Bioterrorism

Bioterrorism
Presentation lecture by:Amy C. Chavarria, RN, MSN, MBA, HCM, CCE

The Face of Bioterrorism
BIOTERRORISM
HISTORY OF BIOLOGICAL WARFARE

* 18th Century: Smallpox Blankets
* 20th Century:
o 1943: USA program launched
o 1953: Defensive program established
o 1969: Offensive program disbanded

BIOLOGICAL WARFARE AGREEMENTS

* 1925 Geneva Protocol
* 1972 Biological Weapons Convention
* 1975 Geneva Conventions Ratified

Bioterrorism: Who are 1st Responders?

* Primary Care Personnel
* Hospital ER Staff
* EMS Personnel
* Public Health Professionals
* Other Emergency Preparedness Personnel
* Laboratory Personnel
* Law Enforcement
* Firefighters

PUBLIC HEALTH

ISSUES

* Existing local, regional, and national surveillance systems
o Adequate to detect traditional agents
o Inadequate to detect potential biowarfare agents
* Specific training for health care professionals
o clinical personnel will be “first responders”
* Civilian biodefense plans are usually based on HAZMAT models
o Assumes responders enter a high exposure environment near the source
o Assumes site of exposure is separate from the health care facility
o Assumes no time pressure for decontamination
o Maximum protection is provided for a minimum number of workers / rescuers
* HAZMAT
o OSHA mandates use of PPE based on site hazard, but site hazards are more easily defined at the point of release
o Traditional HAZMAT products are expensive, take time to set up, and are inadequate for large numbers of patients
o Difficult to train and maintain proficiency in a civilian work force with high turnover

Key Problems

* Managing an outbreak
o The hard problem
* Investigating the attack if it is bioterrorism
o Does not require any special laws
o Demands effective public health infrastructure
* Preventing bioterrorism
o Laws on control of agents and personnel

Minimal Threat

* Limited and non-communicable
o Anthrax Letters
* Scary, but very small risk to a small number of people
* Gross Overreaction in Government Office Buildings
* Huge Costs dealing with copycats
* No special legal problems

Significant Threat, Not Destabilizing
* Broad and non-communicable
o Anthrax from a crop duster over a major city
* Could be managed with massive, immediate antibiotic administration and management of causalities
* Panic will quickly become the core problem

Significant Threat, Potentially Destabilizing
* Limited and communicable
o A few cases of smallpox in one place
* Demands fast action
* If it spreads it can undermine public order
* Probably controllable, but with significant vaccine related causalities

Imminent Threat of Governmental Destabilization

* Broad and communicable
o Multiple cases of smallpox, multiple locations
* Would demand complete shutdown on transportation
* Would quickly require military intervention
* Local vaccination plans are mostly unworkable

POTENTIAL BIOTERRORISM AGENTS

* Bacterial Agents
o Anthrax
o Brucellosis
o Cholera
o Plague, Pneumonic
o Tularemia
o Q Fever
Source: U.S. A.M.R.I.I.D.
* Viruses
o Smallpox
o VEE
o VHF-viral hemorrhagic fever
* Biological Toxins
o Botulinum
o Staph Entero-B
o Ricin
o T-2 Mycotoxins

CRITICAL BIOLOGICAL AGENTS
CATEGORY A

* High priority agents that pose a threat to national security because they:
o can be easily disseminated or transmitted person-to-person
o cause high mortality, with potential for major public health impact
o might cause panic and social disruption
o require special public health preparedness
* Variola major (smallpox)
* Bacillus anthracis (anthrax)
* Yersinia pestis (plague)
* Clostridium botulinum toxin (botulism)
* Francisella tularensis (tularemia)
* Filoviruses
o Ebola hemorrhagic fever
o Marburg hemorrhagic fever
* Arenaviruses
o Lassa (Lassa fever)
o Junin (Argentine hemorrhagic fever) and related viruses

CRITICAL BIOLOGICAL AGENTS CATEGORY B

* Second highest priority agents that include those that:
o are moderately easy to disseminate
o cause moderate morbidity and low mortality
o require specific enhancements of CDC’s diagnostic capacity and enhanced disease surveillance
* Coxiella burnetti (Q fever)
* Brucella species (brucellosis)
* Burkholderia mallei (glanders)
* Alphaviruses
o Venezuelan encephalomyelitis
o eastern / western equine encephalomyelitis
* Ricin toxin from Ricinus communis (castor bean)
* Epsilon toxin of Clostridium perfringens
* Staphylococcus enterotoxin B
* Subset of Category B agents that include pathogens that are food- or waterborne
* Salmonella species
* Shigella dysenteriae
* Escherichia coli O157:H7
* Vibrio cholerae
* Cryptosporidium parvum

CRITICAL BIOLOGICAL AGENTS CATEGORY C

* Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of:
o availability
o ease of production and dissemination
o potential for high morbidity and mortality and major health impact
* Preparedness for Category C agents requires ongoing research to improve detection, diagnosis, treatment, and prevention
* Nipah virus
* Hantaviruses
* Tickborne hemorrhagic fever viruses
* Tickborne encephalitis viruses
* Yellow fever
* Multidrug-resistant tuberculosis

ADVANTAGES OF BIOLOGICS AS WEAPONS

* Infectious via aerosol
* Organisms fairly stable in environment
* Susceptible civilian populations
* High morbidity and mortality
* Person-to-person transmission (smallpox, plague, VHF)
* Difficult to diagnose and/or treat
* Previous development for BW
* Easy to obtain
* Inexpensive to produce
* Potential for dissemination over large geographic area
* Creates panic
* Can overwhelm medical services
* Perpetrators escape easily

BIOTERRORISM: HOW REAL IS THE THREAT?

Hoax vs. Actual BT Event
ANTHRAX BIOTERRORISM
ISSUES

* Existing local, regional, and national surveillance systems
o Adequate to detect traditional agents
o Inadequate to detect potential biowarfare agents
* Specific training for health care professionals
o clinical personnel will be “first responders”
* Civilian biodefense plans are usually based on HAZMAT models
o Assumes responders enter a high exposure environment near the source
o Assumes site of exposure is separate from the health care facility
o Assumes no time pressure for decontamination
o Maximum protection is provided for a minimum number of workers / rescuers

Threats reported to FBI Source: FBI personal communication

CHEMICAL & BIOLOGICAL TERRORISM
SALMONELLOSIS CAUSED BY INTENTIONAL CONTAMINATION
CLINICAL STATUS OF PATIENTS EXPOSED TO
SHIGELLOSIS CAUSED BY INTENTIONAL CONTAMINATION
FEDERAL AGENCIES INVOLVED IN BIOTERRORISM
COST OF BIOTERRORISM
AGENT TRANSMISSION
ROUTES OF INFECTION
* Skin
o Cuts
o Abrasions
o Mucosal membranes
* Gastrointestinal
o Food
+ Potentially significant route of delivery
+ Secondary to either purposeful or accidental exposure to aerosol
o Water
+ Capacity to affect large numbers of people
+ Dilution factor
+ Water treatment may be effective in removal of agents
* Respiratory
o Inhalation of spores, droplets & aerosols
o Aerosols most effective delivery method
o 1-5F droplet most effective

MEDICAL RESPONSE TO BIOTERRORISM
* Pre-exposure
o active immunization
o prophylaxis
o identification of threat/use
* Incubation period
o diagnosis
o active and passive immunization
o antimicrobial or supportive therapy
* Overt disease
o diagnosis
o treatment
+ may not be available
+ may overwhelm system
+ may be less effective
o direct patient care will predominate

PUBLIC HEALTH RESPONSE TO BIOTERRORISM
PRIORITIES FOR PUBLIC HEALTH PREPAREDNESS

* Emergency Preparedness and Response
* Enhance Surveillance and Epidemiology
* Enhance Laboratory Capacity
* Enhance Information Technology
* Stockpile

COMPONENTS OF PUBLIC HEALTH RESPONSE TO BIOTERRORISM

* * Detection - Health Surveillance
* * Rapid Laboratory Diagnosis
* * Epidemiologic Investigation
* * Implementation of Control Measures


LABORATORY RESPONSE NETWORK FOR BIOTERRORISM
CDC BT RAPID RESPONSE AND ADVANCED TECHNOLOGY LAB
BIOTERRORISM: What Can Be Done?

* Awareness
* Laboratory Preparedness
* Plan in place
* Individual & collective protection
* Detection & characterization
* Emergency response
* Measures to Protect the Public’s Health and Safety
* Treatment
* Safe practices

BIOTERRORISM AND THE PUBLIC HEALTH SECTOR
Bioterrorism Preparedness and Response Program
Centers for Disease Control and Prevention
Planning for Bioterrorism
Overt is the observable disease

Bioterrorism.ppt