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Bioterrorism health preparedness l.jpg

BIOTERRORISMhealth preparedness

Dr.T.V.Rao MD

Dr.T.V.Rao MD

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Definition of Bioterrorism

"Bioterrorism” - The unlawful use, or threatened use, of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. The act is intended to create fear and intimidate governments or societies in the pursuit of political, religious, or ideological goals.

Dr.T.V.Rao MD

Note: There is no single, universally accepted definition of bioterrorism.

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1346Siege of Kaffa; plague

1763French and Indian War; smallpox

WW IGerman program; anthrax, glanders

1925Geneva protocol bans biological weapons

WW IIJapanese program; anthrax, plague, cholera, shigella

History of Biological Warfare

Dr.T.V.Rao MD

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1941George W. Merck named U.S. civilian head of Chemical Warfare Service later changed to War ResearcService

1946 U.S. announces its involvement in bioweapons research

1969 Nixon eliminates offensive biological warfare program

History of Biological Warfare (cont.)

Dr.T.V.Rao MD

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1972Biological Weapons Convention

1979Accidental release of B. anthracis spores at bioweapon research center, Sverdlovsk, U.S.S.R

1989-92 Scientists from the former U.S.S.R. involved in biological weapons research defect to the West

History of Biological Warfare (cont.)

Dr.T.V.Rao MD

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Domestic Biological Terrorism

  • 1984Rajneesh cult members contaminate salad bar with Salmonella typhimurium in Oregon

  • 1992Ricin attack planned by Minnesota militia

  • 2001 Anthrax releases in FL, DC, NY, NJ

Dr.T.V.Rao MD

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Biological Terrorism

The use of biological agents to intentionally produce illness or intoxication in a susceptible population

Dr.T.V.Rao MD

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Public Health impact criteria based on:

Morbidity and mortality

Delivery potential

Public perception (fear, civil disruption)

Public health preparedness needs

Biological Agents Ranking System

Dr.T.V.Rao MD

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• Bacillus anthracis (spores)

• Brucella abortus

• Brucella melitensis

• Brucella suis

• Burkholderia mallei

(aka Pseudomonas mallei)

• Burkholderia pseudomallei

(aka Pseudomonas pseudomallei)

CDC Select Agents* – Bacteria

• Clostridium (botulinum-

producing species)

• Coxiella burnetii

• Francisella tularensis

• Rickettsia prowazekii

• Rickettsia rickettsii

• Yersinia pestis

n = 12

* Not including agents only on USDA lists.

Dr.T.V.Rao MD

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CDC Select Agents* – Fungi

• Coccidioides immitis

• Coccidioides posadasii

n = 2

* Not including agents only on USDA lists.

Dr.T.V.Rao MD

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CDC Select Agents* – Viruses I

• Central European Tick-borne encephalitis

• Cercopithecine herpesvirus 1

• Crimean-Congo haemorrhagic fever

• Eastern Equine encephalitis

• Ebola

• Far Eastern Tick-borne encephalitis

• Flexal South American haemorrhagic fever

• Guanarito South American haemorrhagic fever

• Hendra

• Junin South American haemorrhagic fever

• Kyasanur Forest disease

• Lassa fever

• Marburg

* Not including agents only on USDA lists.

Dr.T.V.Rao MD

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CDC Select Agents* – Viruses II

• Machupo South American haemorrhagic fever

• Monkeypox

• Nipah

• Omsk haemorrhagic fever

• Reconstructed 1918 influenza

• Rift Valley fever

• Russian Spring and Summer encephalitis

• Sabia South American haemorrhagic fever

• Variola major (smallpox)

• Variola minor (alastrim)

• Venezuelan Equine encephalitis

n = 24

* Not including agents only on USDA lists.

Dr.T.V.Rao MD

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CDC Select Agents* – Toxins

• Abrin

• Botulinum neurotoxins

• Clostridium perfingens epsilon toxin

• Conotoxins

• Diacetoxyscirpenol

• Ricin

• Saxitoxin

• Shiga-like ribosome-inactivating proteins

• Shigatoxin

• Staphylococcal enterotoxins

• Tetrodotoxin

• T-2 toxin n = 12

* Not including agents only on USDA lists.

Dr.T.V.Rao MD

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food poisoning


hemorrhagic fever

lassa fever



Bioweapon-related Diseases

  • psittacosis

  • Q-fever

  • salmonellosis

  • shigellosis

  • smallpox

  • tularemia

  • typhoid fever

  • typhus

  • viral encephalitis

Dr.T.V.Rao MD

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Additional Potential Bioterrorism Agents

  • • Chlamydia psittaci

  • • Cryptosporidium parvum

  • • Escherichia coli O157:H7

  • • hantavirus

  • • Salmonella species

  • • Shigella species

  • • Vibrio cholerae

Dr.T.V.Rao MD

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Potential Bioterrorism Agents

  • Potentially thousands

  • NATO NBC Handbook lists 31 agents

  • CDC created Category A, B, & C lists

    • Based on:

    • Ease of dissemination

    • Potential for Public Health Impact

    • Potential for Public Panic and Social Disruption

Dr.T.V.Rao MD

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Bioterrorism agent classification system CDC

  • The Centers for Disease Control (2004) have placed agents in one of three priority categories for initial public health preparedness efforts: A, B, or C. Agents

Dr.T.V.Rao MD

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  • Contagious

  • High death rates and high health impact on the public



  • Moderately easy to spread

  • Some illness & death rates



  • Easily available

  • Easily produced and spread

  • Have potential for high death & illness rates


Hey look, a llama! Never can be too careful…

Dr.T.V.Rao MD

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Critical biological agents Category A

  • Can be easily disseminated or transmitted person-to-person

  • Cause high mortality, with potential for major public health impact

  • Might cause public panic and social disruption

  • Require special action for public health preparedness

    • MMWR 49;RR-4, April 21, 2000

Dr.T.V.Rao MD

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Category Aagents include

  • variola major (smallpox)

    • Bacillus anthracis (anthrax)

    • Yersinia pestis (plague)

    • Clostridium botulinum toxin (botulism)

    • Francisella tularensis (tularaemia)

    • filoviruses

      • Ebola hemorrhagic fever

      • Marburg hemorrhagic fever

    • arenaviruses

      • Lassa (Lassa fever)

      • Junin (Argentine hemorrhagic fever) and related viruses

  • MMWR 49;RR-4, April 21, 2000

Dr.T.V.Rao MD

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Category B

  • Are moderately easy to disseminate

  • Cause moderate morbidity and low mortality

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

    • MMWR 49;RR-4, April 21, 2000

Dr.T.V.Rao MD

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Category B agents

  • Coxiella burnetti (Q fever);

    • Brucella species (brucellosis)

    • Burkholderia mallei (glanders)

    • alpha viruses

      • Venezuelan encephalomyelitis

      • eastern and western equine encephalomyelitis

    • ricin toxin from Ricinus communis (castor beans)

    • epsilon toxin of Clostridium perfringens

    • Staphylococcus enterotoxin B.

      • MMWR 49;RR-4, April 21, 2000

Dr.T.V.Rao MD

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subset of List B agents includes pathogens that are food- or waterborne - these pathogens include

  • Salmonella species

    • Shigella dysenteriae

    • Escherichia coli O157:H7

    • Vibrio cholerae

    • Cryptosporidium parvum

Dr.T.V.Rao MD

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Category C Includes emerging pathogens that could be engineered for mass dissemination in the future

  • Nipah virus

  • Hantaviruses

  • Fick-borne hemorrhagic fever viruses

  • Tick-borne encephalitis viruses

  • Yellow fever

  • Multidrug-resistant tuberculosis

Dr.T.V.Rao MD

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Biological Delivery Methods

  • Food / Water

  • Aircraft sprayers

  • Vehicle sprayers

  • Hand sprayers

  • Mail

  • Air handling systems

  • Human Vector

  • Animal Vector

Dr.T.V.Rao MD

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Key Indicators of a Biological TERROR Event

  • Occurrence of vector-borne disease where there is no vector

  • Cluster of sick or dead animals

  • Atypical seasonality

  • Geographic Pattern of Illness

  • More respiratory presentation of disease

Dr.T.V.Rao MD

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The Ideal Bioterror Weapon Would Be

  • contagious

  • virulent

  • robust

  • difficult to detect

  • drug-resistant

  • user-controllable

No natural agent meets all of these criteria. Thus, sooner

or later, terrorists may decide to devise novel weapons

using the techniques of synthetic biology to enhance or

replace the characteristics of pre-existing organisms or

toxins. Countermeasures must be pursued vigorously –

in advance.

Dr.T.V.Rao MD

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Familiarize medical staff with BT agents

Incorporate into Disaster Planning

Decontamination & Infection Control

Communications with key agencies

Laboratory, Respective health authorities of the Nation.

Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc.

Security preparations

Preparation for BT Attack

Dr.T.V.Rao MD

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What To Do if You Suspect a Bioterrorist Disease


  • Hospital Infection Control

    • Isolation: Smallpox, plague, hemorrhagic fevers

  • Laboratory

  • Hospital Administration

  • Local Public Health Department

Dr.T.V.Rao MD

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Assess health impacts in the community

Environmental health assesses water safety and sanitation

Public health nurses coordinate with Shelter Operations

Acute communicable disease tracks infectious diseases

Injury program tracks injuries and fatalities

Health Officer coordinates information for the public and health care providers

Public Health Laboratories identify agents (either in-house or through referral to State governments or health authorities )

What does Public Health Do in a Bioterrorist Event?

Dr.T.V.Rao MD

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Special Problems with BT

  • Identifying a covert attack

  • Social disruption

  • Prophylaxis for large populations

  • Decontamination

  • Secondary transmission

Dr.T.V.Rao MD

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Technology At Work

Forensic teams work hard to identify biological agents, their origins and effects

Dr.T.V.Rao MD

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Technology At Work

  • Labs are working on advanced detection systems to detect early attacks, identify at-risk areas, and to give proper treatment

Dr.T.V.Rao MD

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Technology At Work

  • Bio surveillance:Real-Time-Outbreak Disease Surveillance system made its debut in 1999. This collects data from labs, hospitals, and environmental studies in order to detect bioterror attacks as early as possible.

Dr.T.V.Rao MD

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bioterrorism bioagent warning systems

  • Wyatt-Lorenz was founded as a spin-off of Wyatt Technology Corporation ("WTC") with a unique mission: To provide immediate bioterrorism bioagent warning systems for the protection of people and property from biological and chemical threats. These Bioterrorism threats are often directed toward elements of the private sector long ignored by the Department of Defense and Department of Homeland Security

Dr.T.V.Rao MD

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Special Problems with BIOTERRORISM

  • Specialized labs needed for some agents

  • Risks to laboratory workers

  • Limited resources

  • Communication between agencies

Dr.T.V.Rao MD

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Familiarize medical staff with BT agents

Incorporate into Disaster Planning

Decontamination & Infection Control

Communications with key agencies

Laboratory, CDC, Police, FBI, etc.

Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc.

Security preparations

Preparation for BIOTERRORISMAttack

Dr.T.V.Rao MD

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Classification of BioterrorismLaboratories

D - High level characterization (seek evidence of

molecular chimeras) and secure banking of isolates

Safety & proficiency to probe for universe of

bio- and chemical agents in non-clinical specimen

Level D Lab


C - Safety and proficiency sufficient

to probe, type, perform toxigenicity testing

Level C Lab


B - Safety and proficiency adequate

to confirm & characterize susceptibility

Level B Lab

Work at BSL-3 with BT agents

A - Adequate safety to rule-out

and forward organisms

Level-A Labs - Assess Risks

for Aerosols and Use Biosafety Cabinet

Dr.T.V.Rao MD

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What To Do if You Suspect a Bioterrorist Disease


  • Hospital Infection Control

    • Isolation: Smallpox, plague, hemorrhagic fevers

  • Laboratory

  • Hospital Administration

  • Local Public Health Department

Dr.T.V.Rao MD

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Public Health’s Role in Bioterrorism Event

  • Health Officer coordinates information for the public and medical providers

  • Community Health and PHN’s provide education, information to the public and to community providers

  • Treatment and prophylaxis

  • Quarantine

Dr.T.V.Rao MD

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"We refuse to remain idle when modern technology might be turned against us. We will rally the great promise of American science and innovation to confront the greatest danger of our timeFormer President George W. Bush, at the signing of the Project Bio shield Act of 2004

Authorized spending of $5.6 billion over a span of 10 years in order to pay for vaccines and medical facilities in case of national biological emergency

Gave the National Institute of Health grants to pursue medical research & technology

Emergency Use Authorization – EUA – gave access to best medical responses in case of an emergency as declared by the Secretary of Human Healthy & Services OR Secretary of Homeland Security

Project Bioshield

Dr.T.V.Rao MD

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Coordinating with system is priority

Coordinating with the Public Health System

Dr.T.V.Rao MD

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What We Need To Prepare for Bioterrorism

  • More trained epidemiologists to speed detection

  • Increased laboratory capacity

  • Health Alert Network

  • Medical professionals “back to school”

  • National Pharmaceutical Stockpile

Dr.T.V.Rao MD

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Familiarize medical staff and lab with bioterrorist threat agents

Incorporate BT planning into disaster planning

Infection control

Notification procedures and contact numbers

Daily surveillance and reporting

Security preparations


Personal Protective Equipment (PPE)

How can Hospitals Prepare?

Dr.T.V.Rao MD

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Is it a True Terrorism ?

  • Outbreak of rare disease

  • Seasonal disease at wrong time

  • Unusual age distribution

  • Unusual clinical symptoms

  • Unusual epidemiologic features

  • Outbreak in region normally not seen

Dr.T.V.Rao MD

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Steps in Preparing Public Health Agencies for Biological Attacks

  • Enhance epidemiologic capacity to detect and respond to biological attacks.

  • Supply diagnostic reagents to state and local public health agencies.

  • Establish communication programs to ensure delivery of accurate information.

  • Enhance bioterrorism-related education and training for health-care professionals.

    • MMWR 49;RR-4, April 21, 2000

Dr.T.V.Rao MD

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  • Preparation for a biological mass disaster requires coordination of diverse groups of medical and non-medical personnel

  • Preparation can not occur without support and participation by all levels of government

  • Preparation must be a sustained and evolutionary process

Dr.T.V.Rao MD

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  • Created by Dr.T.V.Rao MD for ‘e” Learning Resources for Medical and Public Personal on Bioterrorism

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