Association of Occupational and Environmental Clinics : Association of Occupational and Environmental Clinics Edward W. Cetaruk, M.D.
Toxicology Associates
University of Colorado Health Sciences Center
Denver, Colorado, USA Worker Preparedness and Response to Bioterrorism
Section 1 An Overview of Biological Weapons : Section 1 An Overview of Biological Weapons Objectives:
To be able to list biological agents that may be weaponized
To describe the process of weaponization
To develop an understanding of the bioterrorist threat
To be able to recognize a biological attack
Probability vs. Potential Impact : POTENTIAL
IMPACT PROBABILITY/LIKELIHOOD NUCLEAR
WEAPON IMPROVISED
NUCLEAR
DEVICE RADIOACTIVE
MATERIAL CHEMICAL AGENT
OR TOXIC
INDUSTRIAL
CHEMICAL BIOLOGICAL
AGENT Probability vs. Potential Impact
History of Biological Warfare : Oldest of the NBC triad of agents
Used for > 2,000 years
Sieges of middle ages
Smallpox blankets given to Native Americans
Germany in World War I
Japan in World War II
Modern Bioterrorism History of Biological Warfare
Aum Shinrikyo Cult : Sarin Nerve Agent attacks 1994 and 1995
Attempted Botulinum Toxin release multiple times
Anthrax released multiple times
Attempted to obtain Ebola virus in Zaire Aum Shinrikyo Cult
Anthrax Letters United States : Anthrax Letters United States
Weaponized Biowarfare Agents : Anthrax
Botulinum Toxin A
Brucellosis
Glanders
Marburg Virus
Plague
Q Fever
Salmonella
Smallpox
Staph Enterotoxin B
Monkey Pox
Ricin
Tularemia
VEE
VHFs Weaponized Biowarfare Agents
Biological Agents of Highest Concern Category A : Biological Agents of Highest Concern Category A 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
Incubation Periods of Selected Biological Agents : Anthrax 1-5 Days++
Plague 2-3 Days
Q Fever 10-40 Days
Tularemia 2-10 Days
Smallpox 7-17 Days
Viral encephalitides V(2-6d); E&W (7-14 d)
VHFs 4-21 Days
Botulinum toxin 1-5 Days
Staph. enterotoxin B 1-6 Hours Incubation Periods of Selected Biological Agents
Infective Aerosol Doses of Selected Biological Agents : Anthrax 8,000 (or fewer) spores
Plague 100-500 organisms
Q Fever 1-10 organisms
Tularemia 10-50 organisms
Smallpox 10-100 organisms
Viral encephalitides 10-100 organisms
VHFs 1-10 organisms
Botulinum toxin 0.001 ug/kg Infective Aerosol Doses of Selected Biological Agents
Aerosol Size and Infectivity : 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 Size and Infectivity
Epidemiologic Clues : Large epidemic with high illness and death rate
Immunocompromised individuals may have first susceptibility
Respiratory symptoms predominate
Infection non-endemic for region
Multiple, simultaneous outbreaks
Multi-drug-resistant pathogens
Sick or dead animals
Delivery vehicle or intelligence information Epidemiologic Clues
Epidemiologic Information : Travel history
Local
Distant
Infectious contacts
Employment history
Activities over the preceding 1 to 2 weeks Epidemiologic Information
Section 2 Bioterrorism and the Workplace : Section 2 Bioterrorism and the Workplace Objectives:
To be able to develop practices and procedures to defend workers and the workplace from a bioterrorist attack
To respond the unique risks faced by first responders
To be able to choose and use the correct PPE needed for biological weapons
Bioterrorism Educational Needs of the Worker : Bioterrorism Educational Needs of the Worker Awareness
Fundamental understanding of biowarfare agents
Recognition and handling of suspicious mail or dissemination devices
PPE and workplace safety
Recognition of bioterrorist attack
Post exposure management
Bioterrorism: Who are First Responders? : Primary Care Personnel
Hospital ER Staff
Public Health Professionals
Emergency Response Personnel
Laboratory Personnel
Law Enforcement
Public
Military Bioterrorism: Who are First Responders?
First Responders : First Responders Often dealing with unknown agent(s)
May be exposed to infectious agent
May be exposed to infectious patients
May be targeted with secondary devices
May be first to notice the epidemiological pattern of a bioweapons attack
Emergency Plan : Emergency Plan All Hazards Approach
Identify areas with risk of exposure
Develop controls to minimize risk
Engineering Controls
Administrative Controls
Housekeeping Controls
PPE for workers
Develop response and recovery plan
Training and Exercises
Emergency Plan Exposure to Biological Agent : Emergency Plan Exposure to Biological Agent Policies and Procedures for handling suspicious mail or packages
Plan for facility response
Plan for involving appropriate authorities
Medical Surveillance
Training and Exercises
Handling of Suspicious Mail : Handling of Suspicious Mail Do not shake, empty contents
Do not carry, show others, or allow others to examine it
Do not sniff, touch, look closely at it, or any contents that may have spilled
Leave on stable surface, alert others, leave area, close doors, shut off ventilation
Wash hands with soap and water
Notify law enforcement
Create list of persons with potential contact
Personal Protective Equipment : Personal Protective Equipment Level A
SCBA, Encapsulation
Level of protection for entering contaminated, unsecured scene
Level B
Level C
Level D
Personal Protective Equipment Respirators : Personal Protective Equipment Respirators Powered Air-Purifying Respirator (PAPR)
HEPA filter face masks (N95, N100)
Respirators must be in compliance with
OSHA respiratory standard
(29 CFR 1910.134)
Respirators must be fit tested
Powered Air Purifying Respirator (PAPR) : Powered Air Purifying Respirator (PAPR)
PPE Respirators : PPE Respirators Respirators should be used in accordance with a respiratory-protection program that complies with the OSHA respiratory-protection standard (29 CFR 1910.134). N95 N100
Personal Protective Equipment Respirators :
The respirator is properly positioned over your nose and mouth at all times
The top strap or head harness assembly is positioned high on the back of the head
The lower strap is worn at the back of the neck below the ears
The straps are snug enough to keep the respirator from moving but not overly tight
Nothing (beards, head coverings, etc.) passes between the skin of the face and the respirator’s sealing edge Personal Protective Equipment Respirators
PPE Dermal Protection : PPE Dermal Protection Disposable
Reusable
Overgarments, Booties, Hoods, Gloves
All PPE should be decontaminated prior to leaving potentially contaminated area
PPE should be removed and discarded prior to removing face mask
Section 3 Anthrax as a Biological Weapon : Section 3 Anthrax as a Biological Weapon Objectives:
To understand the microbiology and epidemiology of anthrax
To understand the pathophysiology of the different anthrax clinical syndromes
To be able to recognize cutaneous anthrax
To be able to recognize an intentional anthrax release
To be able to treat patients with anthrax
Anthrax Microbiology & Epidemiology : Bacterium
Spores may survive > 100 yrs
Worldwide soil distribution
Common disease of herbivores
Herbivores in USA vaccinated
Man infected via animal products
Woolsorter’s Disease Anthrax Microbiology & Epidemiology
Anthrax Worldwide Occurrence : Source: WHO World Anthrax Data Site Anthrax Worldwide Occurrence
Anthrax Pathophysiology : Spore enters skin, GI tract, or lung
Germinates in macrophage
Transported to regional lymph nodes
Local production of toxins
Swelling and Tissue Death
Toxemia Anthrax Pathophysiology
Anthrax Clinical Syndromes : Cutaneous
Gastrointestinal
Inhalational Multiple forms can be
seen as the result of a BW attack Anthrax Clinical Syndromes
Anthrax Gastrointestinal : Anthrax Gastrointestinal Abdominal pain, usually accompanied by bloody vomiting or diarrhea, followed by fever and signs of sever infection
GI anthrax is sometimes seen as mouth and throat ulcerations with tender neck glands and fever
Develops after ingestion of contaminated, poorly cooked meat.
Incubation period: 1–7 days
Case-fatality: 25–90% (role of early antibiotic treatment is undefined)
Anthrax: Cutaneous : Anthrax: Cutaneous
Begins as a papule, progresses through a vesicular stage to a depressed black necrotic ulcer (eschar)
Edema, redness, and/or necrosis without ulceration may occur
Form most commonly encountered in naturally occurring cases
Incubation period: 1–12 days
Case-fatality:
Without antibiotic treatment: 20%
With antibiotic treatment: 1%
Cutaneous Anthrax : JAMA. 2002;287:869-874 Hospital Day 5 2 months
after
discharge Hospital Day 12 Cutaneous Anthrax
Inhalational Anthrax Clinical Presentation : Incubation Period: 1-6 days
A brief prodrome resembling a “viral-like” illness, characterized by muscle aches, fatigue, fever, with or without respiratory symptoms, nausea, vomiting, abdominal pain
Early Symptoms: malaise, fever, fatigue, non-productive cough, chest discomfort
Confusion, neck stiffness, and headache suggest meningitis (seen in 50% of patients) Inhalational Anthrax Clinical Presentation
Inhalational Anthrax Clinical Presentation : Inhalational Anthrax Clinical Presentation After initial onset of illness, symptoms may remain mild or even improve slightly before worsening
Terminal Phase: dyspnea, stridor, cyanosis, shock, chest wall edema, meningitis, widened mediastinum with effusion with overall toxic/septic clinical picture
Presenting Symptoms : Presenting Symptoms Emerg Infect Dis vol.7, no. 6, 2001
Anthrax Diagnosis : Clinical picture of sudden onset of respiratory distress with mediastinal widening on x-ray
A small number of patients may present with GI or cutaneous anthrax
Gram stain of blood and blood cultures - but these may be late findings in the course of the illness
ELISA, FA, PCR and immunohistology testing may confirm diagnosis but samples must go to reference laboratory Anthrax Diagnosis
Anthrax Treatment : Acute Treatment
Usually futile in severe mediastinitis patients who inhaled or ingested spores
Ciprofloxacin - 400 mg IV q 8 to 12 hr
Doxycycline - 100 mg IV q 12 hr
Vaccination Post-exposure
Oral prophylaxis
Ciprofloxacin (500 mg PO q12 h) X 60 days and until 3 doses of vaccine
Doxycycline (100 mg PO q12 h) X 60 days and until 3 doses of vaccine
Vaccination Anthrax Treatment
Anthrax Vaccine : FDA approved 1970
Cell Free filtrate (NO organisms, dead or alive)
Adverse effects 1-3%
Bioport Corporation Anthrax Vaccine
Laboratory Workers : Laboratory Workers Increased number of highly pathogenic bacterial and viral samples
Increased need for universal precautions
Increased need for security, including maintaining chain of custody for forensic samples
Increased need for decontamination procedures
Laboratory Response Network (LRN)
Laboratory Workers Decontamination and Disinfection : Laboratory Workers Decontamination and Disinfection Effective sporicidal solutions:
Commercially-available bleach diluted to 0.5% Sodium hypochlorite (1 part household bleach to 9 parts water)
Rinse off concentrated bleach to avoid caustic effects
Approved sporicidal agents
Section 4 Plague as a Biological Weapon : Section 4 Plague as a Biological Weapon Objectives:
To be able to describe the pathophysiology and epidemiology of plague.
To be able to recognize and treat the different clinical forms of plague.
To be able to control the secondary transmission of plague
Plague History : Plague History 200,000,000 deaths
Biblical (I Sam.) - 1320 BC, Philistines
Major Pandemics
541 - Plague of Justinian
1346 - ‘Black Death’
1894 - Modern Pandemic
Plague Distribution : Plague Distribution 1894 - Began in China
1898 - Southwest to India
1898 - South to Vietnam
1900 - Trans-Pacific to United States
Plague Epidemiology : Plague Epidemiology Vector: fleas, >80 species
Xenopsylla cheopis (Oriental rat flea)
Fleas feed on plague-infected mammal
Bacteria multiply in gut
Coagulum blocks gut
Plague organisms are regurgitated into bite wound with next feeding Photo: Ken Gage, Ph.D., CDC, Fort Collins, CO
Plague Epidemiology : Reservoir: mammals, >200 species.
Rattus rattus (Black rat)
Ground squirrels, prairie dogs, cats Plague Epidemiology
Plague Pathogenesis : Plague Pathogenesis Yersinia pestis - a Gram negative, nonmotile, nonsporulating bacteria
Size: 0.5–0.8 × 1.5–2.0 µm
Normally a disease of rodents
Virulence Factors: antiphagocytic fraction 1 capsule, pH 6 antigen, antiphagocytic Yops H and E, V antigens, Yop M, and plasminogen activator
Plague Pathophysiology : Plague Pathophysiology Inoculation or inhalation
(1-10 organisms) (100-20,000 organisms) Macrophage Lymphatics Regional lymph nodes Blood
Bubonic Plague Clinical Presentation : Bubonic Plague Clinical Presentation Incubation 1-8 days (mode 3-5 days)
Sudden onset of flu-like syndrome
(Fever, rigors, malaise, myalgias, nausea)
Bubo formation - within 24 hours
Swollen, infected lymph node (very painful!)
Cutaneous findings in 25% of cases
Mortality: Untreated 60% Treated <5%
Bubonic Plague : Photographs: Ken Gage, Ph.D., Centers for Disease Control and Prevention, Fort Collins, CO Bubonic Plague
Pneumonic Plague Clinical Presentation : Pneumonic Plague Clinical Presentation 2 to 3 day incubation period followed by high fever, muscle aches, chills, headache
Cough with bloody sputum within 24 hours
pneumonia progresses rapidly – shortness of breath, stridor, cyanosis, difficulty breathing, chest pain
respiratory failure, shock, bleeding
In contrast to anthrax, Plague pneumonia and sepsis develop acutely and may be fulminant
Patchy lung infiltrates or consolidation seen on chest x-ray
Pneumonic Plague : Pneumonic Plague Photograph by Ken Gage, Ph.D., Centers of Disease Control and Prevention, Fort Collins, CO.
Plague Transmission : Plague Transmission PNEUMONIC BUBONIC and SEPTICEMIC SECONDARY
PNEUMONIC
and
OROPHARYNGEAL Fleas
(active or dormant) Rodent Aerosol Surface contact
Plague Diagnosis : Plague Diagnosis Gram stain and culture of lymph node aspirates, sputum, or CSF samples
Bipolar staining “Safety Pin” may be present
Immunoassays are also available Photomicrograph: Ken Gage, Ph.D., Centers for
Disease Control and Prevention, Fort Collins, CO.
Plague - Treatment : Plague - Treatment Antibiotic Therapy:
Streptomycin (choice)15-30 mg/kg IM bid x 10 days
Gentamicin - 2 mg/kg IV then 1.0-1.5 mg/kg q8h or 5 mg/kg IV q24h x 10 days
Doxycycline - 200 mg IV then 100 mg bid x 10-14 days
Ciprofloxacin - 400 mg IV q12h x 10 days
Plague Control of Secondary Transmission : Plague Control of Secondary Transmission Secondary transmission is possible and likely Standard, contact, and aerosol precautions for at least 48 hrs until sputum cultures are negative or pneumonic plague is excluded
Section 5 Smallpox as a Biological Weapon : Section 5 Smallpox as a Biological Weapon Objectives:
To be able to describe the epidemiology and microbiology of smallpox
To be able to recognize clinical smallpox
To be able control the secondary transmission of smallpox
To describe treatment and vaccination options for smallpox.
Smallpox : Smallpox The world’s first eradicated disease
1977- last endemic case in Somalia
1978- two laboratory cases in Britain
1980- WHO declares global eradication of smallpox
Smallpox : Smallpox 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
Smallpox as a Bioweapon : 1763- French & Indian War
Fort Ticonderoga
Lord Jeffrey Amherst
World War II
Unit 731 experiments in China
Cold War
USSR arsenal Smallpox as a Bioweapon
Why would smallpox Make A Good Biological Weapon? : Infectious via aerosol
Vaccination discontinued
Decreased potency of vaccine stocks
Severe morbidity and mortality
Transmissible
Clinical inexperience
“Brand-name” recognition Why would smallpox Make A Good Biological Weapon?
Clinical Smallpox Prodrome : Incubation 7-17 days (mean 12)
Infection of respiratory mucosa
Minor viremia: seeding of liver, spleen
Major viremia: seeding of skin
Acute onset fever, rigors, headache, vomiting
Virus cultured from blood Clinical Smallpox Prodrome
Clinical Smallpox : Enanthem
Exanthem
begins on face, hands, forearms
spreads to lower extremities
centrifugal distribution
Macules papules vesicles pustules scabs/crusts scars Clinical Smallpox
Breman & Henderson, NEJM, 346(17), April, 2002 : Breman & Henderson, NEJM, 346(17), April, 2002
Smallpox Day 3 of Rash : Smallpox Day 3 of Rash From: Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 10–14. Photographs by I. Arita.
Smallpox Day 5 of Rash : Smallpox Day 5 of Rash From: Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 10–14. Photographs by I. Arita.
Smallpox Day 7 of Rash : Smallpox Day 7 of Rash From: Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 10–14. Photographs by I. Arita.
Smallpox : Smallpox
Smallpox Clinical Forms : Smallpox Clinical Forms Variola Major
30% fatal in unvaccinateds
3% fatal in vaccinateds
Variola Minor
Flat-Type Smallpox
Hemorrhagic Smallpox
Modified-Type Smallpox
Variola Sine Eruptione
Variola Minor : Variola Minor From: Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 10–14. Photographs by I. Arita.
Flat-type Smallpox : Flat-type Smallpox From Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 33. Photograph by F. Dekking
Hemorrhagic Smallpox : Hemorrhagic Smallpox From Herrlich A, Mayr A, Munz E, Rodenwaldt E. Die pocken; Erreger, Epidemiologie und klinisches Bild. 2nd ed. Stuttgart, Germany: Thieme; 1967.
Smallpox vs. Chickenpox : Smallpox vs. Chickenpox
Smallpox Management of Contacts : Smallpox Management of Contacts Immediate vaccination or boosting
VIG 0.6 ml/kg
Pregnant patients
Dermatoses patients
?? Normal hosts
Limited data: Vaccine + VIG better than vaccine alone?
STRICT quarantine x 17 days
Vaccination : Vaccination Employs Vaccinia virus
Given by scarification
One dose protective for 5-10 years
Must keep vaccinia immunoglobulin (VIG) on hand to treat complications of vaccination
Complications of Vaccination : Complications of Vaccination Normal host
Inadvertent Autoinoculation (skin, eye)
Generalized vaccinia
Erythema multiforme
Encephalitis
Pregnancy - fetal vaccinia
Dermatoses/Burns - eczema vaccinatum
Immunocompromised - vaccinia necrosum
Ocular Vaccinia : From Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 298. Photograph by C. H. Kempe Ocular Vaccinia
Vaccinia Necrosum : From Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 298. Photograph by C. H. Kempe Vaccinia Necrosum
Eczema Vaccinatum : Eczema Vaccinatum N Engl J Med, Vol. 346, No. 17, April 25, 2002
Smallpox Therapy : Public health emergency
Supportive care
Vaccinia Immunoglobulin
Strict quarantine until scabs off
At least 17 days
Codofovir
Smallpox Therapy
Section 6 Other Viruses as Biological Weapons : Section 6 Other Viruses as Biological Weapons Objectives:
To become familiar with viral hemorrhagic fever viruses (VHFs) and Venezuelan equine encephalitis virus pathophysiology
To be familiar with necessary PPE to able to limit the secondary spread of VHF
To be able to treat victims of these biological agents
Viral Hemorrhagic Fevers Microbiology : Viral Hemorrhagic Fevers Microbiology RNA viruses causing high fevers and generalized vascular damage
Filoviruses (Ebola, Marburg)
Human infections by insect bites or by contact with blood
and body fluids Photograph: Robert Swanepoel, PhD, DTVM, MRCVS,
National Institute of Virology, Sandringham, South Africa.
Viral Hemorrhagic Fevers (VHFs) : RNA viruses causing high fevers and generalized vascular damage
May be spread by aerosol, on fomites, and by oral secretions and eye drainage in animals
Human infections by contact with blood and body fluids Viral Hemorrhagic Fevers (VHFs)
VHF Pathogenesis : VHF Pathogenesis Fever, muscle aches, prostration
Cases evolve into shock and generalized mucous membrane hemorrhage
Conjunctival injection, petechial hemorrhage, and hypotension
Abnormal kidney and liver function tests poor prognosis
Mortality varies; 50 - 80% Ebola Zaire
Disease severity and survival depends on various host factors; target organ is the blood vessel system.
Ebola Virus : 1976 - First reported case in Sudan
1989 - Reston, VA health facility
among imported monkeys
April 1995 - Ebola epidemic Kikwit, Zaire
1996 - Ebola outbreak in Alice, TX - monkeys
1996 - Gabon patient infection transferred to Johannesburg clinic healthcare worker
50 to 80% mortality rate in humans - extensive hemorrhage, shock, and end organ failure
2002 – Gabon – most recent outbreak Ebola Virus
VHF Treatment : VHF Treatment Blood pressure resuscitation and monitoring
Careful fluid management
Use of colloids (e.g. plasma)
Vasopressors and inotropes
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 Animal studies indicate aerosol transmission possible
Single room with adjoining anteroom as only entrance
Handwashing station with decontamination solution
Negative air pressure room if possible
Strict barrier precautions (PPE):
Gloves, gown, mask. shoe covers, protective eyeware/faceshield
Consider HEPA respirator (e.g. N95) for severe hemorrhage, vomiting, diarrhea, cough
Prevention of Secondary VHF Transmission : Prevention of Secondary VHF Transmission Chemical toilet
All body fluids disinfected
Disposable equipment/sharps into rigid containers and autoclaved/incinerated
Double-bag refuse-outside bag disinfected
Electronic/mechanical equipment must be disinfected
Venezuelan Equine Encephalitis (VEE) : Venezuelan Equine Encephalitis (VEE) Alphavirus spread by mosquitoes
Endemic to Central and South America, Mexico, and Florida
Highly infectious - 100% of exposed individuals develop symptoms
Low mortality rate - 1%
VEE Clinical Course : ?? Inhalational
Mosquito-borne Febrile syndrome
lasting 3 days,
100- 104º fever
chills, headache,
photophobia,
sore throat Weakness for
1 - 2 weeks Recovery Mild CNS symptoms
for 3 days Liver Damage More severe
CNS signs 10 - 37% mortality 20% Children
4% Adult
cases 1 to 5 day incubation VEE Clinical Course
VEE Diagnosis & Treatment : DIAGNOSIS
Immunoassay
Viral Culture
Serologic Testing TREATMENT
Supportive
No antiviral medication exists VEE Diagnosis & Treatment
Section 7 Toxin Weapons : Section 7 Toxin Weapons Objectives:
To be able to explain how each of the presented toxin weapons act
To be able to recognize victims to toxin weapon poisoning
To understand that toxin weapons are NOT infectious and CANNOT be secondarily spread
Botulinum Toxin : Neurotoxin produced by Clostridium botulinum - Botulism
Most lethal compound per weight (15,000 times more toxic than the nerve agent VX)
Different toxicity if inhaled or ingested Botulinum Toxin
Botulinum Toxin Normal Muscle Contraction : Botulinum Toxin Normal Muscle Contraction Acetylcholine MUSCLE CONTRACTION Motor Nerve Muscle NMJ
Botulinum Toxin Botulinum-Paralyzed Muscle : Botulinum Toxin Botulinum-Paralyzed Muscle BOTOX NO MUSCLE CONTRACTION NMJ Motor Nerve Muscle
Botulism Signs & Symptoms : Descending paralysis
Bulbar Palsies
Blurred vision
Dilated pupil
Double vision
Drooping eyelids
Light intolerance
Difficulty swallowing
Difficulty speaking
Respiratory failure Botulism Signs & Symptoms “Floppy” baby flaccid paralysis
Botulism Diagnosis and Treatment : Clinical diagnosis: bulbar palsies with descending paralysis
Mouse neutralization assay confirms diagnosis
Treatment is supportive
Long-term mechanical ventilation
Antitoxins are available but must be administered early to be effective
CDC vaccine protective for A,B and E toxins Botulism Diagnosis and Treatment
Ricin : Ricin Potent toxin - a protein byproduct of castor bean processing for castor oil
5 times more toxic per weight than VX
Blocks protein synthesis within the cell, causes cell death, and airway tissue death and swelling when inhaled
Ricin Diagnosis & Treatment : Ricin Diagnosis & Treatment Fever, chest tightness, cough.
Shortness of breath, nausea, and joint pain.
Ingestion causes severe diarrhea, hemorrhage, and necrosis of the liver, spleen, and kidneys - shock and death within 3 days
Treatment is supportive, including airway management
No antitoxin or vaccine available
Staphylococcal Enterotoxin B (SEB) : Common cause of food poisoning in improperly handled foods
80% of exposed individuals develop symptoms
Symptoms vary by route of exposure - can be aerosolized or introduced into food system Staphylococcal Enterotoxin B (SEB)
SEB Signs & Symptoms : Sudden onset of high fever, headache, chills, muscle aches, and non-productive cough, and malaise.
Inhalational: Severe shortness of breath & chest pain with larger doses
Ingestion: Nausea, vomiting, and diarrhea SEB Signs & Symptoms
SEB Treatment : Supportive Care: Oxygenation Hydration
Most victims will recover
No vaccine available
No antibiotic is effective SEB Treatment