Bioterrorism and Natural Outbreaks

1. Ian Britton - FreeFoto.com Bioterrorism and Natural Outbreaks

2. What is bioterrorism? The intentional or threatened use of viruses, bacteria, fungi, or toxins from living organisms to produce death or disease in humans, animals, or plants.

3. What is a Natural Outbreak? A disease outbreak is the occurrence of disease cases in excess of normal expectancy. The number of cases varies according to the disease-causing agent, and the size and type of previous and existing exposure to the agent.

4. When does a Natural Outbreak become a Bioterrorist Attack?

5. Natural Disease vs Bioterrorism • Recent endemic exposure • Recent travel to endemic area • Sporadic, infrequent cases • Multiple cases associated with exposure to the same food product or water source

6. Natural Disease vsBioterrorism • No known endemic exposure • Point source in urban, crowded setting • Cluster of severe and fatal illness • Cases that don’t respond to recommended antibiotic treatment

7. Human SalmonellaEnteritidis Associated with Shell Eggs • September 7, 2010, a total of 2,612 illnesses reported • 1,519 illnesses associated with outbreak • 11 states • 29 restaurants or event clusters • 1 egg supplier in 15 of these 29 restaurants or event clusters

8. Why Biological Attacks? • Easy to obtain • Inexpensive to produce • Environmental stability • Aerosol distribution • Delayed recognition/response • Perpetrators escape easily • Susceptible population

9. The use of biological weapons through history. • 400 B.C.: Archers dipped arrows into the manure, blood and rotting bodies. • 14th Century: Bodies of bubonic plague victims were catapulted over the walls of the city of Kaffa. • 15th Century: Spanish contaminated French wine with the blood of leprosy victims. • 17th Century: A Polish General put saliva from rabid dogs into hollow artillery spheres. • 18th Century: Smallpox blankets were given to American Indians.

10. U.S. Biological Warfare Program • Geneva Protocol developed in 1925 • prohibits the use of biological and chemical agents during warfare • U.S. offensive program in 1942-1969 • research program tested the use of anthrax, botulism, plague, tularemia, Q fever, Venezuelan equine encephalitis virus, brucellosis and Staphylococcal enterotoxin B. • U.S. defensive program in 1969 • offensive biological weapons production terminated in the US and all stockpiles of bioweapons destroyed • Biological Weapons Convention in 1972 • Banned the possession of biological agents except for defensive research. After signing the document, the Soviet Union soon began an offensive weapons program. • Geneva Convention Ratified in 1975

11. History of Biological Agent Use/Possession in the U.S. 1972 College students produced 30-40 kg of Salmonella typhi with plans to release it into the water supplies of major Midwestern cities.

12. History of Biological Agent Use/Possession in the U.S. 1984 Members of the Rajneesh cult sprayed Salmonella on eight local salad bars in Oregon in an attempt to influence a local election. They caused 715 cases of illness, but didn’t alter the election results.

13. History of Biological Agent Use/Possession in the U.S. 1992 Members of the Patriots Council plotted to kill law enforcement officers using ricin placed on the door knobs of their vehicles. The plot failed because an informant notified authorities, and the conspirators were arrested.

14. History of Biological Agent Use/Possession in the U.S. 1996 A disgruntled med tech brought doughnuts spiked with Shigella for her co-workers coffee break.

15. History of Biological Agent Use/Possession in the U.S. Multiple anthrax attacks 22 cases (+ 1 lab-acquired case) 11 inhalational cases 11 skin cases 5 deaths 2001

16. Agent Selection Considerations • Catastrophic public health consequences • Mass casualties which overwhelm medical systems • High morbidity or mortality • Contagious

17. What are the main bioterrorist weapons?

18. Biological Agents of Highest Concern • Bacillus anthracis (Anthrax) • Yersiniapestis (Plague) • Francisellatularensis (Tularemia) • Botulinum toxin (Botulism) • Variola major (Smallpox) • Filoviruses and Arenaviruses (Viral hemorrhagic fevers)

19. Most of the information on what would happen in a Bioterrorist attack is based on what we know about the natural disease.

20. Why These Agents? • Can cause disease via aerosol route • Organisms fairly stable in aerosol • Susceptible civilian populations • High morbidity and mortality • Some with person-to-person transmission (smallpox, plague, VHF) • Difficult to diagnose and/or treat • Previous development for Biological Warfare

21. 3 Categories of Bioterrorist Agents

22. Category A • Easily transmitted • Easily disseminated • High mortality rate • Potential for major public health impact • Can cause public panic and social disruption • Requires special action for public health preparedness

23. Bacterial Agents - Category A • Bacillus anthracis • Yersiniapestis • Francisellatularensis

24. Category B • Moderate morbidity • Low mortality • Require specific non-standard diagnostic capacity • Moderately easy to distribute • Requires enhanced disease surveillance

25. Bacterial Agents - Category B • Brucellosis - Brucella species • Q Fever - Coxiellaburnetii • Psittacosis - Chlamydia psittaci

26. Bacterial Agents - Category B continued • Glanders - Burkholderiamallei • Meliodiosis - Burkholderiapseudomallei • Typhus fever - Rickettsiaprowazekii

27. Bacterial Agents - Category B continued • Water Threats • Cholera -Vibriocholerae • Cryptosporosis - Cryptosporidium parvum (PROTOZOA)

28. Bacterial Agents - Category B continued • Food Safety Threats • Escherichia coli O157:H7 • Salmonella serotype Typhimurium • Salmonella serotype Enteritidis • Shigellasonnei • Shigellaflexneri, dysenteriae type 1 • SalmonellaTyphi • Vibriocholerae

29. Category C • Newly discovered disease • Easily obtained • Easy to make and distribute • Potential for high morbidity and mortality

30. Types of Bioterrorist Events • Announced • (Overt) • Unannounced • (Covert)

31. Likely Scenarios • Overt threat • anthrax letters • device, e.g. aerosol bomb, Heating –Air conditioning systems release • Covert release • food or water contamination, aerosol release, surface contamination, zoonotic attack

32. Covert vs. Overt Event OvertCovert Recognition early delayed Response early delayed Treatment early delayed Responders Traditional Health Care “FirstResponders” Workers

33. Delivery Systems • Air • aerosol most effective dissemination method • droplet size < 10 µm, 1-5 µm optimal • Food • Water • Skin and mucous membranes

34. Step 1 in Preparing forBioterrorism

35. Recognition of Biological Attack • Environmental detection not feasible • Onset of symptoms is delayed • incubation periods range from days to weeks • Symptoms may be nonspecific • initial presentation mimics “flu” • Symptoms may be acute • incapacitation, paralysis, coma, death

36. Maintain a high level of suspicion in a number of clinical situations: • A rapidly increasing disease incidence in a normally healthy population • An epidemic curve that rises and falls during a short period of time • An unusual rise in the number of people seeking care, especially with fever, respiratory, or gastrointestinal complaints • An endemic disease rapidly emerging at an uncharacteristic time or in an unusual pattern

37. Lower attack rates among people who have been indoors, compared with people who have been outdoors • Clusters of patients arriving from a single locale • Large numbers of rapidly fatal cases • Patient presenting with a disease that is relatively uncommon and has bioterrorism potential • Concurrent reports of increased animal deaths • Unusual age distribution • Atypical disease presentations

38. Step 2 in Preparing forBioterrorism

39. Develop and use epidemiological tools • Presence or lack of an appropriate exposure history • Travel to a location that has high-consequence disease transmission • Pathogens with unusual antimicrobial resistance • Routine surveillance and disease-reporting mechanisms

40. American Academy of Family Physician Suggestions • Know how to contact local and state health departments. • Maintain contacts with local health officials. • Maintain reference materials on the diagnosis and treatment of agents of bioterrorism.

41. Develop a bioterrorism response plan for your office. Be prepared to use infection control practices. • Know the requirements for laboratory support. • Be aware of proper post-exposure management for patients and health care staff. • Develop skills in and resources for counseling patients to minimize the psychologic consequences.

42. Clinical and microbiological characteristics

44. Fear is the enemy. • Know which of the biological warfare agents occur naturally in your area. • If a biological attack is identified, keep a calm face. • Remind people not to rush to the hospital or Doctor’s office. • Help family members understand the facts. • Do not let the news media and sensational reporting distract from accurate information.

45. Since the 9/11 attacks, the federal government has spent about $50 billion to improve the way it detects and responds to biological threats. But progress has been limited, and some security experts say the threat is greater than it was.

46. Scenario • On April 1, 2009 a 20 year old male student from the University of North Carolina comes home to visit his family in Cayce. • While he is home he develops a fever. This rapidly progressed to shortness of breath, chest pain, dry cough, headache, chills and rigors, generalized body aches (in the low back), head cold symtoms, and sore throat • On April 5th his mother takes him to the E.R. With sever shortness of breath, chest pain and dry cough. • Findings on clinical examination - undifferentiatedfebrile illness with incipient pneumonia, pleuritis, and hilarlymphadenopathy.

47. This was 3 days after the NCAA basketball tournament sweet 16 in Charlotte. • What do you look for? Which organisms could it be and what additional information would you need? Who do you contact? • Unusual respiratory disease in its early stages, could be difficult to distinguish from a natural outbreak ofcommunity-acquired infection, especially influenza or variousatypical pneumonias.

48. Tularemia would be expected to have a slower progressionof illness and a lower case-fatality rate than either inhalationalplague or anthrax. • Plague would most likely progress very rapidlyto severe pneumonia, with copious watery or purulent sputumproduction, hemoptysis, respiratory insufficiency, sepsis, andshock. • Inhalational anthrax would be differentiated by itscharacteristic radiological findings of prominent symmetricmediastinal widening and absence of bronchopneumonia. • Anthrax patients would be expected to develop fulminating, toxic,and fatal illness despite antibiotic treatment. • Milder formsof inhalational tularemia could be clinically indistinguishablefrom Q fever; establishing a diagnosis of either would be problematicwithout reference laboratory testing. • Presumptive laboratorydiagnoses of plague or anthrax would be expected to be maderelatively quickly, although microbiological confirmation couldtake days. Isolation and identification of F tularensis usingroutine laboratory procedures could take several weeks.