1. BIOTERRORISM: A PRIMER
11/5/01
BIOTERRORISM: A PRIMER
Carol Sulis, MD
Boston University School of Medicine
Boston Medical Center
in collaboration with
Boston Public Health Commission
Surveillance Task Force, City of Boston
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2. Supplemental Information
11/5/01
Supplemental Information
List of ~ 50 Diseases Reportable by Healthcare Providers
Example of Reporting Card
Initial Assessment Form for ED/UC Volume Exceedence
3 Articles
MMWR: Biological and Chemical Terrorism:Strategic Plan for Preparedness and Response, April 21, 2000, Vol 49
Richards CF, Burstein J, et al:Emergency Physicians and Biological Terrorism. Ann Emerg Med 1999;34:
Franz DR, et al: Clinical Recognition and Management of Patients Exposed to Biological Warfare Agents. JAMA 1997;278(5):
Selected Bioterrorism Websites
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3. Lecture Overview What is Terrorism? Biological vs Chemical Terrorism
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Lecture Overview
What is Terrorism?
Biological vs Chemical Terrorism
Biological Warfare and Bioterrorism Events in the US
Modes of Transmission
Agents of Concern
Who to Contact for Infectious Disease Reporting
How to Prepare
Examples of Biologic Agents and Description
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4. What is Terrorism ? Use of fear, threat, or force to advance a belief
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What is Terrorism ?
Use of fear, threat, or force to advance a belief
Usually targeted at civilians
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5. Conventional Terrorism
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Conventional Terrorism
Bullets
Bombs and blasts
Building collapse
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6. Weapons of Mass Destruction
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Weapons of Mass Destruction
Nuclear
Chemical
Biological
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7. Nuclear, Radiologic & Chemical
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Nuclear, Radiologic & Chemical
Nuclear/Radiologic
Radiologic weapons
Improvised nuclear devices
Broken Arrows
Chemical
Improvised HazMat
Military Agents
Nerve Agents
Blister Agents
Riot Control Agents
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8. Biologics as Weapons: Desired Properties
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Biologics as Weapons: Desired Properties
Infectious via aerosol
Organisms fairly stable in environment
Susceptible civilian populations
High morbidity and mortality
Person-to-person transmission (smallpox, plague, VHF)
Difficult to diagnose and/or treat
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9. Biologics as Weapons: Desired Properties
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Biologics as Weapons: Desired Properties
Potential for widespread dissemination
Concern  fear and panic  overwhelm medical services
Perpetrators escape easily
No treatment or vaccine
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10. Biological Terrorism Bacteria Viruses Toxins 11/5/01
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11. Methods of Dissemination
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Methods of Dissemination
Aerosol
Ingestion
Cutaneous
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12. Classification of Bioterrorism
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Classification of Bioterrorism
Small Scale Bioterrorism
Common pathogens
Unlikely to be identified as bioterrorism
Larger-Scale Bioterrorism
Identified package/parcel (low risk)
Identified mechanical device (higher risk)
Unidentified release (human cases)
Need sentinel cases to identify that release occurred
Real, unknown source
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13. 11/5/01
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14. 11/5/01
Biological Warfare
300 BC - Greeks used animal carcasses to poison wells
Bubonic plague during siege of Khaffa
WWI - German agents shipped animals inoculated with anthrax and glanders to Europe
WWII - Unit 731 in China (Japan)
Biological Weapons Convention
Sverdlovsk incident
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15. Recent US Events 415 incidents between 1/1/60 - 1/31/99
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Recent US Events
415 incidents between 1/1/60 - 1/31/99
Terrorist event: involve organization or person that conspires to use violence to advance a political, ideological, or religious goal
Criminal incident: involve extortion, murder, other nonpolitical objective.
Jonathan B. Tucker. Historical Trends Related to Bioterrorism: An Empirical Analysis. Emerging Infectious Diseases 1999;5(4).
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16. Bioterrorism Events in the US
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Bioterrorism Events in the US
1984, The Dalles, Oregon
Salmonella in salad bars
751 ill (45 hospitalized)
1996, Dallas, Texas
Shigella in micro-lab donuts
12 ill (4 hospitalized)
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17. Bioterrorism Today’s threat Terrorist organizations Iraq
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Bioterrorism
Today’s threat
Terrorist organizations
Iraq
Former Russian programs
Not hard to “manufacture” some biologic agents
Hard to “weaponize” them
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18. How Might It Happen? Modes of Transmission
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How Might It Happen? Modes of Transmission
Airborne
Foodborne
Waterborne
Other vectors
Mosquitoes
Contaminated medications or illicit drugs
Heroin in Scotland and Norway
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19. Military Weapons 11/5/01 C://LECTURE/BTLECTURE110801CS.PPT
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20. Agents of Concern Category A Anthrax Botulism Plague Smallpox
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Agents of Concern
Category A
Anthrax
Botulism
Plague
Smallpox
Tularemia
Viral Hemorrhagic Fevers (VHF)
Category B
Q fever
Brucellosis
Glanders
Ricin toxin
Epsilon toxin
Staphylococcal enterotoxin B
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21. Agents of Concern Category C Nipah virus Hantaviruses
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Agents of Concern
Category C
Nipah virus
Hantaviruses
Tickborne hemorrhagic fever
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22. Typical Incubation Periods
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Typical Incubation Periods
> 1 week
brucellosis
Q fever
smallpox
EEE/WEE
VHF
anthrax
< 1 day
Staphylococcal enterotoxin B
< 1 week
anthrax
plague
tularemia
VEE
botulism
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23. SYNDROMES THAT MAY BE ASSOCIATED WITH BIOTERRORISM
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SYNDROMES THAT MAY BE ASSOCIATED WITH BIOTERRORISM GI
Fever
Nausea/vomiting
Diarrhea ?bloody
Neurologic
HA, fever, bulbar palsy, encephalopathy
Septic Shock
DIC
Organ failure
Pulmonary
Fever
Cough
Myalgias
Hypoxia
Rash and fever
Vesicular
Petechial
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24. IS IT A CHEMICAL OR A BIOLOGIC EVENT ?
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IS IT A CHEMICAL OR A BIOLOGIC EVENT ?
CHEM
Rapid onset (obvious)
Field first response
Police and Fire
EMS
Decon critical
Antidotes
BIO
Slow onset (insidious)
Medical response
Hospital
Office
Decon useless
Antibiotics and vaccines
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25. Epidemiologic Clues to a BT Event E clues
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Epidemiologic Clues to a BT Event E clues
Point source Exposure
Low attack rates in “protected” areas
High attack rate among exposed
Strep throat at a wedding in Boston
Compressed Epidemic curve
Young and healthy die
Exotic - Unusual illness, season, location
Tularemia in 2000
Epizootic (Animals also acquiring disease)
WNV in 1999
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26. Recognition of a Bioterrorism Event
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Recognition of a Bioterrorism Event
Syndromes
Clinical recognition of an agent (e.g. smallpox)
Epidemiology
Warning and surveillance networks
Intelligence data
Laboratory results (usually delayed)
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27. WHO TO CALL ? Hospital Emergency Department Infectious Disease Fellow
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WHO TO CALL ?
Hospital Emergency
Department
Infectious Disease
Fellow
Boston Public Health
Commission
(BPHC)
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29. Infectious Disease Reporting
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Infectious Disease Reporting
Legal reporting requirement (MA General Law)
~ 50 reportable infectious diseases
Clusters and outbreaks (regardless of etiology)
What happens to the case report
BPHC uses the information to investigate, control and prevent further infection
Completed case report form sent to MDPH
Information sent to CDC in Atlanta
All information is confidential.
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30. What Help Will Come in a WMD Event?
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What Help Will Come in a WMD Event?
Initial response will be local
In some settings, external assistance will be needed
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31. What Types of Assistance Are Available in a WMD Event?
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What Types of Assistance Are Available in a WMD Event?
Security and Law Enforcement
Police Officers, Firefighters
Drugs, vaccines, and ventilators
National Pharmaceutical Stockpile (NPS)
Analytic and intelligence support
FBI, Epidemiologists, lab researchers, and technicians
Medical Personnel
FEMA, DMAT
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33. National Pharmaceutical Stockpile
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National Pharmaceutical Stockpile
National repository of pharmaceuticals and medical devices
Assets are stored at strategic places around the US
Designed to support/supplement state, local, private stocks
Assets deployed as requested by appropriate officials
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34. 11/5/01
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35. How to Prepare Personal education, knowledge of available resources
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How to Prepare
Personal education, knowledge of available resources
Hospital planning - Emergency Preparedness Group at BMC
Review the bioterrorism portion of the disaster plan
Call security ( or ) with concerns
Call the ID Fellow for unusual presentation of an illness or unusual cluster of patients with similar illness
Community-wide planning and coordination
Government, public health, medical facilities
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36. Examples of Biologic Agents
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Examples of Biologic Agents
Anthrax
Smallpox
Plague
Ebola
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37. 11/5/01
Anthrax
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38. 11/5/01
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39. Cutaneous Anthrax 11/5/01 C://LECTURE/BTLECTURE110801CS.PPT
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40. Cutaneous Anthrax 11/5/01 C://LECTURE/BTLECTURE110801CS.PPT
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41. Cutaneous Anthrax 11/5/01 C://LECTURE/BTLECTURE110801CS.PPT
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42. Inhalational Anthrax Inhale spores Germinate into bacteria
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Inhalational Anthrax
Inhale spores
Germinate into bacteria
Produce toxins
Bleeding and edema in LN  mediastinal widening and fluid around lungs
No pneumonia
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43. Inhalational Anthrax During treatment One year later 11/5/01
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44. Smallpox Variola virus Variola major (30% fatality rate)
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Smallpox
Variola virus
Variola major (30% fatality rate)
Variola minor (<1% fatality rate)
Transmission: fomite, droplet, ?airborne
Incubation: d (range 7-17 d)
Infectious from rash onset
Vaccine protection: limited duration
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45. Smallpox: Clinical Presentation
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Smallpox: Clinical Presentation
Variola virus
Variola major (30% fatality rate)
Variola minor (<1% fatality rate)
Transmission: fomite, droplet, ?airborne
Incubation: d (range 7-17 d)
High fever, malaise, headache, backache, prostration
Delirium 15%
Rash starts on face and forearms  trunk and legs
Crusts at day 8-9, scabs separate leaving scars
Infectious from rash onset
Vaccine protection: limited duration
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46. Smallpox: Clinical Presentation
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Smallpox: Clinical Presentation
Day 7 Day Day
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47. Smallpox vs Chickenpox
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Smallpox vs Chickenpox
Variola
Rash centrifugal
Pox over 1-2 day period, all evolve at same rate
All pox at same stage
Rash on palms and soles
Lesions extend into the dermis
Varicella
Rash centripetal
Crops of lesions at different stages of development
Adjacent lesions at different stages
Never on palms or soles
Lesions not as deep
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48. Smallpox vs Chickenpox
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Smallpox vs Chickenpox
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49. Smallpox Vaccine Live vaccinia-derived virus
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Smallpox Vaccine
Live vaccinia-derived virus
Significant adverse reactions (~25/100,000)
Stockpiles in Russia and South Africa
Up to 15 million doses in U.S. stockpile
Production of new vaccine underway
Vaccination within 4 days of exposure protective
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50. Infection Control for Smallpox
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Infection Control for Smallpox
Droplet, contact, airborne precautions
Virus inactivated within two days in environment
Post exposure prophylaxis (face-to-face contact after onset of fever and rash in patient)
Vaccinate, isolate and place under surveillance
Vaccine supply controlled by Feds
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51. Plague ~ 10-15 cases/year U.S. SW states Bubonic most common
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Plague
~ cases/year U.S.
SW states
Bubonic most common
Natural vector - Rodent flea
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52. Plague: Bubonic Incubation: 2-8 days
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Plague: Bubonic
Incubation: 2-8 days
Sudden onset fever, chills, weakness, tender LN (Buboes)
Source: USAMRICD
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53. 11/5/01
Pneumonic Plague
Droplet precautions to prevent secondary infection for pneumonic form.
Incubation period 2-3 days
Acute, fulminant onset of malaise, fever, chills, headache, myalgia, cough, bloody sputum and sepsis
Must initiate treatment within 24 hours of sx onset
Preventive therapy - tetracycline
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54. The Hemorrhagic Fever Viruses
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The Hemorrhagic Fever Viruses
Acute onset
febrile illness
High fever, myalgia,
GI disturbances
Ebola
Major
organ
necrosis
Lassa
Severe systemic illness
coagulation abnormalities
Oropharyngeal
lesions
Marburg
Machupo
Renal
failure
Hantaan
Severe bleeding
ecchymosis
Congo fever
7 days
Pulmonary
Syndrome
Yellow fever
Dengue (2x)
Rift Valley
Rapid progression into
shock and death
Jaundice
Syndrome
Four Corners Agent
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55. 11/5/01
Ebola Virus
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56. The Hemorrhagic Fever Viruses
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The Hemorrhagic Fever Viruses
Isolation precautions
Contact
? Droplet
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57. Uganda Oct 2000 11/5/01 C://LECTURE/BTLECTURE110801CS.PPT
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58. 11/5/01
Precautions
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59. 11/5/01
Precautions
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60. Standard Precautions Wash hands after patient contact
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Standard Precautions
Wash hands after patient contact
Gown, gloves when touching blood, body fluids, secretions, excretions
Mask - if splash or splatter anticipated
Shoe covers - if splash or splatter anticipated
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61. Precautions Standard Standard plus Contact Standard plus Droplet
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Precautions
Standard
anthrax
brucellosis
Q fever
tularemia
viral encephalitis
botulism
Staph enterotoxin B
Standard plus Contact
viral hemorrhagic fever
Standard plus Droplet
pneumonic plague
Standard plus Airborne
smallpox
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62. 11/5/01
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63. 11/5/01
Laboratory Personnel
May rely on laboratory diagnosis rather than clinical diagnosis
Alert laboratory personnel
to any suspicions regarding
possible bio-agents
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64. There are lots of creepy, crawly things out there . . .
11/5/01
There are lots of creepy, crawly things out there . . .
Bioterrorism related websites:
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