1. PU 430 Unit 5 Chapters 2 and 3

2. Bioterrorism http://www.youtube.com/watch?v=2t_MsSO9qRk http://www.youtube.com/watch?v=2t_MsSO9qRk Chapter Two

3. Basic Facts About Bioterrorism Threats Bioterrorism is the use or threatened use of biological agents as weapons of terror Current U.S. laws make the threat alone a severe crime The biological material used may be lethal or nonlethal, a common bacteria or virus, the toxic by-product of a pathogen, a rare organism, or even a specially engineered organism, never before diagnosed or treated These acts are intended to instill fear in the targeted population in support of terrorist goals Organisms or other biological materials can be released in the air, or placed in food or water sources

4. Advantages of Biologics as Weapons Easy to obtain Inexpensive to produce Potential dissemination over large geographic area Creates panic Can overwhelm medical services Susceptible civilian populations High morbidity and mortality Difficult to diagnose and/or treat Some are transmitted person-to-person via aerosol

5. Routes of Infection Routes of Infection Skin (cuts, abrasions, mucosal membranes ) Gastrointestinal ◦Food  Potentially significant route of delivery  Secondary to either purposeful or accidental exposure to aerosol ◦Water  Capacity to affect large numbers of people  Dilution factor  Water treatment may be effective in removal of agents Respiratory ◦Inhalation of spores, droplets & aerosols ◦Aerosols most effective delivery method ◦1-5 F droplet most effective

6. Medical Response Pre-exposure ◦active immunization ◦prophylaxis ◦identification of threat/use Incubation period ◦detection and diagnosis ◦active and passive immunization ◦antimicrobial or supportive therapy Overt disease ◦diagnosis ◦treatment  may not be available  may overwhelm system  may be less effective ◦direct patient care will predominate

7. Bioterrorism : Who are 1st Responders? Primary Care Personnel Hospital ER Staff EMS Personnel Public Health Professionals Other Emergency Preparedness Personnel Laboratory Personnel Law Enforcement

8. Scenarios Overt Event ◦Announced ◦Patients Fall ill or Die (Increased Morbidity and Mortality) ◦Microorganisms Unconfirmed ◦Hoaxes Assumed to be Real

9. Scenarios Covert Event ◦No Prior Warning - Unannounced ◦Patients Fall ill or Die from Causes of Unknown or Unusual Origin ◦Unusual Cluster(s) of Cases - May be Geographically Distributed ◦Undetermined Causative Agent

10. U.S. Bioterrorism Preparedness Controversies Bioterrorism preparedness activities include: ◦The development & practice of a mass emergency distribution of pharmaceuticals ◦Risk communication training ◦Incident Command System training for public health & healthcare workers Controversy surrounds many issues, including: ◦Vaccinations & antibiotics ◦The potential for increasing bioterrorism & biocrime risks ◦Funding of public health programs

11. Categorization of Threats Category A pathogens - High priority organisms & toxins posing the greatest threat to public health Category B agents - Fairly easy to disperse but have lower morbidity & mortality than the Category A agents & can be successfully addressed Category C agents - Emerging infectious organisms that could become easily available at some point in the future & used as a weapon

12. Health Threats: Category A Organisms Anthrax (Bacillus anthracis) – considered by many to be the perfect biological weapon Botulism (Clostridium botulinum toxin) - regarded as the most potent poison in the world Plague (Yersina pestis) - without quick antibiotic treatment, can cause death in several days Smallpox (Variola major, Variola minor) - the most destructive infectious disease in human history Tularemia (Francisella tularensis) - highly infectious for individuals directly exposed to the organisms, but is not spread from person to person Viral Hemorrhagic Fevers (Filoviruses,Arenaviruses, Bunyaviruses, & Flavivruses) – have potential lethality & infectiousness at low doses when delivered as an aerosol

14. Anthrax: Current Issues in the U.S.  Anthrax remains an endemic public health threat through annual epizootics.  B. anthracis is one of the most important pathogens on the list of bioterrorism threats  Aerosolized stable spore form  Human LD50 8,000 to 40,000 spores, or one deep breath at site of release http://www.youtube.com/watch?v=4IxFU_itIUE

15. Exposure Situation Management: B. anthracis in Envelope Antimicrobial prophylaxis for those potentially exposed Environmental samples ◦Surface swabs ◦Nasal swabs of potentially exposed persons (if <7 days) Refine list of potentially exposed persons ◦Not exposed: stop treatment ◦Likely exposed: continue treatment for 60 days total

16. Anthrax: Post- Exposure Treatment Start oral antibiotics as soon as possible after exposure ◦Ciprofloxacin or Doxycycline or Amoxicillin/Penicillin (if known PCN sensitive)

17. Post-Exposure Treatment (continued) Antibiotics for 60 days without vaccine Antibiotics for 30 days with 3 doses of vaccine (animal studies) Long-term antibiotics necessary because of spore persistence in lung/lymph node tissue

18. Anthrax: Vaccine (continued) Current U.S. vaccine (FDA Licensed) - continued ◦FDA approved for 6 dose regimen over 18 months ◦3 dose regimen (0, 2, and 4 weeks) may be effective for post-exposure treatment (animal studies) ◦Limited availability

19. Prevention Prevention of bioterrorism Public Health Security & Bioterrorism Preparedness & Response act of 2002 The Pandemic Preparedness & Response Act

20. FOODBORNE BOTULISM Infective dose: 0.001 g/kg Incubation period: 18 - 36 hours Dry mouth, double vision, droopy eyelids, dilated pupils Progressive descending bilateral muscle weakness & paralysis Respiratory failure and death Mortality 5-10%, up to 25%

21. Level A Procedures for Botulism Event Properly collected specimens are to be referred to designated testing laboratories Prior to the shipment of any botulism- associated specimen, the designated laboratory must be notified and approved by the State Health Department

22. Plague: Overview Natural vector - rodent flea Mammalian hosts ◦rats, squirrels, chipmunks, rabbits, and carnivores Enzootic or Epizootic CDC: Wayson’s Stain of Y. pestis showing bipolar staining

23. Plague Epidemiology Three Clinical Types: ◦bubonic (infected lymph nodes) ◦septicemic (blood-borne organisms) ◦pneumonic (transmissible by aerosol; deadliest)

24. Plague: Prophylaxis Bubonic contacts ◦If common exposure, consider oral Doxycycline, Tetracycline, or TMP/SMX for 7 days ◦Other close contacts, fever watch for 7 days (treat if febrile)

25. Plague: Prophylaxis (continued) Pneumonic contacts (respiratory/droplet exposure) ◦Consider oral Doxycycline, Tetracycline, or TMP/SMX ◦Continue for 7 days after last exposure Vaccine no longer manufactured in U.S. ◦Not protective against pneumonic plague

26. Detection Limiting the impact of a bioterrorism attack requires healthcare providers with sufficient training & support to remain diligent Regular disease surveillance includes: ◦Mandatory disease reporting by local healthcare providers ◦Data entry & analysis by local or regional public health agencies ◦Additional analysis, reporting, & allocation of needed resources by state & federal public health agencies Other forms of surveillance include environmental monitoring & standoff detection

27. Plague: Medical Management Supportive therapy Isolation with droplet precautions for pneumonic plague until sputum cultures negative Antibiotic resistant strains have been documented

28. Plague: Clinical Forms Bubonic Bubonic ◦Inguinal, axillary, or cervical lymph nodes most common ◦80% can become bacteremic ◦60% mortality if untreated

29. USAMRICD: Inguinal/femoral buboes Plague: Bubonic Incubation: 2-6 days Sudden onset headache, malaise, myalgia, fever, tender lymph nodes Regional lymphadenitis (Buboes) Cutaneous findings ◦possible papule, vesicle, or pustule at inoculation site ◦Purpuric lesions - late

30. Smallpox: Overview 1980 - Global eradication Humans were only known reservoir Person-to-person transmission (aerosol/contact) Up to 30% mortality in unvaccinated CDC: Electron micrograph of Variola major

31. Smallpox: Clinical Features Prodrome (incubation 7-17 days) ◦Acute onset fever, malaise, headache, backache, vomiting ◦Transient erythematous rash

32. Level A Procedures Smallpox virus Rule out chickenpox (PCR)! Specimen of choice is lesion material from pustules Contact your State Public Health Laboratory for guidance

33. Smallpox: Current Vaccine Made from live Vaccinia virus Intradermal inoculation with bifurcated needle (scarification) ◦Pustular lesion/induration surrounding central scab/ulcer 6-8 days after vaccination WHO: Smallpox vaccine vials

34. Smallpox: Medical Management Strict respiratory/contact isolation of patient ◦Patient infectious until all scabs have separated Notify public health authorities immediately for suspected case Identify contacts within 17 days of the onset of case’s symptoms

35. Immediate Actions With quick identification of the biothreat agent & population at risk, there is a window of opportunity for prophylactic treatment Decisions must be made rapidly & the response needs to begin immediately Communication must be quickly established with the population at risk Those working in healthcare, public health, & the first response community need to be provided with detailed instructions on how to respond

36. Bioterrorism : What Can Be Done? Awareness Laboratory Preparedness Plan in place Individual & collective protection Detection & characterization Emergency response Measures to Protect the Public’s Health and Safety Treatment Safe practices

37. Recovery Clean-up will not be difficult for most pathogenic organisms, with the notable exception of anthrax Federal Insecticide, Fungicide, & Rodenticide Act (FIFRA) ◦The Environmental Protection Agency has established a listing of “antimicrobial products” to ensure that effective cleaning agents are used

38. Bombings and Explosions Chapter Three

39. Introduction Between 2006 & 2007, the death toll related to bombs increased by 30% & the number of suicide bombings increased by approximately 50% Today’s bombers often want to generate as many civilian casualties as possible & are acquiring the technologies & methods to reach that objective

40. Health Threat Four categories have been established to aid in the understanding of the complex assortment of injuries associated with explosions & provide structure for the triage process: ◦Primary blast injuries ◦Secondary blast injuries ◦Tertiary blast injuries ◦Quaternary blast injuries

41. Prevention 1.) Physical Security 2.) Threat Detection & Identification

42. Immediate Actions If a threat necessitates an evacuation from a building: ◦Everyone at risk must be evacuated immediately to a safe distance ◦Occupants should quickly collect personal items so they are not among the possible threats needing to be assessed by bomb technicians ◦Elevators should not be used ◦There should be a rallying point away from the building for a head count

43. Health & Medical Response The Centers for Disease Control & Prevention have established several essential concepts that caregivers need to keep in mind concerning provision of care to those injured in explosions It is important for all the first responders to be aware of risks when approaching a potential bomb scene It is important to consider the possibility of residual explosive material Local public health agencies also have an important role in long-term monitoring & follow- up of survivors