard, plus Contact-dropletContact-droplet AirborneAirborne

23. Let’s recap… DiseaseAgent MKSAP Point(s) Smallpox Variola virus Rash - face/extremities in same stage AnthraxB.anthracis Widened mediastinum on CXR PlagueY.pestis Treatment - Streptomycin BotulismC.botulinum Symptoms – 5 D’s Treatment - Antitoxin TularemiaF.tularensis Treatment – Streptomycin/Gentamicin Viral hemorrhagic fever Ebola, Marburg, Lassa, etc. Treatment – supportive/Ribavirin

24. What’s Your Role?  Change your underwear  Immediate isolation  Wear personal protective gear  Notify appropriate authorities  Collect necessary specimens  Provide prophylaxis

25. Isolation  No human to human transmission in: TularemiaTularemia BotulismBotulism AnthraxAnthrax  Droplet: Pneumonic plaguePneumonic plague  Airborne/Contact-droplet: SmallpoxSmallpox Viral hemorrhagic feverViral hemorrhagic fever

26. The End.