Transcript BNICE 101 - Health Sciences Center for Knowledge Management

An Introduction to the Threat
of Bioterrorism
What Every Health Care Provider Should Know
The Ohio Center of Excellence for
Bioterrorism Preparedness and Response
Bioterrorism Training and Curriculum Development Program
PL 107-188, Section 105; 1-T01-HP-00091-01
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An Introduction to the Bioterrorist Threat
What Every Health Care Provider Should Know
Purposes of Presentation
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Overview of the Threat
Bioterrorism - BNICE 101
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Biological - Anthrax, Smallpox, Botulism
Nuclear - Dirty Bomb
Incendiary and Explosion
Chemical - Sarin
Being prepared
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Bioterrorism
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History of Bioterrorism
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The Assyrians
• Poisoned enemy wells
with rye ergot
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Middle Ages 1300s
• Plague victims
catapulted into Kafka
Sixth Century B.C.
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History of Bioterrorism
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French and Indian Wars
• British forces
distribute smallpoxladen blankets to
native American
Indians loyal to the
French
1754
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History of Bioterrorism
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Rajneeshee cult
Contaminates salad bars in
an Oregon town with
Salmonella typhimurium
More than 750 people
become seriously ill
1984
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National Security Environment
• Nation-State Adversaries
• Focus on Communism
• Threat of Global Nuclear War
• Dangerous, but relatively predictable
• Forward Defense
• Short of global war, U.S. homeland
perceived as secure from any major
threat
Cold-War Era
1989
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11 September 2001
The Attack on the US
Source: www.thaibase.com/news/wtc/images
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National Security Environment
• Fewer Nation-State Adversaries
• No “peer competitor” - U.S. is only
remaining “superpower”
• Trans-national extremist groups
• Development and proliferation of “dual
use technologies” … WMD (“BNICE”)
• Increase use of tactical terrorism
• Homeland is non-secure and at risk
Cold-War Era
1989
9/11/01
War on Terrorism Era
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Threat Trends
FBI MOST WANTED FUGITIVE
Nation States
Iran
Iraq
North Korea
Trans-National
Groups
Al Qaeda
Extremist/Radical
Organizations
Aliases: Usama Bin Muhammad Bin Ladin,
Shaykh Usama Bin Ladin, The Prince,
The Emir, Abu Abdallah, Mujahid Shaykh, Hajj, The Director
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Threat Trends
B
Cyber
N
E
I
C
Weapons of
Mass Destruction
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The greatest threat to the United States and its citizens
in the first decade of the 21st century will not come
from a military confrontation. Rather, it will come from
an attack within our borders from a single individual or
group that has access to weapons of mass destruction,
including large conventional explosives and nuclear,
chemical or biological weapons.
COL Ed Eitzen, Senior Medical Advisor to the US Assistant Secretary for Public
Health Emergency Preparedness.
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Terror Is a Weapon Itself
“The real force multiplier in
bioterrorism is the panic,
misinformation and paranoia
associated with it.”
Sidell FR, Patrick WC, Dashiell TR.
Jane’s Chem-Bio Handbook.
Alexandria, VA, Jane’s Information Group, 1998.
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Psychological Reactions to
Disaster Events
Disbelief
Outcry
Heroism
Rage
Anger
Blame
Anxiety
Intrusions
Reconstructing A
New Life
Reclaiming
Life
Coming to
Terms with
New Realities
Shock Denial
Disorientation
0 to 7 Days
Isolation
Loneliness
Depression
Sadness
Despair Guilt
TIME
2 to 5 Years
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Terrorism forces us to make a choice.
We can be afraid. Or we can be ready.
Tom Ridge, U.S. Department of Homeland Security, www.ready.gov
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Defense Against Bioterrorism
• Health care professionals
are the 1st line of defense
• Education is key
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The Ohio Center of Excellence for Bioterrorism
Preparedness and Response
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Rationale
• A need exists to train healthcare
professional students to be
prepared to respond to terrorist
acts and other public health
emergencies
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What Every Health Care
Provider Should Know
1.
2.
3.
4.
Early recognition
Early management
Whom to notify
How to work together as a team
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What do we mean by “prepared”?
…the
“right place” on the continuum
between mindless complacency and
all consuming paranoia
All Consuming
Paranoia
Mindless
Complacency
Dr. Irwin Redlener, Associate Dean & Director
The National Center for Disaster Preparedness
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BNICE 101
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Biological
Nuclear
Incendiary/fire
Chemical
Explosive
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Bioterrorism Defined
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Unlawful release of biologic agents or toxins
Intent
• to intimidate or coerce a government or
civilian population to further political or
social objectives
Targets - humans, animals, plants
First recognized by the astute healthcare
provider in the community
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Biological Agents as WMD
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Relatively easy to obtain
Technology easily concealed
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Characteristics of a “Good”
Biological Agent
• Pathogenic at low doses
• High rate of morbidity & mortality
• Highly infectious
• Difficult to diagnose and treat
• Insidious at onset
• Easy, fast, and cheap to produce
• Concentrated for distribution
• Adaptable to weapons systems
• Name causes fear and panic
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Popular Interest in Bioterrorism
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Be Informed - Biological Threat
http://www.ready.gov
Be Informed - Biological Threat
http://www.ready.gov
Be Informed - Biological Threat
http://www.ready.gov
Biological Attack
Transmission
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Aerosol
Gastrointestinal
Transcutaneous
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Biological Attack - Aerosol
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Effectively delivered as an
aerosol
Protection
• Protective mask
• 2 to 3 layers of cotton
• Several layers of tissue or
paper towels
Explosives are inefficient
delivery systems
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Biological Attack
Contamination of Food
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Heat destroys
most pathogens
and toxins
Raw food
Added after food
is prepared
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Biological Attack
Contamination of Water
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Water purification methods
inactivate most pathogens and
toxins
Successful attack on water
supply would have to occur
after treatment
Dilution reduces concentration
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Biological Attack
Contamination of Milk
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Botulinum toxin
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Category A Biological Agents
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High-priority agents
Risk to national security
Characteristics
• Easily disseminated or
transmitted from person to
person
• High mortality rates
• Major public health impact
• Public panic and social
disruption
• Require special action for
public health preparedness
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Category A Biological Agents
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Anthrax
• Bacillus anthracis
Smallpox
• variola major
Botulism
• Clostridium botulinum
toxin
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Plague
• Yersinia pestis
Tularemia
• Francisella tularensis
Viral hemorrhagic
fevers
• filoviruses [e.g.,
Ebola, Marburg]
• arenaviruses [e.g.,
Lassa, Machupo])
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Acute infectious disease
Spore-forming
bacterium Bacillus
anthracis
Most commonly occurs
in wild and domestic
lower vertebrates
Can also occur in
humans
• exposed to infected
animals or to tissue
from infected animals
• anthrax spores used
as a bioterrorist
weapon
FAQ about Anthrax http://www.bt.cdc.gov/agent/anthrax/faq/index.asp
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Three forms
• cutaneous (skin)
• inhalation
• gastrointestinal
NOT contagious
Can NOT be transmitted from
person to person
Household contacts do NOT
need antibiotics unless also
exposed to the same source
of anthrax
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Weaponized anthrax spores
1996 - Iraq
2001 - spores intentionally distributed
through postal system
• 22 cases of anthrax, including 5 deaths
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Cutaneous Anthrax
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Develops when
bacterium enters a skin
cut or abrasion
Handling contaminated
wool, hides, leather or
hair products (especially
goat hair) of infected
animal
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Cutaneous Anthrax
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Raised itchy bump like an
insect bite
In 1-2 days develops into a
vesicle and then a painless
ulcer 1-3 cm in diameter
Black necrotic center
Local lymph glands may
swell
20% will die if not treated
with antibiotics
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Inhalation Anthrax
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Initial symptoms may
resemble a common cold
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sore throat
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mild fever
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muscle aches
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malaise
Symptoms progress to
severe breathing
problems and shock
Usually fatal
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Inhalation Anthrax
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Humans must inhale anthrax
spores to become infected
Inhaled anthrax must be 1 to 5
microns to reach alveoli (air sacs)
Size comparisons
microns
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Dot ( . )
600
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Anthrax
5
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Pollen
10 - 1,000
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Human hair 40 - 300
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Inhalation Anthrax
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Similar to common cold
“Flu-like” symptoms
• Fever, muscle aches,
cough
No runny nose (rhinorrhea)
with Anthrax infection
Mediastinal widening with
inhalational anthrax.
JAMA 1999:281:1735-45
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Gastrointestinal
Anthrax
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Consume contaminated meat
Acute inflammation
Initial signs
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nausea, loss of appetite,
vomiting, fever
Later signs
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abdominal pain, vomiting
of blood, severe diarrhea
Death in 25% to 60%
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Anthrax Treatment
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Exposure - 60 days of Rx
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Amoxicillin
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Doxycycline
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Ciprofloxacin
Infection - IV
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Ciprofloxacin
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Doxycycline
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Plus others…
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Anthrax Immunization
Who Should Receive It?
Advisory Committee on Immunization Practices
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Work directly with the organism
in the lab
Work with imported animal
hides or furs in areas where
standards are insufficient
Handle potentially infected
animal products in highincidence areas
Military personnel deployed to
areas at high risk for exposure
Senior Chief Payhurst administers an
anthrax vaccination to a sailor aboard
the USS John C. Stennis.
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Anthrax and Mail Safety
Handling of Suspicious Packages or Envelopes
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Do not shake or empty the
contents
Do not carry it, show it to others
or allow others to examine it
Put it down on a stable surface
Do not sniff, touch, taste, or
look closely at it or at any
contents which may have spilled
Alert others in the area
Leave the area, close any doors,
and take actions to prevent
others from entering the area
If possible, shut off the
ventilation system.
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Anthrax and Mail Safety
Handling of Suspicious Packages or Envelopes
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WASH hands with soap and water
Seek additional instructions
Notify the local health department
immediately
Create a list of persons who
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were in the room or area when it
was opened
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may have handled it
Give this list to both the local public
health authorities and law
enforcement officials
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Smallpox (Variola major)
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DNA virus
Serious, contagious, and
sometimes fatal infectious disease
NO specific treatment
Only prevention is vaccination.
Name smallpox derived from Latin
word for “spotted”
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refers to raised bumps that
appear on face and body
Humans are only known reservoir
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Not known to be spread by
insects or animals
Electron micrograph of Variola Major
Courtesy of CDC Public Health Image Library
Dr. Fred Murphy, Sylvia Whitfield
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Smallpox Eradication
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1949 - last natural outbreak of
smallpox in the U.S.
1972 - routine smallpox vaccinations
for children in the U.S. no longer
required
1980 - “wiped out” worldwide
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No cases of naturally occurring
smallpox have happened since
2004 - smallpox virus kept in two
approved labs in the U.S. and Russia
But… credible concern exists that the
virus was made into a weapon by
some countries and that terrorists
may have it
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The Spread of Smallpox
1. Prolonged face-to-face contact
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Most common method of spread in the past
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Exposure does not necessarily result in
infection
2. Direct contact with infected..
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bodily fluids
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object such as bedding or clothing
3. Aerosol (through the air)
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Rare in the past - enclosed spaces
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Suspected method for terrorists
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Virus is heat- & light-sensitive
• 90% of virus dies within 24 hours of
exposure
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Smallpox Incubation
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Incubation period
• Range 7-17 days
• Average 12-14 days
No symptoms
Infected person NOT contagious
Electron Microscope, Variola
Major
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Smallpox Infection
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Prodrome period 2-4 days
• High fever, fatigue, head and body aches
Then, small red spots on tongue and
mouth
• Sores break open and spread large
amounts of virus into mouth and throat
• At this time, the person becomes most
contagious
Facial rash -> extremities -> trunk
• “centrifugal” rash
• Involves palms and soles
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The Smallpox Rash
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4th-5th day of rash
• pustules develop
“Umbilicated” rash
• Major distinguishing
characteristic
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The Smallpox Rash
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2nd week of rash - scabs develop
3rd week of rash - scabs fall off
• Pitted scars develop
• Person is contagious until ALL
scabs have fallen off
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CDC Guide - Smallpox
Poster available at
http://www.cdc.gov/nip/smallpox/Providers.htm
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Smallpox Vaccination
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Smallpox Vaccination
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100% effective if given before exposure
Within 3 days of exposure will prevent or
significantly lessen severity of smallpox
symptoms in vast majority
4 to 7 days after exposure likely offers
some protection from disease or may
modify the severity of disease
Nigeria 1969
What you need to know about small pox vaccine:
http://www.bt.cdc.gov/agent/smallpox/vaccination/vaccine.asp
Bifurcated needle
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Botulism (Clostridium botulinum)
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Spore-forming, anaerobic grampositive rod
Produces botulinum toxin
• Muscle-paralyzing
• Most lethal substance known
Foodborne
• Illness occurs 6-36 hours of
ingestion of toxin
• NO human to human spread
Grams stain of C. botulinum
Courtesy of CDC
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Botulism
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Symptoms
• Visual disturbance, slurred speech, dry mouth,
difficulty swallowing
• Muscle weakness descends through the body
• Respiratory paralysis
Treatment
• Supportive care
• Antitoxin
• 8% mortality rate
• Recovery weeks to months
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Tularemia
Francisella tularensis
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Gram-negative bacteria
Found in rodents
One of the most
infectious agents known
• Few organisms can
cause disease
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Tularemia
Francisella tularensis
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Non-specific, “flu-like” symptoms
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Fever, chills
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Headache
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Muscle aches
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Non-productive cough
Deadly if not treated!
Diagnosed by index of suspicion
and confirmed by laboratory
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Whom to Contact for Suspected
Biological Threat?
Your Local Health Department!
BNICE - The Nuclear Threat
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BNICE - Dirty Bomb
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Old transport container. Photo
from: Center for
Nonproliferation Studies
Radiological dispersion device
Conventional explosives with
radioactive materials
Purposes
• Fear, panic
• Disruptive, not necessarily
destructive
• Make buildings, land, food
and water unusable for long
periods of time
http://www.ready.gov/radiation.html
http://www.bt.cdc.gov/radiation/index.asp
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BNICE - Nuclear Threat
Shielding
Distance
Time
http://www.ready.gov
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BNICE
Incendiary/Fire & Explosive Threat
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BNICE
Incendiary/Fire & Explosive Threat
“I say goodbye with tears in my
eyes and heart, and I ask God
for victory. Father, don't blame
yourself. I am happy to be here.
Mother, don't be weak. Raise
your children to be martyrs for
the cause.”
Letter found in abandon shed in Fallujah from suicide bomber
Source: Washington Post, April 2004
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BNICE
Incendiary/Fire & Explosive Threat
http://www.ready.gov
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BNICE
Incendiary/Fire & Explosive Threat
http://www.ready.gov
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BNICE
Incendiary/Fire & Explosive Threat
http://www.ready.gov
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BNICE - The Chemical Threat
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BNICE - The Chemical Threat
Sarin (GB)
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1938 - pesticide
Nerve agent
• Toxic
• Rapidly acting
More potent than organophosphate
pesticides
Properties
• Clear, colorless, tasteless liquid
• No odor in pure form
• Evaporates into a gas
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BNICE - The Chemical Threat
Sarin (GB)
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Binds to acetylcholine esterase
• The body’s “off switch”
• Glands and muscles now
constantly stimulated
• Respiratory muscle fatigue
Routes of exposure
• Breathing contaminated air
• Eating contaminated food
• Drinking contaminated water
• Touching contaminated surfaces
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BNICE - The Chemical Threat
Sarin (GB)
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Symptoms within seconds of exposure
• Runny nose and watery eyes
• Drooling and excessive sweating
• Rapid breathing
• Diarrhea and increased urination
• Loss of consciousness, seizures
• Paralysis, respiratory failure -> death
Prognosis based on exposure
• Mild to moderate - complete recovery
• Severe - death
Agency for Toxic Substances and Disease Registry website:
http://www.atsdr.cdc.gov/tfactsd4.html
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BNICE - The Chemical Threat
http://www.ready.gov
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BNICE - The Chemical Threat
http://www.ready.gov
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Working Together as a Team
Public Health
Officials
Health Care
Providers
Incident
Commander
First Responders
Fire, Police, EMT
FBI
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Terrorism forces us to make a choice.
We can be afraid. Or we can be ready.
Tom Ridge, U.S. Department of Homeland Security, www.ready.gov
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Be Prepared
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Review your local Disaster/Bioterrorism Safety Plan
Review the Ohio Department of Health Disaster
Preparedness & Response Plan
• http://www.odh.state.oh.us/alerts/alertmain.asp
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Be Prepared
http://www.cdc.gov
http://www.ready.gov/
http://www.redcross.org/services/disaster/beprepared/hsas.html
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Summary
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Be prepared
Be alert
Manage initial casualties
Know whom to contact
Know your team role
Have ready references
The Ohio Center of Excellence for
Bioterrorism Preparedness and Response
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Thank You!
Questions?
The Ohio Center of
Excellence for
Bioterrorism
Preparedness and
Response
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