PU 430PU 430Unit 5

Chapters 2 and 3

Bioterrorismhttp://www.youtube.com/watch?v=2t_MsSO9qRk

Chapter Two

Basic Facts About Bioterrorism Threats Bioterrorism is the use or threatened use of

biological agents as weapons of terrorCurrent U.S. laws make the threat alone a

severe crimeThe biological material used may be lethal or

nonlethal, a common bacteria or virus, the toxic by-product of a pathogen, a rare organism, or even a specially engineered organism, never before diagnosed or treated

These acts are intended to instill fear in the targeted population in support of terrorist goals

Organisms or other biological materials can be released in the air, or placed in food or water sources

Advantages of Biologics Advantages of Biologics as Weaponsas Weapons

Easy to obtainInexpensive to producePotential dissemination over large

geographic areaCreates panicCan overwhelm medical servicesSusceptible civilian populationsHigh morbidity and mortalityDifficult to diagnose and/or treatSome are transmitted person-to-person via

aerosol

Routes of InfectionRoutes of Infection Skin (cuts, abrasions, mucosal membranes) Gastrointestinal

◦ Food Potentially significant route of delivery Secondary to either purposeful or accidental

exposure to aerosol◦ Water

Capacity to affect large numbers of people Dilution factor Water treatment may be effective in

removal of agents Respiratory

◦ Inhalation of spores, droplets & aerosols◦ Aerosols most effective delivery method◦ 1-5 droplet most effective

Medical ResponseMedical Response Pre-exposure

◦ active immunization◦ prophylaxis◦ identification of threat/use

Incubation period◦ detection and diagnosis◦ active and passive immunization◦ antimicrobial or supportive therapy

Overt disease◦ diagnosis◦ treatment

may not be available may overwhelm system may be less effective

◦ direct patient care will predominate

BioterrorismBioterrorism::Who are 1st Responders?Who are 1st Responders?

Primary Care PersonnelHospital ER StaffEMS PersonnelPublic Health ProfessionalsOther Emergency Preparedness

PersonnelLaboratory PersonnelLaw Enforcement

ScenariosScenariosOvert Event

◦Announced◦Patients Fall ill or Die (Increased Morbidity and Mortality)

◦Microorganisms Unconfirmed◦Hoaxes Assumed to be Real

ScenariosScenariosCovert Event

◦No Prior Warning - Unannounced◦Patients Fall ill or Die from Causes of Unknown or Unusual Origin

◦Unusual Cluster(s) of Cases - May be Geographically Distributed

◦Undetermined Causative Agent

U.S. Bioterrorism Preparedness Controversies

Bioterrorism preparedness activities include:◦The development & practice of a mass

emergency distribution of pharmaceuticals◦Risk communication training◦Incident Command System training for public

health & healthcare workers

Controversy surrounds many issues, including:◦Vaccinations & antibiotics◦The potential for increasing bioterrorism &

biocrime risks◦Funding of public health programs

Categorization of Threats

Category A pathogens - High priority organisms & toxins posing the greatest threat to public health

Category B agents - Fairly easy to disperse but have lower morbidity & mortality than the Category A agents & can be successfully addressed

Category C agents - Emerging infectious organisms that could become easily available at some point in the future & used as a weapon

Health Threats: Category A Organisms

Anthrax (Bacillus anthracis) – considered by many to be the perfect biological weapon Botulism (Clostridium botulinum toxin) - regarded as the most potent poison in the worldPlague (Yersina pestis) - without quick antibiotic treatment, can cause death in several daysSmallpox (Variola major, Variola minor) - the most destructive infectious disease in human historyTularemia (Francisella tularensis) - highly infectious for individuals directly exposed to the organisms, but is not spread from person to personViral Hemorrhagic Fevers (Filoviruses,Arenaviruses,

Bunyaviruses, & Flavivruses) – have potential lethality & infectiousness at low doses when delivered as an aerosol

Anthrax: Current Issues in the U.S.

Anthrax remains an endemic public health threat through annual epizootics.

B. anthracis is one of the most important pathogens on the list of bioterrorism threats

Aerosolized stable spore form Human LD50 8,000 to 40,000 spores,

or one deep breath at site of releasehttp://www.youtube.com/watch?v=4IxFU_itIUE

Exposure Situation Management: Exposure Situation Management: B. anthracisB. anthracis in Envelope in Envelope

Antimicrobial prophylaxis for those potentially exposed

Environmental samples◦Surface swabs◦Nasal swabs of potentially exposed persons (if <7 days)

Refine list of potentially exposed persons◦Not exposed: stop treatment◦Likely exposed: continue treatment for 60 days total

Anthrax: Post-Anthrax: Post-Exposure TreatmentExposure Treatment

Start oral antibiotics as soon as possible after exposure◦Ciprofloxacin or Doxycycline or

Amoxicillin/Penicillin (if known PCN sensitive)

Post-Exposure Treatment Post-Exposure Treatment (continued)(continued)

Antibiotics for 60 days without vaccine Antibiotics for 30 days with 3 doses of

vaccine (animal studies) Long-term antibiotics necessary

because of spore persistence in lung/lymph node tissue

Anthrax: VaccineAnthrax: Vaccine(continued)(continued)

Current U.S. vaccine (FDA Licensed) - continued◦FDA approved for 6 dose regimen over 18

months◦3 dose regimen (0, 2, and 4 weeks) may be effective for post-exposure

treatment (animal studies)◦Limited availability

Prevention

Prevention of bioterrorism

Public Health Security & Bioterrorism Preparedness & Response act of 2002

The Pandemic Preparedness & Response Act

FOODBORNE FOODBORNE BOTULISMBOTULISM

Infective dose: 0.001 g/kgIncubation period: 18 - 36 hoursDry mouth, double vision, droopy

eyelids, dilated pupilsProgressive descending bilateral

muscle weakness & paralysisRespiratory failure and deathMortality 5-10%, up to 25%

Level A ProceduresLevel A Proceduresfor Botulism Eventfor Botulism Event

Properly collected specimens are to be referred to designated testing laboratories

Prior to the shipment of any botulism-associated specimen, the designated laboratory must be notified and approved by the State Health Department

Plague: Overview Plague: Overview

Natural vector - rodent flea

Mammalian hosts◦rats, squirrels, chipmunks,

rabbits, and carnivoresEnzootic or Epizootic

CDC: Wayson’s Stain of Y. pestis showing

bipolar staining

Plague EpidemiologyPlague Epidemiology

Three Clinical Types:◦bubonic (infected lymph nodes)◦septicemic (blood-borne organisms)◦pneumonic (transmissible by aerosol;

deadliest)

Plague: ProphylaxisPlague: ProphylaxisBubonic contacts

◦If common exposure, consider oral Doxycycline, Tetracycline, or TMP/SMX for 7 days

◦Other close contacts, fever watch for 7 days (treat if febrile)

Plague: ProphylaxisPlague: Prophylaxis(continued)(continued)

Pneumonic contacts (respiratory/droplet exposure)◦Consider oral Doxycycline, Tetracycline,

or TMP/SMX◦Continue for 7 days after last exposure

Vaccine no longer manufactured in U.S.◦Not protective against pneumonic plague

Detection

Limiting the impact of a bioterrorism attack requires healthcare providers with sufficient training & support to remain diligent

Regular disease surveillance includes:◦ Mandatory disease reporting by local healthcare

providers◦ Data entry & analysis by local or regional public health

agencies◦ Additional analysis, reporting, & allocation of needed

resources by state & federal public health agenciesOther forms of surveillance include

environmental monitoring & standoff detection

Plague:Plague:Medical ManagementMedical Management

Supportive therapyIsolation with droplet precautions for

pneumonic plague until sputum cultures negative

Antibiotic resistant strains have been documented

Plague: Clinical FormsPlague: Clinical FormsBubonicBubonic

Bubonic ◦Inguinal, axillary, or cervical lymph nodes most

common◦80% can become bacteremic◦60% mortality if untreated

USAMRICD: Inguinal/femoral buboes

Plague: BubonicPlague: BubonicIncubation: 2-6 daysSudden onset headache,

malaise, myalgia, fever, tender lymph nodes

Regional lymphadenitis (Buboes)

Cutaneous findings◦possible papule, vesicle, or

pustule at inoculation site◦Purpuric lesions - late

Smallpox: OverviewSmallpox: Overview1980 - Global

eradicationHumans were only

known reservoirPerson-to-person

transmission (aerosol/contact)

Up to 30% mortality in unvaccinated

CDC: Electron micrograph of Variola major

Smallpox: Smallpox: Clinical FeaturesClinical Features

Prodrome (incubation 7-17 days)◦Acute onset fever, malaise, headache, backache, vomiting

◦Transient erythematous rash

Level A ProceduresLevel A ProceduresSmallpox virusSmallpox virus

Rule out chickenpox (PCR)! Specimen of choice is lesion material from

pustulesContact your State Public Health

Laboratory for guidance

Smallpox:Smallpox:Current VaccineCurrent Vaccine

Made from live Vaccinia virus

Intradermal inoculation with bifurcated needle (scarification)◦Pustular lesion/induration

surrounding central scab/ulcer 6-8 days after vaccination

WHO: Smallpox vaccine vials

Smallpox:Smallpox:Medical ManagementMedical Management

Strict respiratory/contact isolation of patient◦Patient infectious until all scabs have

separatedNotify public health authorities immediately for

suspected caseIdentify contacts within 17 days of the onset of

case’s symptoms

Immediate Actions

With quick identification of the biothreat agent & population at risk, there is a window of opportunity for prophylactic treatmentDecisions must be made rapidly & the response needs to begin immediatelyCommunication must be quickly established with the population at riskThose working in healthcare, public health, & the first response community need to be provided with detailed instructions on how to respond

BioterrorismBioterrorism::What Can Be Done?What Can Be Done?

AwarenessLaboratory Preparedness Plan in placeIndividual & collective protectionDetection & characterizationEmergency response Measures to Protect the Public’s Health

and SafetyTreatmentSafe practices

Recovery

Clean-up will not be difficult for most pathogenic organisms, with the notable exception of anthrax

Federal Insecticide, Fungicide, & Rodenticide Act (FIFRA)

◦The Environmental Protection Agency has established a listing of “antimicrobial products” to ensure that effective cleaning agents are used

Bombings and Explosions

Chapter Three

Introduction

Between 2006 & 2007, the death toll related to bombs increased by 30% & the number of suicide bombings increased by approximately 50%

Today’s bombers often want to generate as many civilian casualties as possible & are acquiring the technologies & methods to reach that objective

Health Threat

Four categories have been established to aid in the understanding of the complex assortment of injuries associated with explosions & provide structure for the triage process:

◦ Primary blast injuries

◦ Secondary blast injuries

◦ Tertiary blast injuries

◦ Quaternary blast injuries

Prevention

1.) Physical Security

2.) Threat Detection & Identification

Immediate Actions

If a threat necessitates an evacuation from a building: ◦Everyone at risk must be evacuated

immediately to a safe distance◦Occupants should quickly collect personal

items so they are not among the possible threats needing to be assessed by bomb technicians

◦Elevators should not be used◦There should be a rallying point away from the

building for a head count

Health & Medical Response

The Centers for Disease Control & Prevention have established several essential concepts that caregivers need to keep in mind concerning provision of care to those injured in explosions

It is important for all the first responders to be aware of risks when approaching a potential bomb scene

It is important to consider the possibility of residual explosive material

Local public health agencies also have an important role in long-term monitoring & follow-up of survivors