Transcript Biologicals out of the box

Chemical and Biological
Warfare Agents
Charles Stewart MD FACEP
Thinking Out of The Box
Unrestricted warfare
“With technological developments being
in the process of striving to increase the
types of weapons, a breakthrough in our
thinking can open up the domain of the
weapons kingdom at one stroke.”
Unrestricted Warfare is a Way
of Thinking Out of the Box…
Unrestricted warfare
“The new concept of weapons will cause
ordinary people and military men alike to
be greatly astonished at the fact that
commonplace things that are close to
them can also become weapons with
which to engage in war. We believe that
some morning people will awake to
discover with surprise that quite a few
gentle and kind things have begun to
have offensive and lethal characteristics.”
Unrestricted warfare
“It means that all weapons and technology can
be superimposed at will, it means that all the
boundaries lying between the two worlds of war
and non-war, of military and non-military, will
be totally destroyed.”
Unrestricted Warfare
Qiao Liang and Wang Xiangsui
Beijing: PLA Literature and Arts Publishing House,
February 1999
Realism in Theater


Are we sufficiently prepared for the
Right Threats?
Some other possible problems
NIH. –Not invented here
Media “guidance“ does not actually define
a real threat.
Politicians often “react” and nay not
properly plan for real threats
“Security” may make us less secure
Simple solutions don’t always solve
complex problems.
What Should We Really Plan For?







Explosives
Flammable agents
Chemical agents
Biological Agents
Radiological dispersion weapons
Nuclear weapons
Snipers?
All of them are possible threats !
Bombings are still the single
most common form of terrorism


Conventional explosives are easy to get
and easy to use.
Look for new ways to make and deliver
them.
Types of terror attacks?
Think Bombs!
87%
6%
4%
3%
Bombings
Kidnappings
Shootings
All others
Terrorist threat of explosives

Readily available
Predictable
Familiar effects


Abundant training
available
Abundant information
available
No difficulty with
delivery
Asymmetric Warfare

Them:
4 small crews
100% “ martyrs”

Us:
More than 4000 direct casualties
100’s of millions of $$ in damages
Massive damage to tourism and
transportation industries
Law of unintended consequences

Lessons learned
Big missions can cause big consequences but
provoke large responses
Little missions can cause big consequences with
minimal risks

Anthrax or sniper model attacks
Does this mean that new incidents will be small
in scope with maximum media impact?

Possibly
Law of unintended consequences


“Pearl Harbor” syndrome fully activated
Secondary losses
Loss of safe haven
Afghanistan
 Iraq?

System degradation
Financial support degradation
Potential Terrorist Targets

Critical facilities and infrastructure
Congress
Presidential staff
Supreme Court



Enclosed spaces
Large crowds (high profile events)
Facilities of interest to terrorists’ cause
In 2001, They Planned for at
Least 3 and Possibly 4 Targets
?
In 2003, They Chose 3 Targets
in Saudi Arabia
Terrorist threat of snipers

Weapons are readily
available in almost
all countries
Predictable
Effects familiar to
EMS
Absolutely no
difficulty with
delivery
High media impact
Terrorist threat of snipers

Look at how two poorly trained and
poorly equipped snipers affected 3
states in 2002
10 dead,3 injured
Think about how two or three teams of
well trained snipers would be able to hurt
us.
Has your EMS unit
discussed/gamed/planned how to handle
this type of terrorism?
Terrorist Threat of Chemical
and Biological Agents

Ideal weapons of terrorism
Easily and cheaply made
Easily delivered
Rapidly manufactured
Technical information not “hot”
Political effects far beyond local casualties
Terrorist Threat of Incendiary
Agents

Readily available
Predictable
Familiar effects
Abundant training
available
 Abundant
information
available

No difficulty
delivering
Terrorist Threat of Nuclear Weapons

Not easily available
Fairly predictable
Great difficulty with
delivery??
Unfamiliar effects to most
EMS
Abundant training available
 Abundant information
available

Readily detected ?
Closely controlled
Terrorist Threat of Radiological
Weapons

Moderately available
Fairly predictable
Unfamiliar effects to most
EMS


Abundant training available
Abundant information
available
No difficulty with delivery
 Readily detected

This is the easiest type of
terrorism to detect!
Media hype expected
Radiologic Dispersal Weapons

Great media hype
Probably a small number of actual
casualties
A quantity of sufficiently radioactive agent
to cause real damage must:
Be set up as a fine particle (ground)
 Transported to the area where it is to be used
 Shielded from detection

This is not an easy set of tasks
Chemical and biological weapons are
simply tools of unrestricted warfare
Terrorist Threat of Chemical
Weapons

Moderately available
Fairly predictable
Unfamiliar effects to
most EMS ?
Abundant training
available
 Abundant information
available
 Readily detected ??

No difficulty with
delivery
Simplistic solutions?

Decontamination –wash them all down
with water?
Simple, easily implemented solution
Particularly effective for Sarin
Simplistic solutions?

Neglects fact that hydrolysis is not
always effective or beneficial

Water is not particularly effective for Vx and
other oily or thickened Agents?
– Thickened Soman was in Russian inventory.

Vx is hydrolyzed to EA2192
– Water actually makes VX into a far more toxic and
longer lasting substance
EA2192 = Diethyl methylphosphonate, 2 diisopropylaminoethyl
mercaptan, ethyl hydrogen methyl-phosphonate,
bis(ethylmethylphosphonic)anhydride, bis S- (2-diisopropylaminoethyl)
methylphosphononodithiote.
Simplistic solutions?

Bleach is bad ?
GRAS – generally recognized as safe!
Theoretically could consume 4 oz with no ill
effects.
 Hundreds of children have done so.

Bleach is a better decontamination agent
than water
Much more rapid than water
 Known activity against mustard, Soman, and
VX-(military evidence in 50’s)

Simplistic solutions?

Water is not particularly effective for
mustard
Europeans found bleach and sodium
thiosufate to be more effective

No experience at all with water
decontamination of “dusty” agents
Dusty mustard
Dusty Soman and Sarin
Decon Shower
Simplistic solutions?

Water will dilute and render safe this
substance by lowering the
concentration so that no significant
downstream damage will occur?
Sarin – probably -volatile and non
persistent
VX-???-long lived toxic hydrolysis products
Soman-???
Mustard -???
Downstream safety
?
Dusty Agents

Combination of a chemical warfare
agent with a very finely divided silica or
talc powder to make a particulate
aerosol

Civilian technology
Ortho Ant-Stop is an organophosphate in
an inert carrier
Dusty mustard

Enhanced penetration of protective
equipment
Goes under MOPP gear
“May” penetrate Level A PPE


Insufficient data exists to substantiate this
statement
More rapid and enhanced pulmonary
effect of mustard on unprotected
Dusty VX –Sarin –Soman

Enhanced penetration of protective
equipment
Goes under MOPP gear
“May” penetrate Level A PPE*

More rapid and enhanced pulmonary
absorption of VX on unprotected
“May” give a picture more like Sarin*

“May” make Sarin or Soman less volatile*
*Insufficient data exists to substantiate this statement
Dusty Agents

Original Solution
”WHILE EMPHASIZING THAT THERE IS NO
EVIDENCE THAT IRAQ HAS DEVELOPED A DUSTY
V-AGENT, FATALITIES RANGING FROM 3 TO 38
PERCENT ARE PROJECTED FOR THE SAME
CONCENTRATIONS CITED ABOVE FOR TROOPS
IN FULL MOPP IF SUCH AN AGENT WERE USED.
USE OF THE PONCHO OVER THE MOPP GEAR IS
EXPECTED TO REDUCE THESE PROJECTED
CASUALTIES TO NEAR ZERO EVEN FOR A DUSTY
NERVE AGENT. “
Dusty Agents


One senses that the prior
recommendation was a desperate
attempt to offer reassurance and a
temporary “solution” for the troops.
Certainty, an open flapping poncho
would offer no substantial improvement
in chemical threat protection
SERPACWA

Better solution took 8
years to develop
 Skin Exposure Reduction
Paste Against Chemical
Warfare Agents
 Paste contains a
perfluoroalkylpolyether
(PFAPE) oil as a base
polymer and
polytetrafluoroethylene
(Teflon polymer)
dispersed within the base
oil

ATSP soon to come
Simplistic solutions?

Everybody needs to be in Level A-B-C
gear for personal protection
Governmental recommendations?
OSHA?
 OPP gear is, at best, level C protection

– Splash-Resistant over suit
– Purified air (Negative Pressure) Protective mask

Turn-out gear +SCBA = 30 minutes protection?
I don’t know the “ Right” answer to this question.
MOPP
Chemical Threats –NIH
Problem

What is best cyanide antidote?
? Lilly cyanide kit?
Expensive
 Awkward to use
 Dangerous to peds

Chemical Threats –NIH
Problem
Hydroxycobalamin
NlH?
 Vitamin B12
 Widely available and quite cheap
 Not FDA approved for this

Kelocyanor?
NIH?
 Available and widely used in Europe
 Pricy?

Terrorist Threat of Biowar Agents

We were assured that biological agents
were poor weapons of terrorism??
Unpredictable
Weather
 Lifespan (survivability) ?
 Few good studies on effectiveness

Stigma
Difficulty with delivery ??
Terrorist Threat of Biowar
Agents

We were assured that biological agents
were poor weapons of terrorism??
Unpredictable
Weather
 Lifespan (survivability) ?
 Few good studies on effectiveness

Stigma
Difficulty with delivery ??
We Were Expecting “ The Big
One”...
We Got …

Historically most
episodes of
terrorism are rather
small affairs…
This is a principle of
asymmetric
warfare…
Think about the
confusion generated
by …
Why Bioweapons? Other Advantages


Undetectable by usual means
Remote effect (time-lag)
Perpetrator can leave scene
Widespread effect before discovery

Flexible
Covert vs Overt
Small scale vs large scale

Small amounts can inspire significant terror
Real Threat…or Fancy Fiction

Delivery will be a
problem???
Real Threat…or Fancy Fiction

Terrorists need more expertise than they’ve got???
Larry Wayne
Harris
Real Threat…or Fancy Fiction

You just can’t get
these bugs
anymore….
(we have controls,
you know)???
Endemic source of plague in western USA
Real Threat…or Fancy Fiction

High lethality does not mean a large
number of deaths???
Remains to be proven.
Biowarfare Agent Sources





Home production
Laboratory / commercial production
Industrial facilities
Foreign military sources
Medical / university research facilities
History

Romans
Used dead animals to foul water supply

Mongols
Catapulted plague victims into Kaffa

English
Gave smallpox infested blankets to Indians
during French-English war in colonies.
History:
German Agents in WWI

Dr. Alton Dilger in
Washington DC
Anthrax and
Glanders
About 3500 horses
infected
More people died
than from the 2001
anthrax
History - Terrorist



1915 Dr. A Dilger (German-American)
produces anthrax and glanders
1972 ‘Order of the Rising Sun’ prepares
30 kg of typhoid bacteria cultures
1978 Giorgi Markov assassinated with
ricin
History - Unit 731


1918 - Unit 731 established in Japan
Unit 731 deploys in Manchuria in
WWII

Investigates multiple organisms including
plague
1941 Bubonic plague sprayed in China
by Japanese
1942 Bacterial “bombs” used by
Japanese
History - USA Experiments

1950-1969 Off coast USA –
Experiments with Serratia
US Army and Navy
 for several cities including San Francisco and LA


1966 Bacillus subtilis via subway route in NYC


US Army
1966 Pentagon ‘bombed’ by Chemical Corps
History: A Salad Bar in Oregon

1984 Rajneesh cult
seeds salad bars in
Oregon with typhoid
to influence an
election
Anthrax


Known experience with this agent
Sverdlovsk (Ekatrinburg) Russia 1979
Accidental military release
We will talk about this later.
History


1983 2 brothers in Northeastern USA
produce 1 ounce of pure ricin
1984 Red Army Faction found with
botulinum toxin in Paris
History


1991 Iraq bioweapons program
uncovered during Gulf War
1992 Ken Alibek defects to USA and
exposes the Soviet program
Ladies and gentlemen… we have a real problem.
History

2001 Anthrax used
via postal delivery
methods…. Osma
Bin Laden
suspected.
History

Sort of puts the lie to anybody who
thinks this ain’t gonna happen here …
Asymmetric Warfare

We need to be prepared for the next
phase… and we don’t know what that
phase is or when it will occur.
We aren’t ready for a lot of these problems
Possible Biologic Agents
anthrax, cryptococcosis, escherichia coli, haemophilus
influenzae, brucellosis (undulant fever), coccidioidomycosis
(San Joaquin Valley or desert fever), psittacosis (parrot
fever), yersina pestis (the Black Death of the 14th
Century), tularemia (rabbit fever), malaria, cholera,
typhoid, bubonic plague, cobra venom, shellfish toxin,
botulinal toxin, saxitoxin, ricin, smallpox, shigella flexneri, s.
dysenteriae (Shiga bacillus), salmonella, staphylococcus
enterotoxin B, hemorrhagic fever, Venezuelan equine
encephalitis, histoplasma capsulatum, pneumonic plague,
West Nile fever, Rocky Mountain spotted fever, dengue
fever, Rift Valley fever, diptheria, melioidosis, glanders,
tuberculosis, infectious hepatitus, encephalitides,
blastomycosis, nocardiosis, yellow fever, typhus,
tricothecene mycotoxin, aflatoxin, and Q fever.
Who knows?
Possible Biologic Agents

The CDC “master list”
A compromise between
A limited budget
 Public /media fears
 Agents known to hove been developed as
warfare agents

Does not cover all threats!
A growing threat
 New and emerging diseases not listed

Detection of Outbreak


Epidemiologic investigation
Syndrome Based
Inhalation anthrax
BW - Epidemiologic Clues





Large epidemic with high illness and
death rate
Infection non-endemic for region
Multiple, simultaneous outbreaks
Multi-drug-resistant pathogens
Sick or dead animals
BW - Epidemiologic Clues…


Delivery vehicle or vector found
Intelligence of possible event
BW - Epidemiological Information




Travel history
Infectious contacts
Employment history
Activities over the
preceding 3 to 5 days
Aerosol Spread

Ideal aerosol is a homogeneous
population of 2 or 3 micron particulates
This is the best “suspension” of particles
for RESPIRATORY spread
Please note that other sizes may well be
infective also.

Maximum human respiratory infection is
a particle within 1 to 5 micron size
Aerosol / Infectivity Relationship
Infection
Severity
Particle Size
Less
Severe
18-20
15-18
7-12
4-6
(bronchioles)
More
Severe
1-5
(alveoli)
Delivery Systems

Airborne
Biological Agents - Types and
Characteristics


Live Agents
Biotoxins
These are more like
chemical warfare
agents
Possible Live Biowarfare
Agents





Viruses
Rickettsia
Bacteria
Fungi
?? Prions ?? (mad cow disease)
Anthrax
Anthrax

Anthrax is an acute infectious disease of
animals caused by Bacillus anthracis.
Gram positive rods
Spore forming

May persist in soil for over 50 years!
Anthrax

Humans can develop
infection from
handling
contaminated fluids or
hides
(“Woolsorters
Disease”)
Anthrax

Spores can be produced
in a dry form for
biological warfare
may be stored and ground
into particles.
When inhaled by humans,
these particles cause
respiratory failure and
death within a week.
Anthrax

It is rare to find
infected animals in
the United States..

Most United States
cases are in Texas,
Louisiana,
Mississippi,
Oklahoma and
South Dakota.
Anthrax

Anthrax is most
common in
under-developed
agricultural
regions

South and Central
America

Southern and Eastern
Europe

Asia, Africa,

the Caribbean

the Middle East.
Anthrax

3 forms of Anthrax infection
cutaneous (skin) - most common
inhalation
gastrointestinal
Anthrax - Pathogenesis

Virulent bacteria produce toxins
edema factor
lethal factor

Spores are ingested by WBC’s and
travel to the regional lymph nodes
Cutaneous Anthrax

Cutaneous
Vesicle
Ulcerates with black necrotic center
Regional lymphadenopathy

Untreated skin infection - 20% mortality
if septicemia develops (treated 1%)
Cutaneous Anthrax
Inhalation Anthrax

Initial symptoms like a viral syndrome
1 to 6-day incubation period followed by
fever, myalgias, cough, and fatigue
Often get better for short time

Initial improvement is followed by
abrupt onset of respiratory distress,
shock, and death in 24 to 36 hours
Inhalation Anthrax
Chest x-ray shows
a widened
mediastinum with
or without a bloody
pleural effusion
Inhalation Anthrax

Inhaled anthrax causes mediastinitis
Germinated bacteria travel to regional
lymph nodes

50 % of cases have associated
hemorrhagic meningitis
Anthrax Meningitis
Intestinal Anthrax

Consumption of contaminated meat
Inflammation of the intestinal tract
Nausea, loss of appetite, vomiting, fever
Abdominal pain, bloody vomit, and diarrhea

Death in 25% to 60% of cases
Anthrax

Biowarfare agent
Does not spread person to person
Spores may be spread with multiple types
of equipment
Prophylaxis is possible
Cheap and easy to produce
Readily available
Anthrax Transmission


No documented person-to-person
transmission of inhalation anthrax has
ever occurred
Cutaneous transmission is possible
Universal precautions required
Inhalation Anthrax - Diagnosis

Nonspecific symptoms
Fever, headache, malaise


Substernal chest pain
Sudden onset of respiratory distress
Widened mediastinum on chest x-ray
Hemorrhagic mediastinitis

Some patients may present with GI or
cutaneous anthrax
Inhalation Anthrax - Diagnosis


Emergency physicians are “first
responders” in this disease.
This is contrary to usual EMS thinking
But the “ first response “ for patients with
initial complaints of malaise, fever,
headache probably won’t occur in the field.

The first Anthrax diagnosis was made
by emergency physicians
Anthrax -diagnosis

Nasal swabs
Poor way to check asymptomatic folks

Gram stain of blood
Often too late for inhalation disease

ELISA and immunohistology testing
may confirm diagnosis but samples
must go to reference laboratory for
cultures
Anthrax - Prophylaxis

Anthrax vaccine
Cell free filtrate
Proven for cutaneous
Not proven for inhalation or massive
exposures.
Requires 6 injections
Requires yearly booster
Anthrax - Prophylaxis

Unimmunized persons
Cipro 500 bid PO

No reason why another quinolone would not be
effective.
Doxycycline 100 bid PO
?? Penicillin
Continue antibiotics for 4 weeks at a
minimum
Vaccinate!
Anthrax - Therapy

Penicillin
Resistance is easy to achieve



Cipro
Chloramphenicol
Doxycycline
Tetracycline

Erythromycin
Anthrax - Pediatric
Treatment

Prophylaxis
Penicillin
Doxycycline
? Cipro

IV Therapy
Penicillin
? Cipro
Doxycycline
Anthrax



Known experience with this agent
Sverdlovsk (Ekatrinburg) Russia 1979
Accidental military release
Sverdlovsk = Ekaterinburg
Anthrax - Sverdlovsk

This
accident
resulted in
over 66
deaths
downwind.
Biological Warfare
research, production and
storage facility
Path of airborne
Anthrax – over 20
kilometers
downwind
Inhalation Anthrax is a slow
infection
Exposure
0
2
1
4
3
6
5
8
7
10
9
12
11
14
16
18
20
22
24
26
28
30
32
34
13
38
40
42
43
1979 Sverdlovsk deaths… per day after exposure
Each
36
represents one death
Current
experience


We still don’t
know who did
this.
The technology
could still be reused???
Plague

Yersinia (Pasturella) pestis
The Black Death - Bubonic plague
Flea bite
 Found
worldwide
 Prairie dogs in Rocky Mountain areas

Bipolar gram-negative rod
Plague

3 Presentations
Bubonic
Septic
Respiratory
Plague - bubonic




Usual natural transmission form
Localized abscess at site of infection
Regional lymph glands form large
abscesses
Incubation 2-10 days
Plague Disease Complex
Fever/rigors
Inhalational
Pharyngitis
2 -3 Sudden
days onset
Fever,
URI syndrome
APTT
ecchymosis
DIC
Tender bubo
1 - 10 cm
9%
24 hrs
Liver
enzymes
Fulminant
Pneumonia
6% late
meningitis
Stridor, cyanosis,
productive cough,
bilateral infiltrates
Leukemoid
reaction
Gram negative
rods in sputum
Erythema
2 - 10 days
Systemic
Toxicity
Respiratory failure
& circulatory collapse
Bubonic Plague



Erythema, fever, rigors
Bubo formation in
regional lymph nodes
Bubo aspiration and gram
stain is diagnostic
Plague - pneumonic



Aerosol transmission
Highly lethal
Rapid infection (1-2 days)
Plague - pneumonic


2 to 3 day incubation period followed by
high fever, myalgias, chills, headache,
and cough with bloody sputum
Pneumonia and sepsis develop acutely
and may be fulminant
Patients develop dyspnea, stridor, cyanosis,
and circulatory collapse
Plague – pneumonic

Patchy infiltrates or consolidation seen
on chest x-ray
Plague - septic

Blood-borne spread from other sites to
lungs, CNS and other sites
Highly lethal
Often has features of pneumonic but
slower onset
Acral Gangrene


Late complication of
pneumonic or
septicemic plague
May occur in the
fingers, toes,
earlobes, nose, or
penis.
Plague - diagnosis


Clinical suspicion
Lymph node aspirate
Gram stain


Check sputum and CSF too….
Culture of the aspirate, sputum, CSF, or
blood
Plague




Therapy must be started rapidly!
Streptomycin (30 mg/kg/day IM divided
BID for 10 days)
Doxycycline (100 mg IV BID for 10
days)
Chloramphenicol for plague meningitis
Plague - Pediatric Treatment

Prophylaxis
Doxycycline
Trimethoprim/Sulfamethoxazole

IV Therapy
Streptomycin (over 1 year of age)
Gentamicin
Chloramphenicol
Plague - prophylaxis


Vaccine is available… but it won’t
protect against aerosol spread…
Vaccine effective only for bubonic
plague
Prophylactic doxycycline will ‘probably’
be effective if started prior to
exposure...
Plague - Prophylaxis


Secondary transmission is
possible and likely
Universal and aerosol
precautions until
sputum cultures are
negative
pneumonic plague is
excluded
Plague - prophylaxis

Strict isolation is important for plague
victims…
Respiratory isolation is mandatory for the
first 48 hours of treatment
Violent coughing easily spreads infected
sputum

Vector control is important to prevent
infection of local fleas and rodents.
Plague


This agent is not an ideal war bug...but
it is readily available, has limited
spread, and is relatively hardy. It would
cause substantial casualties.
It has the potential of infecting local
fleas and rodents as a persistent agent.
It was used in WWII as a warfare agent
Tularemia





Incubation 2-10 days
Oculoglandular
Typhoidal
Treatment: gentamicin
Prophylaxis: vaccine (experimental) or 2
weeks of tetracycline
Smallpox


Variola virus
Extinct?
2 ‘legal’ repositories known
US and Russia
 Russia developed military stocks of smallpox

Monkeypox, cowpox, and ‘chickenpox’ are
quite similar
May lend to genetic manipulation

Or just selection of a specific variant
Smallpox
Last known natural
smallpox victim
Ali Maalim
Somalia 1977
Smallpox - presentation



Incubation period 12-14 days
Prodromal period
Skin lesions
Uniform progression of the lesions
Rash looks like chickenpox lesions only
uniform


Healing in 1-2 weeks
Fatal in 30% of cases (Variola major)
Smallpox …comes in more thon one variant



Variola major …30% mortality
Variola minor …5% mortality
Variola “hemorrhagic variant”
mortality unknown …probably >70%

Variola “flat variant “
mortality unknown …probably >50%
Smallpox



Diagnosis by clinical examination
Electron microscopy
Viral culture
Smallpox


Therapy is supportive
Would antiviral drugs…work?
There are some drugs that appear to have
appropriate effect in animal studies, but
these are in short supply
Child with Smallpox rash
CDC/Cheryl Tryon
Smallpox

Prophylaxis
Vaccine is available and very effective.
 Jenner
Vaccinia immune globulin
 Role
is unclear
 Used for treatment of vaccina reactions
Smallpox rash close-up
CDC/James Hicks, 1973
Smallpox


All material used in patient care should
be burned or autoclaved
Considerable potential for person-toperson spread
Smallpox - prophylaxis


Quarantined all
contacts for at least
17 days
Infectious until all
scabs are healed
over
Smallpox

Has already been used in warfare
British use of smallpox infested blankets
for Indians
Last child with Smallpox
CDC
Smallpox

Current plan is to
encircle an outbreak
of small pox with a
ring of immunization
so that the infection
can’t spread any
further .
Smallpox

Ring system requires
A group of health care
providers who are
already immunized .
Rapid identification of
cases
Isolation of the suspected
cases
Smallpox ring system requires




Contact tracing
Massive
immunizations
Isolated outbreak
Effective
immunization
(prevents disease)
Smallpox

Ring system assumes
Folks will not refuse
vaccination
Resources are not
exhausted
Quarantine will be
observed.
1:3-1:5 infectivity
What about O’ Hara ?

Any major airport
Agent release or
infected person
High travel season

Widespread infection
Infection date may
not be known
Contact tracing
difficult
Look at SARS
Smallpox

Ring system assumes
that immunization will
be effective both in
decreasing mortality of
the disease in those
who have been exposed
and effective in
preventing further
spread of disease
But… will it be “ blackpox “

The smallpox variant developed by the
Russians was a hemorrhagic smallpox
(This type of smallpox is sometimes called” blackpox”
because of the massive subcutaneous hemorrhage
found in these patients )

Vozozhdeniye Island in Aral Sea was
site of a presumed accidental release in
1971
Aralsk smallpox outbreak
Patient
#
Age
Sex
Date of
onset
Type of Rash
Prior
Vacc
Dead vs
live
1
24
F
8/17
Classic
Yes
Rec
2
9
M
8/27
Classic
Yes
Rec
3
23
F
9/10
Hemorrhagic
No
†
4
36
F
9/10
Classic
Yes
Rec
5
5.5
M
9/18
Classic
Yes
Rec
6
38
M
9/24
Mild
Yes
Rec
7
0.8
M
9/26
Hemorrhagic
No
†
8
60
F
9/26
Mild
Yes x3
Rec
9
33
M
9/28
Mild
Yes
Rec
10
0.33
F
10/2
Hemorrhagic
No
†
The Aralsk smallpox epidemic in 1971 was a presumed weapon release from
Vozozhdeniye Island in the Aral Sea.
Smallpox –blackpox variant

Ring Strategy would not stop spread of this
form of disease
It was not protective against getting the disease.

Vaccination is protective against death in
black pox
Massive immunization would decrease mortality
100% mortality in unimmunized.

Note: Data about this variant of smallpox is scanty and may well not be
this grim
What about the Toronto model ?

SARS
Health care system
devastated
Resources exhausted
EMS shut down

This is for a disease
with 10% mortality
Monkeypox Virus
Viral hemorrhagic fever
Fever, myalgias, prostration
 Target organ is the vascular bed.

Conjunctival injection, petechial
hemorrhage, and hypotension
Followed by shock and generalized
hemorrhage
Ebola virus


Viral Hemorrhagic
fever
No known therapy
Some antisera
may…be effective

No known
prophylaxis
VHF

Mortality varies
50 - 80% Ebola Zaire
Abnormal renal and liver function
tests - poor prognosis
 Disease severity and survival
depends on various host factors

VHF Treatment

Hemodynamic resuscitation and
monitoring
Invasive Swan Gantz catheter as feasible

Careful fluid management
use of colloid

Vasopressors and cardiotonic drugs
VHF Treatment



Cautious sedation and analgesia
No anti-platelet drugs or IM injections
Coagulation studies and replacement of
clotting factors / platelet transfusions
Prevention of VHF

Single room w/ adjoining anteroom as
only entrance
handwashing facility with decontamination
solution

Negative air pressure if possible
Prevention of VHF

Strict barrier precautions
gloves, gown, mask. shoe covers,
protective eyeware/faceshield
consider HEPA respirator for prominent
hemorrhage, vomiting, diarrhea, cough

There is no effective vaccine at this
time.
Ebola Case Study 1995

April 5 - Zaire laboratory worker
 fever and bloody diarrhea

May 17 - 93 cases - 92% fatality
most cases were in health care providers


June 25 - 296 cases
When institutional barrier precautions
were implemented by WHO/CDC - the
infection rate among health care
workers dramatically decreased.
Possible biotoxins







Botulinum
Clostridia
Ricin
Saxitoxin
Tetrodotoxin
Staphylococcal enterotoxin
Tricothecene mycotoxins
Botulinum toxins


Seven species (A-G)
Anaerobic spore forming bacterium
Canned foods
GI tract
Wounds

Aerosol of toxin
Lethal toxin
Botulinum toxins
Clostridum botulinum
Botulinum toxins

Signs and symptoms
Ptosis
Diplopia
Dysphagia
Dysphonia
Flaccid paralysis
Respiratory failure
Botulinum toxins

Diagnosis
No available rapid laboratory diagnosis
 Assay
exists… but is only good for confirmation
 Takes a while to return the results….
Suspect if numerous casualties develop
bulbar paralysis, muscle weakness, and
respiratory failure
Botulinum toxins

Treatment
Supportive care
 Intubation
 Ventilation
Trivalent antitoxin (A,B,E)
 Horse
serum
 Must be given as soon as possible
Heptavalent USAMRIID antitoxin
 Investigational
horse serum
Botulinum toxins

Prophylaxis
Toxoid (A,B, C, D, E)
 Investigational
product
 3x injections with yearly booster
 High risk of exposure
Botulinum toxins

Decontamination
Was with bleach or soap and water
Pressure cook all foods
Toxin does not go through skin
Botulinum

Outbreak control
Immediate release
 Rapidly
decontaminated
Late contamination
 Boil
for 10 minutes
Ok… Why haven’t we seen...

Unpredictable
Collateral damage
Moral qualms???


Personal safety
Severe response
Damage cause
Out of control
?? Deny responsibility
Why haven’t we seen..




Higher authority says no...
Present day tactics are successful
Lack of precedent
Can’t get credit for the...
Delivery Systems – Improv

The ‘experts’ have constantly pointed
out that biowarfare can’t be used by
“unsophisticated” folks.
You need a lot of training to effectively use
biowarfare
You need a lot of equipment to make
biowarfare agents effective
Aum Shin tried it and failed (before sarin).
Bioterrorism

Obviously this line of reasoning didn’t
stop the current terrorists from using
anthrax
Delivery
system
… crude, but
very effective
for
terrorism…
and not very
expensive
Delivery Systems - Improv

It depends on just what you want to
accomplish…
English with smallpox and blankets during
French & Indian War
Letter ‘biobombs’
Other improv devices
Terrorism is changing


Increased security about other means
Increase in spectacular and/or high
casualty events
NYC and Pentagon


Increase in state sponsorship
Increase in religious sponsorship
`Everybody who doesn’t worship my way
deserves to die!”
And biotechnology is
changing...




Dual use technology is burgeoning
Gene sequences are becoming public
knowledge
Increased availability of information
Private hire of former Soviet scientists
Foreign Outlook on the US is changing



The “last” superpower
Jealousy of our freedom and lifestyle
The great Satan
Imposing ‘Our’ view and religions
A fickle bully
A place where
TV makes the decisions and is constantly
present
 The soft and decadent live in the US

The Changing Role of the US
Decrease in international stability leads to
increase use of US forces as police
Retribution / Retaliation cycle of current
‘wars’ in Afghanistan and Iraq
In Topoff II, we trained at 2
major places…
Topoff II

Pre-arranged
Date and location known
Compressed time format



Limited scope
Limited # of patients
No significant disruption of normal
medical services
What if every yellow spot were a
biological release ....
Please remember

Sophisticated planning of simultaneous
attacks on multiple targets
Detailed knowledge of system weaknesses
Understand and employ media to best
effect


Use of unusual “tools” to achieve high
casualties and shock effect
Self-sacrifice (martyr) can be expected
Who?


Undefined constituency and/or vague
objectives
Prior pattern of high casualty incidents
Sophisticated planning of simultaneous
attacks on multiple targets



Demonstration of sophistication
Willing to take risks
?? State sponsorship
OBL?
Who else


OBL or a successor?
Palestine
PLF-GC
Abu Nidal


Saddam or a successor ?
United States Aryan Nations
Neo-Nazi groups?



Japanese Red Army
Hizbollah
Sikh
Who will reap the
whirlwind???