BIOTERRORISM Dr. E. McNamara Public Health Lab., SWAHB, 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 people 40-50 facilities 50 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 test • 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%
Anthraxcontd. • 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
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
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
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.
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
