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
Slide2: 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
Slide14: 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
Slide16: 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 Bioterrorism Toxins and Chemical Agents: Comparison of Bioterrorism Toxins and Chemical Agents Source: AHLS
Comparison of Bioterrorism Toxins 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 Plague Prevention 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 Plague Signs 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
Slide41: 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
Slide47: Questions? www.adls.info