Dr.T.V.Rao MD

BIOTERRORISM HEALTH PREPAREDNESS

DR.T.V.RAO MD 1

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Definition of Bioterrorism

"Bioterrorism” - The unlawful use, or

threatened use, of microorganisms or

toxins derived from living organisms to

produce death or disease in humans,

animals, or plants. The act is intended to

create fear and intimidate governments

or societies in the pursuit of political,

religious, or ideological goals.

Note: There is no single, universally accepted definition of bioterrorism. DR.T.V.RAO MD

HISTORY OF BIOLOGICAL

WARFARE

• 1346 Siege of Kaffa; plague

• 1763 French and Indian War; smallpox

• WW I German program; anthrax, glanders

• 1925 Geneva protocol bans biological weapons

• WW II Japanese program; anthrax, plague, cholera, shigella

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HISTORY OF BIOLOGICAL

WARFARE (CONT.) • 1941 George W. Merck named U.S. civilian

head of Chemical Warfare Service later changed to War ResearcService

• 1946 U.S. announces its involvement in bioweapons research

• 1969 Nixon eliminates offensive biological warfare program

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• 1972 Biological Weapons Convention

• 1979 Accidental release of B. anthracis spores at bioweapon research center, Sverdlovsk, U.S.S.R

• 1989-92 Scientists from the former U.S.S.R. involved in biological weapons

research defect to the West

History of Biological Warfare (cont.)

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Domestic Biological Terrorism

• 1984 Rajneesh cult members contaminate salad bar with Salmonella typhimurium in Oregon

• 1992 Ricin attack planned by Minnesota militia

• 2001 Anthrax releases in FL, DC, NY, NJ

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The use of biological

agents to

intentionally produce

illness or intoxication

in a susceptible

population

BIOLOGICAL TERRORISM

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BIOLOGICAL AGENTS RANKING

SYSTEM

Public Health impact criteria based on:

• Morbidity and mortality

• Delivery potential

• Public perception (fear, civil disruption)

• Public health preparedness needs

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CDC SELECT AGENTS* – BACTERIA

• Bacillus anthracis (spores)

• Brucella abortus

• Brucella melitensis

• Brucella suis

• Burkholderia mallei

(aka Pseudomonas mallei)

• Burkholderia pseudomallei

(aka Pseudomonas pseudomallei)

• Clostridium (botulinum- producing species) • Coxiella burnetii • Francisella tularensis • Rickettsia prowazekii • Rickettsia rickettsii • Yersinia pestis

n = 12 * Not including agents only on USDA lists.

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CDC Select Agents* – Fungi

• Coccidioides immitis • Coccidioides posadasii

n = 2

* Not including agents only on USDA lists.

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CDC Select Agents* – Viruses I

• Central European Tick-borne encephalitis • Cercopithecine herpesvirus 1 • Crimean-Congo haemorrhagic fever • Eastern Equine encephalitis • Ebola • Far Eastern Tick-borne encephalitis • Flexal South American haemorrhagic fever • Guanarito South American haemorrhagic fever • Hendra • Junin South American haemorrhagic fever • Kyasanur Forest disease • Lassa fever • Marburg

* Not including agents only on USDA lists. DR.T.V.RAO MD 11

CDC Select Agents* – Viruses II • Machupo South American haemorrhagic fever • Monkeypox • Nipah • Omsk haemorrhagic fever • Reconstructed 1918 influenza • Rift Valley fever • Russian Spring and Summer encephalitis • Sabia South American haemorrhagic fever • Variola major (smallpox) • Variola minor (alastrim) • Venezuelan Equine encephalitis

n = 24

* Not including agents only on USDA lists.

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CDC Select Agents* – Toxins • Abrin • Botulinum neurotoxins • Clostridium perfingens epsilon toxin • Conotoxins • Diacetoxyscirpenol • Ricin • Saxitoxin • Shiga-like ribosome-inactivating proteins • Shigatoxin • Staphylococcal enterotoxins • Tetrodotoxin • T-2 toxin n = 12

* Not including agents only on USDA lists.

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BIOWEAPON-RELATED DISEASES

• anthrax

• botulism

• brucellosis

• cholera

• food poisoning

• glanders

• hemorrhagic fever

• lassa fever

• melioidosis

• plague

• psittacosis

• Q-fever

• salmonellosis

• shigellosis

• smallpox

• tularemia

• typhoid fever

• typhus

• viral encephalitis

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ADDITIONAL POTENTIAL BIOTERRORISM AGENTS

• • Chlamydia psittaci

• • Cryptosporidium parvum

• • Escherichia coli O157:H7

• • hantavirus

• • Salmonella species

• • Shigella species

• • Vibrio cholerae

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Potential Bioterrorism Agents

• Potentially thousands

• NATO NBC Handbook lists 31 agents

• CDC created Category A, B, & C lists

• Based on:

– Ease of dissemination

– Potential for Public Health Impact

– Potential for Public Panic and Social

Disruption

DR.T.V.RAO MD

• The Centers for

Disease Control (2004)

have placed agents in

one of three priority

categories for initial

public health

preparedness efforts: A,

B, or C. Agents

BIOTERRORISM AGENT CLASSIFICATION

SYSTEM CDC

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CLASS A • Contagious

• High death rates and high health impact on the public

• ANTHRAX, BOTULISM, SMALLPOX, TULAREMIA, PLAGUE

CLASS B • Moderately easy to spread

• Some illness & death rates

• TYPHUS, WATER SAFETY THREATS, SALMONELLA

CLASS C • Easily available

• Easily produced and spread

• Have potential for high death & illness rates

• NIPAH VIRUS

CLASSIFYING BIOTERROR AGENTS

Hey look, a llama! Never can be too careful…

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CRITICAL BIOLOGICAL AGENTS

CATEGORY A

• Can be easily disseminated or transmitted person-to-person

• Cause high mortality, with potential for major public health impact

• Might cause public panic and social disruption

• Require special action for public health preparedness • MMWR 49;RR-4, April 21, 2000

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• variola major (smallpox)

• Bacillus anthracis (anthrax)

• Yersinia pestis (plague)

• Clostridium botulinum toxin (botulism)

• Francisella tularensis (tularaemia)

• filoviruses

• Ebola hemorrhagic fever

• Marburg hemorrhagic fever

• arenaviruses

• Lassa (Lassa fever)

• Junin (Argentine hemorrhagic fever) and related viruses

• MMWR 49;RR-4, April 21, 2000

CATEGORY A AGENTS INCLUDE

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CATEGORY B

• Are moderately easy to disseminate

• Cause moderate morbidity and low mortality

• Require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance

• MMWR 49;RR-4, April 21, 2000

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CATEGORY B AGENTS • Coxiella burnetti (Q fever);

• Brucella species (brucellosis)

• Burkholderia mallei (glanders)

• alpha viruses

• Venezuelan encephalomyelitis

• eastern and western equine encephalomyelitis

• ricin toxin from Ricinus communis (castor beans)

• epsilon toxin of Clostridium perfringens

• Staphylococcus enterotoxin B.

• MMWR 49;RR-4, April 21, 2000

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• Salmonella species

• Shigella dysenteriae

• Escherichia coli O157:H7

• Vibrio cholerae

• Cryptosporidium parvum

SUBSET OF LIST B AGENTS INCLUDES PATHOGENS THAT

ARE FOOD- OR WATERBORNE - THESE PATHOGENS

INCLUDE

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CATEGORY C

INCLUDES EMERGING PATHOGENS THAT COULD BE

ENGINEERED FOR MASS DISSEMINATION IN THE FUTURE

• Nipah virus

• Hantaviruses

• Fick-borne hemorrhagic fever viruses

• Tick-borne encephalitis viruses

• Yellow fever

• Multidrug-resistant tuberculosis

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Biological Delivery Methods

• Food / Water

• Aircraft sprayers

• Vehicle sprayers

• Hand sprayers

• Mail

• Air handling

systems

• Human Vector

• Animal Vector

DR.T.V.RAO MD

• Occurrence of vector-borne

disease where there is no

vector

• Cluster of sick or dead

animals

• Atypical seasonality

• Geographic Pattern of

Illness

• More respiratory

presentation of disease

KEY INDICATORS OF A BIOLOGICAL

TERROR EVENT

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The Ideal Bioterror Weapon Would Be

1. contagious 2. virulent 3. robust 4. difficult to detect 5. drug-resistant 6. user-controllable

No natural agent meets all of these criteria. Thus, sooner or later, terrorists may decide to devise novel weapons using the techniques of synthetic biology to enhance or replace the characteristics of pre-existing organisms or toxins. Countermeasures must be pursued vigorously – in advance.

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PREPARATION FOR BT ATTACK

• Familiarize medical staff with BT agents

• Incorporate into Disaster Planning

• Decontamination & Infection Control

• Communications with key agencies

• Laboratory, Respective health authorities of the Nation.

• Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc.

• Security preparations

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IMMEDIATELY NOTIFY:

• Hospital Infection Control

• Isolation: Smallpox, plague, hemorrhagic fevers

• Laboratory

• Hospital Administration

• Local Public Health Department

WHAT TO DO IF YOU SUSPECT A

BIOTERRORIST DISEASE

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WHAT DOES PUBLIC HEALTH DO IN A

BIOTERRORIST EVENT?

• Assess health impacts in the community

• Environmental health assesses water safety and sanitation

• Public health nurses coordinate with Shelter Operations

• Acute communicable disease tracks infectious diseases

• Injury program tracks injuries and fatalities

• Health Officer coordinates information for the public and health care

providers

• Public Health Laboratories identify agents (either in-house or

through referral to State governments or health authorities )

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• Identifying a covert

attack

• Social disruption

• Prophylaxis for large

populations

• Decontamination

• Secondary

transmission

SPECIAL PROBLEMS WITH BT

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Forensic teams

work hard to

identify

biological

agents, their

origins and

effects

TECHNOLOGY AT WORK

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• Labs are working on

advanced detection

systems to detect

early attacks, identify

at-risk areas, and to

give proper

treatment

TECHNOLOGY AT WORK

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• Bio surveillance: Real-

Time-Outbreak Disease

Surveillance system made

its debut in 1999. This

collects data from labs,

hospitals, and

environmental studies in

order to detect bioterror

attacks as early as

possible.

TECHNOLOGY AT WORK

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• Wyatt-Lorenz was founded as a

spin-off of Wyatt Technology

Corporation ("WTC") with a

unique mission: To provide

immediate bioterrorism bioagent

warning systems for the

protection of people and property

from biological and chemical

threats. These Bioterrorism

threats are often directed toward

elements of the private sector

long ignored by the Department

of Defense and Department of

Homeland Security

BIOTERRORISM BIOAGENT WARNING

SYSTEMS

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• Specialized labs

needed for some

agents

• Risks to laboratory

workers

• Limited resources

• Communication

between agencies

SPECIAL PROBLEMS WITH

BIOTERRORISM

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PREPARATION FOR BIOTERRORISM

ATTACK

• Familiarize medical staff with BT agents

• Incorporate into Disaster Planning

• Decontamination & Infection Control

• Communications with key agencies

• Laboratory, CDC, Police, FBI, etc.

• Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc.

• Security preparations

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CLASSIFICATION OF

BIOTERRORISM LABORATORIES

Level-A Labs - Assess Risks

for Aerosols and Use Biosafety Cabinet

A - Adequate safety to rule-out

and forward organisms

Level B Lab

Work at BSL-3 with BT agents

B - Safety and proficiency adequate

to confirm & characterize susceptibility

Level C Lab

BSL-3

C - Safety and proficiency sufficient

to probe, type, perform toxigenicity testing

Safety & proficiency to probe for universe of

bio- and chemical agents in non-clinical specimen

D - High level characterization (seek evidence of

molecular chimeras) and secure banking of isolates

Level D Lab

BSL-4

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IMMEDIATELY NOTIFY:

• Hospital Infection Control

• Isolation: Smallpox, plague, hemorrhagic fevers

• Laboratory

• Hospital Administration

• Local Public Health Department

WHAT TO DO IF YOU SUSPECT A

BIOTERRORIST DISEASE

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• Health Officer coordinates

information for the public

and medical providers

• Community Health and

PHN‟s provide education,

information to the public

and to community providers

• Treatment and prophylaxis

• Quarantine

PUBLIC HEALTH’S ROLE IN BIOTERRORISM

EVENT

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PROJECT BIOSHIELD "We refuse to remain idle when modern technology might be turned against

us. We will rally the great promise of American science and innovation to

confront the greatest danger of our timeFormer President George W. Bush,

at the signing of the Project Bio shield Act of 2004

• Authorized spending of $5.6 billion over a span of 10 years in order to pay for vaccines

and medical facilities in case of national biological emergency

• Gave the National Institute of Health grants to pursue medical research & technology

• Emergency Use Authorization – EUA – gave access to best medical responses in case

of an emergency as declared by the Secretary of Human Healthy & Services OR

Secretary of Homeland Security

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Primary Care Physicians

Hospitals

Local Labs

Public Health

System

Feedback/

Recommendations

Coordinating with the Public Health System

COORDINATING WITH SYSTEM IS PRIORITY

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• More trained

epidemiologists to speed

detection

• Increased laboratory

capacity

• Health Alert

Network

• Medical professionals “back

to school”

• National Pharmaceutical

Stockpile

WHAT WE NEED TO

PREPARE FOR BIOTERRORISM

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HOW CAN HOSPITALS PREPARE?

• Familiarize medical staff and lab with bioterrorist threat agents

• Incorporate BT planning into disaster planning

• Infection control

• Notification procedures and contact numbers

• Daily surveillance and reporting

• Security preparations

• Media

• Personal Protective Equipment (PPE)

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• Outbreak of rare disease

• Seasonal disease at wrong

time

• Unusual age distribution

• Unusual clinical symptoms

• Unusual epidemiologic

features

• Outbreak in region normally

not seen

IS IT A TRUE TERRORISM ?

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STEPS IN PREPARING PUBLIC HEALTH

AGENCIES FOR BIOLOGICAL ATTACKS

• Enhance epidemiologic capacity to detect and respond to biological attacks.

• Supply diagnostic reagents to state and local public health agencies.

• Establish communication programs to ensure delivery of accurate information.

• Enhance bioterrorism-related education and training for health-care professionals.

• MMWR 49;RR-4, April 21, 2000

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• Preparation for a biological

mass disaster requires

coordination of diverse

groups of medical and

non-medical personnel

• Preparation can not occur

without support and

participation by all levels

of government

• Preparation must be a

sustained and evolutionary

process

BIOTERRORISM AND THE PUBLIC HEALTH SECTOR

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• Created by Dr.T.V.Rao MD for „e” Learning

Resources for Medical and Public

Personal on Bioterrorism

• Email

doctortvrao@gmail.com

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