Transcript Bioterrorism and Weapons of Mass Destruction

Bioterrorism and Weapons of
Mass Destruction
John van der Steeg MD
In peace the sons bury their
fathers, but in war the fathers
bury their sons.
Croesus
Naturally the common people don't want war; neither
in Russia, nor in England, nor in America, nor in
Germany. That is understood. But after all, it is the
leaders of the country who determine policy, and it is
always a simple matter to drag the people along,
whether it is a democracy, or a fascist dictatorship, or
a parliament, or a communist dictatorship. Voice or no
voice, the people can always be brought to the
bidding of the leaders. That is easy. All you have to do
is to tell them they are being attacked, and denounce
the pacifists for lack of patriotism and exposing the
country to danger. It works the same in any country.
Categories of Weapons of Mass
Destruction
B
N
I
C
E
Biological
Nuclear
incendiary
Chemical
Explosives
History of Biological Weapons
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184 BC Hannibal ordered pots of venomous snakes thrown of decks of enemy
ships.
Tartar army catapulted bodies of plague victims into the city of Caffa in 1346
British army provided blankets to Delaware Indians in 1763…after they were
used by smallpox patients.
During WW II Japanese utilized Yersinia pestis containing rice and fleas spread
by airplane against Chinese and Russian troops.
America had prepared 5000 anthrax bombs at Camp Detrick, Maryland in
1942. (none used during the war)
Aum Shinrikyo religious cult contaminated a Tokyo subway with Sarin gas in
1995. (5500 hospital visits and 5 deaths)
Aum Shinrikyo make several unsuccessful attempts to release anthrax or
botulinum toxin to other areas around Tokyo
Anthrax laden envelopes sent via US mail in 2001, resulting in 11 cases of
inhalational anthrax (including 5 deaths) and 12 cases of cutaneous anthrax.
History of Biological Weapons
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Many countries agree to stop research and development of Biological weapons
in 1972.
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Many smaller countries continue to develop biological warfare programs.
A little perspective
 200lbs of aerosolized anthrax spread over a
city the size of Omaha on a clear breezy
night could kill as many as 2.5 Million
people.
 200lbs of Botulinum toxin could kill as many
as 40,000 people in an area the size of the
Mall of America.
 200lbs of VX gas sprayed over Disney land
could kill 12500 people.
Critical Biological Agents
 The CDC published a list of Critical
Biological Agents in 2000.
 List is divided into categories A, B, and C.
 Category A agents are of the highest priority
and Category C are of a lesser priority.
Category A
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Pose a risk to national security.
Spread easily by person to person contact.
Cause a high death rate.
Require special action for public health
preparedness.
– Bacillus anthracis (Anthrax) would be a
category A biological agent.
Category A Threats
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Anthrax
Botulism
Plague
Small pox
Tularemia
Viral hemorrhagic fevers
Category B
 Fairly easy to disseminate.
 Cause moderate illness and have a lower
death rate than Category A agents.
 Require an enhanced diagnostic capacity
and disease surveillance.
– Coxiella burnetii (Q fever) is an example of a
Category B biological agent.
Category C
 Include new pathogens which could be
engineered for mass dissemination in the
future.
 Widely available.
 Easy to produce and dispense.
 Potential to cause high rate of death and
sickness.
– Nipah virus is an example of an Category C
biological agent
Dissemination
 Biologic agents designed to enter the body
one of three ways.
 Inhalation
– All category A agents may be aerosolized
 Ingestion
– Contaminated food and water
 Skin contact
Aerosolization
 Aerosols may be delivered in wet or dry
forms.
 May be used in closed or open spaces
 Crop dusting planes, ventilation systems in
buildings, fine powder that are easily
aerosolized when disrupted
Anthrax
 Not just the name of a speed metal band
 Discovered in 1877, may have been cause
of plague described in Egypt 4000yrs. Ago.
 Also known as wool sorters of black bane dz
 Weaponized in 1950’s & 1960’s in the US
 70 Russians died in 1979 after aerosol
release by military facility in Svedlovsk
 Weaponized by Iran in 1995
Anthrax
 Caused by spore forming bacterium B.
anthracis.
 Symptoms occur approximately 7 days post
exposure.
 Most common form is cutaneous anthrax
 Symptoms of inhalational anthrax initially
mimic common cold and progress rapidly to
resp. distress and sepsis.
Anthrax
 Direct person to person spread does not occur.
 Fatality Rate
– Cutaneous :untreated 5-20%, treated 1%
– Inhalational :untreated 100%, treated >80% if >48hrs
after symptom onset
 Infective dose 2500-80,000 spores by inhalation
 Spore viability >40yrs in soil and resistant to sun
light, heat and disinfectants
Anthrax
Treatment
 Ciprofloxacin 400mg iv q 12 hrs OR
 Doxycycline 100mg iv q12 hrs AND
– One or two additional antimicrobials i.e.
Rifampin, vancomycin, penicillin, ampicillin,
clindamycin, clarithromycin, chloramphenicol
Cutaneous Anthrax
Inhalational Anthrax
Botulism
Botulism
Botulism
 Researched by Iraq in 1991
 Weaponized & deployed in 100 munitions in
1995 by Iraq
 Nerve toxin produced by Clostridium
botulinum which produces a descending
paralysis.
 The most potent and lethal substance
known to man
Botulism
 Gram + anaerobic bacillus which forms spores
 Block presynaptic ACh release
 Infective dose 0.001mcg/kg, lethal dose .09.15mcg/kg IV or .7 mcg IM
 Pt’s are alert, oriented and afebrile
 Pt can require vent. Support for 2-3 MONTHS due
to resp. failure
– Occurs in 20 – 60 % of cases
Botulism
 Signs and symptoms can include nausea,
dry mouth, blurred vision, dysphagia,
fatigue, and dyspnea which may begin
several hours to days after the exposure
Botulism
Treatment
 Not spread from person to person
 If diagnosed early food and wound botulism
may be treated with antitoxin
 Recovery may take several weeks.
Plague
 Used as a weapon in the 14th century
(Infected corpses catapulted into enemy
strongholds)
 One of the greatest engines of
socioeconomic change
 Potential agent in 1950’s & 1960’s by USA
 Investigated by Japan in WWII (unit 731)
Plague
Plague
 Caused by Yersinia pestis, a gram negative
bacteria found in rodents and their fleas.
 Bacteria may be grown in large amounts
and aerosolized.
 Aerosolization allows for pneumonic form of
disease with potential for secondary
contamination. (resp. droplets are infectious
until pt gets therapy for 72 hrs)
 Infective dose <100 organisms
Plague
 Aerosol of bacillus viable for 1 hr at
distances of 10 km
 Morality
– Untreated bubonic plague: 50 – 60 %
– Untreated pneumonic plague or septicemia:
100%
– Treated pneumonic plague (<24hrs) 10 – 20 %
Plague
 Pneumonic plague
– incubation in 2 – 4 days
– Rapid onset
– High fevers, chills, hemoptysis, bloody sputum,
dyspnea, stridor, cyanosis
– Death from resp. failure, circulatory collapse
and bleeding diathesis
Plague
Treatment
 Preferred choices
– Streptomycin 30mg/kg div bid IM x 10d
– Gentamycin 5mg/kg IM or IV QD x 10d
 Vaccine: effective against bubonic plague
not against aerosol exposure
– Not approved for peds < 18 y/o
 PEP: doxycycline 100 mg po bid x 7d OR
– Ciprofloxacin 500 mg po bid x 7d
Ricin
Ricin
 Significant due to the wide availability of; 1
million tons of castor beans processed
annually in production of castor oil.
 Used in assassination of Bulgarian exile
Georgi Markov in London in 1978.
Ricin
 Ricin is part of the waste “mash” produced
when castor oil is made.
 May be produced in the form of a powder,
mist, or a pellet or it can be dissolved in
water or a weak acid.
 Depending on route of exposure, inhalation
vs ingestion, it can take as little as 500 mcg
to kill a person. (about the size of the head
of a pin)
Ricin
respiratory exposure
 Results in pulmonary toxicity with sever
resp. symptoms within 8 hrs.
 Followed by respiratory failure in 36 – 72
hrs. (marked by nonspecific findings such as
weakness, fever, vomiting, cough,
hypoxemia, hypothermia, and hypotension)
Ricin
gastrointestinal exposure
 Rapid onset of gastrointestinal symptoms
such as nausea, vomiting, abdominal
cramps, and severe diarrhea.
 Followed by vascular collapse and death.
Ricin
Treatment
 No antidote, vaccine or prophylactic
antitoxin available
 Treatment aimed at avoiding exposure and
eliminating toxin from the body as quickly as
possible.
Smallpox
Smallpox
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Considered by Japan in WWII
Global eradication program began in 1967
Declared eradicated in May 8, 1980
In 1996 WHO recommends all stockpiles be
eradicated by 1999
 Still exists in government labs of US and
Russia
Smallpox
 Variola virus which causes disease is very
stable
 Infectious dose is very small (10-100
organisms)
 Virus spread from person to person via resp.
droplets. (w/in 3 meters), their bedding or
clothing
 Incubation 7 – 19 days
Smallpox
 Signs and symptoms include high fever,
fatigue, head and back aches.
 Followed w/in 2 – 3 days by smallpox rash
and skin lesions.
 Mortality:
– 3% vaccinated
– 30% if unvaccinated
– 50% if develop secondary bact. Pneumonia
Smallpox
 At this time the government does not
recommend prophylactic vaccination of
healthcare workers or the general public
Smallpox
Treatment
 No proven treatment of smallpox.
 Patients affected with smallpox require
supportive care and quarantine.
Tularemia
Tularemia
Tularemia
 First found in Tulare County, California
 Found in Japan in 1800’s and Russia in
1926
 Caused by Francisella tularensis, a gram
negative bacterium found in animals,
especially in rodents, rabbits and hares.
 Common in people who skin rabbits,
rodents.
Tularemia
 Highly infectious disease and some strains
are resistant to antibiotics.
 Bacterium may be delivered by aerosol and
infection by inhalation or from skin, mucus
membrane, or gastrointestinal being
exposed.
 Transmission of the disease from person to
DOES NOT occur
Tularemia
 Pulmonary form:
– Most likely bioterrorism form
– Aerosol exposure
– Presents with fever, chills, headache, weight
loss, non productive cough
– Pneumonia in 30 – 80%
Tularemia
 Inhalation
– Sudden febrile illness
– Pharyngitis, bronchiolitis, pneumonitis, pleuritis
– Hilar lymphadenitis and/or sepsis
Tularemia
Treatment
 Streptomycin 1g IM bid x 10 D until afebrile
for 5 – 7 days OR
 Gentamycin 5mg/kg/d IM or IV QD x 10d
OR
 Cipro 400 mg IV BID OR
 Doxycycline 100 mg IV BID for 14d
Tularemia
Treatment
 PEP
– Cipro 500 mg po BID for 14 d OR
– Doxycycline 100 mg po BID for 14 d
Viral Hemorrhagic Fevers
(VHF)
Viral Hemorrhagic Fevers
(VHF)
 VHF group of illnesses caused by a distinct
family of viruses which include arenaviruses,
filoviruses, bunyaviruses, and flavaviruses.
 Most are highly infectious if spread by
aerosolization, some can cause infection
just by touching corpse at burial!
 Cause multisystem syndrome characterized
by hemorrhagic disease.
Viral Hemorrhagic Fevers
(VHF)
 Signs and symptoms
– Fever, fatigue, dizziness, muscle aches, loss of
strength, exhaustion, bleeding from mucous
membranes, internal organs, or from mouth,
eyes, or ears.
– Shock, renal failure, CNS dysfunction, coma,
and seizures may develop as well
Viral Hemorrhagic Fevers
(VHF)
Treatment
 Supportive
 quarantine
Nuclear and Radiological Threats
Nuclear and Radiological Threats
 Most likely scenario involving terrorist use of
radioactive material would involve use of a
Radiation Dispersion Device (RDD) also
known as a Dirty bomb or Dirty nuke.
 Require little technical knowledge to build
and deploy and do not require relatively
difficult to obtain weapons-grade plutonium
or uranium.
Nuclear and Radiological Threats
 Main type of RDD combines an explosive with
radioactive material.
 Extent of contamination would depend on a
number of factors such as size of the explosive,
amount and type of radioactive material used and
weather conditions.
 Detonation of an RDD releases radioactive fallout
which could cause radiation sickness, severe
burns, and long term cancer fatalities.
Nuclear and Radiological Threats
 In most cases the conventional explosive
will cause more deaths than the exposure to
the radioactive material.
Nuclear and Radiological Threats
 Principles of time, distance, and shielding
should be used for personal protection and
the protection of others
– Limit time at scene
– Increase distance from scene
– Shield self with appropriate personal protective
equipment, geography, or structural materials
whenever possible.
Nuclear and Radiological Threats
 Rad (radiation absorbed dose):
– Special unit of absorbed dose
 Rem (roetgen equivalent man):
– Biologic effect of radiation
– Unit of radiation dose equivalent
– Equal to absorbed dose in rads x relative
biological effectiveness of radiation in question
Nuclear and Radiological Threats
 Exposure levels
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Sleeping next to a human 0.1 mR
Flying in an aircraft 0.5 mR
3 mile island accident 1.5 mR
Nuclear weapon fallout 4.5 mR
Single Cxr 12 -17 mR
Cosmic rays & terrestrial sources 25 mR/yr
Radon 200 mR/yr
Smoking 280 mR/pack yr
Cancer Rx 5000R
Nuclear and Radiological Threats
Symptoms by Dose
(whole body dose in rem)
 5 – 100 asymptomatic-decr leuks/plat,
chromosomal aberrations
 100 – 200 n/v, anorexia, decr lympocytes w/i 48
hrs
 200 – 400 n/v for 2 – 4 days, skin erythema,
epilation
 400 – 600 n/v/d, 50% mortality w/i 30d,
 600 – 1000 acute radiation syndrome, n/v/d, GI
hemorrhage, incr. mortality w/i 14 d
 >1000 rapid onset GI symptoms, cns, cvs
complications, 100% mortality w/i 72 hrs
Nuclear and Radiological Threats
Exposure risks
 1 R over a few mins: incr risk of CA btwn 1
in 2000 and 1 in 100,000
 10 R: incr. risk of genetic abn. btwn 1 in 300
to 1 in 20,000; can cause prenatal death
 15 R: decrease in sperm count
Nuclear and Radiological Threats
Treatment
 No symptoms 6hr post exposure: exposure < 50
rems
 Symptoms 2 – 6 hrs post exposure: exposure 200
rems
 Symptoms <2 hrs: exposure > 400 rems, acute
radiation syndrome
 Follows abc’s stabilize pt, Potassium iodide may
protect thyroid
 Containment and monitoring of radioactive fallout,
evacuation, and decontamination.
Incendiary threats
 Range of device from the simple molotov
cocktail to larger more sophisticated devices
 The main use in terrorism is to generate
panic (weapon of mass disruption)
 Primary concerns include:
– Possible large number of injured victims and
fatality
– Overwhelming of local resources
– Public fear
Incendiary threats
Management
 Dependent on nature of attack
 First responders should not approach until
scene is safe.
 High probability of second device designed
to injure/kill emergency response personnel.
 Biological, chemical or nuclear materials
may have been used in the explosion.
Chemical Threats
Chemical Threats
Chemical Threats
 Developed in pre WWII Germany
 US stockpiles contain nerve agents Sarin
(GB) and VX
 Matsumato GB attack in 1994
 Tokyo subway GB attack in 1995
Chemical Threats
 Most toxic and rapidly acting of the known
warfare chemical agents
 Nerve agents work similarly to
organophosphates in terms of how they
work and what kind of harmful effects they
cause. (inhibit effect of acetylcholinesterase,
leads to cholinergic overdrive)
Chemical Threats
 Sarin (BG) clear, colorless, and tasteless
w/o odor; can evaporate into a vapor rapidly
and mixes easily with water.
 Anyway you can contact this stuff, it can kill
you.
 Symptoms start w/in min. to hours dep on
dose: headache, salivation, chest pain,
abdominal cramps, fasiculations, sz, resp.
failure and death
Chemical Threats
 Soman (GD) and Tabun (GA)
 Similar to Sarin except GD has odor similar
to Vicks vapor rub or a rotting fruit odor.
 GA has a faint fruity odor.
 Effects similar to Sarin
Chemical Threats
 VX thick amber colored odorless liquid.
 Most potent of all nerve agents
– Considered much more toxic than other agents
when absorbed thru the skin and somewhat
more toxic when inhaled than the other agents
 Symptoms appear w/i seconds after to
exposure to vapor and w/i min. to hrs after
exposure to the liquid form
Chemical Threats
Treatment
 Rapid decontamination, clothing can release
agent for about 30 min. after exposure
 Atropine and pralidoxime chloride are
antidotes. (available in auto injector kits ie.
Mark I)
 Large and repeated doses of these drugs
may be required
Chemical Threats
 Lethal dermal dose for 70 kg adult
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Sarin 1.7 g
Tabun 1 g
Soman 100 mg
VX 1 mg
 Persistence in environment
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Sarin 5 d
Tabun 1 – 2 d
Soman 1 – 2 d
VX 6d
Chemical Threats
(poisonous gases)
 Popular weapons in WWI
 Produced in large quantities worldwide for
use by the industrial sector
Chemical Threats
(poisonous gases)
 Chlorine gas- yellow green gas, odor of
pineapple and pepper.
 Shipped as a liquid under pressure, quickly
aerosolizes when released
 Exposure thru skin, inhalation, or eye
contact
 May also be released in water as well
Chemical Threats
(poisonous gases)
 Exposure:
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1 – 3 ppm: mild mucous memb. Irritation after 1 hr
5 – 15 ppm: mod. Irritation of upper resp. tract
30 ppm: immediate chest pain, vomiting and coughing
40 – 60 ppm: toxic pneumonitis & pulmonary edema
430 ppm: lethal after 30 min.
1000 ppm: fatal w/i a few mins.
Chemical Threats
(poisonous gases)
 Phosgene (CG)
– Gray/white cloud and smells of freshly mown
hay
– Shipped as a liquid under pressure but changes
to vapor when released
– Stays close to the ground and spreads rapidly
– Can be mixed with water as well
Chemical Threats
(poisonous gases)
 Both chlorine and phosgene gas produce
similar symptoms:
– Chest pain
– Burning sensation in nose, eyes, or throat
– GI distress, dermal burns
– Sob/dyspnea, pulmonary edema
– Phosgene also causes hypotension and heart
failure
Chemical Threats
(poisonous gases)
 Treatment
– No specific treatment
– Remove from exposure
– Do not induce vomiting
– O2 and bronchodilators for bronchospasm
– Steroids of no proven benefit
– Treat pulm. Edema with cpap or peep
Explosive Threats
classification
 Unconventional: conventional object used in
an unconventional way…think 9/11
 Vehicle bomb
 Pipe bomb
 Satchel charge: old military term for
explosives carried in a canvas satchel, now
any backpack/daypack bomb
 Package or letter bomb
Explosive Threats
 Same warnings from incendiary bombs
apply
Hermann Goering