BIOLOGICAL TERRORISM

Edward L. Goodman, MD, Chief of Infectious Diseases

Presbyterian Hospital of Dallas

December 14, 2005

Biological Terrorism

Use of biological agents to intentionally produce disease or intoxication in susceptible populations to meet terrorist aims

Has been done in the past on a limited scale

U.S. must be prepared to respond to this threat

History of Biological Warfare

In 1346, Tartar army hurled corpses of plague victims over the walls of Caffa, a seaport on the Crimean coast

In 1718, Russians used same tactic against Sweden

During the Pontiac Rebellion in 1763, the British army provided the Delaware Indians with blankets and handkerchiefs from the “Smallpox Hospital”

History of Biological Warfare (cont.)

German program in WWI Japanese program in WWII In 1943, the U.S. began research into the

offensive use of biological agents: Program stopped by President Nixon in 1969

History of Biological Warfare (cont.)

In 1972, U.S. and many other countries signed the Biological Weapons Convention

Former Soviet Union program began massive effort in 1970s

Today, term “warfare” is outdated…terrorism of civilian populations major risk: Anthrax in 12 persons 2001

Why There was a Belief Bioterrorism in the U.S. Would Not Happen

Biologic weapons seldom used Their use is morally repugnant to most Technologically difficult? Concept of “nuclear winter” was

“unthinkable” and thus dismissed until suicide hijackers and anthrax appeared

The “Coming of Age” and Bioterrorism

Perpetrators Availability of biological agents Methods of dissemination

The Spectrum of Terrorists

State-sponsored Insurgent/rebel Doomsday/cult-type group Non-aligned terrorists Splinter groups Lone offenders

Sources of Agents for Terrorism Use

World Directory of Collections of Cultures and Microorganisms 453 worldwide repositories in 67 nations 54 ship/sell anthrax 18 ship/sell plague

International black-market sales associated with governmental programs

Methods of Dissemination of Biologic Agents

Postal service: never previously reported Aerosol

Enclosed areas Community-wide

Ingestion Mass produced food Water supplies

“You have to be lucky all the time. We have to be lucky just once!”

– Irish Republican Army

“The only difference between reality and fiction is that fiction has to make sense.”

– Tom Clancy

Syndromes Suggesting BT

Encephalitis Hemorrhagic mediastinitis Pneumonia with abnormal liver function Papulopustular rash Hemorrhagic fever Descending paralysis Nausea, vomiting +/- diarrhea

Biological Terrorism: Likely Agents

Bacterial: Anthrax Q fever Brucellosis Tularemia Plague

Viral: SmallpoxViral encephalitidesViral hemorrhagic fever

Toxin: BotulismRicin Staph, Enterotoxin B

Ideal Characteristics for Potential Biological Terrorism Agent

Inexpensive and easy to produce Can be aerosolized (1-10µm) Survives sunlight, drying, heat Cause lethal or disabling disease Person-to-person transmission No effective treatment or prophylaxis

Anthrax

Caused by Bacillus anthracis, a rod shaped, sporulating organism

Is a zoonotic disease in cattle, sheep, and horses

Transmission through scratches or abrasions of skin, wounds, eating insufficiently cooked infected meat, or inhalation of spores

Dixon, T. C. et al. N Engl J Med 1999;341:815-826

Pathophysiology of Anthrax

Dixon, T. C. et al. N Engl J Med 1999;341:815-826

Cutaneous Anthrax Infection of the Hand and Cheek

Anthrax (cont.)

Case fatality in untreated inhalational disease is almost 100% In recent 2001 occurrence, “only” 3/6 died

Incubation 1 – 45 days, most within 21 days Initial flu-like symptoms are often followed by

abrupt development of severe respiratory distress, shock, and death within 24 hours

                                                                                                    

                                                                                        

Bush, L. M. et al. N Engl J Med 2001;345:1607-1610

Anteroposterior Chest Radiograph Obtained on Admission, Showing the Widened Mediastinum That Is Characteristic of Anthrax

Bush, L. M. et al. N Engl J Med 2001;345:1607-1610

Cerebrospinal Fluid Specimen Containing Many Polymorphonuclear White Cells and Gram-Positive Bacilli (Gram's Stain, x1000)

Dixon, T. C. et al. N Engl J Med 1999;341:815-826

Differential Diagnosis of Clinical Manifestations of Anthrax

Anthrax (cont.)

Medical management must be reserved for those with early symptoms or no symptoms

Use of antibiotics for treatment (penicillin, ciprofloxacin, or IV doxycycline) and prophylaxis and vaccination

No secondary transmission

Swartz, M. N. N Engl J Med 2001;345:1621-1626

Recommendations for Postexposure Prophylaxis

Swartz, M. N. N Engl J Med 2001;345:1621-1626

Recommendations for Antimicrobial Therapy of Clinical Inhalational Anthrax

Anthrax (cont.)

Weaponized by the U.S. in 1950s and 60s Major emphasis of USSR program Can be delivered as aerosol

                                                                                        

Incubation-Days

0-67-1314-2021-2728-44

Cases*

62896

11

Died

625765

Days to Death

4.52.53.04.53.5

* 15 additional cases without an exact date of onset; all died.

Inhalational AnthraxSverdlovsk, USSR, 1979

Shopping Mall Scenario - Denver

Anthrax aerosolized into shopping mall ventilation system; 10,000 people are present and 9,000 people are exposed; terrorist announces attack at 24 hours.

90% of exposed started on antibiotics by end of day 2, 10% cannot be found initially

Total number hospitalized: 4,950; total requiring ICU care: 2,925; total deaths: 855; total ventilators required: 2601

Shopping Mall Scenario – Denver (cont.)

The 13,000 military beds deployed for the Persian Gulf War would STILL not provide enough ICU beds (approximately 1,300)

Even a small biological terrorism event completely overwhelms a city’s medical care resources

Smallpox

An even worse scenario

Smallpox

Killed more than 500 million persons in the 20th century despite being eradicated in 1978

Mortality of 30% in susceptible population Incubation period of 8 to 16 days

Smallpox (cont.)

Clinical manifestations begin acutely with fever, rigors, vomiting, headache and backache

Approximately 10% of light-skinned patients exhibit erythematous rash during early phase

Two to three days later, an enanthem appears on face, hands, and forearms

Smallpox (cont.)

Transmission begins with rash and lasts throughout convalescence

Ongoing transmission is critical factor Most in the world are no longer protected

by vaccination Currently vaccine and treatment limited

                                                                                        

                                                                                        

January February

4

3

2

1

Case

s

13 15 17 19 21 23 25 27 29 31 2 4 6 8 10 12 14 16 18

Hospital Stay Case 1

Date of Onset of Smallpox Cases by Two-Day IntervalsMeschede Hospital, 1970

Plague

Not as likely but of concern

                                                                                        

                                       

                                                                                                    

                                                                               

                     

Botulism

                                                                                        

                                                                                                     

                                                                                              

       

Challenges in Recognizinga Bioterrorism Attack

Biologic agents with delayed onset Medical community is unfamiliar with

many of these diseases Current surveillance system may not be

adequate to detect attack

Epidemiological Clues to BT Event

Uncommon illness in epidemic form Explosive point source epidemic curve Unexplained high mortality Discordant attack rate: outdoor>indoor Sentinel illness – even one case of

anthrax or smallpox

Syndromes Suggesting BT

Encephalitis Hemorrhagic mediastinitis Pneumonia with abnormal liver function Papulopustular rash Hemorrhagic fever Descending paralysis Nausea, vomiting +/- diarrhea

Ten CommandmentsSummary

1. Index of Suspicion2. Protect Thyself and Thy

Patients3. Assess the Patient 4. Decontaminate 5. Diagnosis6. Treatment7. Infection Control8. Alert 9. Epidemiologic Assessment10. Spread the Gospel

Response Planning

Federal government State and local government Healthcare systems Media Infrastructure support

Impact on Healthcare System

Potential for widespread illness, in unprecedented numbers

Limited therapeutic stockpiles Need special protective measures for

medical care, clinical lab, and autopsy Panic/terror among the ill, the exposed,

and healthcare providers

Other Critical Issues

Legal aspects Criminal investigation Controlling civil disorder Quarantine

Continued public health activities

Planning Responses to Biological Terrorism

Are we ready? Should we get ready? Is it possible to be effectively prepared?

It’s not a matter of “if,” but when, which agent,

and how bad it will be!

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