Chem and Biol Terrorism Dr Coule

Chemical and Biological Terrorism: 

Chemical and Biological Terrorism Phillip L. Coule, M.D. Medical College of Georgia Assist. Professor of Emergency Medicine Director, EMS and ECC An Overview of the Threat

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Expert??? After September 11?

Objectives: 

Objectives Review history and define Nuclear, Chemical and Biological Terrorism Review previous ChemBio events Overview of CDC Class A bioterrorism agents Overview of chemical agents and toxins Types of nuclear terrorist events Specific information on agents

Definitions: 

Definitions Nuclear, Biological or Chemical agents to terrorize attack or terrorize a population NBC – nuclear, biological, chemical “Biochem” “Chembio” WMD – Weapons of Mass Destruction

Other Terms: 

Other Terms NBC – nuclear, biological, chemical “Biochem” “Chembio” WMD – Weapons of Mass Destruction

Biological terrorism: 

Biological terrorism Dispersal of microbes or their toxins to produce illness, death and terror Microbes Bacteria Viruses Toxins

Is this something new?: 

Is this something new? 14th Century – Kaffa City on Crimean Peninsula Strategic to Silk trade routes between China and Europe Rival trade groups captured city Multiple unsuccessful attempts to retake city Hurled plague infested corpses over walls of city to infest it

Is this something new?: 

Is this something new? 18th Century French and Indian War British Officers gave blankets from smallpox victims to indians aligned with French Caused an epidemic in tribes Effective means of incapacitating group

Bioterroism- the 20th Century: 

Bioterroism- the 20th Century 1943 US Biological Warfare program 1953 Defensive program established 1969 Offensive program disbanded

NBC Events since 1970: 

NBC Events since 1970 1972 Typhoid March 1995 Sarin 12 Dead, 5500 Affected November 1995 Radioactive Cesium December 1995 Ricin June 1996 Uranium 1992 Cyanide March 1995 Ricin April 1995 Sarin April-June 1995 Cyanide, Phosgene, Pepper Spray February 1997 Chlorine 14 Injured, 500 Evacuated June 1994 Sarin 7 Dead, 200 Injured May 1995 Plague April 1997 U235 1984 Salmonella 200 Injured 1985 Cyanide 1984 Botulinum 2001 Anthrax 5 dead ??? Injured San Diego Medical Society

1972- “Order of the Rising Sun”: 

1972- “Order of the Rising Sun” Possession of 30-40 kg of Typhoid Cultures Were going to poison water supplies of Chicago, St Louis, and other large Midwestern cities Thwarted by FBI

1984 – Bhagwan Shree Rajneesh: 

1984 – Bhagwan Shree Rajneesh The Dalles, Oregon fall 1984 Sprayed Salmonella on salad bars at 10 restaurants Attempt to sway local election by decreasing turnout of voters 751 Ill 45 Hospitalized 0 fatalities

1990’s Aum Shinrinkyo Cult: 

1990’s Aum Shinrinkyo Cult Attempted release of Anthrax on at least 8 occasions- no illness Sarin Subway Attack 1995- 5,510 affected Dead 8 Critical 17 Severe 37 Moderate 984 Outpatient 4,073 Unknown 391

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Today? – Questions?

Ideal Biological Weapon: 

Ideal Biological Weapon Easy to manufacture/obtain Lethality / Incapacitation Easy to store Easy to deliver to target in large quantities large population – particle size Highly infective / contagious Incubation period Fear factor - untreatable

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18-20 15-18 7-12 4-6 (bronchioles) 1-5 (alveoli) Infection Severity Particle Size (Micron, Mass Median Diameter) The ideal aerosol contains a homogeneous population of 2 or 3 micron particulates that contain one or more viable organisms Maximum human respiratory infection is a particle that falls within the 1 to 5 micron size Less Severe More Severe Aerosol / Infectivity Relationship Source: San Diego Medical Society

CDC Threat Classification: 

CDC Threat Classification Category A Agents that pose a threat to National Security Easily disseminated or transmitted from person to person Cause high mortality – public health impact Public panic / Social disruption Require special action for PH preparedness

CDC Threat Classification: 

CDC Threat Classification Category B Moderately easy to disseminate Moderate morbidity and low mortality Require specific enhancement of CDC and PH surveillance

CDC Threat Classification: 

CDC Threat Classification Emerging pathogens that could be engineered for mass dessemination Availability Ease of production and dissemination Potential for high morbidity and mortality and major health impact

CDC Critical Biological Agents“Category A”- Viruses: 

CDC Critical Biological Agents “Category A”- Viruses

CDC Critical Biological Agents“Category A”- Bacteria: 

CDC Critical Biological Agents “Category A”- Bacteria

CDC Critical Biological Agents“Category A” - Toxins: 

CDC Critical Biological Agents “Category A” - Toxins

CDC Threat Classification – Category B: 

CDC Threat Classification – Category B

CDC Classification – Category C: 

CDC Classification – Category C

Chemical Agents: 

Chemical Agents Blister / vesicants Cellular Respiration poisons Choking/ Pulmonary agents Incapacitating Agents Nerve Agents Riot Control / Tear Gases Emetic agents

Comparison of BioterrorismToxins and Chemical Agents: 

Comparison of Bioterrorism Toxins and Chemical Agents Source: AHLS

Comparison of BioterrorismToxins and Chemical Agents-2: 

Comparison of Bioterrorism Toxins and Chemical Agents-2 * Exceptions, trichothecene (T-2) mycotoxins Source: AHLS

Chemical Terrorism Agents : 

Chemical Terrorism Agents Source: AHLS

Chemical Terrorism Agents – 2: 

Chemical Terrorism Agents – 2 Source: AHLS

Nuclear Terrorism: 

Nuclear Terrorism More likely Less Likely Source: AHLS

Anthrax: 

Anthrax Gram positive bacillus Spore Forming 1 micron spore size Spores are persistent in soil >100 yrs

Botulism: 

Botulism Toxin produced by Clostridium botulinum Lethal dose is 1 ng/kg Neurotoxin Incubation 1-5 D (foodborne), blocks cholinergic synapses Diplopia, weakness, paralysis Death from respiratory failure Tx: ventilatory support, trivelant antitoxin

Plague – Yersinia pestis: 

Plague – Yersinia pestis Gram negative coccobacillus (rods) Two forms: Bubonic plague Pneumonic plague Can occur naturally, but usually as bubonic Sx’s fever, cough with mucopurulent sputum, hemoptysis, chest pain

Plague - Pathogenesis: 

Plague - Pathogenesis Consumed by macrophages transported to regional lymph nodes regional adenitis Bacteremia – spread Lungs Spleen Liver Brain

Pneumonic PlaguePrevention of Secondary Infection: 

Pneumonic Plague Prevention of Secondary Infection Secondary transmission is possible and likely Standard, contact, and aerosol Until sputum cultures are negative pneumonic plague is excluded

Pneumonic Plague Signs and Symptoms: 

Pneumonic Plague Signs and Symptoms 2 to 3 day incubation High fever, myalgias, chills, HA, and cough and bloody sputum Pneumonia and sepsis develop acutely Dyspnea, stridor, cyanosis, circulatory collapse Patchy infiltrates or consolidation CXR Suspicion for lobar pneumonia out of season

Bubonic PlagueSigns and Symptoms : 

Bubonic Plague Signs and Symptoms Erythema, fever, rigors Bubo formation in regional lymph nodes Bubo aspiration and gram stain is diagnostic Differentiate from Tularemia Cat-scratch fever Staph-strep lymphadenitis

Acral Gangrene: 

Acral Gangrene Acral gangrene Late complication of pneumonic or septicemic plague Fingers Toes Earlobes Nose Penis.

Plague - Treatment: 

Plague - Treatment Care is otherwise supportive Vaccine effective only for bubonic plague Prophylaxis - tetracycline or doxycycline Antibiotics must be started within 24 hours of symptoms to impact survival Streptomycin (30 mg/kg/day IM divided BID for 10 days) Doxycycline (100 mg IV BID for 10 days) Chloramphenicol for plague meningitis Respiratory isolation mandatory for the first 48 hours of treatment

Smallpox - Microbiology: 

Smallpox - Microbiology Variola (Var-ï-óla) virus, an Orthopox virus, both minor and major forms of smallpox exist Structure is a large DNA virus Declared eradicated in 1980 and the U.S. stopped its civilian vaccination in 1981, U.S. military stopped in 1985

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Close-up Smallpox rash CDC/Public domain

VHF Pathogenesis: 

VHF Pathogenesis Fever, myalgias, prostration Shock, mucous membrane hemorrhage Conjunctival injection, petechial hemorrhage, and hypotension Abnormal renal and LFT - poor prognosis Mortality varies; 50 - 80% Ebola Zaire Disease severity and survival host factors target organ is the vascular bed.

VHF Treatment: 

VHF Treatment Hemodynamic resuscitation and monitoring Invasive Swan Ganz catheter as feasible Careful fluid management use of colloid Vasopressors and cardiotonic drugs Cautious sedation and analgesia No anti-platelet drugs or IM injections Coagulation studies and replacement of clotting factors / platelet transfusions

Prevention of Secondary VHF Transmission: 

Prevention of Secondary VHF Transmission No vaccine is available at this time Single room w/ adjoining anteroom as only entrance handwashing facility with decontamination solution Negative air pressure if possible Strict barrier precautions gloves, gown, mask. shoe covers, protective eyeware/faceshield consider HEPA respirator for prominent hemorrhage, vomiting, diarrhea, cough

Isolation Precautions: 

Isolation Precautions Anthrax: Standard Plague: Respiratory (X 48 hrs) then droplet Smallpox: Respiratory Tularemia: Standard Brucellosis: Standard

Summary: 

Summary Bioterrorism is not new, just more prevalent Diseases of greatest concern Anthrax Botulism Tularemia Plague Smallpox VHF’s Disaster preparedness should focus on all threats Chemical Agents Nuclear Threats

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