Transcript BIOTERRORISM Dr. E. McNamara Public Health Lab. HSE, Dublin. St. James’s Hospital.

BIOTERRORISM
Dr. E. McNamara
Public Health Lab. HSE, Dublin.
St. James’s Hospital.
‘9/11 – Changes’
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Move to high risk
Biological Threat, specialist public
arena
Newsworthy
Rare/eradicated infections
Low clinical experience
‘Autumn 2001 – USA’
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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’
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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
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Co-operation internationally
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WHO
CDC
EU
National preparedness Plans
Multidisciplinary
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Government
Admininstrative
Emergency services
Medical
Scientific
History – Biological Warfare
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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
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Germany WWI
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WWI-II
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sold anthrax infected horses
Many countries started biological programme
WWII – Not Used
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UK
USA
Canada
Germany
Japan
5 million anthrax ‘cattle-cakes’
Botulinum
Plague
Salmonella
POW/Chinese trials
Post WWII
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USA
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3400 people 1969, BTWC
Allegation
 Korean War
Cuba
Misinformation, FBI to Soviets
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Soviets
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1920 – 1969, BTWC signed
1975
Enlarged, Biopreparat
60,000 people
40-50 facilities
50 agents
Post WWII contd.
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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
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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
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Category A
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Category B
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Easily dessiminated
High mortality
Public panic
Require special preparedness
Moderately easy to dessiminate
Low mortality
Need enhanced Dx./surveillance
Category C
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Emerging pathogens
Anthrax, B. anthracis
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Zoonotic, spore forming rod
Soil reservoir, years
Affects large domestic and wild herbivoires
Worldwide
Humans
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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.
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Bioterrorist threat – inhalation spores
No person – person spread ! (cutaneous?)
Cutaneous
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Skin inoculation
Painless swelling
Papular – vescle – ulcer
Black eschar
Toxaemia
Mortality with Rx., < 1%.
GIT
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Ingest contaminated meat
Pain, diarrhoea, haematemesis, septicaemia
Mortality > 50%
Anthrax contd.
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Dx. (Confirm reference laboratory)
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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
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Category A
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Category B
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Easily dessiminated
High mortality
Public panic
Require special preparedness
Moderately easy to dessiminate
Low mortality
Need enhanced Dx./surveillance
Category C
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Emerging pathogens
Anthrax, B. anthracis
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Zoonotic, spore forming rod
Soil reservoir, years
Affects large domestic and wild herbivoires
Worldwide
Humans
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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.
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Bioterrorist threat – inhalation spores
No person – person spread ! (cutaneous?)
Cutaneous
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Skin inoculation
Painless swelling
Papular – vescle – ulcer
Black eschar
Toxaemia
Mortality with Rx., < 1%.
GIT
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Ingest contaminated meat
Pain, diarrhoea, haematemesis, septicaemia
Mortality > 50%
Anthrax contd.
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Dx. (Confirm reference laboratory)
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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
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Bioterrorist agent
Mortality 90%
Incubation 1 – 60 days
Initial Phase (hrs – days)
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Non-specific symptoms
Non-specific clincial signs + Dx. test
Recover / Progress to fulminant
Fulminant Phase
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Septicaemia / Toxaemia
Dyspnoea with CXR mediastenal widening
50% haemorrhagic menigitis and death
Mortality increased with short incubation
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Small Pox
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Human, DNA variola virus
2 Forms
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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.
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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.
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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
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Small Pox Vaccine
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Face – face contacts
HCW (core, prepardness)
Designated emergency personnel
Vaccine
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Live vaccinia virus (not variola)
Vaccine site, infectious until scab heals
Newer vaccine development
S/E
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Small Pox Vaccine contd.
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CI – atopic dermatitis, pregnant,
immunocompromised
S/E
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Fever headache, rigors, vastles
Generalised vaccinia (GV)
Eczema vaccinatum (EV)
Progressive vaccinia (PV)
Post vaccinial CNS (PVE)
Incident 1968
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Life threatening = 52 / million
Deaths = 1.5 / million
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Cl. Botulinum
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Botulinum neurotoxin – most potent
Contaminated food, canned
products
Wound botulism, contaminated soil,
IVDA
Bioterrorism agent
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Aerosolisation – inhalation
Contaminate food – ingestion
Large numbers with acute flaccid
paralysis
Cl. Botulinum contd.
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Incubation
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Foodborne
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V+D, diplopia, dysarthria, weakness
Ptosis, facial palsy, ↓gag Hypotonic
Inhalation
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2hrs – 8 days, Foodborne
1hr – 5 days, Aerosol
Dysplagia, nystagmins, ↓speech, ↓gait
Terminal
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Progressive muscular paralysis
Mortality 5% (with Rx.)
Cl. Botulinum contd.
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Differential Dx.
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Guillain-Barré
Myastheria gravis
Stoke
CNS despressants
Cl. Botulinum contd.
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Dx.:
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Rx.:
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Detect botulinum toxin
Culture
Antitoxin
Supportive
Infection Control – standard
precautions
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Plague
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Yersinia pestis – HG3
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Aerosol, flea vector, person-person
3 Forms
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GNCB, 02
Bubonic – 90%
Septicaemic – 10%
Pneumonic – 1%
Bioterrorist agent
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Aerosol – pneumonic
Fleas – bubonic, septicaemic
Bubonic Plague
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Incubation 1-8 days
Fever, rigors, headache
Buboes – painful lymph nodes
15% develop pneumonic plague
Mortality = 12%
Septicaemic Plague
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Primary, or secondary to bubonic
Rigors, abdominal pain, V+D
Purpura, DIC, necrosis
Mortality = 30%
Pneumonic Plague
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Highest bioterrorism risk
Primary or secondary from
haematogenous
Incubation 1-3 days
Pneumonic symptoms
Respiratory failure and shock
Mortality - ↓with rx. = 8%
Plague
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Dx.:
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Rx.:
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Gentamicin, Streptomycin IV
Ciprofloxacin, Doxycycline P.O.
Infection Control:
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Culture
Standard and droplet, single room, surgical mask
Contacts:
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Prophylaxis – Ciprofloxacin – 72 hrs.
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Tularaemia
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F. tularensis
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Ulceroglandular
Typhoidal
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Non-motile, aerobic, GNCB, zoonosis, rabbits,
deerfly
HG3
Worldwide
Low inoculum – 10 CFU
Mortality 35-60% (untreated)
Inhalation
Infection Control – standard (no personperson)
Rx. Gentamicin/Streptomycin – 10 days
Contacts : prophylaxis
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Tularaemia
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Tularaemia