13523323234781372-Biological-Weapons.ppt

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1. DETECTING AND RESPONDING
TO A BIOTERRORIST AGENT
INFECTING YOUR PATIENT(S)
Panel Discussion
Leland S. Rickman, M.D.
Associate Clinical Professor of Medicine
Division of Infectious Diseases
Director, Epidemiology Unit UCSD Medical Center
UC San Diego

2. Outline
•Brief history of biowarfare
•Potential impact and effects of BT
•Transmission of BT agents
•Clues to BT
•“Most likely BW agents”
•Rational perspectives
•Management
•Overview of potential pre-exposure prophylaxis,
post-exposure prophylaxis and therapy

3. BIOLOGIC WARFARE:
HISTORY
•14
TH
century, Kaffa: Attacking Tatar force
catapulted cadavers of plague victims into city –
outbreak of plague led to defeat
•18
th
century, Fort Pitt, North America: Blankets
from smallpox hospital provided to Native
Americans –resulted in epidemic of smallpox
among tribes in Ohio River valley
•1932-45, Manchuria: Japanese military physicians
infected 10,000 prisoners with biological agents (B.
anthracis, N. meningitidis, Y. pestis, V. cholerae) –
11 Chinese cities attacked via food/water
contamination, spraying via aircraft

4. USE OF BIOLOGICAL
AGENTS: US
•Site: The Dalles, Oregon, 1984
•Agent: Salmonella typhimurium
•Method of transmission: Restaurant salad bars
•Number ill: 751
•Responsible party: Members of a religious
community had deliberately contaminated the
salad bars on multiple occasions (goal to
incapacitate voters to prevent them from voting
and thus influence the outcome of the election)
Torok TJ, et al. JAMA 1997;278:389-395

5. USE OF BIOLOGICAL
AGENTS: US
•Site: Large medical center, Texas, 1996
•Agent: Shigella dysenteriae
•Method of transmission: Ingestion of
muffins/doughnuts
•Number ill: 12 (27% attack rate)
•Responsible party: Disgruntled lab employee? S.
dysenteriaeidentical by PFGE from stock culture
stored in laboratory
Kolavic S, et al. JAMA 1997;278:396-398.

6. Known
Iraq
Russia
Probable
China
Iran
North Korea
Libya
Syria
Taiwan
Possible
Cuba
Egypt
Israel
Source: Committee on Armed Services, House of Representatives. Special Inquiry into the Chemical and Biological Threat. Countering the Chemical and
Biological Weapons Threat in the Post-Soviet World. Washington, D.C.: U.S. Government Printing Office; 23 Feb 1993. Report to the Congress.
International Biological Weapons
Programs
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7. BIOTERRORISM: IMPACT
•Direct infection: Mortality, morbidity
•Indirect infection: Person-to-person
transmission, fomite transmission
•Environmental impact: Environmental
survival, animal infection
•Other: Social, political, economic

8. EFFECTS OF A BIOLOGICAL
WEAPONS RELEASE
Siegrist, Emerging Infectious Diseases 1999

9. BIOLOGICAL WARFARE:
IMPACT
[release of 50 kg agent by aircraft along a 2 km line
upwind of a
population center of 500,000 –Christopher et al., JAMA 278;1997:412]
Agent Downwind
reach, km
No. deadNo.
incapacitated
Rift Valley fever 1 400 35,000
Tick-borne encephalitis1 9,500 35,000
Typhus 5 19,000 85,000
Brucellosis 10 500 125,000
Q fever >20 150 125,000
Tularemia >20 30,000 125,000
Anthrax >20 95,000 125,000

10. TRENDS FAVORING BIOLOGICAL
WEAPONS
•Biological weapons have an unmatched destructive
potential
•Technology for dispersing biologic agents is becoming
more sophisticated
•The lag time between infection and appearance of
symptoms generally is longer for biological agents
than with chemical exposures
•Lethal biological agents can be produced easily and
cheaply
•Biological agents are easier to produce clandestinely
than are either chemical or nuclear weapons

11. TRENDS FAVORING BIOLOGICAL
WEAPONS
•Global transportation links facilitate the potential for
biological terrorist strikes to inflict mass casualties
•Urbanization provides terrorists with a wide array of
lucrative targets
•The Diaspora of Russian scientists has increased the
danger that rogue states or terrorist groups will accrue
the biological expertise needed to mount catastrophic
terrorist attacks
•The emergence of global, real-time media coverage
increases the likelihood that a major biological
incident will induce panic

12. DEVELOPING A RISK
ASSESSMENT OF BIOLOGIC
WARFARE AGENTS
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 safely handle and store the agent (may
be difficult for hemorrhagic fever viruses)

13. DEVELOPING A RISK
ASSESSMENT OF BIOLOGIC
WARFARE AGENTS
General difficulties in weaponizing a biologic
agent
•Ability to disseminate the agent as an aerosol
•Ability to generate aerosol particles of the proper
size (1-10 u)
•Ability to assess climatic effects in order to
disseminate agent effectively
•Different Federal agencies have reached different
conclusions regarding the likelihood of an attack
using a biologic agent

14. CHARACTERISTICS OF
BIOWARFARE
•Potential for massive numbers of casualties
•Ability to produce lengthy illnesses requiring
prolonged and intensive care
•Ability of certain agents to spread via contagion
•Paucity of adequate detection systems
•Diminished role for self-aid and buddy aid,
thereby increasing sense of helplessness

15. CHARACTERISTICS OF
BIOWARFARE
•Presence of an incubation period, enabling victims
to disperse widely
•Ability to produce non-specific symptoms,
complicating diagnosis
•Ability to mimic endemic infectious diseases,
further complicating diagnosis
US Army, Biologic Casualties Handbook, 2001

16. Bioterrorism: Modes of Spread
Aerosol Sprays
Particle size of agent
Stability of agent
Wind Speed
Wind direction
Atmospheric stability
Explosives Tend to inactivate biological agents
Food and Water
Contamination
Fairly self-limited

17. Epidemiologic Clues to
Bioterrorism
•Multiple simultaneous patients with
similar clinical syndrome
•Severe illness among healthy
•Predominantly respiratory symptoms
•Unusual (nonendemic) organsims
•Unusual antibiotic resistance patterns
•Atypical clinical presentation of
disease
•Unusual patterns of disease such as
geographic co-location of victims
•Intelligence information
•Reports of sick or dead animals or
plants

18. Soviet BW Priorities
“Agents Likely to be Used”
•Smallpox
•Plague
•Anthrax
•Botulism
•VEE
•Tularemia
•Q Fever
•Marburg
•Influenza
•Melioidosis
•Typhus
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19. Category A: Highest Priority
•Can be easily disseminated or
transmitted person-to-person
•Cause high mortality, with
potential major public health
impact
•Might cause public panic and
social disruption
•Require special action for
public health prepardeness
•Smallpox
•Anthrax
•Yersinia pestis
•Botulism
•Tularaemia
•Filoviruses (Ebola and
Marburg)
•Arenaviruses (Lassa and Junin)

20. Category B: Second Highest Priority
•Moderately easy to disseminate
•cause moderate morbidity and
low mortality
•Require specific enhancements
of CDC’s diagnostic capacity
and enhanced disease
surveillance
•Coxiella burnetti (Q fever)
•Brucella
•Burkholderia mallei (glanders)
•Alphaviruses (Venezuelan
encephalomyelitis and Eastern
and Western equine)
•Ricin toxin from Ricinus
communis
•Epsilon toxin of C. perfringes
•Staph enterotoxin B
•Salmonella
•Shigella
•E. coli O157:H7
•Vibrio cholerae
•Cryptosporidium parvum

21. Category C: Third Highest Priority
•Pathogens that could be
engineered for mass destruction
because of availability, ease of
production and dissemination
and potential for high morbidity
and mortality and major health
impact
•Nipah virus
•Hantavirus
•Tickborne hemorrhagic fever
viruses
•Tickborne encephalitis viruses
•Yellow fever
•MDR TB

22. RISK OF DYING (US, per year)
Major risks
•Heart disease: 1 in 400
•Cancer: 1 in 600
•Stroke: 1 in 2,000
•Flu & pneumonia: 1 in 3,000
•MVA: 1 in 7,000
•Being shot by a gun: 1 in
10,000
USA Today: October 16, 2001
Other risks
•Falling down: 1 in 20,000
•Crossing the street: 1 in
60,000
•Drowning: 1 in 75,000
•House fire: 1 in 100,000
•Bike accident:1 in 500,000
•Commercial plane crash: 1
in 1 million
•Lightening strike: 1 in 3
million
•Shark attack: 1 in 100
million
•Roller coaster accident: 1 in
300 million

23. PERSON-TO-PERSON
ACQUISITION
Disease Transmission Risk
Andes virus Undefined Low
Anthrax Contact with skin lesionsRare
Ebola, Lassa, Marburg,
Congo-Crimean, AHF, BHF
Contact with infective fluid,
droplet?
High
Smallpox Contact, droplet, airborneHigh
Plague (pneumonic) Droplet High
Q fever Contact with infected placentaRare

24. Precautions
SAC
SAC
SAC
SAC
S D
S
S
S
S
S
S
S
Lassa Fever
Ebola
Marburg virus
Smallpox
Pneumonic plague
Inhalational anthrax
Venezuelan equine encephalitis
Botulism
Brucellosis
Cholera
Q fever
Pulmonary tularemia
Airborne ContactStandard
Droplet

25. FOMITE ACQUISITION
•Agents acquired from contaminated clothes
–Variola major (smallpox)
–Bacillus anthracis(anthrax)
–Coxiella burnetii(Q fever)
–Yersinia pestis(plague)
•Management
–Remove clothing, have patient shower
–Place contaminated clothes in impervious bag, wear
PPE
–Decontaminate environmental surfaces with EPA
approved germicidal agent or 0.5% bleach (1:10
dilution)

26. BW AGENTS
CHARACTERISTICS
DiseaseID IncubationDurationMortality
*
Anthrax**8,000-50,000 spores1-6 d 3-5 dHigh
Smallpox1-10 organisms~12 (7-17d)4 wksMod-High
Plague**100-500 organisms2-3 d 1-6 dHigh
Q fever1-10 organisms10-40 d 2-14 dVery low
Tularemia10-50 organisms3-5d (2-10d)>2 wksMod
VHF 1-10 organisms4-21 d 7-16 dMod-HighVHF-viral hemorrhagic fevers
* Untreated, ** Pneumonic form
US Army, Biological Casualties Handbook, 2001

27. BW AGENT PROPHYLAXIS
AND TREATMENT
Disease Vaccine Efficacy* PEP Treatment
Anthrax**^Effective, 1,000 LD
50monkeysAntibioticsAntibiotics
SmallpoxEffective, high dose primatesVaccine, VIGCidofovir?
Plague**^Ineffective, 118 LD
50monkeysAntibioticsAntibiotics
Q fever
#
94%, 3500 LD
50guinea AntibioticsAntibiotics
Tularemia
#
80%,1-10 LD
50 AntibioticsAntibiotics
VHF
+
No vaccine None Ribavirin
@
VHF-viral hemorrhagic fevers, PEP-postexposure prophylaxis
*Aerosol exposure; **Pneumonic form; ^FDA approved vaccine (not available);
#
IND
US Army, Biological Casualties Handbook, 2001
+
IND BHF, RVF;
@
CCHF, Lassa

28. STEPS IN MANAGEMENT
1. Maintain an index of suspicion
2. Protect thyself
3. Assess the patient
4. Decontaminate as appropriate
5. Establish a diagnosis
6. Render prompt therapy
7. Practice good infection control

29. STEPS IN MANAGEMENT
8. Alert the proper authorities
9. Assist in the epidemiologic investigation
10. Maintain proficiency and spread the
gospel
US Army, Biologic Casualties Handbook, 2001