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BIOTERRORISM. Dr. E. McNamara Public Health Lab., SWAHB, St. James’s Hospital. ‘9/11 – Changes’. Move to high risk Biological Threat, specialist public arena Newsworthy Rare/eradicated infections Low clinical experience. ‘Autumn 2001 – USA’. 5 letters, finely milled anthrax spores

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Bioterrorism

BIOTERRORISM

Dr. E. McNamara

Public Health Lab., SWAHB,

St. James’s Hospital


9 11 changes

‘9/11 – Changes’

  • Move to high risk

  • Biological Threat, specialist public arena

  • Newsworthy

  • Rare/eradicated infections

  • Low clinical experience


Autumn 2001 usa

‘Autumn 2001 – USA’

  • 5 letters, finely milled anthrax spores

  • 11 pulmonary anthrax (5 died)

  • 7 cutaneous anthrax

  • All sent from Trenton, New Jersey, 1 person

  • American origin, B. anthracis

  • Criminal Act : Terrorist


Lessons learned

‘Lessons Learned’

  • No one prepared

  • Easy to produce contagious material

  • Easy to spread, (except aerosolization)

  • Small numbers affected, major concern

  • Copy cat phenomenon – ‘Hoaxes’

  • Lab. techniques for diagnosis

  • Major disruption

  • Use of prophylactic antibiotics


Benefits

Benefits

  • Co-operation internationally

    • WHO

    • CDC

    • EU

  • National preparedness Plans

  • Multidisciplinary

    • Government

    • Admininstrative

    • Emergency services

    • Medical

    • Scientific


History biological warfare

History – Biological Warfare

  • Water wells contaminated with corpses

  • Siege Caffa, Crimea 1346, used plague corpses

  • British, gave Smallpox contaminated blankets as presents to Native Americans


Modern history biological warfare

Modern History – Biological Warfare

  • Germany WWI

    • sold anthrax infected horses

  • WWI-II

    • Many countries started biological programme

  • WWII – Not Used

    • UK5 million anthrax ‘cattle-cakes’

    • USABotulinum

    • CanadaPlague

    • GermanySalmonella

    • JapanPOW/Chinese trials


Post wwii

Post WWII

  • USA

    • 3400 people 1969, BTWC

    • Allegation

      • Korean War

      • Cuba

    • Misinformation, FBI to Soviets

  • Soviets

    • 1920 – 1969, BTWC signed

    • 1975Enlarged, Biopreparat

      60,000 people

      40-50 facilities

      50 agents


Post wwii contd

Post WWII contd.

  • 1979 Sverdlovks, Anthrax, 69 died

  • 1980 – 1990 Defections

  • 1990 Yelsin – cessation?

  • Iraq 1974?, S. Africa 1980-1993

  • 10 – 12 trying to acquire, evidence?


Preparing for biological attacks

Preparing for Biological Attacks

  • Enhance surveillance

  • Resource laboratories

  • Communication systems

  • Bioterrorism education

  • Stockpile vaccines and drugs

  • Molecular surveillance microbial strains

  • Support development diagnostic test

  • Support research Rx. and vaccines

    CDC April 2000


Biological agents

Biological Agents

  • Category A

    • Easily dessiminated

    • High mortality

    • Public panic

    • Require special preparedness

  • Category B

    • Moderately easy to dessiminate

    • Low mortality

    • Need enhanced Dx./surveillance

  • Category C

    • Emerging pathogens


Anthrax b anthracis

Anthrax, B. anthracis

  • Zoonotic, spore forming rod

  • Soil reservoir, years

  • Affects large domestic and wild herbivoires

  • Worldwide

  • Humans

    • Contact with infected animals/products

    • Skin – cutaneous

    • GIT/resp. – inhalation

  • 2000 cases, cutaneous / year

  • 5 cases USA, 1 case UK

  • No cases Ireland for 25 years


Anthrax contd

Anthrax contd.

  • Bioterrorist threat – inhalation spores

  • No person – person spread ! (cutaneous?)

  • Cutaneous

    • Skin inoculation

    • Painless swelling

    • Papular – vescle – ulcer

    • Black eschar

    • Toxaemia

    • Mortality with Rx., < 1%.

  • GIT

    • Ingest contaminated meat

    • Pain, diarrhoea, haematemesis, septicaemia

    • Mortality > 50%


Anthrax contd1

Anthraxcontd.

  • Dx. (Confirm reference laboratory)

    • Hazard Group 3 – CL3

    • Non motile, GPB, Aerobic

    • Central / Terminal spores

    • Non–haemolytic

    • Sensitivity tests

  • Rx. – Penicillin / Ciprofloxacin

  • Post exposure prophylaxis = Ciprofloxacin

  • Infection Contol – standard precautions


Inhalation anthrax

Inhalation Anthrax

  • Bioterrorist agent

  • Mortality 90%

  • Incubation 1 – 60 days

  • Initial Phase (hrs – days)

    • Non-specific symptoms

    • Non-specific clincial signs + Dx. test

    • Recover / Progress to fulminant

  • Fulminant Phase

    • Septicaemia / Toxaemia

    • Dyspnoea with CXR mediastenal widening

    • 50% haemorrhagic menigitis and death

    • Mortality increased with short incubation


Small pox

Small Pox

  • Human, DNA variola virus

  • 2 Forms

    • Variola major, mortality 30% (3% vaccinated)

    • Variola minor, mortality 1%

    • Airborne spread, contact

    • Secondary attack rate 50% (unvaccinated)

    • Last death – 1978 UK.

    • WHO 1980, eradicated.


Small pox contd

Small Pox contd.

  • Incubation 12-14 days, rash further 2-4 days

  • Fever, headache, myalgia, abdominal pain and vomiting

  • Delirium 15%

  • Rash, centrifugal, face and extremities

  • Copious virus on mucosal lesions

  • Secondary bacterial pneumonia (mortality > 50%)

  • Haemorrhagic Small Pox (95% mortality)

  • Differental = Chicken Pox.


Small pox contd1

Small Pox contd.

  • Dx.

    • Hazard Group 4

    • EM (Herpes : Pox) - CL3

    • PCR (differentites Pox viruses) – CL4

    • Culture – CL4

  • Public Health Emergency – International

  • Case: Standard, contact and airborne precautions

    • Isolate: negative pressure, HEPA extract

    • PPE. Decontamination protocol

    • Immune HCW (vaccinated)

    • Rx. = supportive

  • Contact/Exposed

    • Quarantine for 18 days - monitor temperature

  • Infectious form onset of fever


Small pox vaccine

Small Pox Vaccine

  • Face – face contacts

  • HCW (core, prepardness)

  • Designated emergency personnel

  • Vaccine

    • Live vaccinia virus (not variola)

    • Vaccine site, infectious until scab heals

    • Newer vaccine development

      • S/E

      • Efficancy


Small pox vaccine contd

Small Pox Vaccine contd.

  • CI – atopic dermatitis, pregnant, immunocompromised

  • S/E

    • Fever headache, rigors, vastles

    • Generalised vaccinia (GV)

    • Eczema vaccinatum (EV)

    • Progressive vaccinia (PV)

    • Post vaccinial CNS (PVE)

  • Incident 1968

    • Life threatening = 52 / million

    • Deaths = 1.5 / million


Cl botulinum

Cl. Botulinum

  • Botulinum neurotoxin – most potent

  • Contaminated food, canned products

  • Wound botulism, contaminated soil, IVDA

  • Bioterrorism agent

    • Aerosolisation – inhalation

    • Contaminate food – ingestion

    • Large numbers with acute flaccid paralysis


Cl botulinum contd

Cl. Botulinum contd.

  • Incubation

    • 2hrs – 8 days, Foodborne

    • 1hr – 5 days, Aerosol

  • Foodborne

    • V+D, diplopia, dysarthria, weakness

    • Ptosis, facial palsy, ↓gag Hypotonic

  • Inhalation

    • Dysplagia, nystagmins, ↓speech, ↓gait

  • Terminal

    • Progressive muscular paralysis

    • Mortality 5% (with Rx.)


Cl botulinum contd1

Cl. Botulinum contd.

  • Differential Dx.

    • Guillain-Barré

    • Myastheria gravis

    • Stoke

    • CNS despressants


Cl botulinum contd2

Cl. Botulinum contd.

  • Dx.:

    • Detect botulinum toxin

    • Culture

  • Rx.:

    • Antitoxin

    • Supportive

  • Infection Control – standard precautions


Plague

Plague

  • Yersinia pestis – HG3

    • GNCB, 02

  • Aerosol, flea vector, person-person

  • 3 Forms

    • Bubonic – 90%

    • Septicaemic – 10%

    • Pneumonic – 1%

  • Bioterrorist agent

    • Aerosol – pneumonic

    • Fleas – bubonic, septicaemic


Bubonic plague

Bubonic Plague

  • Incubation 1-8 days

  • Fever, rigors, headache

  • Buboes – painful lymph nodes

  • 15% develop pneumonic plague

  • Mortality = 12%


Septicaemic plague

Septicaemic Plague

  • Primary, or secondary to bubonic

  • Rigors, abdominal pain, V+D

  • Purpura, DIC, necrosis

  • Mortality = 30%


Pneumonic plague

Pneumonic Plague

  • Highest bioterrorism risk

  • Primary or secondary from haematogenous

  • Incubation 1-3 days

  • Pneumonic symptoms

  • Respiratory failure and shock

  • Mortality - ↓with rx. = 8%


Plague1

Plague

  • Dx.:

    • Culture

  • Rx.:

    • Gentamicin, Streptomycin IV

    • Ciprofloxacin, Doxycycline P.O.

  • Infection Control:

    • Standard and droplet, single room, surgical mask

  • Contacts:

    • Prophylaxis – Ciprofloxacin – 72 hrs.


Tularaemia

Tularaemia

  • F. tularensis

    • Non-motile, aerobic, GNCB, zoonosis, rabbits, deerfly

    • HG3

    • Worldwide

    • Low inoculum – 10 CFU

  • Ulceroglandular

  • Typhoidal

    • Mortality 35-60% (untreated)

    • Inhalation

  • Infection Control – standard (no person-person)

  • Rx. Gentamicin/Streptomycin – 10 days

  • Contacts : prophylaxis


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