1. The Role of Information Technologies and Science in the Prevention of Bioterrorism
Eugene Shubnikov, MD, Institute of Internal Medicine, Russia;
Supercourse Team, Pittsburgh and the Rest of the world
What we can do for improvement of prevention for the population of our countries being public health persons, not in military, clinical or veterinary services? Supercourse Team think that Internet provides powerful and inexpensive tools for improvement of the health and protection from Bioterrorism Threats. A lot of have been done in this area already.
MORE ABOUT Supercourse will be reported in other lectures by Supercourse Members.

2. Novosibirsk, Ebola Virus Laboratory, Vector
My closest relation with Ebola virus
How I can get here? Novosibirsk, Ebola Virus Laboratory, Vector
Novosibirsk, Ebola Virus Laboratory, Vector

3. The Russian Federation, covering an area of 17 million square km, is the largest country in the world in terms of surface area. Forests and woodland cover 46% of the Russian land.

4. Steps in Developing of Russian/FSU Supercourse:
Network of the scientists involved in prevention and the Internet in Russia and FSU
Russian Language or Russia/ FSU’s connected Public Health Library of lectures at the Internet
I-prevention Program with relations between Russian, FSU, US and scientists from around of the world
First, our goal was to network the scientists involved in prevention and the Internet in Russia.
Second, it was important to establish a large Russian Language Lecture Library on the Internet.
This is created a backbone for a Russian I-PREVENTION program based upon the model established (Supercourse).

5. Russia and FSU 15 countries in FSU Supercourse
Later we decided to expand our network to Former Soviet Union countries, as health indices at these countries were similar. Now we have participants of our project in each FSU country.
15 countries in FSU Supercourse

6. Communications between members
Mailing list
Sharing of lectures
Personal contacts
Personal meetings
We have monthly newsletter for all members from FSU countries together with scientists from other countries, representatives from different agencies, Medical Academies and private organizations. We use regular meetings as Moscow meeting last summer and forthcoming meeting in Lithuania for personal contacts.

7. Our Help for Russian/ FSU Public Health Teachers
Cutting edge, interesting lectures available from Supercourse
Free access to the Supercourse web library of lectures
Share knowledge, education and training systems with other public health professionals in FSU and worldwide
Information has always improve health. Our program is different from Telemedicine, which use expensive telecommunication technologies to a small number of sick people. But as people will always get sick, we believe that I-PREVENTION together with Telemedicine will improve health in Russia.

8. FSU Supercourse page has now 260 lectures from FSU authors or with topics related to FSU countries. Half of these lectures are in Russian language and there are 15 Health Profiles with the health indicators for all FSU countries. (

9. One of the first lectures Supercourse received was a lectures on bioterrorism.
Supercourse is a project designed to create a free lecture library of PowerPoint prevention
slides. More than Academic Faculty from more than 150 countries with over 2600 available Free
Powerpoint Lectures already participated in order to bring the Internet into the prevention of all forms
f diseases and terrorism/bioterrorism.

10. Biological terrorism
Dispersal of microbes or their toxins to produce illness, death and terror
The paths of infection can be contaminated water, food, air and packages.
Microbes
Bacteria
Viruses
Toxins
Ron Laporte and Supercourse Team decided to write a lecture - Understanding Sept 11 for education, fight with Fear and to place at Supercourse website. Lecture was based on the slides provided by others, including Philip L.Coule. Recently Ron mentioned that his slides included now to about 50% of all lectures on epidemiological transition. No reason do not use slides which is better than yours during presentations.
Phillip L. Coule, M.D.

11. Types of Terrorism
Domestic terrorism involves groups whose terrorist activities are directed at elements of our government without foreign involvement. Oklahoma City is a primary example.
International terrorism involves groups whose terrorist activities are foreign-based and/or directed by countries or groups outside the United States. Sept. 11 is an example of International Terrorism.
the Center for National Security Studies

12. Methods of Terrorism Firearms Explosive and Incendiary Devices
Chemical Agents
Biological Agents
Nuclear Weapon

13. J. David Piposzar, Allegheny County Health Department
This slide is from the Supercourse lecture received just after beginning of work of Supercourse Library.
J. David Piposzar, Allegheny County Health Department

14. J. David Piposzar, Allegheny County Health Department
Biological weapons are oldest of the NBC Triad.
J. David Piposzar, Allegheny County Health Department

15. Definition of bioterrorism
Bioterrosim is the threat or use of biological agents by individuals or groups motivated by political, religious, ecological, social or for other ideological objectives to inculcate fear or cause illness or death in order to achieve their objective. (Carus 1998*).
Fred T Muwanga MD Msc

16. Response and prevention of bioterrorism
Response involves:
emergency measures to save lives
active case finding through surveillance
establish diagnostic criteria(case definition) and case management
prevention and management of secondary contamination
Accurate laboratory work
Prevention measures
Strategy formulation that stress deterrence as well as crisis and consequence management.
Do a threat analysis so as to define the requirements
contingency planning with clear definition of roles
global surveillance of disease outbreaks to create more understanding on emerging threats
Fred T Muwanga MD Msc

17. Questions for reflection
With largely theoretical knowledge on bioterrorism, how best can we understand the problem we are faced with ?
What ability and/or capacity does the world have to respond to the challenges of bioterrorism?
What is the dividing line between bioterrorism and criminal activity ?
Fred T Muwanga MD Msc

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

19. Bioterrorism Basics Ease of Acquisition
What makes the use of biological agents so attractive to the terrorist?
Ease of Acquisition
Information readily accessible on World Wide Web
American Type Culture Collection, other sources
Ease and Economy of Production
Only basic microbiology equipment necessary
Small labs require no special licensing
Investment to cause 50% casualty rate per sq. km:
Conventional weapon $2000, nuclear $800, anthrax $1
Lethality
50 kg aerosolized anthrax = 100,000 mortality
Sverdlovsk experience, former USSR
Poor man’s nuclear bomb( J. David Piposzar, Allegheny County Health Department )

20. Bioterrorism Basics Stability Infectivity
What makes the use of biological agents so attractive to the terrorist?
Stability
Infectivity
Weaponized agents may be easily spread
Clinical symptoms days to weeks after release
Low Visibility
Ease and Stealth of Delivery
Remote, delayed, undetectable release
Difficult/impossible to trace origin of agent

21. Bioterrorism Basics Routes of Delivery for Biological Agents
Aerosol is most likely method of dissemination
Easy, silent dispersal
Maximum number of victims exposed
Inhalation is most efficient and contagious route of infection
Food/Water-borne dispersal less likely
Less stable, ineffective for some agents
Inefficient compared to aerosol

22. Agents of Bioterrorism
Bacterial Agents
Bacillus anthracis (Anthrax)
Yersinia pestis (Plague)
Francisella tularensis (Tularemia)
Brucella spp. (Brucellosis)
Coxiella burnetii (Q Fever)
Burkholderia mallei (Glanders)
Vibrio cholerae (Cholera)

23. Agents of Bioterrorism
Viral Agents
Variola virus (Smallpox)
Venezuelan Equine Encephalitis Virus (VEE)
Hemorrhagic Fever Viruses: Ebola, Marburg, Lassa Fever, Argentine and Bolivian Hemorrhagic Fever Viruses, Hantavirus, Congo-Crimean Virus, Rift Valley Fever Virus, Yellow Fever Virus, Dengue Virus

24. Agents of Bioterrorism
Biological Toxins
Botulinum Toxins
Staphylococcal Enterotoxin B
Ricin
Mycotoxins (T2)

25. Characteristics of BT Agents
Chotani, 2003

26. Bioterrorism Basics Events Suggesting the Release of a Bioweapon
Multiple people ill at the same time (epidemic)
Previously healthy persons affected
High morbidity and mortality among affected individuals
Identification of diseases and pathogens unusual to a particular region
Recent terrorist claims or activity
Unexplained epizootic of sick or dead animals

27. Bioterrorism Basics Events Suggesting the Release of a Bioweapon
Severe respiratory disease in a healthy host
An epidemic curve rising and falling rapidly
Increase in fever, respiratory, and GI symptoms
Lower attacks rates in people working indoors vs. outdoors
Seasonal disease during a different time of year
Known pathogen with unusual antimicrobial resistance pattern
Genetically-identical pathogen in different areas

28. Bioterrorism Basics What Can We Do As Medical Professionals?
Maintain a high index of suspicion by including biological agents in differential diagnoses
Learn to recognize historical and physical examination findings suggestive of bioweapon exposure
Stay informed of local, regional and national epidemiologic trends
Be knowledgeable about treatment and prophylaxis of patients exposed to biological agents
Know whom to report suspected biological agent exposures and illnesses to (Police, State Intelligence agency, Infectious Disease Specialists, Local and State Health Officials)

29. Is this something new? 14th Century – Kaffa City on Crimean Peninsula
Hurled plague infested corpses over walls of city to infest it
1346 – Tatar army hurls its plague ridden dead over the walls of the city
Phillip L. Coule, M.D.

30. Is this something new? 18th 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
Source: Chemical and Biological Terrorism, an overview of the threat. Phillip L. Coule, M.D.
In the United States at the time of the French and Indian War, the British provided tainted blankets to Indians with the goal of disabling the opposing forces.
History of Biological Warfare - US
Phillip L. Coule, M.D.

31. Reported Cases of Bioterrorism
World war II - Polish resistance organizations used biological agents against German forces
Mau Mau, an independence movement in Kenya , used a plant toxin to poison livestock.
Dr.Mitsuru Suzuki a Japanese physician, infected healthcare providers and patients with Salmonella typhi
Dark harvest group got anthrax contaminated soil from Gruinard Island and damped it on Porton Down.
Rajneeshees in Portland, Oregon(USA)used Salmonella typhimurium to contaminate restaurant salad bars.
AUM Shinrikyo used sarin nerve gas in the Tokyo subway in Japan
Anthrax contaminated s mail sent to various people in USA.
Fred T Muwanga MD Msc

32. Biological Terrorism - A New Trend?
1978: Bulgarian exile injected with ricin in London
1979: Sverdlovosk, USSR – accidental anthrax released – 40 fatalities
1984: Oregon, Salmonella – Rajneeshee cult
1991: Minnesota, ricin toxin
1994: Tokyo, Sarin and biological attacks
1995: Arkansas, ricin toxin
1995: Indiana, Y. pestis purchase
1997: Washington DC, ‘Anthrax/plague’ hoax
1998: Nevada , nonlethal strain of B. anthracis
1998-9: Multiple ‘Anthrax’ hoaxes
2001: Anthrax Outbreak USA

33. Casualties Fred T Muwanga MD Msc Incident Number of Cases
Number of deaths
Polish Resistance
Not reported
200 Germans
Mau
Mau
Not reported
33 head of cattle
Dark Harvest
None
None
Rajneeshes
751
no deaths
(45 hospitalised)
AUM
Shrinkyo
5500 ( 641 seen at
106 hospitalised at
SLIH* on day 1 &
SLIH. 12 deaths (2
349 following week) at
SLIH)
Dr.Suzuki
200
4 deaths
Anthrax(USA) 22
4 deaths
Fred T Muwanga MD Msc

34. Motive for bioterrorism
Incident
Motive
Polish resistance
Resistance against foreign occupation
Mau
Mau
Resistance against colonialism
Dark Harvest
Send a political message
Rajneeshes
Win a local election by incapacitating the
non-
Rajneeshee voters
AUM
Shrinkyo
Seize control of Japan through mass
murder, causing fear and apprehension
Dr.Suzuki
Revenge for unfair treatment he received
at the medical training
Anthrax (USA)
Inculcate fear
Fred T Muwanga MD Msc

35. Lessons learnt There are various methods of dissemination:
Direct application (Dr.Suzuki)
Food or water contamination (Rajneeshes)
Aerosol contamination (Aum Shrinkyo and anthrax cases)
The effects of bioterrorism can be immediate(illness and death) or long term (Post-stress disorder)
Motives for bioterrorism vary and could include:
- murder(Aum Shrinkyo)
- gaining political mileage (Mau Mau and Dark harvest)
- desire for revenge (Dr.Suzuki)
- Cause fear (Anthrax cases)
- Incapacitation (Rajneeshes)
- anti-agriculture (Mau Mau)
Terrorists do not usually announce their intent
secondary contamination can occur (SLIH workers)
Fred T Muwanga MD Msc

36. Responses to Bioterrorism
Early detection of active and potential cases
Emergency measures to save lives
Prevention and management of secondary contamination
Bioterrorism can be attacked from several different levels. This presents the public health perspective whereby the response begins at the finding of the first case. A complimentary view is that of law enforcement where prevention begins before any event takes place, in the 5 year period of preparation. This could be a simple as identifying people who want to take flying lessons but who do not want to learn how to land, or those purchasing Anthrax from web sites. Both of these approaches have to go hand and hand to prevent attacks.

37. Anatomy of a Bioterrorist Attack
Terrorism takes much
Time and planning
Preparation
5 years
The problem is that few recognize the time course of terrorism. There is a long, protracted time period of planning, followed by a short execution phase and short diagnosis phase. The terrorist on Sept. 11 prepared for almost 5 years before finally attacking. The time between execution and first death is typically small. For example, if a nuclear devise were to be detonated, death would arise within seconds. We want to be able to intervene to prevent children and adults from experiencing a terrorist attack, and death.
Execution 1 day
Diagnosed case 3 days
First Death
Multiple deaths