BIOTERRORISM AND BIOTERRORISM AND VETERINARY PUBLIC VETERINARY PUBLIC

HEALTHHEALTH

Dr. Shahnawaz ahmadDr. Shahnawaz ahmadI.V.R.II.V.R.I

Div. Of SurgeryDiv. Of Surgery

Definition of BioterrorismDefinition of BioterrorismBioterrorism is the threat of use of biological Bioterrorism is the threat of use of biological

agents by individuals or groups motivated by agents by individuals or groups motivated by

political, religious, ecological, social or for other political, religious, ecological, social or for other

ideological objectives to inculcate fear or cause ideological objectives to inculcate fear or cause

illness or death in order to achieve their illness or death in order to achieve their

objectivesobjectives

(Carus 1998).(Carus 1998).

According to the United States According to the United States

Centers for Disease Control and Centers for Disease Control and

Prevention (CDC) Prevention (CDC) a bioterrorism a bioterrorism

attack is the deliberate release of attack is the deliberate release of

viruses, bacteria or other germs viruses, bacteria or other germs

(agents) or toxins used to cause (agents) or toxins used to cause

illness or death in people, animals illness or death in people, animals

or plantsor plants. .

BIOLOGIC WARFARE: HISTORY

1414THTH century, Caffa: Attacking Tatar force catapulted century, Caffa: Attacking Tatar force catapulted

cadavers of plague victims into city – outbreak of cadavers of plague victims into city – outbreak of

plague led to defeatplague led to defeat

1818thth century, Fort Pitt, North America: Blankets from century, Fort Pitt, North America: Blankets from

smallpox hospital provided to Native Americans – smallpox hospital provided to Native Americans –

resulted in epidemic of smallpox among tribes in Ohio resulted in epidemic of smallpox among tribes in Ohio

River valleyRiver valley

Gen. Jeffrey Amherst, in a letter dated 16 Jully 1763, approved the plan to spread smallpox to Delaware Indians

1932-45, Manchuria: Japanese military 1932-45, Manchuria: Japanese military

physicians infected 10,000 prisoners with physicians infected 10,000 prisoners with

biological agents (biological agents (B. anthracis, N. B. anthracis, N.

meningitidis, Y. pestis, V. choleraemeningitidis, Y. pestis, V. cholerae) –) – 11 11

Chinese cities attacked via food/water Chinese cities attacked via food/water

contamination, spraying via aircraftcontamination, spraying via aircraft

The Japanese army used Chinese prisoners to test bioweapons.

Reported cases of bioterrorism

World war II – Polish resistance organizations used

biological agents against German

forces

1952 – Mau Mau, an independence movement in

Kenya, used a plant toxin to poison

livestock

1966 – Dr. M. Suzuki, a Japanese physician,

infected health care providers and patients with

S. typhi

1981 – Dark harvest groups got anthrax

contaminated soil from Gruinard Island and

damped it on Porton Down.

1984 – Rajaneesh in Portland, Oregon (USA) used

S. thphimurium to contaminate restaurants salad

bars

1995 – AUM Shinrikyo used sarin nerve gas in the

Tokyo subway in Japan.

2001- Anthrax contaminated mails sent to various

people in USA

CasualtiesCasualtiesIncident Number of cases Number of deaths

Polish resistance

Not reported 200 Germans

Mau Mau Not reported 33 head of cattle

Dark Harvest

None None

Rajaneesh 751 (45 Hospitalized No deaths

AUM Shrinkyo

5500 (641 seen at SJIH on day I & 349 following week

106 hospitalized at SLIH, 12 deaths ( 2 at SLIH)

Dr. Suzuki 200 4 deaths

Anthrax (USA)

22 4 deaths

Motive for Bioterrorism

Incident Motive

Polish resistance

Resistance against foreign occupation

Mau Mau Resistance against colonialism

Dark Harvest

Send a political message

Rajneesh Win a local election by incapacitating the non-Rajneeshees 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

BIOTERRORISM: WHY BIOTERRORISM: WHY NOW?NOW?

Nuclear arms have great killing Nuclear arms have great killing

capacity but are hard to get.capacity but are hard to get.

chemical weapons are easy to get but chemical weapons are easy to get but

lack such killing capacitylack such killing capacity

Biological agents have both qualitiesBiological agents have both qualities..

TRENDSTRENDS FAVORING BIOLOGICAL FAVORING BIOLOGICAL WEAPONSWEAPONS

Biological weapons have an unmatched destructive Biological weapons have an unmatched destructive

potentialpotential

Technology for dispersing biologic agents is becoming Technology for dispersing biologic agents is becoming

more sophisticated.more sophisticated.

The lag time between infection and appearance of The lag time between infection and appearance of

symptoms generally is longer for biological agents than symptoms generally is longer for biological agents than

with chemical exposures.with chemical exposures.

Lethal biological agents can be produced easily and Lethal biological agents can be produced easily and

cheaply.cheaply.

Biological agents are easier to produce clandestinely than Biological agents are easier to produce clandestinely than

are either chemical or nuclear weapons.are either chemical or nuclear weapons.

TRENDS FAVORING BIOLOGICAL TRENDS FAVORING BIOLOGICAL WEAPONSWEAPONS

Global transportation links facilitate the Global transportation links facilitate the

potential for biological terrorist strikes to potential for biological terrorist strikes to

inflict mass casualtiesinflict mass casualties

Urbanization provides terrorists with a wide Urbanization provides terrorists with a wide

array of lucrative targetsarray of lucrative targets

The emergence of global, real-time media The emergence of global, real-time media

coverage increases the likelihood that a coverage increases the likelihood that a

major biological incident will induce panicmajor biological incident will induce panic

CENTERS FOR DISEASE CONTROLCENTERS FOR DISEASE CONTROLBIOTERRORIST AGENTS: CATEGORY ABIOTERRORIST AGENTS: CATEGORY A Easily disseminated or transmitted Easily disseminated or transmitted

person-to-personperson-to-person

High mortality, with potential for public High mortality, with potential for public

health impacthealth impact

Require special action for public health preparedness .Require special action for public health preparedness .

Viruses:Viruses: Variola major (smallpox), Variola major (smallpox),

Filoviruses (Ebola, Marburg), Filoviruses (Ebola, Marburg),

Arenaviruses (Lassa, Junin)Arenaviruses (Lassa, Junin)

BacteriaBacteria: : Bacillus anthracisBacillus anthracis (anthrax), (anthrax), Yersinia pestisYersinia pestis (plague), (plague),

Francisella tularensisFrancisella tularensis (tularemia) (tularemia)

ToxinsToxins: : Clostridium botulinumClostridium botulinum toxin (botulism) toxin (botulism)

CENTERS FOR DISEASE CONTROLCENTERS FOR DISEASE CONTROLBIOTERRORIST AGENTS: CATEGORY BBIOTERRORIST AGENTS: CATEGORY B

Moderately easy to disseminateModerately easy to disseminate

Moderate morbidity and low mortalityModerate morbidity and low mortality

Require improved diagnostic capacity & enhanced surveillance .Require improved diagnostic capacity & enhanced surveillance .

VirusesViruses: Alphaviruses (VEE, EEE, WEE): Alphaviruses (VEE, EEE, WEE)

BacteriaBacteria: : Coxiella burnetiiCoxiella burnetii (Q fever), (Q fever), Brucella sppBrucella spp. (brucellosis), . (brucellosis),

Burkholderia malleiBurkholderia mallei (glanders) (glanders)

Toxins:Toxins: Rinus communisRinus communis (caster beans) ricin toxin, (caster beans) ricin toxin, Clostridium Clostridium

perfringensperfringens episolon toxin, episolon toxin, StaphylococcusStaphylococcus enterotoxin B enterotoxin B

Food/waterborne pathogensFood/waterborne pathogens: : Salmonella sppSalmonella spp., ., Vibrio choleraeVibrio cholerae, ,

Shigella dyseneriaeShigella dyseneriae, , E. coliE. coli O157:H7, O157:H7, Cryptosporidium parvumCryptosporidium parvum, ,

etc. etc.

CENTERS FOR DISEASE CONTROLCENTERS FOR DISEASE CONTROLBIOTERRORIST AGENTS: CATEGORY CBIOTERRORIST AGENTS: CATEGORY C

AvailabilityAvailability

Ease of production and disseminationEase of production and dissemination

Potential for high morbidity and mortality and Potential for high morbidity and mortality and

major public health major public health impact impact

Viruses:Viruses: Nipah, hantaviruses, tick borne Nipah, hantaviruses, tick borne

hemorrhagic fever viruses, tick borne hemorrhagic fever viruses, tick borne

encephalitis viruses, yellow feverencephalitis viruses, yellow fever

BacteriaBacteria: Multi-drug resistant : Multi-drug resistant Mycobacterium Mycobacterium

tuberculosistuberculosis

CHARACTERISTICS* OF PRIORITY AGENTSCHARACTERISTICS* OF PRIORITY AGENTS

Infectious via aerosolInfectious via aerosol

Organisms fairly stable in aerosolOrganisms fairly stable in aerosol

Susceptible civilian populationsSusceptible civilian populations

High morbidity and mortality High morbidity and mortality

Person-to-person transmission Person-to-person transmission

Difficult to diagnose and/or treatDifficult to diagnose and/or treat

Previous development for BWPrevious development for BW

* * * Priority agents may exhibit all or some of the above * Priority agents may exhibit all or some of the above

characteristicscharacteristics

SOURCES OF SOURCES OF BIOTERRORISMBIOTERRORISM

Biological warfareBiological warfare

State sponsored terrorismState sponsored terrorism

International terrorist groupsInternational terrorist groups

National cultsNational cults

The deranged “loner”The deranged “loner”

BIOTERRORISM: IMPACTBIOTERRORISM: IMPACT

Direct infection: Mortality, morbidityDirect infection: Mortality, morbidity

Indirect infection: Person-to-person transmission, Indirect infection: Person-to-person transmission,

fomite transmissionfomite transmission

Environmental impact: Environmental survival, Environmental impact: Environmental survival,

animal infectionanimal infection

Other: Social, political, economic Other: Social, political, economic

The terrorists have an option to use exotic

organisms to spread disease in animals and plants.

Imagine somebody spread Foot and Mouth disease,

Glanders, VEE, Rinderpest, Brucellosis, Swine fever, Fowl

plague, Rabies and so on.

THREAT TO ECONOMYTHREAT TO ECONOMY

Similarly Rice blast, Stem Rust, Late blight of

potato, Black Rust and Maize Rust and so on

would destroy all the crops and shatter the

economy of the country.

Eg:-Irish Potato Famine in 1940 due to Potato

Blast

Half a million people died of starvation and half a

million people migrated. It took one century for

the country’s economy to recover.

BIOLOGICAL WARFARE: IMPACTBIOLOGICAL WARFARE: IMPACT[[release of 50 kg agent by aircraft along a 2 km line upwind release of 50 kg agent by aircraft along a 2 km line upwind

of a of a population center of 500,000 – Christopher et al., JAMA population center of 500,000 – Christopher et al., JAMA

278;1997:412278;1997:412

AgentAgent Downwind No. deadDownwind No. dead No. No.

reach, km reach, km incapacitatedincapacitated

Rift Valley feverRift Valley fever 11 400 400 35,00035,000

Tick-borne encephalitisTick-borne encephalitis 1 1 9,500 9,500 35,00035,000

TyphusTyphus 5 5 19,000 85,00019,000 85,000

BrucellosisBrucellosis 10 10 500 500 125,000125,000

Q feverQ fever >20>20 150 150 125,000125,000

TularemiaTularemia >20>20 30,000 30,000 125,000125,000

AnthraxAnthrax >20>20 95,00095,000 125,000125,000

Biological Delivery Methods

• Food / Water

• Aircraft sprayers

• Vehicle sprayers

• Hand sprayers

• Mail

• Air handling

systems

• Human Vector

• Animal Vector

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

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

FOMITE ACQUISITIONFOMITE ACQUISITION

Agents acquired from contaminated clothesAgents acquired from contaminated clothes

Variola major (smallpox)Variola major (smallpox)

• Bacillus anthracisBacillus anthracis (anthrax) (anthrax)

• Coxiella burnetiiCoxiella burnetii (Q fever) (Q fever)

• Yersinia pestisYersinia pestis (plague) (plague)ManagementManagement

•Remove clothing, have patient showerRemove clothing, have patient shower

•Place contaminated clothes in impervious bag, wear PPEPlace contaminated clothes in impervious bag, wear PPE

•Decontaminate environmental surfaces with EPA approved Decontaminate environmental surfaces with EPA approved

germicidal agent or 0.5% bleach (1:10 dilution)germicidal agent or 0.5% bleach (1:10 dilution)

Bioterrorism agents: Laboratory riskBioterrorism agents: Laboratory risk

AgentAgent BSLBSL Laboratory RiskLaboratory Risk

B. anthracisB. anthracis 2 2 lowlow

Y. pestisY. pestis 2 2 mediummedium

F. tularensisF. tularensis 2/3 2/3 highhigh

Brucella sppBrucella spp. . 2/3 2/3 highhigh

Botulinum toxin Botulinum toxin 2 2 mediummedium

Smallpox Smallpox 4 4 highhigh

Viral Hemorrhagic feverViral Hemorrhagic fever 44 highhigh

ANTHRAX IN THE US, 2001ANTHRAX IN THE US, 2001

Locations: FL, NY, DC, NJ, CT, VALocations: FL, NY, DC, NJ, CT, VA

Mechanism: Via the mail (4 letters positive)Mechanism: Via the mail (4 letters positive)

Infections: 22 casesInfections: 22 cases

Cutaneous anthrax: 11 (fatality rate = 0)Cutaneous anthrax: 11 (fatality rate = 0)

Inhalation anthrax: 11 (fatality rate = 45%)Inhalation anthrax: 11 (fatality rate = 45%)

Prophylaxis Prophylaxis

Initiated: ~32,000Initiated: ~32,000

60 day course recommended: ~5,00060 day course recommended: ~5,000

UNEXPECTED FEATURES UNEXPECTED FEATURES OF ATTACKOF ATTACK

Targets (news media)Targets (news media)

Vehicle (US mail)Vehicle (US mail)

Source of strain (US, probably weaponized)Source of strain (US, probably weaponized)

Translocation of spore through envelopeTranslocation of spore through envelope

Airborne acquisition in mail facilitiesAirborne acquisition in mail facilities

Wide spread contamination in mail facilitiesWide spread contamination in mail facilities

Transmission via mail-to-mail contaminationTransmission via mail-to-mail contamination

No person or group has claimed responsibilityNo person or group has claimed responsibility

ANTHRAX: EPIDEMIOLOGYANTHRAX: EPIDEMIOLOGY Agent: Agent: Bacillus anthracisBacillus anthracis, a Gram-, a Gram-

positive, positive,

spore forming non-motile bacillus spore forming non-motile bacillus

(straightforward lab identification)(straightforward lab identification)

ReservoirReservoir: Herbivores (cattle, goats,: Herbivores (cattle, goats,

sheep), sheep),

capable of surviving in the environment capable of surviving in the environment

for for

prolonged periodsprolonged periods

TransmissionTransmission

Contact, ingestion, or Contact, ingestion, or inhalation of inhalation of

infectiveinfective spores spores

Sources of infection: Contaminated Sources of infection: Contaminated

hides, wool, hair, bone, meat, or other hides, wool, hair, bone, meat, or other

animal productsanimal products

SVERDLOVSK ANTHRAX OUTBREAKSVERDLOVSK ANTHRAX OUTBREAK

Site: Sverdlovsk, USSRSite: Sverdlovsk, USSR

Year: 1979Year: 1979

Cause: Accidental release Cause: Accidental release

from military microbiologic from military microbiologic

facility – Military report noted: facility – Military report noted:

“Filter clogged so I’ve removed “Filter clogged so I’ve removed

it. Replacement necessary”it. Replacement necessary”

Transmission: AirborneTransmission: Airborne

Impact: 68 human deaths, 79 Impact: 68 human deaths, 79

human cases, multiple animal human cases, multiple animal

deaths (sheep, cowsdeaths (sheep, cows))

ANTHRAX: CLINICAL FEATURESANTHRAX: CLINICAL FEATURES

Incubation period: Incubation period: 1-7 days1-7 days (1-60 days) (1-60 days)

Clinical syndrome(s): Cutaneous ulcer, Clinical syndrome(s): Cutaneous ulcer, respiratoryrespiratory, ,

gastrointestinal, oropharyngealgastrointestinal, oropharyngeal

Inhalation anthrax = main threatInhalation anthrax = main threat

Spores may germinate up to 60 days after exposureSpores may germinate up to 60 days after exposure

LDLD5050 (human): 2,500 to 55,000 spores (human): 2,500 to 55,000 spores

Bronchopneumonia not a component (hemorrhagic Bronchopneumonia not a component (hemorrhagic

lymphadenitis and mediastinitis)lymphadenitis and mediastinitis)

Early diagnosis difficultEarly diagnosis difficult

Anthrax: Cutaneous

Healing after treatment

Gastrointestinal AnthraxGastrointestinal Anthrax

Hemorrhagic meningitis at autopsy. Photo courtesy of USAMRIID

B. ANTHRACISB. ANTHRACIS MENINGITIS MENINGITIS

Lesion on chin

CSF

INHALATION ANTHRAX: DIAGNOSISINHALATION ANTHRAX: DIAGNOSIS

Epidemiology Epidemiology

Sudden appearance of multiple cases of severe flu illness Sudden appearance of multiple cases of severe flu illness

with fulminant course and high mortalitywith fulminant course and high mortality

Clinical symptomsClinical symptoms

Non-specific prodrome of flu-like symptomsNon-specific prodrome of flu-like symptoms

Possible brief interim improvementPossible brief interim improvement

Abrupt onset of respiratory failure and hemodynamic Abrupt onset of respiratory failure and hemodynamic

collapse 2-4 days after initial symptoms, possibly collapse 2-4 days after initial symptoms, possibly

accompanied by thoracic edema and a widened accompanied by thoracic edema and a widened

mediastinum on CxRmediastinum on CxR

INHALATION ANTHRAX: DIAGNOSISINHALATION ANTHRAX: DIAGNOSIS Diagnostic studies Diagnostic studies

Chest radiograph with widened Chest radiograph with widened

mediastinum mediastinum

Peripheral blood smear with gram Peripheral blood smear with gram

(+) bacilli on unspun smear(+) bacilli on unspun smear

Microbiology Microbiology

Blood culture growth of large gram Blood culture growth of large gram

(+) bacilli with preliminary (+) bacilli with preliminary

identification of identification of Bacillus sppBacillus spp..

PLET medium PLET medium

Pathology Pathology

Hemorrhagic mediastinitis, Hemorrhagic mediastinitis,

hemorrhagic thoracic hemorrhagic thoracic

lymphadenitis, hemorrhagic lymphadenitis, hemorrhagic

meningitismeningitis INHALATION ANTHRAX: CxRINHALATION ANTHRAX: CxR

Inhalational anthrax: CT scan

INHALATION ANTHRAX, US

Prominent superior mediastinum,

?small left pleural effusion

B. ANTHRACISB. ANTHRACIS: PERIPHERAL : PERIPHERAL BLOOD SMEAR BLOOD SMEAR

Cutaneous Anthrax, USCutaneous Anthrax, US7 mo male infant hospitalized with 2 day 7 mo male infant hospitalized with 2 day history of swelling left arm and weeping history of swelling left arm and weeping lesion at left elbow. Patient had been at lesion at left elbow. Patient had been at his mother’s office at a TV network. his mother’s office at a TV network. Biopsies yielded Biopsies yielded B. anthracis.B. anthracis.

PlaguePlague

Public Health and ClinicalPublic Health and Clinical

FeaturesFeatures

IntroductionIntroduction Due to infection with Due to infection with

the bacteriumthe bacterium

Yersinia pestisYersinia pestis

Several forms:Several forms: ––BubonicBubonic ––Primary septicemia/Primary septicemia/

secondary secondary

pneumonicpneumonic ––Primary pneumonicPrimary pneumonic

PERIPHERAL BLOOD SMEARPERIPHERAL BLOOD SMEAR

Public Health FeaturesPublic Health Features

Most cases in U.S. occur in southwestMost cases in U.S. occur in southwest

Pneumonic plague can be transmitted Pneumonic plague can be transmitted

person to person via respiratory person to person via respiratory

dropletsdroplets

PLAGUE: CLINICAL FEATURESPLAGUE: CLINICAL FEATURES

Incubation period: 1-4 days (pneumonia), 1-7 days Incubation period: 1-4 days (pneumonia), 1-7 days

(bubonic or septicaemic)(bubonic or septicaemic)

Clinical syndrome(s)Clinical syndrome(s)

Bubonic, septicemic, pneumonic, cutaneous, Bubonic, septicemic, pneumonic, cutaneous,

meningitismeningitis

Epidemiology and symptomsEpidemiology and symptoms

Sudden onset fever, shortness of breath, Sudden onset fever, shortness of breath,

hemoptysis, chest painhemoptysis, chest pain Gastrointestinal symptoms common (N, V, diarrhea)Gastrointestinal symptoms common (N, V, diarrhea)

Fulminant course and high mortalityFulminant course and high mortality

Inguinal buboInguinal bubo Bubo – ruptured Bubo – ruptured inguinal lymph inguinal lymph

nodenode

Axillary buboAxillary buboFemoral buboFemoral bubo

PLAGUE: CLINICAL MANIFESTATIONS PLAGUE: CLINICAL MANIFESTATIONS

Cervical bubo

Ecchymosis, septicemia

Gangrene, septicemia

PNEUMONIC PLAGUE: CxRPNEUMONIC PLAGUE: CxR

PLAGUE: CONTROLPLAGUE: CONTROL

Laboratory precautions: BSL 2 (potentially infective Laboratory precautions: BSL 2 (potentially infective

clinical material), BSL 3 (activities with high potential clinical material), BSL 3 (activities with high potential

for droplet or aerosol production)for droplet or aerosol production)

Prophylaxis:Prophylaxis:

Post-exposure: Doxycycline (alternatives Post-exposure: Doxycycline (alternatives

ciprofloxacin or TMP-SMX)ciprofloxacin or TMP-SMX)

CDC isolation guidelinesCDC isolation guidelines

Bubonic: Standard Bubonic: Standard

Pneumonic: Droplet (until patient treated for 3 Pneumonic: Droplet (until patient treated for 3

days)days)

SMALLPOX: HISTORYSMALLPOX: HISTORY

1754-67: Biological weapon French and Indian wars1754-67: Biological weapon French and Indian wars

1796: Edward Jenner uses vaccinia for 1796: Edward Jenner uses vaccinia for

immunizationimmunization

1967: WHO global eradication campaign1967: WHO global eradication campaign

1972: US ceases routine vaccination1972: US ceases routine vaccination

1977: Last case endemic smallpox (Somalia)1977: Last case endemic smallpox (Somalia)

1978: Last laboratory acquired case (England)1978: Last laboratory acquired case (England)

1982: Worldwide cessation of vaccination1982: Worldwide cessation of vaccination

SMALLPOX: VIROLOGYSMALLPOX: VIROLOGY

Agent: Variola (family poxviridae)Agent: Variola (family poxviridae)

8 genera in family8 genera in family

Human infectious agentsHuman infectious agents

Orthopoxviruses: Variola, varicella Orthopoxviruses: Variola, varicella

(chickenpox)(chickenpox)

Mullucipoxvirus: Mulluscum contagiosum virusMullucipoxvirus: Mulluscum contagiosum virus

Nonhuman orthopoxviruses: Monkeypox, cowpox, Nonhuman orthopoxviruses: Monkeypox, cowpox,

canarypox, rabbitpox, etc.canarypox, rabbitpox, etc.

VARIOLA (SMALLPOX)VARIOLA (SMALLPOX)

Large DNA VirusLarge DNA Virus

Dumb bell shaped Dumb bell shaped

virusvirus

Complex membranesComplex membranes

SMALLPOX: EPIDEMIOLOGYSMALLPOX: EPIDEMIOLOGY

Agent: Variola virusAgent: Variola virus

Reservoir: HumansReservoir: Humans

TransmissionTransmission

Contact, droplet, and airborneContact, droplet, and airborne

Transmission does not occur until the onset rashTransmission does not occur until the onset rash

Maximum infectiousness, days 7-10 of rashMaximum infectiousness, days 7-10 of rash

Increased infectiousness if patient coughing or Increased infectiousness if patient coughing or

has a hemorrhagic form of smallpoxhas a hemorrhagic form of smallpox

SMALLPOX: CLINICAL FEATURESSMALLPOX: CLINICAL FEATURES

Incubation period: 12 days (7-17 days)Incubation period: 12 days (7-17 days)

Clinical featuresClinical features

Non-specific prodrome (2-4 days) of fever, mylagiasNon-specific prodrome (2-4 days) of fever, mylagias

Rash most prominent on face and extremities Rash most prominent on face and extremities

(including palms and soles) in contrast to truncal (including palms and soles) in contrast to truncal

distribution of varicelladistribution of varicella

Rash scabs over in 1-2 weeksRash scabs over in 1-2 weeks

Variola rash has a synchronous onset (in contrast Variola rash has a synchronous onset (in contrast

to the rash of varicella which arises in crops)to the rash of varicella which arises in crops)

SMALLPOX IN A CHILDSMALLPOX IN A CHILD

Classic Centrifugal Rash of Smallpox Involving Face and Extremities. Photo courtesy of National

Archives

Smallpox in an adultNigeria, 197027 yo female

Lesions have a peripheral distribution,Facial edema, and Uniform in terms of Stage of development

SMALLPOX: DIAGNOSISSMALLPOX: DIAGNOSIS

Appearance of rashAppearance of rash

Hemorrhagic smallpox may be mistaken for Hemorrhagic smallpox may be mistaken for

meningococcemia or severe acute leukemiameningococcemia or severe acute leukemia

Culture of lesionsCulture of lesions

Should be obtained by immunized person; place Should be obtained by immunized person; place

specimen in vacutainer tube, tape juncture of specimen in vacutainer tube, tape juncture of

stopper and tube, place in second durable, stopper and tube, place in second durable,

watertight containerwatertight container

Alert labAlert lab

SMALLPOX: CONTROLSMALLPOX: CONTROL

Laboratory precautions: BSL 4Laboratory precautions: BSL 4

Clothing/fomites: DecontaminateClothing/fomites: Decontaminate

ProphylaxisProphylaxis

Pre-exposure: Vaccine Pre-exposure: Vaccine

Post-exposure: Vaccine (within 4 days) or vaccine Post-exposure: Vaccine (within 4 days) or vaccine

plus VIG (>4 days); potential role for cidofovirplus VIG (>4 days); potential role for cidofovir

Isolation: Contact plus airborneIsolation: Contact plus airborne

Vaccination With the Bifurcated NeedleVaccination With the Bifurcated Needle

EVOLVING PRIMARY VACCINATIONEVOLVING PRIMARY VACCINATION

Photo courtesy of CDC

Fatal case of Vaccinia necrosum at inoculation site Accidental auto-inoculation of the Accidental auto-inoculation of the

eye with eye with Vaccinia Vaccinia virusvirus

VACCINIA VACCINE:VACCINIA VACCINE:PRECAUTONS AND CONTRAINDICATIONSPRECAUTONS AND CONTRAINDICATIONS

Severe allergic reaction to prior dose of vaccineSevere allergic reaction to prior dose of vaccine

History or presence of eczema, other skin conditionsHistory or presence of eczema, other skin conditions

Pregnancy (children in the household is not a Pregnancy (children in the household is not a

contraindication)contraindication)

Altered immocompetenceAltered immocompetence

HIV, Leukemia, lymphoma, generalized malignancyHIV, Leukemia, lymphoma, generalized malignancy

Solid organ transplant, BMTSolid organ transplant, BMT

Corticosteroids, alkylating agents, antimetabolites, Corticosteroids, alkylating agents, antimetabolites,

radiationradiation

Cardiac diseaseCardiac disease

AllergiesAllergies

Neomycin, polymyxin b, tetracyclines, streptomycinNeomycin, polymyxin b, tetracyclines, streptomycin

VACCINIA VACCINE:VACCINIA VACCINE:PREVENTION OF CONTACT TRANSMISSIONPREVENTION OF CONTACT TRANSMISSION

Vaccinia virus can be cultured from primary vaccination Vaccinia virus can be cultured from primary vaccination

site beginning at the time of development papule (2-5d site beginning at the time of development papule (2-5d

after vaccination)after vaccination)

Transmission via direct skin contact may occurTransmission via direct skin contact may occur

Vaccination site should be covered with a porous bandage Vaccination site should be covered with a porous bandage

until scab has separated and underlying skin has healed until scab has separated and underlying skin has healed

(do not use an occlusive dressing)(do not use an occlusive dressing)

Use impermeable bandage when bathingUse impermeable bandage when bathing

Vaccinated HCWs may continue to work (vaccination site Vaccinated HCWs may continue to work (vaccination site

covered with sterile gauze and semipermeable dressing, covered with sterile gauze and semipermeable dressing,

and practice of good handwashing)and practice of good handwashing)

Botulism ToxinBotulism Toxin A major bioweapons threat because A major bioweapons threat because

of its extreme potency and of its extreme potency and lethalitylethality

The single most poisonous substance The single most poisonous substance known.known. Easy to produce, transport and misuseEasy to produce, transport and misuse The average incubation period is 12-72 The average incubation period is 12-72

hours after ingestion.hours after ingestion.Neurotoxin produced by Clostridium botulinum

Most lethal substance known

Modes of transmissionModes of transmission No person-to-person No person-to-person

transmissiontransmission

Exposure typesExposure types Foodborne - Ingestion of toxinFoodborne - Ingestion of toxin

Infant – Ingestion of Infant – Ingestion of C. botulinumC. botulinum

Wound – Infection with Wound – Infection with C. botulinumC. botulinum

Inhalation of aerosolized toxinInhalation of aerosolized toxin

As BT agent may be aerosolized As BT agent may be aerosolized

or added to food or wateror added to food or water

Patients with botulism Patients with botulism typically present with typically present with difficulty speaking, seeing difficulty speaking, seeing and/or swallowing.and/or swallowing.

Prominent neurologic Prominent neurologic findings include ptsosis, findings include ptsosis, diplopia, blurred vision, diplopia, blurred vision, dysarthria and dysphagia. dysarthria and dysphagia.

Patients typically are Patients typically are afebrile and do not have an afebrile and do not have an altered level of altered level of consciousness. consciousness.

Patients may initially presentPatients may initially present with gastrointestinal distress, with gastrointestinal distress, nausea, and vomiting nausea, and vomiting preceding neurological symptoms. preceding neurological symptoms.

Six-week old infant withbotulism.

BotulismBotulism

BotulismBotulism

Symptoms:Symptoms: Acute, afebrile, symmetric, decending paralysis of facial Acute, afebrile, symmetric, decending paralysis of facial

musculature, multiple cranial nerve palsies musculature, multiple cranial nerve palsies Onset and severity dependent on amount of toxin Onset and severity dependent on amount of toxin

absorbed absorbed Incubation variable 2 hrs to 8 days after ingestionIncubation variable 2 hrs to 8 days after ingestion

Neurologic symptoms:Neurologic symptoms: Ptosis, diplopia, blurred vision, loss of head controlPtosis, diplopia, blurred vision, loss of head control Deep tendon reflexes diminishDeep tendon reflexes diminish Death results from airway obstruction; Death results from airway obstruction;

Respiratory and diaphragmatic muscle paralysisRespiratory and diaphragmatic muscle paralysis Diagnosis: Diagnosis:

Index of suspicion for botulism; clusters of casesIndex of suspicion for botulism; clusters of cases Treatment:Treatment:

Supportive care and administration of passive equine Supportive care and administration of passive equine antitoxinantitoxin

Botulinum Toxin as a Botulinum Toxin as a BioweaponBioweapon

Aum Shinrikyo 1990, 1993, 1995: attempted Aum Shinrikyo 1990, 1993, 1995: attempted

aerosol dispersion in Japanaerosol dispersion in Japan

Japan WW II (Unit 731): fed cultures to Japan WW II (Unit 731): fed cultures to

prisoners in Chinaprisoners in China

US bioweapons programUS bioweapons program

Soviet Union program: gene splicingSoviet Union program: gene splicing

Iraq 19,000 liters weaponized Iraq 19,000 liters weaponized

? Iran, North Korea, Syria? Iran, North Korea, Syria

Viral Hemorrhagic FeversViral Hemorrhagic Fevers

Arena VirusesArena Viruses Lassa feverLassa fever Argentine hemorrhagic feverArgentine hemorrhagic fever Bolivian hemorrhagic feverBolivian hemorrhagic fever FlaviviridaeFlaviviridae Yellow feverYellow fever DengueDengue BunyaviridaeBunyaviridae Crimean-Congo feverCrimean-Congo fever FilovirusesFiloviruses Marburg Ebola hemorrhagic Marburg Ebola hemorrhagic

feversfevers

Ebola and Marburg – Ebola and Marburg – Etiologic agentsEtiologic agents

Flioviridae Flioviridae family virusesfamily viruses Among the most virulent viruses Among the most virulent viruses

(25-90% case fatality depending (25-90% case fatality depending on strain)on strain)

ZoonoticZoonotic Humans are incidental hosts Humans are incidental hosts

Marburg

Ebola

Clinical features - VHFClinical features - VHF

Severe multisystem syndromeSevere multisystem syndrome

Overall vascular system damage Overall vascular system damage

Body’s ability to regulate itself is Body’s ability to regulate itself is

impairedimpaired

Often accompanied by hemorrhagic Often accompanied by hemorrhagic

(in itself not usually life (in itself not usually life

threatening)threatening)

Ebola & Marburg Viruses - Ebola & Marburg Viruses - clinical courseclinical course

Sudden onset of flu-like illnessSudden onset of flu-like illness

May progress to nausea, vomiting, May progress to nausea, vomiting,

diarrhea, abdominal pain, diarrhea, abdominal pain,

photophobia, maculopapular rash, photophobia, maculopapular rash,

DIC, internal and external DIC, internal and external

hemorrhage, multiorgan failure hemorrhage, multiorgan failure

with jaundice and renal with jaundice and renal

insufficiencyinsufficiency

Atlanta, Georgia: Electron Micrograph: Ebola virus causing African Hemorrhagic Fever. (Courtesy of the National Archives, 82-424)

Marburg & Ebola –Marburg & Ebola –OccurrenceOccurrence

Naturally occurring sporadic outbreaks Naturally occurring sporadic outbreaks

in Africain Africa

Cases have occurred in West as a result Cases have occurred in West as a result

of exposure to animal reservoirsof exposure to animal reservoirs

BT potentialBT potential

Russian biowarfare program Russian biowarfare program

Iraq is believe to have triedIraq is believe to have tried

Ebola and Marburg - Ebola and Marburg - transmissiontransmission

Direct contact with infected tissue Direct contact with infected tissue and body fluids or contaminated and body fluids or contaminated objectsobjects

Probably aerosol inhalationProbably aerosol inhalation

Borio, et al JAMA consensus statement 2002

Maculopapular Rash in Marburg Disease

Ocular Manifestations in Bolivian Hemorrhagic Fever

Psychological and Social Psychological and Social Factors during Factors during bioterrorismbioterrorism1.1. HorrorHorror

2.2. AngerAnger

3.3. PanicPanic

4.4. Magical thinking about microbesMagical thinking about microbes

5.5. Fear of invisible agents Fear of contagionFear of invisible agents Fear of contagion

6.6. Anger at Terrorist/GovernmentAnger at Terrorist/Government

7.7. ScapegoatScapegoat

8.8. ParanoiaParanoia

9.9. Social isolationSocial isolation

10. Demoralization10. Demoralization

11. Loss of faith in social institutions11. Loss of faith in social institutions

12. Attribution of arousal symptoms to infection12. Attribution of arousal symptoms to infection

MANAGEMENT OF PEOPLE WITH MANAGEMENT OF PEOPLE WITH PSYCHOLOGICAL PROBLEMSPSYCHOLOGICAL PROBLEMS

1.1. care of health workerscare of health workers

2.2. Critical incidence stress management (CISM) for rescue Critical incidence stress management (CISM) for rescue

workersworkers

3.3. Prevention of public fleeingPrevention of public fleeing

4.4. Confidence building by the medical workersConfidence building by the medical workers

5.5. Dealing with emotional and psychological problems Dealing with emotional and psychological problems

while dealing with the dead.while dealing with the dead.

6.6. Care of emergency workers, medical and paramedical Care of emergency workers, medical and paramedical

workersworkers

7.7. Critical incidence of stress debriefing(CSID)Critical incidence of stress debriefing(CSID)

8.Prevention of group panic 8.Prevention of group panic

9. Avoidance of emotion based responses (Knee jerk 9. Avoidance of emotion based responses (Knee jerk

quarantine)quarantine)

10. Effective risk communication10. Effective risk communication

11. Control of symptoms secondary to hyper arousal11. Control of symptoms secondary to hyper arousal

12. Reassurance12. Reassurance

13. Management of anger fear (Diazepam and other 13. Management of anger fear (Diazepam and other

anxiolytic drugs)anxiolytic drugs)

14. Provision of respite as required14. Provision of respite as required

15. Social support of the community15. Social support of the community

Role of CliniciansRole of Clinicians

Be prepared to diagnose and Be prepared to diagnose and treat BT diseasestreat BT diseases

Keep alert to unusual disease Keep alert to unusual disease patternspatterns

Use reportable disease system to Use reportable disease system to alert public health officials of a alert public health officials of a potential problempotential problem

Get involved in disaster planning Get involved in disaster planning processprocess

Clusters of patients with the Clusters of patients with the same disease or syndromesame disease or syndrome

Especially when:Especially when: there is more cases than would be expected there is more cases than would be expected cases are geographically or temporally cases are geographically or temporally

clusteredclustered the illness is unexplainedthe illness is unexplained there are multiple atypical presentations of there are multiple atypical presentations of

the disease the disease the mortality or morbidity is higher than the mortality or morbidity is higher than

expectedexpected

Even a single case may be a Even a single case may be a signalsignal

Caused by an uncommon agentCaused by an uncommon agent Unusual for region, age group or Unusual for region, age group or

seasonseason Fulminant disease in otherwise Fulminant disease in otherwise

healthy patienthealthy patient Atypical presentationAtypical presentation

Other cluesOther clues

Similar genetic type of agent from Similar genetic type of agent from distinct sourcesdistinct sources

Unusual, atypical, genetically Unusual, atypical, genetically engineered, or antiquated strainengineered, or antiquated strain

Atypical aerosol, food, or water Atypical aerosol, food, or water transmission transmission

Concurrent animal diseaseConcurrent animal disease

DETECTION OF DETECTION OF OUTBREAKSOUTBREAKS RecognitionRecognition

• Syndrome criteriaSyndrome criteria

• Epidemiological featuresEpidemiological features

CommunicationCommunication

MedicalMedical

•Triage, psychological aspects, lab support, public Triage, psychological aspects, lab support, public

informationinformation

•Patient isolation (Follow CDC guidelines), Patient isolation (Follow CDC guidelines),

decontaminationdecontamination

•Post-exposure prophylaxis, treatment of infected Post-exposure prophylaxis, treatment of infected

personspersons

DETECTION OF DETECTION OF OUTBREAKSOUTBREAKS

Epidemiologic featuresEpidemiologic features

A rapidly increasing disease incidenceA rapidly increasing disease incidence

An unusual increase in the number of people seeking care, esp. An unusual increase in the number of people seeking care, esp.

with with

fever, respiratory, or gastrointestinal symptomsfever, respiratory, or gastrointestinal symptoms

An endemic disease rapidly emerging at an uncharacteristic An endemic disease rapidly emerging at an uncharacteristic

time or in time or in

an usual patternan usual pattern

Lower attack rate among persons who had been indoorsLower attack rate among persons who had been indoors

Clusters of patients arriving from a single localClusters of patients arriving from a single local

Large numbers of rapidly fatal casesLarge numbers of rapidly fatal cases

Any patient presenting with a disease that is relatively Any patient presenting with a disease that is relatively

uncommon and uncommon and

has bioterrorism potentialhas bioterrorism potential

DETECTION AND DETECTION AND IDENTIFICATION OF IDENTIFICATION OF BIOWEAPON AGENTBIOWEAPON AGENT 1.1. The conventional microbiological methods viz., The conventional microbiological methods viz.,

culture, immunodetection, serology, molecular culture, immunodetection, serology, molecular

identification take long time (hours to days) identification take long time (hours to days)

2.2. Several biodetectors (bioluminometer) based Several biodetectors (bioluminometer) based

on the principles of bioluminescence and on the principles of bioluminescence and

biofluorescence are being developed _ biofluorescence are being developed _ Fire fly Fire fly

luciferage geneluciferage gene..

3.3. There are various types of There are various types of biosensors such as biosensors such as

immunosensors, nucleic acid sensors, tissue immunosensors, nucleic acid sensors, tissue

based sensors and laser sensors based sensors and laser sensors

EMERGINGEMERGING INFECTIONS AND INFECTIONS AND BIOTERRORISMBIOTERRORISM

New diseases have also appeared within the developed New diseases have also appeared within the developed

nations including United States. Some of these include: nations including United States. Some of these include:

Lyme diseaseLyme disease

Legionnaires’ diseaseLegionnaires’ disease

New variant of Creutzfeldt -Jakob diseaseNew variant of Creutzfeldt -Jakob disease

West-Nile virus disease West-Nile virus disease

Hantavirus pulmonary syndrome (HPS) Hantavirus pulmonary syndrome (HPS)

Multi-drug resistant TB, Multi-drug resistant TB,

Antibiotic resistant staphylococcal, enterococcal and Antibiotic resistant staphylococcal, enterococcal and

pneumococcal infections pneumococcal infections

Diarrhoeal diseases caused by the parasite Diarrhoeal diseases caused by the parasite

Cryptosporidium parvumCryptosporidium parvum and then certain strains of and then certain strains of

Escherichia coliEscherichia coli bacteria. bacteria.

Factors contribute to the Factors contribute to the emergence and re-emergence of emergence and re-emergence of

infectious diseasesinfectious diseases 1. Unprecedented worldwide population growth draining 1. Unprecedented worldwide population growth draining the natuthe natural resourcesral resources

2. Overcrowding in cities with poor sanitation2. Overcrowding in cities with poor sanitation3. Rapid and increased international travel3. Rapid and increased international travel4. Increased international trade in animals and food 4. Increased international trade in animals and food

productsproducts5. Mass distribution of food and unhygienic food 5. Mass distribution of food and unhygienic food

preparationpreparation practicespractices6. Increased exposure of humans to disease vectors and 6. Increased exposure of humans to disease vectors and

reservoirs in naturereservoirs in nature7. Man-made changes to the environment and climatic 7. Man-made changes to the environment and climatic

changes which have a direct impact on the changes which have a direct impact on the population of insect vectors and animal reservoirs.population of insect vectors and animal reservoirs.

7. Misuse of antibiotics leading to the evolution of 7. Misuse of antibiotics leading to the evolution of resistant microbes. resistant microbes.

Impact of biological agents on Impact of biological agents on

national economiesnational economies Highly pathogenic avian influenza, Highly pathogenic avian influenza,

Hong KongHong Kong

The outbreak of highly pathogenic avian The outbreak of highly pathogenic avian

influenza (HPAI) type A (H5N1) in live influenza (HPAI) type A (H5N1) in live

market chickens in Hong Kong resulted in market chickens in Hong Kong resulted in

6 million deaths and killing of 1.4 million 6 million deaths and killing of 1.4 million

birds.birds.

Nipah virus, MalaysiaNipah virus, Malaysia

Nipah virus, a previously un known virus was Nipah virus, a previously un known virus was

identified in 1998, primarily in identified in 1998, primarily in pigs and in pigs and in

humanshumans in Malaysia. in Malaysia.

The virus caused over 250 human cases The virus caused over 250 human cases

resulting in 100 deaths. Approximately 1 resulting in 100 deaths. Approximately 1

million pigs were killed. Other countries in million pigs were killed. Other countries in

the region banned he importation of pork the region banned he importation of pork

products. products.

Malaysia authorities blamed the disease on a Malaysia authorities blamed the disease on a

deliberate attack by rival Asian countries deliberate attack by rival Asian countries

trying to slowdown Malaysia’s recovery from trying to slowdown Malaysia’s recovery from

the Asian Economic Crisis of the 1997.the Asian Economic Crisis of the 1997.

Foot and Mouth disease, TaiwanFoot and Mouth disease, Taiwan

The 1997 Foot and mouth disease outbreak in The 1997 Foot and mouth disease outbreak in

Taiwan had a devasting effect on export oriented Taiwan had a devasting effect on export oriented

pork industry. pork industry.

The virus is believed to have been brought into The virus is believed to have been brought into

Taiwan through smuggled animals, meat products Taiwan through smuggled animals, meat products

or illegal immigrants from mainland China. or illegal immigrants from mainland China.

The epizootic resulted in the depopulation of 3.8 The epizootic resulted in the depopulation of 3.8

million pigs. million pigs. At one point the outbreak it was blamed as At one point the outbreak it was blamed as deliberate deliberate

introduction of FMD into Taiwan by mainland China. The introduction of FMD into Taiwan by mainland China. The

economic impact on Taiwan has been estimated in the economic impact on Taiwan has been estimated in the

billions of dollars.billions of dollars.

ConclusionsConclusions

Less developed nations can produce biological weapons Less developed nations can produce biological weapons

that are as lethal as nuclear weapons include: Iran, Iraq, that are as lethal as nuclear weapons include: Iran, Iraq,

Israel, North Korea, China, Libya, Syria and Taiwan. Israel, North Korea, China, Libya, Syria and Taiwan.

Recent terrorist activities in India underscores it’s Recent terrorist activities in India underscores it’s

vulnerability to bioterrorism and the need for a vulnerability to bioterrorism and the need for a

comprehensive plan to defend against an attack. comprehensive plan to defend against an attack.

Currently, it does not have the infrastructure to quickly Currently, it does not have the infrastructure to quickly

detect and identify many pests and pathogens nor is the detect and identify many pests and pathogens nor is the

country able to respond to even small-scale attack. country able to respond to even small-scale attack.

TERRORISM TODAY