Worker Preparedness Response to Bioterrorism

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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