1. Bioterrorism: Practical Aspects
Keith S. Kaye, MD, MPH

2. Overview History and Overview of Bioterrorism Smallpox
Update on Anthrax
What to expect in event of a Bioterrorism threat
What can you do to help?

3. Bioterrorism: History
1346, Kaffa: Attacking Mongols catapulted cadavers of plague victims into city
1710: Russians used plague victims against Swedes
1767: French and Indian War: Blankets from smallpox hospital provided to Native Americans – resulted in epidemic of smallpox
World War I: Germany sent infected horses and mules into Allied lines
World War II: Japanese military unit 731 killed thousands of Chinese in Ping Fan, Manchuria, with various agents, including Anthrax
2 incidents in US over past 20 years involving intentional bacterial contamination of food

4. United States Bioweaons Program
1942 established at Camp Detrick, MD
1950 biological simulant sprayed over San Francisco
1966 biological simulant sprayed in New York City subway system
1969 President Nixon suspends offensive program
1972 U.S, U.K., Soviet Union sign Biological Weapons Convention
U.S. begins its offensive biological weapons program and chooses Camp Detrick, Frederick, Maryland as its research and development site
September, 1950-February, In a test of BW dispersal methods, biological simulants are sprayed over San Francisco (Serratia spp)
June, The United States conducts a test of vulnerability to covert BW attack by releasing a harmless biological simulant into the New York City subway system (Bacillus cereus)
November 25, President Nixon announces unilateral dismantlement of the U.S. offensive BW program
*Agents stockpiled/weaponized by US included anthrax, botulinum toxin, francisella, Brucella, Coxiella, Staph enterotoxin B, VEE, rice blast, ricinm, and wheat stem rust

5. Soviet Union Bioweapons Program
Massive program
Many details known through defection of high-ranking scientist
Weaponized numerous biological agents
Much of offensive research took place after signing biological weapons treaty
After dissolution of Soviet Union leaks/dissmination of scientists (known) and bioterrorism agents (suspected)
Employed around 60K at peak
Mention had a few fatalities in scientists (eg due to marburg)
Mention Ken Alibek
Mention current unknown status of Iraq’s program after UN inspectors kicked out in 1998

6. Difficulties in Cultivating Biological Weapons
General difficulties in weaponizing a biologic agent
Ability to procure a virulent strain (e.g., anthrax, tularemia)
Ability to culture large amounts of the agent
Ability to process agent into a suitable form (e.g., anthrax spores)
Ability to safetly handle and store the agent (may be difficult for hemmorhagic fever viruses)

7. Why Biological Weapons?
Although challenging to develop, still easier and cheaper to obtain than nuclear weapons
Soviet scientists with expertise defected to rogue nations
Potential to cause destruction and hysteria

8. Smallpox
Virus with person-to-person transmission; rash similar to chicken pox, but can be easily differentiated
Naturally occurring disease eradicated in 1977
Routine immunization in US stopped in 1972
US and Russia known to have smallpox stocks; but concerns that other countries have Smallpox as well

9. Smallpox (cont) Vaccine exists and is effective
More vaccine is being made
No imminent bioterrorism threat for smallpox, but we want to be prepared
Routine vaccination will probably not be reinstated unless new cases emerge
Stores of vaccine would be made available for control of outbreaks (bioterrorism)

11. Anthrax Prior to 2001, no successful bioterrorist attacks
Known to be stockpiled by Iraq and possibly by former Soviet states
Outbreak due to accidental release, Sverdlovsk (Ekaterinberg, USSR 1979)
Increase in hoaxes in US, late 1990s
-mention historical significance of anthrax: 5th and 6th plagues likely represented outbreaks of anthrax in cattle and humans; was first disease to fulfill koch’s postulate for causation of disease; first bacterial infection for which there was a vaccine
Disease had become quite rare in western countries by the late 20th century, aside from an occasional cutaneous case, inhalational quite rare after banning pakistani wool in 1970s
-while numbers of actual cases were decreasing, there was an increase in hoaxes, dramatically increased in late 1990s. Each hoax had cost approx 500K to investigate.
For example, Larry Wayne Harris, Ohio microbiologist who in 1995 tried to buy plague. A few years later was arrested for claiming to have enough anthrax to decimate las vegas. Turns out he had a harmless veterinary vaccine strain.
-mention aum shinrikyo, who while they released sarin and caused deaths due to that in Japanese subways, they were unsuccessful in causing any illness due to anthrax despite releasing that and botulinum toxin up to 10 times in a similar fashion

12. Antrhax: Clinical Diseases
Cutaneous
Spores enter through cuts/abrasions
Inhalational
Spores inhaled
NO PERSON-PERSON SPREAD!!!
Gastrointestinal
Infected meat ingested
Incubation period generally 1-12 days

13. Cutaneous Anthrax Inoculation of spores into cut/abrasion
Lesions typically on hand/arm or face
Small pruritic papule  ulcer surrounded by vesicles (24-48h)  black eschar
Patients typically have local edema, +/- lymphadenopathy, fever and will feel ill
Antibiotic treatment extremely effective

14. Inhalation Anthrax: Manifestations
Second stage: rapid deterioration (24 h)
Acute dyspnea
Cyanosis
Stridor
Fever
Mediastinal hemorrhage
CxR: Mediastinal widening
Meningismus
Septic Shock
Coma
First stage: insidious onset (1-4 d)
Malaise
Fatigue
Myalgia
Nonproductive cough
Precordial pressure
Fever

15. US Anthrax Cases as of November 9, 2001
Inhalational-10
Florida: 2 (1 fatality)
Washington DC: 5 (2 fatalities)
New Jersey: 2
New York: 1 (1 fatality)
Cutaneous-12
New York: 7
New Jersey: 5
FL: october 4 CDC notified of possible case of anthrax- pt had travelled to NC, became ill in Durham
New York cases: NBC, ABC, CBS, NY Post
DC exposures: listed at 28 in Capitol building (2 police, 2 in feingold office, remainder in Daschle’s office
NJ: Trenton post office

16. Clinical Symptoms of 10 Inhalational Anthrax Cases, U.S., 2001
Almost all had links to contaminated mail (postal workers and press)
Median age 56 yrs (range 43-73)
All presented with fever, chills, malaise 10/10
Cough (often dry) 9/10
Nausea and vomiting 8/10
Paucity of cold symptoms, sore throat
All 10 patients had abnormal CxR findings
All not receiving antibiotics had + blood cultures
6/10 survived

17. US Anthrax Cases to Date November 9, 2001
Source of exposure known for almost all cases (mail)
~32,000 people in US were started on antibiotics for prophylaxis in past several weeks and in 5000 persons a full 60 day antibiotic course was advised.
95/490 patients (~20%) receiving prophylaxis reported one or more side effect in one survey

18. Inhalation Anthrax: Summary Points
Almost all patients had clear epidemiologic links to anthrax source (investigations ongoing)
All patients had prodromal illness with fever
Cold symptoms, sore throat usually absent
Anthrax will readily grow in cultures
Anthrax is much more treatable than previously thought
Anthrax is NOT communicable, person to person
Currently NO anthrax cases in NC
Harmful effects of unnecessary antibiotics are common

19. GUIDELINES FOR MANAGEMENT OF POTENTIALLY THREATENING LETTERS
Do not open suspicious letter/package
Do not shake/empty
Do not show to others (don’t sniff, touch etc)
Place package on stable surface and alert others in the area
Leave area, close doors, prevent others from entering, shut off ventilation system
Wash hands/change clothes
Contact supervisor, local law enforcement via 911
If possible, create list of persons in room (give to public health personnel)

20. Recommendations for Mail Handlers
New recommendations
Major focus is use of gloves for workers handling mail
Respiratory protection (N95 mask) for workers with mail sorting machinery
Follow news for further updates

21. What to expect in the event of a Bioterrorism Threat
Hospitals have plans, but CDC, State will organize response
Patients might be triaged at locations outside of local emergency rooms
Dispensing of antibiotics and vaccines will be organized through CDC/State, but will utilize local hospitals for support
Potential restriction of travel, movement; lock down of hospitals (Smallpox)

22. How Can You Help ?
Don’t crowd emergency rooms if you are not acutely ill
Talk with your primary care physician
Antibiotics not helpful unless there is a clear indication
No role for nasal swabs as diagnostic tool!
Have a high index of suspicion for atypical skin lesions, clusters of cases among friends, co-workers

23. How Can You Help ? (2)
Report suspicious letters/packages/powders to police/FBI, HAZMAT teams (911)
Report suspicious illnesses/clusters to your physician and county or State Health Department
Infection Control within the hospital
Follow the news: web sites for reliable, helpful information:

24. How can you help (3) Increased level of awareness, but . . .
Remain calm
No cases in North Carolina (and in most states)
There are effective ways to prevent and treat anthrax once a threat has been recognized
Flu season is upon us
Let your doctor know if you develop flu symptoms
No reason to suspect anthrax, with no anthrax in NC
If you are ill, and feel you might have had an exposure, let your physician know
Even if you have had flu shot or a negative flu test, you can still might get the flu, or an illness like the flu!