chemical and biological warfare agents charles stewart md facep
TRANSCRIPT
Chemical and Biological Warfare Agents
Chemical and Biological Warfare Agents
Charles Stewart MD FACEP
Thinking Out of The BoxThinking Out of The Box
Unrestricted warfare Unrestricted warfare
“With technological developments being in the process of striving to increase the types of weapons, a breakthrough in our thinking can open up the domain of the weapons kingdom at one stroke.”
Unrestricted Warfare is a Way of Thinking Out of the Box…
Unrestricted Warfare is a Way of Thinking Out of the Box…
Unrestricted warfare Unrestricted warfare
“The new concept of weapons will cause ordinary people and military men alike to be greatly astonished at the fact that commonplace things that are close to them can also become weapons with which to engage in war. We believe that some morning people will awake to discover with surprise that quite a few gentle and kind things have begun to have offensive and lethal characteristics.”
Unrestricted warfare Unrestricted warfare “It means that all weapons and technology can be superimposed at will, it means that all the boundaries lying between the two worlds of war and non-war, of military and non-military, will be totally destroyed.”
Unrestricted Warfare Qiao Liang and Wang Xiangsui
Beijing: PLA Literature and Arts Publishing House, February 1999
Unrestricted Warfare Qiao Liang and Wang Xiangsui
Beijing: PLA Literature and Arts Publishing House, February 1999
Realism in Theater Realism in Theater Are we sufficiently prepared for
the Right Threats? Some other possible problems
NIH. –Not invented here Media “guidance“ does not actually
define a real threat. Politicians often “react” and nay not
properly plan for real threats “Security” may make us less secure Simple solutions don’t always solve
complex problems.
What Should We Really Plan For? What Should We Really Plan For?
Explosives Flammable agents Chemical agents Biological Agents Radiological dispersion weapons Nuclear weapons Snipers?
All of them are possible threats !All of them are possible threats !
Bombings are still the single most common form of terrorism
Bombings are still the single most common form of terrorism Conventional explosives are easy
to get and easy to use. Look for new ways to make and
deliver them.
Types of terror attacks?Think Bombs!
Types of terror attacks?Think Bombs!
8 7 %
6 %
4 %
3 %
B o m b in g s K id n a p p in g s S h o o t in g s A l l o t h e r s
Terrorist threat of explosives Terrorist threat of explosives Readily available
PredictableFamiliar effects
Abundant training available
Abundant information available
No difficulty with delivery
Asymmetric Warfare Asymmetric Warfare Them:
4 small crews100% “ martyrs”
Us: More than 4000 direct casualties 100’s of millions of $$ in damages Massive damage to tourism and
transportation industries
Law of unintended consequences Law of unintended consequences
Lessons learned Big missions can cause big consequences
but provoke large responses Little missions can cause big consequences
with minimal risks Anthrax or sniper model attacks
Does this mean that new incidents will be small in scope with maximum media impact?
Possibly
Law of unintended consequencesLaw of unintended consequences
“Pearl Harbor” syndrome fully activated
Secondary losses Loss of safe haven
Afghanistan Iraq?
System degradation Financial support degradation
Potential Terrorist TargetsPotential Terrorist Targets Critical facilities and infrastructure
CongressPresidential staffSupreme Court
Enclosed spaces Large crowds (high profile events) Facilities of interest to terrorists’
cause
In 2001, They Planned for at Least 3 and Possibly 4 Targets
In 2001, They Planned for at Least 3 and Possibly 4 Targets
?
In 2003, They Chose 3 Targets in Saudi Arabia In 2003, They Chose 3 Targets in Saudi Arabia
Terrorist threat of snipers Terrorist threat of snipers Weapons are
readily available in almost all countries PredictableEffects familiar to
EMS Absolutely no
difficulty with delivery
High media impact
Terrorist threat of snipersTerrorist threat of snipers Look at how two poorly trained and
poorly equipped snipers affected 3 states in 2002 10 dead,3 injured Think about how two or three teams
of well trained snipers would be able to hurt us.
Has your EMS unit discussed/gamed/planned how to handle this type of terrorism?
Terrorist Threat of Chemical and Biological Agents
Terrorist Threat of Chemical and Biological Agents Ideal weapons of terrorism
Easily and cheaply madeEasily deliveredRapidly manufacturedTechnical information not “hot” Political effects far beyond local
casualties
Terrorist Threat of Incendiary Agents Terrorist Threat of Incendiary Agents
Readily available PredictableFamiliar effects
Abundant training available
Abundant information available
No difficulty delivering
Terrorist Threat of Nuclear Weapons Terrorist Threat of Nuclear Weapons Not easily available
Fairly predictable Great difficulty with
delivery?? Unfamiliar effects to most
EMS Abundant training
available Abundant information
available
Readily detected ?Closely controlled
Terrorist Threat of Radiological Weapons Terrorist Threat of Radiological Weapons Moderately available
Fairly predictableUnfamiliar effects to
most EMS Abundant training
available Abundant information
available No difficulty with delivery
Readily detected This is the easiest type of
terrorism to detect! Media hype expected
Radiologic Dispersal Weapons Radiologic Dispersal Weapons
Great media hype Probably a small number of actual
casualties A quantity of sufficiently radioactive
agent to cause real damage must: Be set up as a fine particle (ground) Transported to the area where it is to be
used Shielded from detection
This is not an easy set of tasks
Chemical and biological weapons are simply tools of unrestricted warfare
Chemical and biological weapons are simply tools of unrestricted warfare
Terrorist Threat of Chemical Weapons Terrorist Threat of Chemical Weapons
Moderately available Fairly predictableUnfamiliar effects to
most EMS ? Abundant training
available Abundant information
available Readily detected ??
No difficulty with delivery
Simplistic solutions? Simplistic solutions? Decontamination –wash them all
down with water?Simple, easily implemented solution Particularly effective for Sarin
Simplistic solutions?Simplistic solutions? Neglects fact that hydrolysis is not
always effective or beneficial Water is not particularly effective for Vx
and other oily or thickened Agents? – Thickened Soman was in Russian inventory.
Vx is hydrolyzed to EA2192 – Water actually makes VX into a far more toxic
and longer lasting substance
EA2192 = Diethyl methylphosphonate, 2 diisopropylaminoethyl mercaptan, ethyl hydrogen methyl-phosphonate, bis(ethylmethylphosphonic)anhydride, bis S- (2-diisopropylaminoethyl) methylphosphononodithiote.
Simplistic solutions?Simplistic solutions? Bleach is bad ?
GRAS – generally recognized as safe! Theoretically could consume 4 oz with no
ill effects. Hundreds of children have done so.
Bleach is a better decontamination agent than water
Much more rapid than water Known activity against mustard, Soman,
and VX-(military evidence in 50’s)
Simplistic solutions?Simplistic solutions? Water is not particularly effective
for mustardEuropeans found bleach and sodium
thiosufate to be more effective No experience at all with water
decontamination of “dusty” agentsDusty mustard Dusty Soman and Sarin
Decon Shower Decon Shower
Simplistic solutions?Simplistic solutions? Water will dilute and render safe
this substance by lowering the concentration so that no significant downstream damage will occur? Sarin – probably -volatile and non
persistent VX-???-long lived toxic hydrolysis
products Soman-???Mustard -???
Downstream safety Downstream safety
?
Dusty Agents Dusty Agents Combination of a chemical warfare
agent with a very finely divided silica or talc powder to make a particulate aerosol
Civilian technology Ortho Ant-Stop is an
organophosphate in an inert carrier
Dusty mustardDusty mustard Enhanced penetration of protective
equipment Goes under MOPP gear “May” penetrate Level A PPE
Insufficient data exists to substantiate this statement
More rapid and enhanced pulmonary effect of mustard on unprotected
Dusty VX –Sarin –Soman Dusty VX –Sarin –Soman Enhanced penetration of protective
equipment Goes under MOPP gear “May” penetrate Level A PPE*
More rapid and enhanced pulmonary absorption of VX on unprotected “May” give a picture more like Sarin*
“May” make Sarin or Soman less volatile*
*Insufficient data exists to substantiate this statement
Dusty AgentsDusty Agents Original Solution
”WHILE EMPHASIZING THAT THERE IS NO EVIDENCE THAT IRAQ HAS DEVELOPED A DUSTY V-AGENT, FATALITIES RANGING FROM 3 TO 38 PERCENT ARE PROJECTED FOR THE SAME CONCENTRATIONS CITED ABOVE FOR TROOPS IN FULL MOPP IF SUCH AN AGENT WERE USED. USE OF THE PONCHO OVER THE MOPP GEAR IS EXPECTED TO REDUCE THESE PROJECTED CASUALTIES TO NEAR ZERO EVEN FOR A DUSTY NERVE AGENT. “
Dusty AgentsDusty Agents One senses that the prior
recommendation was a desperate attempt to offer reassurance and a temporary “solution” for the troops.
Certainty, an open flapping poncho would offer no substantial improvement in chemical threat protection
SERPACWASERPACWA Better solution took
8 years to develop Skin Exposure
Reduction Paste Against Chemical Warfare Agents
Paste contains a perfluoroalkylpolyether (PFAPE) oil as a base polymer and polytetrafluoroethylene (Teflon polymer) dispersed within the base oil
ATSP soon to come
Simplistic solutions?Simplistic solutions? Everybody needs to be in Level A-
B-C gear for personal protection Governmental recommendations?
OSHA? OPP gear is, at best, level C protection
– Splash-Resistant over suit – Purified air (Negative Pressure) Protective
mask Turn-out gear +SCBA = 30 minutes
protection? I don’t know the “ Right” answer to this question.
MOPPMOPP
Chemical Threats –NIH Problem Chemical Threats –NIH Problem What is best cyanide antidote?
? Lilly cyanide kit? Expensive Awkward to use Dangerous to peds
Chemical Threats –NIH Problem Chemical Threats –NIH Problem
Hydroxycobalamin NlH? Vitamin B12 Widely available and quite cheap Not FDA approved for this
Kelocyanor? NIH? Available and widely used in Europe Pricy?
Terrorist Threat of Biowar AgentsTerrorist Threat of Biowar Agents
We were assured that biological agents were poor weapons of terrorism??Unpredictable
Weather Lifespan (survivability) ? Few good studies on effectiveness
StigmaDifficulty with delivery ??
Terrorist Threat of Biowar AgentsTerrorist Threat of Biowar Agents We were assured that biological
agents were poor weapons of terrorism??Unpredictable
Weather Lifespan (survivability) ? Few good studies on effectiveness
StigmaDifficulty with delivery ??
We Were Expecting “ The Big One”...We Were Expecting “ The Big One”...
We Got …We Got …
Historically most episodes of terrorism are rather small affairs…This is a principle
of asymmetric warfare…
Think about the confusion generated by …
Why Bioweapons? - Other AdvantagesWhy Bioweapons? - Other Advantages Undetectable by usual means Remote effect (time-lag)
Perpetrator can leave scene Widespread effect before discovery
FlexibleCovert vs OvertSmall scale vs large scale
Small amounts can inspire significant terror
Real Threat…or Fancy Fiction
Real Threat…or Fancy Fiction
Delivery will be a problem???
Real Threat…or Fancy FictionReal Threat…or Fancy Fiction
Terrorists need more expertise than they’ve got???
Larry Wayne Harris
Larry Wayne Harris
Real Threat…or Fancy Fiction
Real Threat…or Fancy Fiction
You just can’t get these bugs anymore….(we have controls,
you know)???
Endemic source of plague in western USA Endemic source of plague in western USA
Real Threat…or Fancy FictionReal Threat…or Fancy Fiction High lethality does not mean a
large number of deaths???
Remains to be proven. Remains to be proven.
Biowarfare Agent SourcesBiowarfare Agent Sources Home production Laboratory / commercial
production Industrial facilities Foreign military sources Medical / university research
facilities
HistoryHistory Romans
Used dead animals to foul water supply
MongolsCatapulted plague victims into Kaffa
EnglishGave smallpox infested blankets to
Indians during French-English war in colonies.
History: German Agents in WWIHistory: German Agents in WWI
Dr. Alton Dilger in Washington DCAnthrax and
GlandersAbout 3500
horses infectedMore people died
than from the 2001 anthrax
History - TerroristHistory - Terrorist 1915 Dr. A Dilger (German-
American) produces anthrax and glanders
1972 ‘Order of the Rising Sun’ prepares 30 kg of typhoid bacteria cultures
1978 Giorgi Markov assassinated with ricin
History - Unit 731History - Unit 731 1918 - Unit 731 established in
Japan Unit 731 deploys in Manchuria in
WWII Investigates multiple organisms
including plague
1941 Bubonic plague sprayed in China by Japanese
1942 Bacterial “bombs” used by Japanese
History - USA ExperimentsHistory - USA Experiments 1950-1969 Off coast USA –
Experiments with Serratia US Army and Navy for several cities including San Francisco and LA
1966 Bacillus subtilis via subway route in NYC
US Army
1966 Pentagon ‘bombed’ by Chemical Corps
History: A Salad Bar in OregonHistory: A Salad Bar in Oregon 1984 Rajneesh
cult seeds salad bars in Oregon with typhoid to influence an election
AnthraxAnthrax Known experience with this agent Sverdlovsk (Ekatrinburg) Russia
1979Accidental military releaseWe will talk about this later.
History History 1983 2 brothers in Northeastern
USA produce 1 ounce of pure ricin 1984 Red Army Faction found with
botulinum toxin in Paris
History History 1991 Iraq bioweapons program
uncovered during Gulf War 1992 Ken Alibek defects to USA
and exposes the Soviet program
Ladies and gentlemen… we have a real problem.
History History 2001 Anthrax
used via postal delivery methods…. Osma Bin Laden suspected.
History History Sort of puts the lie to anybody who
thinks this ain’t gonna happen here …
Asymmetric Warfare Asymmetric Warfare We need to be prepared for the
next phase… and we don’t know what that phase is or when it will occur.We aren’t ready for a lot of these
problems
Possible Biologic AgentsPossible Biologic Agentsanthrax, cryptococcosis, escherichia coli, haemophilus influenzae, brucellosis (undulant fever), coccidioidomycosis (San Joaquin Valley or desert fever), psittacosis (parrot fever), yersina pestis (the Black Death of the 14th Century), tularemia (rabbit fever), malaria, cholera, typhoid, bubonic plague, cobra venom, shellfish toxin, botulinal toxin, saxitoxin, ricin, smallpox, shigella flexneri, s. dysenteriae (Shiga bacillus), salmonella, staphylococcus enterotoxin B, hemorrhagic fever, Venezuelan equine encephalitis, histoplasma capsulatum, pneumonic plague, West Nile fever, Rocky Mountain spotted fever, dengue fever, Rift Valley fever, diptheria, melioidosis, glanders, tuberculosis, infectious hepatitus, encephalitides, blastomycosis, nocardiosis, yellow fever, typhus, tricothecene mycotoxin, aflatoxin, and Q fever.
Who knows?
Possible Biologic AgentsPossible Biologic Agents The CDC “master list”
A compromise between A limited budget Public /media fears Agents known to hove been developed as
warfare agents
Does not cover all threats! A growing threat New and emerging diseases not listed
Detection of OutbreakDetection of Outbreak Epidemiologic investigation Syndrome Based
Inhalation anthrax
BW - Epidemiologic CluesBW - Epidemiologic Clues Large epidemic with high illness
and death rate Infection non-endemic for region Multiple, simultaneous outbreaks Multi-drug-resistant pathogens Sick or dead animals
BW - Epidemiologic Clues…BW - Epidemiologic Clues… Delivery vehicle or vector found Intelligence of possible event
BW - Epidemiological Information
BW - Epidemiological Information
Travel history Infectious contacts Employment history Activities over the
preceding 3 to 5 days
Aerosol SpreadAerosol Spread Ideal aerosol is a homogeneous
population of 2 or 3 micron particulatesThis is the best “suspension” of
particles for RESPIRATORY spreadPlease note that other sizes may well
be infective also. Maximum human respiratory
infection is a particle within 1 to 5 micron size
Infection Severity
Aerosol / Infectivity RelationshipAerosol / Infectivity Relationship
Particle Size
18-20
15-18
7-12
4-6(bronchioles)
1-5 (alveoli)
Less Severe
More Severe
Delivery SystemsDelivery Systems Airborne
Biological Agents - Types and CharacteristicsBiological Agents - Types and Characteristics
Live Agents Biotoxins
These are more like chemical warfare agents
Possible Live Biowarfare AgentsPossible Live Biowarfare Agents Viruses Rickettsia Bacteria Fungi ?? Prions ?? (mad cow disease)
AnthraxAnthrax
AnthraxAnthrax
Anthrax is an acute infectious disease of animals caused by Bacillus anthracis.
Gram positive rods
Spore forming
May persist in soil for over 50 years!
Anthrax Anthrax Humans can
develop infection from handling contaminated fluids or hides (“Woolsorters
Disease”)
AnthraxAnthrax Spores can be
produced in a dry form for biological warfare
may be stored and ground into particles.
When inhaled by humans, these particles cause respiratory failure and death within a week.
AnthraxAnthrax
It is rare to find infected animals in the United States..
Most United States cases are in Texas, Louisiana, Mississippi, Oklahoma and South Dakota.
AnthraxAnthrax Anthrax is most
common in under-developed agricultural regions
South and Central America
Southern and Eastern Europe
Asia, Africa,
the Caribbean
the Middle East.
AnthraxAnthrax 3 forms of Anthrax infection
cutaneous (skin) - most commoninhalationgastrointestinal
Anthrax - Pathogenesis Anthrax - Pathogenesis Virulent bacteria produce toxins
edema factor lethal factor
Spores are ingested by WBC’s and travel to the regional lymph nodes
Cutaneous AnthraxCutaneous Anthrax Cutaneous
VesicleUlcerates with black necrotic centerRegional lymphadenopathy
Untreated skin infection - 20% mortality if septicemia develops (treated 1%)
Cutaneous AnthraxCutaneous Anthrax
Inhalation AnthraxInhalation Anthrax
Initial symptoms like a viral syndrome1 to 6-day incubation period followed by
fever, myalgias, cough, and fatigue
Often get better for short time
Initial improvement is followed by abrupt onset of respiratory distress, shock, and death in 24 to 36 hours
Inhalation AnthraxInhalation Anthrax
Chest x-ray shows a widened mediastinum with or without a bloody pleural effusion
Inhalation AnthraxInhalation Anthrax Inhaled anthrax causes
mediastinitisGerminated bacteria travel to
regional lymph nodes 50 % of cases have associated
hemorrhagic meningitis
Anthrax MeningitisAnthrax Meningitis
Intestinal AnthraxIntestinal Anthrax
Consumption of contaminated meat
Inflammation of the intestinal tract
Nausea, loss of appetite, vomiting, fever
Abdominal pain, bloody vomit, and diarrhea
Death in 25% to 60% of cases
AnthraxAnthrax Biowarfare agent
Does not spread person to personSpores may be spread with multiple
types of equipmentProphylaxis is possibleCheap and easy to produceReadily available
Anthrax TransmissionAnthrax Transmission No documented person-to-person
transmission of inhalation anthrax has ever occurred
Cutaneous transmission is possibleUniversal precautions required
Inhalation Anthrax - DiagnosisInhalation Anthrax - Diagnosis
Nonspecific symptomsFever, headache, malaise
Substernal chest pain Sudden onset of respiratory distress
Widened mediastinum on chest x-rayHemorrhagic mediastinitis
Some patients may present with GI or cutaneous anthrax
Inhalation Anthrax - DiagnosisInhalation Anthrax - Diagnosis
Emergency physicians are “first responders” in this disease.
This is contrary to usual EMS thinking But the “ first response “ for patients
with initial complaints of malaise, fever, headache probably won’t occur in the field.
The first Anthrax diagnosis was made by emergency physicians
Anthrax -diagnosisAnthrax -diagnosis Nasal swabs
Poor way to check asymptomatic folks
Gram stain of bloodOften too late for inhalation disease
ELISA and immunohistology testing may confirm diagnosis but samples must go to reference laboratory for cultures
Anthrax - ProphylaxisAnthrax - Prophylaxis Anthrax vaccine
Cell free filtrateProven for cutaneousNot proven for inhalation or massive
exposures.Requires 6 injectionsRequires yearly booster
Anthrax - ProphylaxisAnthrax - Prophylaxis Unimmunized persons
Cipro 500 bid PO No reason why another quinolone would
not be effective.
Doxycycline 100 bid PO?? PenicillinContinue antibiotics for 4 weeks at a
minimumVaccinate!
Anthrax - TherapyAnthrax - Therapy Penicillin
Resistance is easy to achieve Cipro Chloramphenicol Doxycycline
Tetracycline Erythromycin
Anthrax - Pediatric TreatmentAnthrax - Pediatric Treatment Prophylaxis
PenicillinDoxycycline? Cipro
IV TherapyPenicillin? CiproDoxycycline
AnthraxAnthrax Known experience with this agent Sverdlovsk (Ekatrinburg) Russia
1979 Accidental military release
Sverdlovsk = EkaterinburgSverdlovsk = Ekaterinburg
Anthrax - SverdlovskAnthrax - Sverdlovsk
This accident resulted in over 66 deaths downwind.
Biological Warfare research, production and
storage facility
Biological Warfare research, production and
storage facility
Path of airborne Anthrax – over 20
kilometers downwind
Path of airborne Anthrax – over 20
kilometers downwind
Inhalation Anthrax is a slow infectionInhalation Anthrax is a slow infection
Exposure
01
23
45
67
89
1011
1213
14 16 18 20 22 24 26 28 30 32 38 4034 36 4243
Each represents one death
1979 Sverdlovsk deaths… per day after exposure
Current experience
Current experience
We still don’t know who did this.
The technology could still be re-used???
PlaguePlague Yersinia (Pasturella) pestis
The Black Death - Bubonic plagueFlea bite
Found worldwide Prairie dogs in Rocky Mountain areas
Bipolar gram-negative rod
PlaguePlague 3 Presentations
BubonicSepticRespiratory
Plague - bubonicPlague - bubonic Usual natural transmission form Localized abscess at site of
infection Regional lymph glands form large
abscesses Incubation 2-10 days
Plague Disease ComplexPlague Disease Complex
Inhalational
SystemicToxicity
Respiratory failure & circulatory collapse
Liverenzymes
6% latemeningitis
Fulminant Pneumonia
Fever, URI syndrome
Sudden onset
Leukemoidreaction
Gram negativerods in sputum
Fever/rigors Erythema
Tender bubo1 - 10 cm
APTTecchymosis
DIC
Stridor, cyanosis,productive cough,bilateral infiltrates
Pharyngitis2 -3 days 2 - 10 days
24 hrs
9%
Bubonic PlagueBubonic Plague Erythema, fever, rigors Bubo formation in
regional lymph nodes Bubo aspiration and
gram stain is diagnostic
Plague - pneumonicPlague - pneumonic Aerosol transmission Highly lethal Rapid infection (1-2 days)
Plague - pneumonicPlague - pneumonic 2 to 3 day incubation period
followed by high fever, myalgias, chills, headache, and cough with bloody sputum
Pneumonia and sepsis develop acutely and may be fulminant Patients develop dyspnea, stridor,
cyanosis, and circulatory collapse
Plague – pneumonicPlague – pneumonic Patchy infiltrates or consolidation
seen on chest x-ray
Plague - septicPlague - septic Blood-borne spread from other
sites to lungs, CNS and other sitesHighly lethalOften has features of pneumonic but
slower onset
Acral GangreneAcral Gangrene Late complication
of pneumonic or septicemic plague
May occur in the fingers, toes, earlobes, nose, or penis.
Plague - diagnosisPlague - diagnosis Clinical suspicion Lymph node aspirate
Gram stain Check sputum and CSF too…. Culture of the aspirate, sputum,
CSF, or blood
PlaguePlague Therapy must be started rapidly! Streptomycin (30 mg/kg/day IM
divided BID for 10 days) Doxycycline (100 mg IV BID for 10
days) Chloramphenicol for plague
meningitis
Plague - Pediatric TreatmentPlague - Pediatric Treatment Prophylaxis
Doxycycline Trimethoprim/Sulfamethoxazole
IV TherapyStreptomycin (over 1 year of age)GentamicinChloramphenicol
Plague - prophylaxisPlague - prophylaxis Vaccine is available… but it won’t
protect against aerosol spread… Vaccine effective only for
bubonic plague Prophylactic doxycycline will
‘probably’ be effective if started prior to exposure...
Plague - ProphylaxisPlague - Prophylaxis Secondary
transmission is possible and likely
Universal and aerosol precautions until sputum cultures are
negative pneumonic plague is
excluded
Plague - prophylaxisPlague - prophylaxis Strict isolation is important for
plague victims…Respiratory isolation is mandatory for
the first 48 hours of treatment Violent coughing easily spreads
infected sputum Vector control is important to
prevent infection of local fleas and rodents.
PlaguePlague This agent is not an ideal war
bug...but it is readily available, has limited spread, and is relatively hardy. It would cause substantial casualties.
It has the potential of infecting local fleas and rodents as a persistent agent.It was used in WWII as a warfare agent
TularemiaTularemia Incubation 2-10 days Oculoglandular Typhoidal Treatment: gentamicin Prophylaxis: vaccine
(experimental) or 2 weeks of tetracycline
SmallpoxSmallpox Variola virus Extinct?
2 ‘legal’ repositories known US and Russia Russia developed military stocks of
smallpox
Monkeypox, cowpox, and ‘chickenpox’ are quite similar
May lend to genetic manipulation Or just selection of a specific variant
SmallpoxSmallpox
Last known natural smallpox victim
Ali Maalim Somalia 1977
Smallpox - presentationSmallpox - presentation Incubation period 12-14 days Prodromal period Skin lesions
Uniform progression of the lesionsRash looks like chickenpox lesions only
uniform Healing in 1-2 weeks Fatal in 30% of cases (Variola
major)
Smallpox …comes in more thon one
variant Smallpox …comes in more thon one
variant Variola major …30% mortality Variola minor …5% mortality Variola “hemorrhagic variant”
mortality unknown …probably >70% Variola “flat variant “
mortality unknown …probably >50%
SmallpoxSmallpox Diagnosis by clinical examination Electron microscopy Viral culture
SmallpoxSmallpox Therapy is supportive Would antiviral drugs…work?
There are some drugs that appear to have appropriate effect in animal studies, but these are in short supply
CDC/Cheryl Tryon
Child with Smallpox rashChild with Smallpox rash
SmallpoxSmallpox Prophylaxis
Vaccine is available and very effective.
Jenner
Vaccinia immune globulin Role is unclear Used for treatment of vaccina reactions
CDC/James Hicks, 1973
Smallpox rash close-up Smallpox rash close-up
SmallpoxSmallpox All material used in patient care
should be burned or autoclaved Considerable potential for person-
to-person spread
Smallpox - prophylaxisSmallpox - prophylaxis Quarantined all
contacts for at least 17 days
Infectious until all scabs are healed over
SmallpoxSmallpox Has already been used in warfare
British use of smallpox infested blankets for Indians
CDC
Last child with SmallpoxLast child with Smallpox
Smallpox Smallpox Current plan is to
encircle an outbreak of small pox with a ring of immunization so that the infection can’t spread any further .
Smallpox Smallpox Ring system requires
A group of health care providers who are already immunized .
Rapid identification of cases
Isolation of the suspected cases
Smallpox ring system requires Smallpox ring system requires Contact tracing Massive
immunizations Isolated outbreak Effective
immunization (prevents disease)
Smallpox Smallpox Ring system
assumes Folks will not refuse
vaccination Resources are not
exhausted Quarantine will be
observed. 1:3-1:5 infectivity
What about O’ Hara ?What about O’ Hara ? Any major airport
Agent release or infected person
High travel season
Widespread infection Infection date may
not be known Contact tracing
difficult Look at SARS
Smallpox Smallpox Ring system
assumes that immunization will be effective both in decreasing mortality of the disease in those who have been exposed and effective in preventing further spread of disease
But… will it be “ blackpox “But… will it be “ blackpox “ The smallpox variant developed by
the Russians was a hemorrhagic smallpox
(This type of smallpox is sometimes called” blackpox” because of the massive subcutaneous
hemorrhage found in these patients ) Vozozhdeniye Island in Aral Sea was
site of a presumed accidental release in 1971
Patient #
Age Sex Date of onset
Type of Rash Prior Vacc
Dead vs live
1 24 F 8/17 Classic Yes Rec
2 9 M 8/27 Classic Yes Rec
3 23 F 9/10 Hemorrhagic No †
4 36 F 9/10 Classic Yes Rec
5 5.5 M 9/18 Classic Yes Rec
6 38 M 9/24 Mild Yes Rec
7 0.8 M 9/26 Hemorrhagic No †
8 60 F 9/26 Mild Yes x3 Rec
9 33 M 9/28 Mild Yes Rec
10 0.33 F 10/2 Hemorrhagic No †
The Aralsk smallpox epidemic in 1971 was a presumed weapon release from
Vozozhdeniye Island in the Aral Sea.
Aralsk smallpox outbreak Aralsk smallpox outbreak
Smallpox –blackpox variant Smallpox –blackpox variant Ring Strategy would not stop spread of this
form of disease It was not protective against getting the
disease. Vaccination is protective against death in
black pox Massive immunization would decrease
mortality100% mortality in unimmunized.
Note: Data about this variant of smallpox is scanty and may well
not be this grim
What about the Toronto model ?What about the Toronto model ? SARS
Health care system devastated
Resources exhausted
EMS shut down This is for a
disease with 10% mortality
Monkeypox VirusMonkeypox Virus
Viral hemorrhagic feverViral hemorrhagic fever
Fever, myalgias, prostration Target organ is the vascular
bed.Conjunctival injection, petechial
hemorrhage, and hypotensionFollowed by shock and
generalized hemorrhage
Ebola virusEbola virus Viral
Hemorrhagic fever
No known therapySome antisera
may…be effective
No known prophylaxis
VHFVHF Mortality varies
50 - 80% Ebola Zaire Abnormal renal and liver
function tests - poor prognosis Disease severity and survival
depends on various host factors
VHF TreatmentVHF Treatment Hemodynamic resuscitation and
monitoringInvasive Swan Gantz catheter as
feasible Careful fluid management
use of colloid Vasopressors and cardiotonic
drugs
VHF TreatmentVHF Treatment Cautious sedation and analgesia No anti-platelet drugs or IM
injections Coagulation studies and
replacement of clotting factors / platelet transfusions
Prevention of VHFPrevention of VHF Single room w/ adjoining anteroom
as only entrancehandwashing facility with
decontamination solution Negative air pressure if possible
Prevention of VHFPrevention of VHF Strict barrier precautions
gloves, gown, mask. shoe covers, protective eyeware/faceshield
consider HEPA respirator for prominent hemorrhage, vomiting, diarrhea, cough
There is no effective vaccine at this time.
Ebola Case Study 1995Ebola Case Study 1995 April 5 - Zaire laboratory worker
fever and bloody diarrhea May 17 - 93 cases - 92% fatality
most cases were in health care providers
June 25 - 296 cases When institutional barrier precautions
were implemented by WHO/CDC - the infection rate among health care workers dramatically decreased.
Possible biotoxinsPossible biotoxins Botulinum Clostridia Ricin Saxitoxin Tetrodotoxin Staphylococcal enterotoxin Tricothecene mycotoxins
Botulinum toxinsBotulinum toxins Seven species (A-G) Anaerobic spore forming bacterium
Canned foodsGI tractWounds
Aerosol of toxinLethal toxin
Botulinum toxinsBotulinum toxins
Clostridum botulinum
Botulinum toxinsBotulinum toxins Signs and symptoms
PtosisDiplopiaDysphagiaDysphoniaFlaccid paralysisRespiratory failure
Botulinum toxinsBotulinum toxins Diagnosis
No available rapid laboratory diagnosis
Assay exists… but is only good for confirmation
Takes a while to return the results….
Suspect if numerous casualties develop bulbar paralysis, muscle weakness, and respiratory failure
Botulinum toxinsBotulinum toxins Treatment
Supportive care Intubation Ventilation
Trivalent antitoxin (A,B,E) Horse serum Must be given as soon as possible
Heptavalent USAMRIID antitoxin Investigational horse serum
Botulinum toxinsBotulinum toxins Prophylaxis
Toxoid (A,B, C, D, E) Investigational product 3x injections with yearly booster High risk of exposure
Botulinum toxinsBotulinum toxins Decontamination
Was with bleach or soap and waterPressure cook all foodsToxin does not go through skin
BotulinumBotulinum Outbreak control
Immediate release Rapidly decontaminated
Late contamination Boil for 10 minutes
Ok… Why haven’t we seen...Ok… Why haven’t we seen... Unpredictable
Collateral damageMoral qualms???
Personal safety Severe response
Damage causeOut of control?? Deny responsibility
Why haven’t we seen..Why haven’t we seen.. Higher authority says no... Present day tactics are successful Lack of precedent Can’t get credit for the...
Delivery Systems – ImprovDelivery Systems – Improv The ‘experts’ have constantly
pointed out that biowarfare can’t be used by “unsophisticated” folks.You need a lot of training to
effectively use biowarfareYou need a lot of equipment to make
biowarfare agents effectiveAum Shin tried it and failed (before
sarin).
BioterrorismBioterrorism Obviously this line of reasoning
didn’t stop the current terrorists from using anthrax
Delivery system
… crude, but very effective for terrorism… and not very expensive
Delivery system
… crude, but very effective for terrorism… and not very expensive
Delivery Systems - ImprovDelivery Systems - Improv It depends on just what you want
to accomplish…English with smallpox and blankets
during French & Indian WarLetter ‘biobombs’Other improv devices
Terrorism is changingTerrorism is changing Increased security about other
means Increase in spectacular and/or high
casualty eventsNYC and Pentagon
Increase in state sponsorship Increase in religious sponsorship
`Everybody who doesn’t worship my way deserves to die!”
And biotechnology is changing...And biotechnology is changing... Dual use technology is burgeoning Gene sequences are becoming
public knowledge Increased availability of
information Private hire of former Soviet
scientists
Foreign Outlook on the US is changingForeign Outlook on the US is changing
The “last” superpower Jealousy of our freedom and
lifestyle The great Satan
Imposing ‘Our’ view and religionsA fickle bully A place where
TV makes the decisions and is constantly present
The soft and decadent live in the US
The Changing Role of the USThe Changing Role of the US
Decrease in international stability leads to increase use of US forces as police
Retribution / Retaliation cycle of current ‘wars’ in Afghanistan and Iraq
In Topoff II, we trained at 2 major places…In Topoff II, we trained at 2 major places…
Topoff IITopoff II Pre-arranged
Date and location known Compressed time format
Limited scope Limited # of patients No significant disruption of normal
medical services
What if every yellow spot were a biological release .... What if every yellow spot were a biological release ....
Please remember Please remember Sophisticated planning of
simultaneous attacks on multiple targetsDetailed knowledge of system
weaknessesUnderstand and employ media to best
effect Use of unusual “tools” to achieve high
casualties and shock effect Self-sacrifice (martyr) can be expected
Who?Who? Undefined constituency and/or
vague objectives Prior pattern of high casualty
incidentsSophisticated planning of simultaneous
attacks on multiple targets Demonstration of sophistication Willing to take risks ?? State sponsorship
OBL?OBL?
Who elseWho else OBL or a successor? Palestine
PLF-GCAbu Nidal
Saddam or a successor ? United States Aryan Nations
Neo-Nazi groups? Japanese Red Army Hizbollah Sikh
Who will reap the whirlwind???Who will reap the whirlwind???