1. BIOTERRORISM 9/10/2018 DR.SILPA T SASI MD COMMUNITY MEDICINE PG STUDENT MES MEDICAL COLLEGE,PERINTHALMANNA

2. Introduction Bioweapons is a thorny issue due their destructive capabilities, and for the potential to generate panic and terror. Resulted in the decimation of whole populations and have changed the geopolitics of several places. Widespread introduction of biotechnology.

3. Use of bioweapons in terroristic attacks is attributed: Easy access to a wide range of disease-producing agents low production cost Non-detection by routine security systems Easy transportation from one place to another Invisibility and virtual weightlessness render detection

4. EVOLUTION 1st phase : World War I chlorine and phosgene were used in Ypres Belgium. 2 nd phase :World War II use of nerve agents e.g. Tabun, a cholinesterase inhibitor, and the beginnings of the anthrax and the plague. 3 rd phase : The Vietnam War in 1970 - use of lethal chemical agents e.g. Agent Orange

5. 4thphase: Era of the biotechnological revolution and the use of genetic engineering. 1.organisms producing a toxin, venom or bioregulator 2.More stable 3.Resistant to antibiotics, routine vaccines, and therapeutics 4.Altered immunologic profiles 5.Those render detection by antibody-based sensor systems

6. "Bioterrorism” The unlawful use/ threatened use, of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals/plants. The act is intended to create fear and intimidate governments or societies in the pursuit of political, religious, or ideological goals.

7. Biological agents They are found in nature They can be changed to increase their ability to cause disease They can be made resistant to current medicines or to increase their ability to be spread into the environment.

8. Stages Research Development Demonstration programmes Large-scale production of the invasive agent Devising and testing of efficiency of appropriate delivery systems Maintenance of lethal and pathogenic properties during delivery, storage and stockpiling.

9. WHY? Extremely difficult to detect and do not cause illness for several hours to several days. some can be spread from person to person and some, can not.

10. HISTORY 6 th century : Assyrians poisoned enemy wells with rye ergot, sieges in krissa. Scythian archers used arrows dipped in human feaces to cause illness. Ancient rome : Feces were thrown into faces of enemies

11. 14th century : Kaffa - Bubonic plague was used to infiltrate enemy cities Instilling the fear of infection in residences and evacuation To destroy defending forces

12. Enemies who escaped death led to widespread epidemics affecting not only the enemy forces but also other nearby inhabitants. Due to lack of medical advancement it spread to whole of Europe.

13. 20 th century : world war I, germany launched a biological sabotage campaign in the united states, russia, romania, and france. Anton Dilger lived in germany, but in 1915 he was sent to the united states carrying cultures of glanders, a virulent disease of horses and mules.

14. Dilger set up a laboratory in his home in Maryland At the port he used stevedores working the docks to infect horses with glanders while they were waiting to be shipped to Britain.

15. HISTORY OF BIOLOGICAL WARFARE 1346 Siege of Kaffa ; plague 1763 French and Indian War; smallpox WW I German program; anthrax, glanders. 1925 Geneva protocol bans biological weapons WW II Japanese program; anthrax, plague, cholera, shigella

16. 1946 U.S. announces its involvement in bioweapons research 1969 Nixon eliminates offensive biological warfare program

17. 1972 Biological Weapons Convention 1979 Accidental release of B. anthrax spores at bioweapon research center, Sverdlovsk, U.S.S.R.

18. 1984 : Followers of the Bhagwan Shree Rajneesh (OSHO) attempted to control a local election by incapacitating the local population in oregon. Infecting salad bars in 11 restaurants, products in grocery stores, door knobs, and other public domains with Salmonella Typhimurium bacteria in the city of The Dalles, Oregon.

19. The attack infected 751 people with severe food poisoning. There were no fatalities. This incident was the first known bioterrorist attack in the United States in the 20th century.

20. AMERITHRAX 2001 : Anthrax releases in FL, Washington DC, NY, NJ In September and October 2001several cases of anthrax broke out in the United States. Letters laced with infectious anthrax were delivered to news media offices and the U.S Congress.

21. Tests on the anthrax strain used in the attack pointed to a domestic source, from the biological weapons program Ames strain : Bruce Edwards Irvin, suicided in 2008 Total of 22 confirmed cases

23. BIOLOGICAL AGENTS RANKING SYSTEM Morbidity and mortality Delivery potential Public perception (fear, civil disruption) Public health preparedness needs

24. CDC SELECT AGENTS 1.BACTERIA BACILLUS ANTHRACIS (SPORES) BRUCELLA ABORTUS BRUCELLA MELITENSIS BRUCELLA SUIS BURKHOLDERIA MALLEI (AKA PSEUDOMONAS MALLEI) BURKHOLDERIA PSEUDOMALLEI (AKA PSEUDOMONAS PSEUDOMALLEI) CLOSTRIDIUM (BOTULINUM- PRODUCING SPECIES) COXIELLA BURNETII FRANCISELLA TULARENSIS RICKETTSIA PROWAZEKII RICKETTSIA RICKETTSII YERSINIA PESTIS

25. CDC Select Agents – Fungi COCCIDIOIDES IMMITIS COCCIDIOIDES POSADASII

26. CDC Select Agents – Viruses I CENTRAL EUROPEAN TICK- BORNE ENCEPHALITIS CERCOPITHECINE HSV-1 CRIMEAN-CONGO HAEMORRHAGIC FEVER EASTERN EQUINE ENCEPHALITIS EBOLA FAR EASTERN TICK-BORNE ENCEPHALITIS FLEXAL SOUTH AMERICAN HAEMORRHAGIC FEVER GUANARITO SOUTH AMERICAN HEMORRHGIC FEVER. HENDRA JUNIN SOUTH AMERICAN HAEMORRHAGIC FEVER KYASANUR FOREST DISEASE LASSA FEVER MARBURG

27. CDC Select Agents – Viruses II MONKEYPOX NIPAH OMSK HAEMORRHAGIC FEVER RECONSTRUCTED 1918 INFLUENZA RIFT VALLEY FEVER RUSSIAN SPRING AND SUMMER ENCEPHALITIS SABIA SOUTH AMERICAN HAEMORRHAGIC FEVER VARIOLA MAJOR (SMALLPOX) VARIOLA MINOR (ALASTRIM) VENEZUELAN EQUINE ENCEPHALITIS MACHUPO SOUTH AMERICAN HAEMORRHAGIC FEVER

28. CDC Select Agents – Toxins ABRIN BOTULINUM NEUROTOXINS CLOSTRIDIUM PERFINGENS EPSILON TOXIN CONOTOXINS DIACETOXYSCIRPENOL RICIN SAXITOXIN SHIGA-LIKE RIBOSOME- INACTIVATING PROTEIN SHIGATOXIN STAPHYLOCOCCAL ENTEROTOXINS TETRODOTOXIN T-2 TOXIN

29. BIOWEAPON-RELATED DISEASES ANTHRAX BOTULISM BRUCELLOSIS CHOLERA FOOD POISONING GLANDERS HEMORRHAGIC FEVER LASSA FEVER MELIOIDOSIS PLAGUE PSITTACOSIS Q-FEVER SALMONELLOSIS SHIGELLOSIS SMALLPOX TULAREMIA TYPHOID FEVER TYPHUS VIRAL ENCEPHALITIS

30. ADDITIONAL POTENTIAL BIOTERRORISM AGENTS CHLAMYDIA PSITTACI CRYPTOSPORIDIUM PARVUM ESCHERICHIA COLI HANTAVIRUS SALMONELLA SPECIES SHIGELLA SPECIES VIBRIO CHOLERAE

31. BIOTERRORISM AGENT CLASSIFICATION SYSTEM The Centers for Disease Control (2004) have placed agents in Three categories A, B, or C Agents

32. CLASS A Contagious High death rates and high health impact on the public Anthrax, Botulism, Smallpox, Tularemia, Plague CLASS B Moderately easy to spread Some illness & death rates Typhus, water safety threats, salmonella CLASS C Easily available Easily produced and spread Have potential for high death & illness rates NIPAH virus

33. CATEGORY A Can be easily disseminated or transmitted person-to- person Cause high mortality, with potential for major public health impact Might cause public panic and social disruption Require special action for public health preparedness

34. Category A agents Variola Major (Smallpox) Bacillus Anthracis (Anthrax) Yersinia Pestis (Plague) Clostridium Botulinum Toxin (Botulism) Francisella Tularensis (Tularaemia) Filoviruses Ebola Hemorrhagic Fever Marburg Hemorrhagic Fever Arenaviruses Lassa (Lassa Fever) Junin (Argentine Hemorrhagic Fever) &Related Viruses

35. TULAREMIA Rabbit fever Very low fatality rate if treated The disease is caused by the Francisella tularensis bacterium Contact with the fur, inhalation, ingestion of contaminated water or insect bites.

36. Francisella tularensis People who inhale an infectious aerosol experience life-threatening pneumonia and systemic infection Occur widely in nature and can be isolated and grown in laboratory. Manufacturing require considerable sophistication

37. ANTHRAX Non-contagious disease caused by the spore-forming bacterium B.Anthracis Vaccine : requires many injections for stable use. First : Scandinavian "freedom fighters" supplied by the German General Staff - used anthrax against the Imperial Russian Army in Finland during 1916. In 1993, the Aum Shinrikyo used anthrax in an unsuccessful attempt in Tokyo with zero fatalities

39. Anthrax was used in a series of attacks on the offices of several United States Senators in late 2001. The anthrax was in a powder form and it was delivered by the mail. Anthrax is one of the few biological agents that federal employees have been vaccinated for. The strain used in the 2001 anthrax attack was identical to the strain used by the USAMRIID.

40. Steps in suspicion Do not shake Do not clean up, switch off fans, ACs Put into other container Leave room and close the door Wash hands Call local police Remove contaminated cloths Anthrax vaccine

41. Small pox

42. Smallpox is a highly contagious virus. It is transmitted easily through the atmosphere and has a high mortality rate (20-40%). Smallpox was eradicated in the world in the 1970s- worldwide vaccination program.

43. Those born before 1970 were vaccinated for smallpox under the WHO program, the effectiveness of vaccination is limited as level of immunity is only upto 3 to 5 years virus samples are still available in Russian and American laboratories. After the collapse of the Soviet Union, cultures of smallpox have become available in other countries.

44. Revaccination's protection lasts longer. As a biological weapon smallpox is dangerous because of the highly contagious nature of both the infected and their pox. Smallpox occurs only in humans, and has no external hosts or vectors.

45. CATEGORY B Are moderately easy to disseminate Cause moderate morbidity and low mortality Require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance

46. CATEGORY B AGENTS Coxiella Burnetti (Q Fever); Brucella Species (Brucellosis) Burkholderia Mallei (Glanders) Alpha Viruses Venezuelan Encephalomyelitis Eastern And Western Equine Encephalomyelitis Ricin Toxin From Ricinus Communis (Castor Beans) Epsilon Toxin Of Clostridium Perfringens Staphylococcus Enterotoxin B.

47. SUBSET OF LIST B AGENTS INCLUDES PATHOGENS THAT ARE FOOD- OR WATERBORNE - THESE PATHOGENS INCLUDE Salmonella Species Shigella Dysenteriae Escherichia Coli Vibrio Cholerae Cryptosporidium Parvum

48. CATEGORY C Includes emerging pathogens that could be Engineered for mass dissemination in the future Nipah virus Hantaviruses Tick-borne hemorrhagic fever viruses Tick-borne encephalitis viruses Yellow fever Multidrug-resistant tuberculosis

49. Biological Delivery Methods Food / Water Aircraft sprayers Vehicle sprayers Hand sprayers Mail Air handling systems Human Vector Animal Vector

50. Biological Delivery Methods Air : small pox, plague, Botulinum, hemorrhagic fever Food : salmonella, shigella Drinking water : cholera Fomites : anthrax Vectors : yellow fever, Ebola etc.

51. The Ideal Bioterror Weapon Would Be 1. Contagious 2. Virulent 3. Robust 4. Difficult To Detect 5. Drug-resistant 6. User-controllable

52. KEY INDICATORS OF A BIOLOGICAL TERROR EVENT Occurrence of vector-borne disease where there is no vector Cluster of sick or dead animals Atypical seasonality Geographic Pattern of Illness More respiratory presentation of disease

53. Control Measures Enactment of national laws that criminalize the production, stockpiling, transfer and use of chemo- and bioweapons Enactment of national laws that monitor the use of precursor chemicals that lend themselves to the development of chemical and bio-weapons.

54. National and international databanks : monitor precursor chemicals, their use in industry, and their licensed availability in national, regional and international markets. Use of protocols in the destruction and dispersal of outdated stockpiles, and chemical precursor components

55. Detection Biosensors using fibre optic or electrochemical devices, have been developed for detecting micro- organisms in clinical, food technology, and military applications An immunosensor is used for the detection of Candida albicans. Bacillus anthracis, and bacteria in culture are detected by optical sensors

56. Detection Generic and polyvalent immune-sensors : metabolic damage,whose antigenic structure has been altered to which prevents its detection by antibody-based detection systems. Detection of biological particle densities by laser eyes and electronic noses with incorporated alarms.

57. PLANING AND RESPONSE Planning may involve the development of biological identification systems. Nowadays most biological defense strategies have been geared to protect soldiers on the battlefield rather than ordinary people in cities.

58. Financial cutbacks have limited the tracking of disease outbreaks. Some outbreaks, such as food poisoning due to E- coli or Salmonella, could be of either natural or deliberate origin.

59. PREPAREDNESS ● Biological agents are relatively easy to obtain by terrorists and are becoming more threatening in the U.S., ● Laboratories are working on advanced detection systems - provide early warning, identify contaminated areas and populations at risk, and to facilitate prompt treatment.

60. preparedness and investigation checklists in the response planning process: (a) Confirmation Specimens (b) Notification of disease

61. (c ) Coordination Several types of personnel : interviewers, environmental health inspectors, disease control investigators, epidemiologists, data entry operators and data managers (d) Communication Information : outbreak investigation is communicated to other bioterrorism response team.

62. (e) Epidemiological 1.Hypothesis generation with initial cases Investigation 2.Case definition based on initial hypothesis-generating interviews 3. Case finding by local and state public health officials through multiple sources

63. 4. Case interviews using a uniform questionnaire 5. Data analysis for epidemiologic investigation and contact tracing activities.

64. (f) Contact tracing : identified and interviewed, information is entered into a database All contacts are referred for vaccination, prophylaxis, isolation and/or quarantine and kept under active surveillance

65. (g) Laboratories Questions regarding specimen collection, packaging, storage and shipment should be clear (h) Expanded surveillance If the disease outbreak is thought to involve animals, public health officials from the vector borne / veterinary surveillance health will be informed

66. (i) Overt or announced bioterrorism threat: Intelligence and law enforcement agency which coordinates the epidemiologic investigation. e.g. Time, Place, mode and/or contents of the release made available to public health personnel.

67. ● Methods for predicting the use of biological agents in urban areas as well as assessing the area for the hazards associated with a biological attack are being established in major cities

68. ● In addition, forensic technologies have to identify biological agents and their geographical origins. ● Efforts include decontamination technologies to restore facilities without causing additional environmental concerns.

69. Protection against bioterrorism in US 1.Detection and resilience strategies in combating bioterrorism. Office of Health Affairs (OHA), a part of the Department of Homeland Security (DHS) 30 high risk areas

70. OHA's Bio Watch program More proactive response to a disease outbreak rather than the more passive treatment like in the past.

71. 2. Implementation of the Generation-3 automated detection system Action is taken in 4-6 hours, automatic response system Exercises that establish preparedness

72. Anthrax response exercise series - All emergency personnel will be aware of the role they must fill. Providing information and education to public leaders, emergency medical services and all employees of the DHS, can significantly decrease the impact of bioterrorism

73. Enhancing the technological capabilities of first responders. Science and Technology Directorate (S&T) of DHS to ensure that the danger of suspicious powders could be effectively assessed. By testing the accuracy and specificity of commercially available systems used by first responders, all biologically harmful powders can be rendered ineffective.

74. Enhanced equipment for first responders. New form of Tyvex™ armor which protects first responders and patients from chemical and biological contaminants.

75. Self-Contained Breathing Apparatuses (SCBA) which has been recently made more robust against bioterrorism agents.

76. Project BioShield(2004): Increase in expense of vaccines and treatments, medical countermeasures-in tackling bioterrorism There was improvement in the Department of Defense laboratories to increase the quantity and efficacy of countermeasures that comprise the national stockpile.

77. Efforts were taken to ensure that these medical countermeasures are able to be disseminated effectively in the event of a bioterrorist attack. The National Association of Chain Drug Stores championed this cause by encouraging the participation of the private sector in improving distribution of countermeasures.

78. PROJECT BIOSHIELD "We refuse to remain idle when modern technology might be turned against us. We will rally the great promise of American science and innovation to confront the greatest danger of our time “ $5.6 billion over a span of 10 years in order to pay for vaccines and medical facilities in biological emergency.

79. Gave the National Institute of Health grants to pursue medical research & technology Emergency Use Authorization (EUA) gave access to best medical responses in case of an emergency as declared by the Secretary of HSS / HS.

80. WHAT TO DO IF YOU SUSPECT A BIOTERRORIST DISEASE Immediately notify : Hospital Infection Control Isolation: Smallpox, plague, hemorrhagic fevers Laboratory Hospital Administration Local Public Health Department

81. WHAT DOES PUBLIC HEALTH DO IN A BIOTERRORIST EVENT? Impacts in the community Environmental,water safety and sanitation Nurses -shelter operations Tracking of CD Injury programme Health Officer coordinates public and health care providers Public Health Laboratories- identify agents

82. BIOSURVEILLANCE RODS (1999) Real-Time Outbreak Disease Surveillance 1 st automated bioterrorism detection system This collects data from labs, hospitals, and environmental studies in order to detect bioterror attacks as early as possible. Also use them to perform signal detection

83. The RODS laboratory's first efforts eventually led to the establishment of the National Retail Data Monitor, a system which collects data from 20,000 retail locations nation-wide.

84. Response to Bioterrotism Incident Government agencies which would be called include Law enforcement team Hazardous materials or decontamination units Emergency medical units

85. specialized units US Marine Crop's Chemical Biological Incidence Response Force US army's 20 th Supprot Command(CBRNE), which can identify and neutralize threats and decontaminate victims exposed to bioterror agents.

86. PREPARATION FOR BIOTERRORISM ATTACK Familiarize medical staff Incorporate into Disaster Planning Decontamination & Infection Control Communications with key agencies (Laboratory, CDC, Police, FBI) Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines Security preparations

87. PUBLIC HEALTH’S ROLE IN BIOTERRORIS EVENT Health Officer coordinates information for the public and medical providers Community Health and PHN’s provide education, information to the public and to community providers Treatment and prophylaxis Quarantine

88. HOW CAN HOSPITALS PREPARE? Familiarize medical staff and lab with bioterrorist threat agents Incorporate BT planning into disaster planning Infection control Notification procedures and contact numbers Daily surveillance and reporting Security preparations Media Personal Protective Equipment (PPE)

89. STEPS IN PREPARING PUBLIC HEALTH AGENCIES FOR BIOLOGICAL ATTACKS Enhance epidemiologic capacity to detect and respond to biological attacks. Supply diagnostic reagents to state and local public health agencies. Establish communication programs to ensure delivery of accurate information. Enhance bioterrorism-related education and training for health-care professionals.

90. COUNTER MEASURES Prevention Deterrence Strengthening epidemiological surveillance Medical management Information, Education and Communication Capacity building

91. COUNTER MEASURES Bioterrorism Training and Education by CDC Training for Specific Agents Training for All Bioterrorism Laboratory identification

92. THANK YOU