Terror Is Real !

Terrorism: Are We Ready?

Barbara Russell, RN,MPH,CIC,ACRN

Biological and Chemical Terrorism:

How Real is the Threat?

What is Terrorism?

No single definition FBI: “The unlawful use of force or violence

against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.”

“Kill 1, Frighten 10,000”

Sun Tzu

Anthrax 2001 22 confirmed or suspected cases

11 inhalation (confirmed)

11 cutaneous (7 confirmed, 4 suspected)

Inhalation Anthrax (11)

9 confirmed - exposed to mail (other 2 possible)

55% (6) survived

Types of Terrorism

Biological Nuclear Incendiary Chemical Explosive

B-NICE

Target SelectionSSymbolic target to audience or terrorist

Economic, political, social or religious value

Highly visible and photogenic

Random: To create confusion

Diversionary

Asymmetrical attack

Timing

Anniversary of significant historical event

Highly visible event in the area

Increase in international tensions

Chemical & Biological Terrorism

1984: The Dalles, Oregon, Salmonella (salad bar)

1991: Minnesota, ricin toxin (hoax)1994: Tokyo, Sarin and attack1995: Arkansas, ricin toxin (hoax)1995: Ohio, Yersinia pestis (sent in mail)1997: Washington DC, “Anthrax” (hoax)1998: Nevada , non-lethal strain of B. anthracis1998: Multiple “Anthrax” hoaxes

Chemical Warfare Agents

Tokyo Subway Attack

•Odon March 20, 1995, terrorists released sarin, an organophosphate (OP) nerve gas at several points in the Tokyo subway system, killing 11 and injuring more than 5,500 people.

Concealed in lunch boxes and soft-drink containers and placed on subway train floors. It was released as terrorists punctured the containers with umbrellas before leaving the trains. •.On April 19th, 1995 repeat attack in subway which the same terrorist group killed seven and injured more than 200 people.

Chemical Warfare Agents (CWA)

Lethal CWA’s Nerve gas (Sarin, Tabun, soman, and VX)

Organophosphates- anticholinesterase Colorless, odorless, tasteless

Cyanides

Vesicants (=blistering ) agents – mustard gas

Nerve Gas Agents All nerve agents belong chemically to the group of organo-phosphorus compounds.

Stable and easily dispersed, highly toxic and have rapid effects both when absorbed through the skin and via respiration.

Nerve agents can be manufactured by means of fairly simple chemical techniques. The raw materials are inexpensive and generally readily available.

Chemical

Chemical agents are toxic, but…

- They can be detected

- You can protect yourself

- Victims can be decontaminated Can be inhaled, absorbed through the skin or

injected

Nerve Agent Symptoms Salivation Lacrimination Urination Defecation Gastrointestinal pain Emesis

SLUDGE

Decontamination

Removes the agent from the patient

Reduces the chance of secondary spread

Helps the victim psychologically

Nerve Gas Poisoning Eyes: excessive lacrimation

and pain.

Skin: excessive sweating

Muscles: involuntary twitching

Respiratory: Mucous secretion, dyspnea

Digestive: excessive salivation, abdominal pain

Symptoms: minutes to 2 hours

Treatment: Atropine, 2-PAM (pralidoxime-2-chloride)

Decontamination: Soap & Water, Chlorox

Sulfur Mustard Poisoning Eyes: reddening, congestion,

pain 1/2 -12 hours

Skin: itching, burning, erythema, large blisters (1-12 hours)

Respiratory: burning throat, cough, dsypnea. (2-12 hours)

Digestive: abdominal pain, nausea, blood stained vomiting and diarrhea

Treatment: none

Decontamination: Soap & Water, Chlorox

Care: watch for leukopenia, debride bullae

“I’m confident that we can defend against chemical warfare. The one that really scares me to death is biological”

Colin Powell - 1993

Potential Biological Weapon Agents

Characteristics of a Biological Attack:

Civilian Targets Likely. Possibility of Large Numbers of Casualties. Symptoms May Not Appear For Days. Initial Symptoms Likely to be Non-Specific. Diagnoses Will Depend Heavily Upon Laboratory Tests. Complex Epidemiology. Ongoing Need to Care for Large Numbers of Patients Concerns About Availability of Drugs, Supplies, Staff Members. Legal Considerations. Coordination with Local, State, and Federal Authorities.

Potential Bioterrorism Agents Bacterial Agents

Anthrax Brucellosis Cholera Plague, Pneumonic Tularemia

Viruses Smallpox VEE VHF

Biological Toxins Botulinum Staph Entero-B Ricin T-2 Mycotoxins

Source: U.S.A.M.R.I.I.D.

Biological Agents of Highest Concern

Variola major (Smallpox) Bacillus anthracis (Anthrax) Yersinia pestis (Plague) Francisella tularensis (Tularemia) Botulinum toxin (Botulism) Filoviruses and Arenaviruses (Viral hemorrhagic

fevers) ALL suspected or confirmed cases should be

reported to health authorities immediately

Anthrax - The Weapon

Bacillus anthracis (coal = anthrakis) because of black coal like lesions

Aerobic, gram-positive, spore forming, non-motile bacillus species.

Inhalation Anthrax: Most morbidity and mortality as aerosolized biological

weapon. Disease occurs 2 to 43 days after exposure.

Anthrax - The Disease

Inhalation anthrax: Hemorrhagic thoracic lymphadenitis Hemorrhagic mediastinitis Hemorrhagic meningitis

Two Stages 1. Fever, cough, dyspnea, headache, vomiting, chills, weakness 2. Sudden fever spikes, dyspnea, shock, cyanosis, hypotension

Mortality: 89%!!!!

Anthrax:Diagnosis, Prevention, Treatment

CXR: widened mediastinum Blood culture shows growth after 2-6 hours Vaccine: Licensed since 1970, 88% effective, not

available! Treatment: PNC, Doxycycline, Ciprofloxacin,

first generation cephalosporin, vacomycin, clindamycin

AnthraxAnthraxCause Bacillus anthracis

Incubation 1-60 days, average 7 days

Mortality (without treatment)

Cutaneous: 20%Intestinal: 25%-60%Inhalation: Usually fatal

Infectious Dose Varied; 8,000-50,000 spores (inhalation)

Treatable? Yes; antibiotics and supportive care

Human to Human Transmission?

No

Anthrax (bacillus anthracis)

Anthrax (bacillus anthracis)

                                                                                        

What is smallpox?

Serious, contagious, viral disease that causes a fever and distinctive rash

Treatment: supportive Historically, 30% of smallpox patients died,

many developed scars especially on face, some became blind

Prevented by smallpox vaccine (>95% effective)

How is smallpox spread?

By direct, prolonged face-to-face contactLess commonly, indirectly by

contaminated bedding or clothingRarely spread by airTransmission prevented by using airborne

and contact precautions in health care settings

What is the risk of smallpox?

1972: routine smallpox vaccination discontinued in U.S.

1977: last naturally-acquired case in world Deliberate release is possible but risk is unknown Health care workers at higher risk due to exposure

to most severely ill patients In Europe from 1950-71, 50% of smallpox

transmission was in hospitals

How the skin looks with successful vaccine “take”

SmallpoxCause Variola major

Incubation 7-17 days, average 12-14 days

Mortality (without treatment)

30%

Infectious Dose Small

Treatable? Supportive care; vaccine after exposure

Human to Human Transmission?

Yes - Airborne

Smallpox vs. ChickenpoxSmallpox Chickenpox

Distribution of pox

Centrifugal distribution (face, arms, legs)

More covered parts of body, trunk

Stage of pox development

All at same stage of development

Various stages of development

Unique presentation

Pox found on palms and soles of feet

Uncommon to find pox on palms and soles of feet

Smallpox (variola major)Smallpox (variola major)

Treatment

Treatment of smallpox is limited to supportive therapy and antibiotics as required for treating secondary bacterial infections.

There are no proven antiviral agents effective in treating smallpox.

Plague

Found in rodents and their fleas in many parts of the world

Bites from an infected flea Bubonic, septicemic, pneumonic Seen in rural areas (US: 10-15 cases per year) Two recent human cases of primary pneumonic

plague contracted from cats

Plague (cont)

US: 390 cases from 1947-1996

- 84% bubonic (standard precautions)

- 13% septicemic (standard precautions)

- 2% pneumonic (droplet precautions) Patients may present with GI symptoms (N/V, abd

pain) Treated with antibiotics

Plague (cont)BBiological terrorism release clues:- Pneumonic plague outbreak 1-6 days after exposure- Initial severe respiratory illness- Death occurs quickly after onset of illness- Infection in persons with no known risk factors

Plague (cont)

BBiological terrorism release clues (cont)- Occurrence of cases in areas not known to have previous cases- Absence of prior rodent deaths (which may be present after natural disaster)Plague vs. Anthrax presentation

Plague (yersinia pestis)Plague (yersinia pestis)

PlagueCause Yersinia pestis

Incubation 2-6 days

Mortality (without treatment)

50% (bubonic); near 100% (pneumonic)

Infectious Dose Small

Treatable? Yes; antibiotics and supportive care

Human to Human Transmission?

Pneumonic: YesBubonic: No

Botulism Most potent naturally occurring lethal substance

known to man Possible routes of exposure: Ingestion (food),

Inhalation (terrorist), Injection (drug users), dirty wound

In 1999…………. 174 cases26 food borne107 intestinal / infant41 wound

Botulism (cont)CCardinal Signs- Fever is absent (unless infection is present)- Neurological symptoms are symmetrical- Patient remains responsive- Heart rate normal or slow- Sensory deficits do not occur (except for blurred vision)

Botulism (cont)IIncubation period

- Food borne: 12-36 hours (preformed toxin)- Intestinal (Infant): 1-2 weeks- Wound: 4-14 days

Botulinum ToxinCause Clostridium botulinum

Incubation 2 hours – 8days, average 12-72 hours (foodborne)

Mortality High

Lethal Dose 1 ng/kg (about 0.00000009g/200lb person)

Treatable? Yes; antitoxin and supportive care

Human to Human Transmission?

No

TularemiaTularemia

Reservoir: Numerous wild animals (i.e.: rabbits, beavers, some ticks)

Can also be found in contaminated water, soil, vegetation

Infections occur in North America (US: 171 cases / year) – AKA Rabbit Fever, Deer Fly Fever

Infection caused by handling infectious animal tissues or fluids, direct contact with contaminated water, food, soil and inhalation of aerosols.

Tularemia (francisella tularensis)

Tularemia (francisella tularensis)

TularemiaCause Francisella tularensis

Incubation 1-14 days, average 3-5 days

Mortality (without treatment)

Varies; 5%-60%

Infectious Dose 10 organisms

Treatable? Yes; antibiotics and supportive care

Human to Human Transmission?

No

Hemorrhagic Fevers

Ebola, Marburg, Lassa, Junin & related viruses Presentation: Initially febrile illness, malaise, myalgias, H/A, vomiting, diarrhea followed by bleeding, hypo tension, shock Mode of Transmission: Contact with infected blood or other materials, higher risk at late stages of illness

Hemorrhagic Fevers (cont) Incubation period (days):

- Ebola 2-21,

- Marburg 3-9,

-Lassa, commonly 6-21 - Junin 7-16

Diagnostic Tests Available

Significant number of people with hemorrhagic fever symptoms

Intensive supportive care

Standard and Contact Precautions

Hemorrhagic FeverCause Varies; viral

Incubation Varies; days to weeks

Mortality (without treatment)

Varies; high (as much as 80%)

Infectious Dose Unknown

Treatable? No; supportive care only

Human to Human Transmission?

Yes

Key Points

Increase Level of Awareness

Be familiar with Workplace Plan

Be familiar with County Plan

Have a Family Plan

No “I” in Response – It’s a Team Effort

Personal Protective Equipment

Be sure that it is Appropriate to the hazard(s)