BIOTERRORISM

Dr. E. McNamaraPublic Health Lab. HSE, Dublin.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

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’

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 Co-operation internationally

WHO CDC EU

National preparedness Plans Multidisciplinary

Government Admininstrative Emergency services Medical Scientific

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

Germany WWI sold anthrax infected horses

WWI-II Many countries started biological programme

WWII – Not Used UK 5 million anthrax ‘cattle-cakes’ USA Botulinum Canada Plague Germany Salmonella Japan POW/Chinese trials

Post WWII USA

3400 people 1969, BTWC Allegation

Korean War Cuba

Misinformation, FBI to Soviets Soviets

1920 – 1969, BTWC signed 1975 Enlarged, Biopreparat

60,000 people40-50 facilities50 agents

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 Enhance surveillance Resource laboratories Communication systems Bioterrorism education Stockpile vaccines and drugs Molecular surveillance microbial strains Support development diagnostic tests Support research Rx. and vaccines

CDC April 2000

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 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. 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 contd.

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

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 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. 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 contd.

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 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

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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.

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 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 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. 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

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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. 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 contd.

Differential Dx. Guillain-Barré Myastheria gravis Stoke CNS despressants

Cl. Botulinum contd.

Dx.: Detect botulinum toxin Culture

Rx.: Antitoxin Supportive

Infection Control – standard precautions

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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

Incubation 1-8 days Fever, rigors, headache Buboes – painful lymph nodes 15% develop pneumonic plague Mortality = 12%

Septicaemic Plague

Primary, or secondary to bubonic Rigors, abdominal pain, V+D Purpura, DIC, necrosis Mortality = 30%

Pneumonic Plague

Highest bioterrorism risk Primary or secondary from

haematogenous Incubation 1-3 days Pneumonic symptoms Respiratory failure and shock Mortality - ↓with rx. = 8%

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.

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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

Tularaemia

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Tularaemia

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