Playthings of Playthings of

BioterroristsBioterrorists Bioweapons of Mass DestructionBioweapons of Mass Destruction

James Chrosniak, MHS, PA-CJames Chrosniak, MHS, PA-C

OverviewOverview

DefinitionDefinition CharacteristicsCharacteristics Major PlayersMajor Players History of BioWarfareHistory of BioWarfare Indications of a Bioweapons AttackIndications of a Bioweapons Attack What is being done?What is being done?

Definition Definition

Bioterrorism is the intentional use Bioterrorism is the intentional use of any living organisms, such as of any living organisms, such as bacteria or viruses, as a weapon bacteria or viruses, as a weapon

CharacteristicsCharacteristics

What is an effective Bioterror Agent?.What is an effective Bioterror Agent?. High mortality rate agents are the best choiceHigh mortality rate agents are the best choice

Designed to kill a large number of people quicklyDesigned to kill a large number of people quickly

More than one route of infectionMore than one route of infection

High rate of person-to –person transmissionHigh rate of person-to –person transmission

An aerosol route is the most probableAn aerosol route is the most probable

Public panic and social disruptionPublic panic and social disruption

Major PlayersMajor Players

Biological AgentsBiological Agents AnthraxAnthrax Smallpox Smallpox BotulismBotulism PlaguePlague TularemiaTularemia Hemorrhagic Hemorrhagic

FeversFevers

Q FeverQ Fever GlandersGlanders CholeraCholera E.Coli E.Coli O157:H7O157:H7

Chemical AgentsChemical Agents Nerve AgentsNerve Agents Vesicants or Blister Vesicants or Blister

AgentsAgents

History ofHistory of BioWarfare BioWarfare

13461346 As Tartars launched a siege of Caffa, a port on the Black Sea, As Tartars launched a siege of Caffa, a port on the Black Sea, they suffered an outbreak of plague. Tartars sent the infected bodies of they suffered an outbreak of plague. Tartars sent the infected bodies of their comrades over the walls of the city.their comrades over the walls of the city.

14221422 At Karlstein in Bohemia, attacking forces launched the decaying At Karlstein in Bohemia, attacking forces launched the decaying cadavers of men killed in battle over the castle walls.cadavers of men killed in battle over the castle walls.

17631763 During the French and Indian War, British Gen. Jeffery Amherst During the French and Indian War, British Gen. Jeffery Amherst ordered that blankets and handkerchiefs be taken from smallpox ordered that blankets and handkerchiefs be taken from smallpox patients in the fort's infirmary and given to Delaware Indians at a peace-patients in the fort's infirmary and given to Delaware Indians at a peace-making parley.making parley.

(Jenner discovered in 1798 that people could be vaccinated against (Jenner discovered in 1798 that people could be vaccinated against smallpox by using the closely-related cowpox)smallpox by using the closely-related cowpox)

History History cont.cont.

In occupied Manchuria, starting around 1936, Japanese In occupied Manchuria, starting around 1936, Japanese scientists (scientists (Imperial Army Unit 731Imperial Army Unit 731) used scores of human ) used scores of human subjects to test the lethality of various disease agents, including subjects to test the lethality of various disease agents, including anthrax, cholera, typhoid, and plague. As many as 10,000 anthrax, cholera, typhoid, and plague. As many as 10,000 people were killedpeople were killed

Japanese airplanes dropped paper bags filled with plague-Japanese airplanes dropped paper bags filled with plague-infested fleas over the cities of Ningbo and Quzhou in Zhejiang infested fleas over the cities of Ningbo and Quzhou in Zhejiang provinceprovince

Iraq is known to have unleashed chemical weapons in the Iraq is known to have unleashed chemical weapons in the 1980s, both during the Iran-Iraq war and against rebellious 1980s, both during the Iran-Iraq war and against rebellious Kurds in northern Iraq. Kurds in northern Iraq.

History History contcont.. In 1984, the Rajneeshee cult led by the Bhagwan Shree Rajneesh contaminated In 1984, the Rajneeshee cult led by the Bhagwan Shree Rajneesh contaminated

with salmonella bacteria several salad bars in restaurants across Dalles, Ore., with salmonella bacteria several salad bars in restaurants across Dalles, Ore., sickening 751 people in an attempt to influence the results of a local electionsickening 751 people in an attempt to influence the results of a local election

  In 1995, the apocalyptic religious sect Aum Shinrikyo released sarin gas in a In 1995, the apocalyptic religious sect Aum Shinrikyo released sarin gas in a Tokyo subway, killing 12 commuters and injuring thousands. The cult also had Tokyo subway, killing 12 commuters and injuring thousands. The cult also had

enlisted Ph.D. scientists to launch biologicalenlisted Ph.D. scientists to launch biological attacksattacks

In the fall of 2001, several deadly anthrax terrorist attacks took place in the U.S. In the fall of 2001, several deadly anthrax terrorist attacks took place in the U.S. All told, five people died and another 18 became infected, most from being in All told, five people died and another 18 became infected, most from being in the vicinity of anthrax-laced letters, but at least two from completely unknown the vicinity of anthrax-laced letters, but at least two from completely unknown meansmeans

Plans for airborne anthrax bombs and for attacks using botulism were Plans for airborne anthrax bombs and for attacks using botulism were found in houses that had been occupied by Al-Queda leaders in Kabul, found in houses that had been occupied by Al-Queda leaders in Kabul, AfghanistanAfghanistan

AnthraxAnthrax

Bacillus anthracisBacillus anthracis derives from the Greek word for coal, derives from the Greek word for coal, anthrakisanthrakis, because the disease , because the disease causes black, coal-like skin lesionscauses black, coal-like skin lesions

For centuries, anthrax has caused disease in animals and, uncommonly, serious illness For centuries, anthrax has caused disease in animals and, uncommonly, serious illness in humans throughout the world (Usually an occupational disease of farmers, in humans throughout the world (Usually an occupational disease of farmers, slaughterers, tanners.)slaughterers, tanners.)

3 types of anthrax infection occur: inhalational, cutaneous, and gastrointestinal3 types of anthrax infection occur: inhalational, cutaneous, and gastrointestinal

Aerosol spraying is the gravest threat. (No cloud, colorless, tasteless) Aerosol spraying is the gravest threat. (No cloud, colorless, tasteless)

Office of Technology Assessment, estimated that up to 3 million deaths could occur Office of Technology Assessment, estimated that up to 3 million deaths could occur following the release of 100 kilograms of aerosolized anthrax over Washington D.C., following the release of 100 kilograms of aerosolized anthrax over Washington D.C., making such an attack as lethal as a hydrogen bombmaking such an attack as lethal as a hydrogen bomb

Anthrax Anthrax contcont

Incubation period is one to six daysIncubation period is one to six days

Inhalational Anthrax Symptoms: Rapid progression of fever, malaise, cough Inhalational Anthrax Symptoms: Rapid progression of fever, malaise, cough and sub-sternal chest pain is followed by marked respiratory distress. and sub-sternal chest pain is followed by marked respiratory distress. Shock and death generally occur within 36 hours of symptom onsetShock and death generally occur within 36 hours of symptom onset

By the time symptoms develop, it is probably too late.By the time symptoms develop, it is probably too late.

Treatment of choice is Doxycycline or CiprofloxinTreatment of choice is Doxycycline or Ciprofloxin

There is a vaccine for anthrax that requires six immunizations over 18 There is a vaccine for anthrax that requires six immunizations over 18 months plus annual boosters. It is currently available only to the military months plus annual boosters. It is currently available only to the military (Over 2 mil already vaccinated)(Over 2 mil already vaccinated)

Anthrax does not have person to person transmission , but wAnthrax does not have person to person transmission , but watch out atch out what you powder your nose withwhat you powder your nose with

Small PoxSmall Pox Variola major, a virus commonly known as smallpox.Variola major, a virus commonly known as smallpox.

Through natural epidemics, smallpox has likely claimed more lives Through natural epidemics, smallpox has likely claimed more lives than any other infectious diseasethan any other infectious disease

A 12-14 day incubation period after exposure to the virus A 12-14 day incubation period after exposure to the virus (makes it difficult to track)(makes it difficult to track)

Aerosol spreading is the common means of transmission.Aerosol spreading is the common means of transmission. Symptoms include the onset of generalized rash, oral Symptoms include the onset of generalized rash, oral

macular and papular lesions. The onset of fever, headache, macular and papular lesions. The onset of fever, headache, backache and the oral lesions are usually exhibited within backache and the oral lesions are usually exhibited within the first two days of the virus activation. the first two days of the virus activation.

Small Pox Small Pox con’tcon’t

The distinction of smallpox is the The distinction of smallpox is the involvement of the palms of the involvement of the palms of the hands and soles of the feet.hands and soles of the feet.

Generally the greatest Generally the greatest

concentrations of lesions are concentrations of lesions are located on the face.located on the face.

An additional distinction An additional distinction

between smallpox and between smallpox and chickenpox is the uniform chickenpox is the uniform progression of lesions from progression of lesions from maculae to papules to vesicles maculae to papules to vesicles then to scab formations.then to scab formations.

In chicken pox, the lesions are In chicken pox, the lesions are all at various stages of all at various stages of development. development.

Smallpox Smallpox con’tcon’t

Death usually occurs within day 5-7 of lesion progression with Death usually occurs within day 5-7 of lesion progression with increasing fever, abdominal pain, confusion and delirium due to increasing fever, abdominal pain, confusion and delirium due to toxemiatoxemia

Outbreaks of Smallpox usually involve strict quarantineOutbreaks of Smallpox usually involve strict quarantine of all of all individuals who have come in contact with infected individualsindividuals who have come in contact with infected individuals

Mortality is expected to be about 30% for the unvaccinated. Mortality is expected to be about 30% for the unvaccinated. Infants and the elderly historically succumbing firstInfants and the elderly historically succumbing first

As with all viral agents, treatment is supportive.As with all viral agents, treatment is supportive. Vaccination given 3-5 days post-exposure can prevent the disease.Vaccination given 3-5 days post-exposure can prevent the disease.

Because most of North America has not been immunized in 25 Because most of North America has not been immunized in 25 years, there is a risk to the entire populationyears, there is a risk to the entire population

Botulism Botulism Clostridium botulinum is a bacterial agent that occurs in Clostridium botulinum is a bacterial agent that occurs in

nature, but is commonly found in spoiled food itemsnature, but is commonly found in spoiled food items The bacterium produces a nerve toxin that can be fatal The bacterium produces a nerve toxin that can be fatal

if not treated immediately.if not treated immediately.

Botulism toxin is one of the most poisonous substances Botulism toxin is one of the most poisonous substances known. A single gram of crystalline toxin could known. A single gram of crystalline toxin could theoretically kill 1 million peopletheoretically kill 1 million people

Three types: Food borne, wound botulism from contact Three types: Food borne, wound botulism from contact

with an open wound and infant botulism (from with an open wound and infant botulism (from consuming the spores of botulism in items that may not consuming the spores of botulism in items that may not be considered spoiled like natural honey)be considered spoiled like natural honey)

BotulismBotulism Double vision, blurred vision, drooping eyelids, slurred Double vision, blurred vision, drooping eyelids, slurred

speech, difficulty swallowing, dry mouth, and muscle speech, difficulty swallowing, dry mouth, and muscle weaknessweakness

May progress to cause paralysis of the arms, legs, trunk May progress to cause paralysis of the arms, legs, trunk and respiratory musclesand respiratory muscles

Therapy for botulism consists of supportive care (i.e., Therapy for botulism consists of supportive care (i.e., mechanical ventilation) and passive immunization with equine mechanical ventilation) and passive immunization with equine antitoxin (recombinant vaccine is in development)antitoxin (recombinant vaccine is in development)

PlaguePlague The causative agent of pneumonic plague and black (or bubonic) The causative agent of pneumonic plague and black (or bubonic)

plague is Yersinia Pestis, a bacteria that is commonly found in the plague is Yersinia Pestis, a bacteria that is commonly found in the fleas that reside on rodents like rats.fleas that reside on rodents like rats.

In 1346, a bubonic plague pandemic known as the Black Death erupted in In 1346, a bubonic plague pandemic known as the Black Death erupted in Europe and eventually killed 20-30 million people, a third of the populationEurope and eventually killed 20-30 million people, a third of the population

Techniques to aerosolize plague were developed in the Soviet Union, and Techniques to aerosolize plague were developed in the Soviet Union, and many former Soviet scientists that have this know-how have disappeared. many former Soviet scientists that have this know-how have disappeared.

Transmission is by aerosol or person-to-person. Pneumonic plague is Transmission is by aerosol or person-to-person. Pneumonic plague is contagious through respiratory droplets.contagious through respiratory droplets.

Short incubation period of two or three days Short incubation period of two or three days

PlaguePlague Pneumonic plague symptoms Pneumonic plague symptoms

include progressively worsening include progressively worsening fever, malaise, headache, cough fever, malaise, headache, cough with bloody sputum. The with bloody sputum. The pneumonia progresses over 2-4 pneumonia progresses over 2-4 days, without treatment, can lead days, without treatment, can lead to septic shock and death from to septic shock and death from respiratory and circulatory respiratory and circulatory collapsecollapse

Extremely swollen lymph nodes Extremely swollen lymph nodes known as “bubo”known as “bubo”

Doxycycline and Cipro are the Doxycycline and Cipro are the drugs of choicedrugs of choice

A vaccine was licensed in the U.S. but A vaccine was licensed in the U.S. but discontinued by its manufacturer in discontinued by its manufacturer in 1999. Does not prevent the pneumonic 1999. Does not prevent the pneumonic form of plague.form of plague.

TularemiaTularemia

The agent that causes tularemia, The agent that causes tularemia, Francisella tularensis,Francisella tularensis, is one is one of the most infectious bacteria known: inhaling as few as ten of the most infectious bacteria known: inhaling as few as ten microscopic germs can trigger diseasemicroscopic germs can trigger disease

It is so infective that examining an open culture plate can cause It is so infective that examining an open culture plate can cause infection. infection.

WHO has estimated that if 110 pounds of a virulent strain of the WHO has estimated that if 110 pounds of a virulent strain of the bacteria were sprayed over a city of 5 million, it could bacteria were sprayed over a city of 5 million, it could incapacitate 250,000 people and kill 19,000. incapacitate 250,000 people and kill 19,000.

Tularemia occurs naturally in small mammals such as mice, Tularemia occurs naturally in small mammals such as mice, squirrels, and rabbits. Human infection, which is rare, can result squirrels, and rabbits. Human infection, which is rare, can result from tick bites or handling infected animalsfrom tick bites or handling infected animals

TularemiaTularemia

Symptoms include high fever, malaise, severe headache, sore throat, Symptoms include high fever, malaise, severe headache, sore throat, myalgias, non-productive cough, and possibly nausea, vomiting and myalgias, non-productive cough, and possibly nausea, vomiting and diarrheadiarrhea

Without antibiotics, the clinical course could progress to Without antibiotics, the clinical course could progress to respiratory failure, shock and deathrespiratory failure, shock and death

Human to human transmission has not been documentedHuman to human transmission has not been documented

The treatment is Doxycycline for 14 to up to 21 days. Ciprofloxin can The treatment is Doxycycline for 14 to up to 21 days. Ciprofloxin can also be consideredalso be considered

No vaccine is available for the general public. The FDA is investigating No vaccine is available for the general public. The FDA is investigating

a vaccine that is now available for high-risk lab workers.a vaccine that is now available for high-risk lab workers.

Viral Hemorrhagic FeverViral Hemorrhagic Fever

There are a variety of viruses that cause Hemorrhagic fever, There are a variety of viruses that cause Hemorrhagic fever, most common of which include Ebola, Marburg , and Lassamost common of which include Ebola, Marburg , and Lassa

Occurs in nature either in the urine and feces of rodents or Occurs in nature either in the urine and feces of rodents or certain monkeyscertain monkeys

Hemorrhagic fever is very rare in the United States. Most Hemorrhagic fever is very rare in the United States. Most cases occur in Sub-Saharan Africa (Lassa virus infections for cases occur in Sub-Saharan Africa (Lassa virus infections for example, claim an estimated 300,000 infected with about example, claim an estimated 300,000 infected with about 5,000 deaths per year. Marburg virus has a case-fatality rate 5,000 deaths per year. Marburg virus has a case-fatality rate of 25%.)of 25%.)

Japanese cult Aum Shinrikyo sent members to Zaire in 1992 Japanese cult Aum Shinrikyo sent members to Zaire in 1992 to obtain Ebola for weapons development to obtain Ebola for weapons development

Viral Hemorrhagic FeverViral Hemorrhagic Fever Incubation period is about 1-3 weeks after being infected. Incubation period is about 1-3 weeks after being infected.

Human-to-human transmission can occur by contact with infected Human-to-human transmission can occur by contact with infected blood or body fluidsblood or body fluids

Symptoms are progressively worsening high fever, Symptoms are progressively worsening high fever, malaise, headache, myalgias, together with mucous malaise, headache, myalgias, together with mucous membrane bleeding (mouth, nose, eyes) bloody membrane bleeding (mouth, nose, eyes) bloody diarrhea and vomitingdiarrhea and vomiting

The only treatment available is the general antiviral The only treatment available is the general antiviral Ribavarin and life supportive measures available in the Ribavarin and life supportive measures available in the ER or ICUER or ICU

Is this the real thing? Is this the real thing? Indications of a bioweapon attackIndications of a bioweapon attack

Case numbers rapidly increase over a period of hours or Case numbers rapidly increase over a period of hours or days (except food poisoning outbreaks)days (except food poisoning outbreaks)

The rapid outbreak of any disease that is not indigenous The rapid outbreak of any disease that is not indigenous to the local area (i.e., vector-borne illness)to the local area (i.e., vector-borne illness)

Respiratory presentation of illnesses that usually have Respiratory presentation of illnesses that usually have non-pulmonary patterns when contracted in nature (I.e., non-pulmonary patterns when contracted in nature (I.e., anthrax and plague)anthrax and plague)

Large numbers of casualties concentrated in a certain Large numbers of casualties concentrated in a certain area or with wind direction.area or with wind direction.

What is being done?What is being done?

National Pharmaceutical Stockpile Program (NPSP)National Pharmaceutical Stockpile Program (NPSP) -- This resource -- This resource of medical supplies can be sent anywhere in the country within 12 of medical supplies can be sent anywhere in the country within 12 hours of a biological attack. hours of a biological attack.

The Health Alert Network (HAN)The Health Alert Network (HAN) -- The CDC and other health -- The CDC and other health organizations are developing a national communication system on the organizations are developing a national communication system on the InternetInternet

Health department lab preparednessHealth department lab preparedness -- The CDC is working with -- The CDC is working with other officials to ensure that all state health departments are equipped other officials to ensure that all state health departments are equipped to test suspicious substances. to test suspicious substances.

Health advisoriesHealth advisories -- Recent official health advisories from the CDC, -- Recent official health advisories from the CDC, available on the CDC Web site available on the CDC Web site

The Joint Commission on Accreditation of Healthcare Organizations The Joint Commission on Accreditation of Healthcare Organizations recently changed its guidelines so that all hospitals must demonstrate recently changed its guidelines so that all hospitals must demonstrate bioterrorism preparedness to receive accreditationbioterrorism preparedness to receive accreditation

Any Questions?Any Questions?

ReferencesReferences CDC Bioterrorism Section CDC Bioterrorism Section www.bt.cdc.govwww.bt.cdc.gov

Johns Hopkins Center for Civilian Biodefense Studies Johns Hopkins Center for Civilian Biodefense Studies www.hopkins-biodefense.org/www.hopkins-biodefense.org/

The Maryland Institute for Emergency Medical Services The Maryland Institute for Emergency Medical Services Systems Systems www.miemss.umaryland.eduwww.miemss.umaryland.edu

Nova Online “Bioterrism” Nova Online “Bioterrism” www.pbs.orgwww.pbs.org

““Weapons of Mass Destruction” Capt. Charles W. Reed, Weapons of Mass Destruction” Capt. Charles W. Reed, USAF, BSC, PA-C, MEdUSAF, BSC, PA-C, MEd