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Biological Terrorism

Prof.Renaat A.A.M.PelemanChiefMedicalOfficerGhentUniversityHospital,Belgium

NorbertFraeymanSuperiorHealthcouncil

BiologicalTerrorism

• Definition, situate biological terrorism within terrorism

• History

• Agents, Disease, Diagnosis, Treatment

• Detection, Response, Surveillance

• The future, some myths

• Summary

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CategoriesofWeaponsUsedbyTerrorists

• Conventional

• Biological

• Chemical

• Nuclear

• Cyber

DefinitionofBiologicalWarfare

“Biological warfare is the deliberate spreading of(infectious) diseases among humans, animals, andplants in order to cause incapacitation or death of thetarget population.”

Hon. Prof. Graham S. Pearson CBFormer Director General Chemical & Biological Defence EstablishmentPorton Down, Salisbury, England

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DefinitionofBiologicalWarfare

Somehistory…

Year Event

1155 EmperorBarbarossapoisonswaterwellswithhumanbodies,Tortona,Italy

1346 MongolscatapultbodiesofplaguevictimsoverthecitywallsofCaffa,CrimeanPeninsula

1495 SpanishmixwinewithbloodofleprosypatientstoselltotheirFrenchfoes,Naples,Italy

1650 Polishfiresalivafromrabiddogstowardstheirenemies

1675 FirstdealbetweenGermanandFrenchforcesnottouse'poisonbullets'

1763 BritishdistributeblanketsfromsmallpoxpatientstonativeAmericans

1797 NapoleonfloodstheplainsaroundMantua,Italy,toenhancethespreadofmalaria

1863 ConfederatessellclothingfromyellowfeverandsmallpoxpatientstoUniontroops,USA

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FeaturesofBioterrorism

• Weapon: Microbe or Toxin

• Premeditation

• Goals: Political, Religious, Ideological

• Motivation: Fear, Disruption, Instability

DesirableFeaturesofBiologicalAgentsasWeapon

• Inexpensive

• Available

• Easily transported/concealed and dispersed

• Incubation period “Hides Tracks” of perpetrator

• Modifiable (resistance, virulence)

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• Botulinum neurotoxins• Botulinum neurotoxin-producingspeciesofClostridium• Ebolavirus• Francisella tularensis• Marburg virus• Bacillusanthracis• Burkholderia mallei• Burkholderia pseudomallei• Variolamajorvirus(smallpox)• Yersiniapestis• Foot-and-mouthdiseasevirus(aphthovirus)

BiologicalWarfare:tier1

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• Anthrax

• Plague

• Smallpox

• Botulism

• Tularemia

• ViralHemorrhagicFever

HighestConcernCDCdesignated“A”ListofBiologicAgents

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• Inhalationanthrax:aerosol

• Symptoms:initiallynon-specificinfluenza-like;progressintopneumonia,meningitis

• Mortality:high:45%inAmerithrax,90%whencomplicatedwithmeningitis

• Diagnosis:cultures,lungscans(longincubationtimebetween1dayupto6weeks)

• Treatment:ABC-procedures,fluoroquinolone (e.g.ciprofloxacin)

• PEP:vaccinelowerstheburden

• (accidentalreleaseofanthraxfromamilitaryinstallationinSverdlovsk(Russia)with64deaths)

Anthrax(Bacillusantracis)

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• TheworldhasbeendeclaredfreefromsmallpoxbytheWHOin1982!

• Spreadbyaerosol;hightransmissionpersontoperson

• Diagnosis:cultures,lungscans(longincubationtime,10-12days)

• Treatment:nolicensedtreatmentsavailable.Vaccinesstockpiledbythemilitary

• Lethality:3%inrecentlyvaccinatedvictims;40%innon-vaccinatedpersons

• Vaccinationafterexposureisadvisable

Smallpox(varialomajor)

• Within3days-preventorsignificantlylessenseverityofsymptoms

• 4-7daysafterexposure-someprotection,maymodifyseverity

BenefitofVaccineFollowingExposure

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• Bacterialdisease;YersiniaPestis

• Diagnosis:initiallydifficulttodistinguishfromordinaryinfluenza(incubationtime1-3days)

• Lethality:whenuntreated:nearly100%

• Treatment:aminoglycosides(streptomycin…)

• Novaccineavailable

• (1300’s:50-20010e6deathsinAsiaandEurope)

Pneumonicplague(Pest)

• ToxinofClostridiumbotulinum

• Spreadduringattackbyaerosol

• Diagnosis:paralysiswithinhoursafterexposure,lethalityisveryhigh

• Treatment:nospecifictreatmentavailable;ABC-procedures

• Novaccineavailable

Botulism

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• ToxinofFrancisella Turalensis

• Diagnosis:difficulttodistinguishfrompneumonia,cultures,PCR,staining…

• Treatment:10daytreatmentwithaminoglycosides(streptomycin,gentamycin…)

• PEP:7daywithdoxicyclin,ciprofloxacin

• Navaccineavailable.• (Veryrare,lastcaseinTheNetherlandsin1953)

Tularemia

Nominallethality/1,000kgsofdifferentbiologicalweapens

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CluestoBioterrorism• Severediseasemanifestationsinpreviously

healthypeople

• Higherthannormalnumberofpatientswithfeverandrespiratory/G.I.Complaints

• Multiplepeoplewithsimilarcomplaintsfromacommonlocation

• Anendemicdiseaseappearingduringanunusualtimeofyear

CluestoBioterrorism• Unusualnumberofrapidfatalcases

• Greaternumberofill/deadanimals

• Rapidrisingandfallingepidemiccurve

• Greaternumbersofpatientswith:1)Severepneumonia2)Sepsis3)Sepsiswithcoagulopathy4)Feverwithrash5)Diplopiawithprogressiveweakness

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KeepAlert

• Earlydetection

• Highindexofsuspicion

• Immediatereportingofsuspectedcasestoauthorithies

StandardInfectionControl(I.C.)Precautions(forallbio-terroristthreats)

• WashhandsandWeargloves• Wearfaceshield• Wearcap/gown• Processcontaminatedequipmentandlinen• Cleananddisinfectenvironmentalsurfaces• Adheretooccupationalhealthandblood-borne

pathogenrequirements• Placepatientsatriskforenvironmentalcontamination

inprivateorcohortlocation

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AirborneInfectionControl(I.C.)Precautions(SmallpoxandHemmorhagic Fever)

• Placepatientinnegativepressureroom,whenpossible

• Applyhigh-intensityairfilterrespiratoryprotection

• Limitpatienttransport

• Placetightsealingmaskonpatientwhentransporting

• Biotechnologyallowstoconstructnewbacteria,newtoxins.

• CRISPR/Cas9astargetedgenomeediting

• Thiscouldleadtonewcompounds/bacteries :

• Modificationoftheresistancetoantibiotics

• Enhancementoftransmission

• Completelynewanddangerousmicroorganismswithoutanyknowntreatment

Thefuture…..

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Thefuture…..

Thefuture…..

• Wolfgang Rudischhauser, Director of the Weapons of Mass Destruction Non-Proliferation Centre at NATO said: 'ISIS actually has already acquired the knowledge, and in some cases the human expertise, that would allow it to use CBRN materials as weapons of terror.'

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MythsofDeterrenceAgainstBioterrorism

• Morally Repugnant

• Effective Treaties

• Consequences too numerous or terrible

• Science too difficult

• Not easily weaponized

• The infective dose of the potential biological agent• The method of attack on the target population (e.g.,inhalation, ingestion, or by an insect vector)

• The means of dispersion of the biological agent• The ability of the biological agent to survive until itreaches the target

• The time to effect or cause disease in the targetpopulation

• The biological agent needs to be producible

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KnowledgerequiredtoManufactureBiologicalWeapons

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• The methods for making aerosols stay airborne arewidely available.

• The tools for making pathogens in high quantities infermenters are on ebay.

• The recipes for making stable formulations ofpathogens are on the internet.

• The equipment for disseminating these weapons is inhardware or agricultural supply stores.

• This information and technology is almost entirely dualuse - in the sense that it has both legitimate anddangerous uses in the world. 31

TheCapabilitytoMakeBiologicalWeapons

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• Noeventshaveoccurredsincetheanthraxoutbreakin2001

• Technicallydifficulttodisseminateaninfectiousagentortoxin,butpossible

• Smallpoxandanthraxareconsideredthegreatestthreats.Smallpoxvaccinenowstockpiled

• Responseprocessrequiresateamapproach• Recognitionmaybechallenging• Newcomputerizedsurveillancesystemsofferpromiseforearlydetection

Bioterrorism:summary

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History

• 6° century

• 10° century

• 1346 : siege of Caffa : dead bodies from plague ; spread of “black death” in Europe ?

• 1763 : British trying to kill native Americans near fort Pitt

• WWII : Churchill commands the weaponisation of antrax, tularemia…..

• 2013, Afghanistan (53 death), 2006, Iraq (7 death), 2001, USA (5 death), 1987, Philippines (19 death), 1978, Georgetown (913 death), ……

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CharacteristicsBio-warfareMode: AerosolIncubationPeriod: 17d(10-12d)Onset: AbruptDuration: 4weeksLethality: Moderate(20-40%in

unvaccinated;3%inrecentlyvaccinated)

Transmission: High(persontoperson)

Smallpox(Variola virus)

AnthraxCase4/October19,2001

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Smallpox(Variola virus)– Diseaseprogression

• Aerosolized releaseoverdenselypopulated area

• Anthraxmeningitisin50%patwithinhalation anthrax

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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Release

Num

bero

fCases

SymptomOnset SevereIllness

Source:MarcyLayton,NYCDOH

RationaleforSyndromic Surveillance

EID2006www.cdc.gov/ncidod/EID/vol10no5/03-0646.htm

Syndromic Surveillance:NYC2001-02

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Uniquenessof BiologicalAttacks

• Biological‒ Onset - incubation, primary cases

‒ Secondary Cases – contagion, contamination

• Responders - medical

• Response System - untested

• Medical System may be a target

Syndromic surveillance during the Paris terrorist attacksStephanie Vandentorren, Annie-Claude Paty, Elsa Baffert, Pascal Chansard, Celine Caserio-Schönemann

The Lancet, Volume 387, Issue 10021, Pages 846-847 (February 2016)

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DoNot

• Actonrumor

• Giveantibioticsondemand-withoutmedicalindication

• Ordernasalcultures-withoutmedicalindication