Detecting and responding to a bioterrorist agent infecting your patient s panel discussion
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DETECTING AND RESPONDING TO A BIOTERRORIST AGENT INFECTING YOUR PATIENT(S) Panel Discussion. Outline. Brief history of biowarfare Potential impact and effects of BT Transmission of BT agents Clues to BT “Most likely BW agents” Rational perspectives Management

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DETECTING AND RESPONDING TO A BIOTERRORIST AGENT INFECTING YOUR PATIENT(S) Panel Discussion

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Detecting and responding to a bioterrorist agent infecting your patient s panel discussion

DETECTING AND RESPONDING TO A BIOTERRORIST AGENT INFECTING YOUR PATIENT(S)Panel Discussion


Outline

Outline

  • Brief history of biowarfare

  • Potential impact and effects of BT

  • Transmission of BT agents

  • Clues to BT

  • “Most likely BW agents”

  • Rational perspectives

  • Management

  • Overview of potential pre-exposure prophylaxis, post-exposure prophylaxis and therapy


Biologic warfare history

BIOLOGIC WARFARE: HISTORY

  • 14TH century, Kaffa: Attacking Tatar force catapulted cadavers of plague victims into city – outbreak of plague led to defeat

  • 18th century, Fort Pitt, North America: Blankets from smallpox hospital provided to Native Americans – resulted in epidemic of smallpox among tribes in Ohio River valley

  • 1932-45, Manchuria: Japanese military physicians infected 10,000 prisoners with biological agents (B. anthracis, N. meningitidis, Y. pestis, V. cholerae) – 11 Chinese cities attacked via food/water contamination, spraying via aircraft


Use of biological agents us

USE OF BIOLOGICAL AGENTS: US

  • Site: The Dalles, Oregon, 1984

  • Agent: Salmonella typhimurium

  • Method of transmission: Restaurant salad bars

  • Number ill: 751

  • Responsible party: Members of a religious community had deliberately contaminated the salad bars on multiple occasions (goal to incapacitate voters to prevent them from voting and thus influence the outcome of the election)

    Torok TJ, et al. JAMA 1997;278:389-395


Use of biological agents us1

USE OF BIOLOGICAL AGENTS: US

  • Site: Large medical center, Texas, 1996

  • Agent: Shigella dysenteriae

  • Method of transmission: Ingestion of muffins/doughnuts

  • Number ill: 12 (27% attack rate)

  • Responsible party: Disgruntled lab employee? S. dysenteriae identical by PFGE from stock culture stored in laboratory

    Kolavic S, et al. JAMA 1997;278:396-398.


International biological weapons programs

NEXT

International Biological Weapons Programs

Known

Iraq

Russia

Probable

China

Iran

North Korea

Libya

Syria

Taiwan

Possible

Cuba

Egypt

Israel

Source: Committee on Armed Services, House of Representatives. Special Inquiry into the Chemical and Biological Threat. Countering the Chemical and Biological Weapons Threat in the Post-Soviet World. Washington, D.C.: U.S. Government Printing Office; 23 Feb 1993. Report to the Congress.


Bioterrorism impact

BIOTERRORISM: IMPACT

  • Direct infection: Mortality, morbidity

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

  • Environmental impact: Environmental survival, animal infection

  • Other: Social, political, economic


Effects of a biological weapons release

EFFECTS OF A BIOLOGICAL WEAPONS RELEASE

Siegrist, Emerging Infectious Diseases 1999


Detecting and responding to a bioterrorist agent infecting your patient s panel discussion

BIOLOGICAL WARFARE: IMPACT[release of 50 kg agent by aircraft along a 2 km line upwind of a population center of 500,000 – Christopher et al., JAMA 278;1997:412]


Trends favoring biological weapons

TRENDS FAVORING BIOLOGICAL WEAPONS

  • Biological weapons have an unmatched destructive potential

  • Technology for dispersing biologic agents is becoming more sophisticated

  • The lag time between infection and appearance of symptoms generally is longer for biological agents than with chemical exposures

  • Lethal biological agents can be produced easily and cheaply

  • Biological agents are easier to produce clandestinely than are either chemical or nuclear weapons


Trends favoring biological weapons1

TRENDS FAVORING BIOLOGICAL WEAPONS

  • Global transportation links facilitate the potential for biological terrorist strikes to inflict mass casualties

  • Urbanization provides terrorists with a wide array of lucrative targets

  • The Diaspora of Russian scientists has increased the danger that rogue states or terrorist groups will accrue the biological expertise needed to mount catastrophic terrorist attacks

  • The emergence of global, real-time media coverage increases the likelihood that a major biological incident will induce panic


Developing a risk assessment of biologic warfare agents

DEVELOPING A RISK ASSESSMENT OF BIOLOGIC WARFARE AGENTS

General difficulties in weaponizing a biologic agent

  • Ability to procure a virulent strain (e.g., anthrax, tularemia)

  • Ability to culture large amounts of the agent

  • Ability to process agent into a suitable form (e.g., anthrax spores)

  • Ability to safely handle and store the agent (may be difficult for hemorrhagic fever viruses)


Developing a risk assessment of biologic warfare agents1

DEVELOPING A RISK ASSESSMENT OF BIOLOGIC WARFARE AGENTS

General difficulties in weaponizing a biologic agent

  • Ability to disseminate the agent as an aerosol

  • Ability to generate aerosol particles of the proper size (1-10 u)

  • Ability to assess climatic effects in order to disseminate agent effectively

  • Different Federal agencies have reached different conclusions regarding the likelihood of an attack using a biologic agent


Characteristics of biowarfare

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

  • Diminished role for self-aid and buddy aid, thereby increasing sense of helplessness


Characteristics of biowarfare1

CHARACTERISTICS OF BIOWARFARE

  • 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

    US Army, Biologic Casualties Handbook, 2001


Bioterrorism modes of spread

Bioterrorism: Modes of Spread

Aerosol Sprays

Particle size of agent

Stability of agent

Wind Speed

Wind direction

Atmospheric stability

Explosives

Tend to inactivate biological agents

Food and Water Contamination

Fairly self-limited


Epidemiologic clues to bioterrorism

Epidemiologic Clues to Bioterrorism

  • Multiple simultaneous patients with similar clinical syndrome

  • Severe illness among healthy

  • Predominantly respiratory symptoms

  • Unusual (nonendemic) organsims

  • Unusual antibiotic resistance patterns

  • Atypical clinical presentation of disease

  • Unusual patterns of disease such as geographic co-location of victims

  • Intelligence information

  • Reports of sick or dead animals or plants


Soviet bw priorities agents likely to be used

NEXT

Soviet BW Priorities“Agents Likely to be Used”

  • Smallpox

  • Plague

  • Anthrax

  • Botulism

  • VEE

  • Tularemia

  • Q Fever

  • Marburg

  • Influenza

  • Melioidosis

  • Typhus


Category a highest priority

Can be easily disseminated or transmitted person-to-person

Cause high mortality, with potential major public health impact

Might cause public panic and social disruption

Require special action for public health prepardeness

Smallpox

Anthrax

Yersinia pestis

Botulism

Tularaemia

Filoviruses (Ebola and Marburg)

Arenaviruses (Lassa and Junin)

Category A: Highest Priority


Category b second highest priority

Moderately easy to disseminate

cause moderate morbidity and low mortality

Require specific enhancements of CDC’s diagnostic capacity and enhanced disease surveillance

Coxiella burnetti (Q fever)

Brucella

Burkholderia mallei (glanders)

Alphaviruses (Venezuelan encephalomyelitis and Eastern and Western equine)

Ricin toxin from Ricinus communis

Epsilon toxin of C. perfringes

Staph enterotoxin B

Salmonella

Shigella

E. coli O157:H7

Vibrio cholerae

Cryptosporidium parvum

Category B: Second Highest Priority


Category c third highest priority

Pathogens that could be engineered for mass destruction because of availability, ease of production and dissemination and potential for high morbidity and mortality and major health impact

Nipah virus

Hantavirus

Tickborne hemorrhagic fever viruses

Tickborne encephalitis viruses

Yellow fever

MDR TB

Category C: Third Highest Priority


Risk of dying us per year

Major risks

Heart disease: 1 in 400

Cancer: 1 in 600

Stroke: 1 in 2,000

Flu & pneumonia: 1 in 3,000

MVA: 1 in 7,000

Being shot by a gun: 1 in 10,000

USA Today: October 16, 2001

Other risks

Falling down: 1 in 20,000

Crossing the street: 1 in 60,000

Drowning: 1 in 75,000

House fire: 1 in 100,000

Bike accident:1 in 500,000

Commercial plane crash: 1 in 1 million

Lightening strike: 1 in 3 million

Shark attack: 1 in 100 million

Roller coaster accident: 1 in 300 million

RISK OF DYING (US, per year)


Person to person acquisition

PERSON-TO-PERSON ACQUISITION


Precautions

Precautions

Airborne

Contact

Droplet

Standard

Lassa Fever

Ebola

Marburg virus

Smallpox

Pneumonic plague

Inhalational anthrax

Venezuelan equine encephalitis

Botulism

Brucellosis

Cholera

Q fever

Pulmonary tularemia

S

A

C

S

A

C

S

A

C

S

A

C

S

D

S

S

S

S

S

S

S


Fomite acquisition

FOMITE ACQUISITION

  • Agents acquired from contaminated clothes

    • Variola major (smallpox)

    • Bacillus anthracis (anthrax)

    • Coxiella burnetii (Q fever)

    • Yersinia pestis (plague)

  • Management

    • Remove clothing, have patient shower

    • Place contaminated clothes in impervious bag, wear PPE

    • Decontaminate environmental surfaces with EPA approved germicidal agent or 0.5% bleach (1:10 dilution)


Bw agents characteristics

BW AGENTS CHARACTERISTICS

VHF-viral hemorrhagic fevers

US Army, Biological Casualties Handbook, 2001

* Untreated, ** Pneumonic form


Bw agent prophylaxis and treatment

BW AGENT PROPHYLAXIS AND TREATMENT

VHF-viral hemorrhagic fevers, PEP-postexposure prophylaxis

*Aerosol exposure; **Pneumonic form; ^FDA approved vaccine (not available); #IND

+IND BHF, RVF; @ CCHF, Lassa

US Army, Biological Casualties Handbook, 2001


Steps in management

STEPS IN MANAGEMENT

1. Maintain an index of suspicion

2. Protect thyself

3. Assess the patient

4. Decontaminate as appropriate

5. Establish a diagnosis

6. Render prompt therapy

7. Practice good infection control


Steps in management1

STEPS IN MANAGEMENT

8. Alert the proper authorities

9. Assist in the epidemiologic investigation

10. Maintain proficiency and spread the gospel

US Army, Biologic Casualties Handbook, 2001


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