Bioterrorism and Weapons of Mass Destruction

1. Bioterrorism and Weapons of Mass Destruction John van der Steeg MD

2. In peace the sons bury their fathers, but in war the fathers bury their sons. Croesus

3. Naturally the common people don't want war; neither in Russia, nor in England, nor in America, nor in Germany. That is understood. But after all, it is the leaders of the country who determine policy, and it is always a simple matter to drag the people along, whether it is a democracy, or a fascist dictatorship, or a parliament, or a communist dictatorship. Voice or no voice, the people can always be brought to the bidding of the leaders. That is easy. All you have to do is to tell them they are being attacked, and denounce the pacifists for lack of patriotism and exposing the country to danger. It works the same in any country.

4. Categories of Weapons of Mass Destruction • B Biological • N Nuclear • I incendiary • C Chemical • E Explosives

5. History of Biological Weapons • 184 BC Hannibal ordered pots of venomous snakes thrown of decks of enemy ships. • Tartar army catapulted bodies of plague victims into the city of Caffa in 1346 • British army provided blankets to Delaware Indians in 1763…after they were used by smallpox patients. • During WW II Japanese utilized Yersinia pestis containing rice and fleas spread by airplane against Chinese and Russian troops. • America had prepared 5000 anthrax bombs at Camp Detrick, Maryland in 1942. (none used during the war) • Aum Shinrikyo religious cult contaminated a Tokyo subway with Sarin gas in 1995. (5500 hospital visits and 5 deaths) • Aum Shinrikyo make several unsuccessful attempts to release anthrax or botulinum toxin to other areas around Tokyo • Anthrax laden envelopes sent via US mail in 2001, resulting in 11 cases of inhalational anthrax (including 5 deaths) and 12 cases of cutaneous anthrax.

6. History of Biological Weapons • Many countries agree to stop research and development of Biological weapons in 1972. • Many smaller countries continue to develop biological warfare programs.

7. A little perspective • 200lbs of aerosolized anthrax spread over a city the size of Omaha on a clear breezy night could kill as many as 2.5 Million people. • 200lbs of Botulinum toxin could kill as many as 40,000 people in an area the size of the Mall of America. • 200lbs of VX gas sprayed over Disney land could kill 12500 people.

8. Critical Biological Agents • The CDC published a list of Critical Biological Agents in 2000. • List is divided into categories A, B, and C. • Category A agents are of the highest priority and Category C are of a lesser priority.

9. Category A • Pose a risk to national security. • Spread easily by person to person contact. • Cause a high death rate. • Require special action for public health preparedness. • Bacillus anthracis (Anthrax) would be a category A biological agent.

10. Category A Threats • Anthrax • Botulism • Plague • Small pox • Tularemia • Viral hemorrhagic fevers

11. Category B • Fairly easy to disseminate. • Cause moderate illness and have a lower death rate than Category A agents. • Require an enhanced diagnostic capacity and disease surveillance. • Coxiella burnetii (Q fever) is an example of a Category B biological agent.

12. Category C • Include new pathogens which could be engineered for mass dissemination in the future. • Widely available. • Easy to produce and dispense. • Potential to cause high rate of death and sickness. • Nipah virus is an example of an Category C biological agent

13. Dissemination • Biologic agents designed to enter the body one of three ways. • Inhalation • All category A agents may be aerosolized • Ingestion • Contaminated food and water • Skin contact

14. Aerosolization • Aerosols may be delivered in wet or dry forms. • May be used in closed or open spaces • Crop dusting planes, ventilation systems in buildings, fine powder that are easily aerosolized when disrupted

15. Anthrax • Not just the name of a speed metal band • Discovered in 1877, may have been cause of plague described in Egypt 4000yrs. Ago. • Also known as wool sorters of black bane dz • Weaponized in 1950’s & 1960’s in the US • 70 Russians died in 1979 after aerosol release by military facility in Svedlovsk • Weaponized by Iran in 1995

16. Anthrax • Caused by spore forming bacterium B. anthracis. • Symptoms occur approximately 7 days post exposure. • Most common form is cutaneous anthrax • Symptoms of inhalational anthrax initially mimic common cold and progress rapidly to resp. distress and sepsis.

17. Anthrax • Direct person to person spread does not occur. • Fatality Rate • Cutaneous :untreated 5-20%, treated 1% • Inhalational :untreated 100%, treated >80% if >48hrs after symptom onset • Infective dose 2500-80,000 spores by inhalation • Spore viability >40yrs in soil and resistant to sun light, heat and disinfectants

18. AnthraxTreatment • Ciprofloxacin 400mg iv q 12 hrs OR • Doxycycline 100mg iv q12 hrs AND • One or two additional antimicrobials i.e. Rifampin, vancomycin, penicillin, ampicillin, clindamycin, clarithromycin, chloramphenicol

19. Cutaneous Anthrax

20. Inhalational Anthrax

21. Botulism

22. Botulism

23. Botulism • Researched by Iraq in 1991 • Weaponized & deployed in 100 munitions in 1995 by Iraq • Nerve toxin produced by Clostridium botulinum whichproduces a descending paralysis. • The most potent and lethal substance known to man

24. Botulism • Gram + anaerobic bacillus which forms spores • Block presynaptic ACh release • Infective dose 0.001mcg/kg, lethal dose .09-.15mcg/kg IV or .7 mcg IM • Pt’s are alert, oriented and afebrile • Pt can require vent. Support for 2-3 MONTHS due to resp. failure • Occurs in 20 – 60 % of cases

25. Botulism • Signs and symptoms can include nausea, dry mouth, blurred vision, dysphagia, fatigue, and dyspnea which may begin several hours to days after the exposure

26. Botulism Treatment • Not spread from person to person • If diagnosed early food and wound botulism may be treated with antitoxin • Recovery may take several weeks.

27. Plague • Used as a weapon in the 14th century (Infected corpses catapulted into enemy strongholds) • One of the greatest engines of socioeconomic change • Potential agent in 1950’s & 1960’s by USA • Investigated by Japan in WWII (unit 731)

28. Plague

31. Plague • Caused by Yersinia pestis, a gram negative bacteria found in rodents and their fleas. • Bacteria may be grown in large amounts and aerosolized. • Aerosolization allows for pneumonic form of disease with potential for secondary contamination. (resp. droplets are infectious until pt gets therapy for 72 hrs) • Infective dose <100 organisms

32. Plague • Aerosol of bacillus viable for 1 hr at distances of 10 km • Morality • Untreated bubonic plague: 50 – 60 % • Untreated pneumonic plague or septicemia: 100% • Treated pneumonic plague (<24hrs) 10 – 20 %

33. Plague • Pneumonic plague • incubation in 2 – 4 days • Rapid onset • High fevers, chills, hemoptysis, bloody sputum, dyspnea, stridor, cyanosis • Death from resp. failure, circulatory collapse and bleeding diathesis

34. Plague Treatment • Preferred choices • Streptomycin 30mg/kg div bid IM x 10d • Gentamycin 5mg/kg IM or IV QD x 10d • Vaccine: effective against bubonic plague not against aerosol exposure • Not approved for peds < 18 y/o • PEP: doxycycline 100 mg po bid x 7d OR • Ciprofloxacin 500 mg po bid x 7d

35. Ricin

36. Ricin • Significant due to the wide availability of; 1 million tons of castor beans processed annually in production of castor oil. • Used in assassination of Bulgarian exile Georgi Markov in London in 1978.

37. Ricin • Ricin is part of the waste “mash” produced when castor oil is made. • May be produced in the form of a powder, mist, or a pellet or it can be dissolved in water or a weak acid. • Depending on route of exposure, inhalation vs ingestion, it can take as little as 500 mcg to kill a person. (about the size of the head of a pin)

38. Ricin respiratory exposure • Results in pulmonary toxicity with sever resp. symptoms within 8 hrs. • Followed by respiratory failure in 36 – 72 hrs. (marked by nonspecific findings such as weakness, fever, vomiting, cough, hypoxemia, hypothermia, and hypotension)

39. Ricingastrointestinal exposure • Rapid onset of gastrointestinal symptoms such as nausea, vomiting, abdominal cramps, and severe diarrhea. • Followed by vascular collapse and death.

40. RicinTreatment • No antidote, vaccine or prophylactic antitoxin available • Treatment aimed at avoiding exposure and eliminating toxin from the body as quickly as possible.

41. Smallpox

43. Smallpox • Considered by Japan in WWII • Global eradication program began in 1967 • Declared eradicated in May 8, 1980 • In 1996 WHO recommends all stockpiles be eradicated by 1999 • Still exists in government labs of US and Russia

44. Smallpox • Variola virus which causes disease is very stable • Infectious dose is very small (10-100 organisms) • Virus spread from person to person via resp. droplets. (w/in 3 meters), their bedding or clothing • Incubation 7 – 19 days

45. Smallpox • Signs and symptoms include high fever, fatigue, head and back aches. • Followed w/in 2 – 3 days by smallpox rash and skin lesions. • Mortality: • 3% vaccinated • 30% if unvaccinated • 50% if develop secondary bact. Pneumonia

46. Smallpox • At this time the government does not recommend prophylactic vaccination of healthcare workers or the general public

47. SmallpoxTreatment • No proven treatment of smallpox. • Patients affected with smallpox require supportive care and quarantine.

48. Tularemia

49. Tularemia

50. Tularemia • First found in Tulare County, California • Found in Japan in 1800’s and Russia in 1926 • Caused by Francisella tularensis, a gram negative bacterium found in animals, especially in rodents, rabbits and hares. • Common in people who skin rabbits, rodents.