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BIOTERRORISM AND BIOTERRORISM AND VETERINARY PUBLIC VETERINARY PUBLIC
HEALTHHEALTH
Dr. Shahnawaz ahmadDr. Shahnawaz ahmadI.V.R.II.V.R.I
Div. Of SurgeryDiv. Of Surgery
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Definition of BioterrorismDefinition of BioterrorismBioterrorism is the threat of use of biological Bioterrorism is the threat of use of biological
agents by individuals or groups motivated by agents by individuals or groups motivated by
political, religious, ecological, social or for other political, religious, ecological, social or for other
ideological objectives to inculcate fear or cause ideological objectives to inculcate fear or cause
illness or death in order to achieve their illness or death in order to achieve their
objectivesobjectives
(Carus 1998).(Carus 1998).
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According to the United States According to the United States
Centers for Disease Control and Centers for Disease Control and
Prevention (CDC) Prevention (CDC) a bioterrorism a bioterrorism
attack is the deliberate release of attack is the deliberate release of
viruses, bacteria or other germs viruses, bacteria or other germs
(agents) or toxins used to cause (agents) or toxins used to cause
illness or death in people, animals illness or death in people, animals
or plantsor plants. .
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BIOLOGIC WARFARE: HISTORY
1414THTH century, Caffa: Attacking Tatar force catapulted century, Caffa: Attacking Tatar force catapulted
cadavers of plague victims into city – outbreak of cadavers of plague victims into city – outbreak of
plague led to defeatplague led to defeat
1818thth century, Fort Pitt, North America: Blankets from century, Fort Pitt, North America: Blankets from
smallpox hospital provided to Native Americans – smallpox hospital provided to Native Americans –
resulted in epidemic of smallpox among tribes in Ohio resulted in epidemic of smallpox among tribes in Ohio
River valleyRiver valley
Gen. Jeffrey Amherst, in a letter dated 16 Jully 1763, approved the plan to spread smallpox to Delaware Indians
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1932-45, Manchuria: Japanese military 1932-45, Manchuria: Japanese military
physicians infected 10,000 prisoners with physicians infected 10,000 prisoners with
biological agents (biological agents (B. anthracis, N. B. anthracis, N.
meningitidis, Y. pestis, V. choleraemeningitidis, Y. pestis, V. cholerae) –) – 11 11
Chinese cities attacked via food/water Chinese cities attacked via food/water
contamination, spraying via aircraftcontamination, spraying via aircraft
The Japanese army used Chinese prisoners to test bioweapons.
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Reported cases of bioterrorism
World war II – Polish resistance organizations used
biological agents against German
forces
1952 – Mau Mau, an independence movement in
Kenya, used a plant toxin to poison
livestock
1966 – Dr. M. Suzuki, a Japanese physician,
infected health care providers and patients with
S. typhi
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1981 – Dark harvest groups got anthrax
contaminated soil from Gruinard Island and
damped it on Porton Down.
1984 – Rajaneesh in Portland, Oregon (USA) used
S. thphimurium to contaminate restaurants salad
bars
1995 – AUM Shinrikyo used sarin nerve gas in the
Tokyo subway in Japan.
2001- Anthrax contaminated mails sent to various
people in USA
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CasualtiesCasualtiesIncident Number of cases Number of deaths
Polish resistance
Not reported 200 Germans
Mau Mau Not reported 33 head of cattle
Dark Harvest
None None
Rajaneesh 751 (45 Hospitalized No deaths
AUM Shrinkyo
5500 (641 seen at SJIH on day I & 349 following week
106 hospitalized at SLIH, 12 deaths ( 2 at SLIH)
Dr. Suzuki 200 4 deaths
Anthrax (USA)
22 4 deaths
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Motive for Bioterrorism
Incident Motive
Polish resistance
Resistance against foreign occupation
Mau Mau Resistance against colonialism
Dark Harvest
Send a political message
Rajneesh Win a local election by incapacitating the non-Rajneeshees voters
AUM Shrinkyo
Seize control of Japan through mass murder causing fear and apprehension
Dr. Suzuki Revenge for unfair treatment he received at the medical training
Anthrax (USA)
Inculcate fear
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BIOTERRORISM: WHY BIOTERRORISM: WHY NOW?NOW?
Nuclear arms have great killing Nuclear arms have great killing
capacity but are hard to get.capacity but are hard to get.
chemical weapons are easy to get but chemical weapons are easy to get but
lack such killing capacitylack such killing capacity
Biological agents have both qualitiesBiological agents have both qualities..
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TRENDSTRENDS FAVORING BIOLOGICAL FAVORING BIOLOGICAL WEAPONSWEAPONS
Biological weapons have an unmatched destructive Biological weapons have an unmatched destructive
potentialpotential
Technology for dispersing biologic agents is becoming Technology for dispersing biologic agents is becoming
more sophisticated.more sophisticated.
The lag time between infection and appearance of The lag time between infection and appearance of
symptoms generally is longer for biological agents than symptoms generally is longer for biological agents than
with chemical exposures.with chemical exposures.
Lethal biological agents can be produced easily and Lethal biological agents can be produced easily and
cheaply.cheaply.
Biological agents are easier to produce clandestinely than Biological agents are easier to produce clandestinely than
are either chemical or nuclear weapons.are either chemical or nuclear weapons.
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TRENDS FAVORING BIOLOGICAL TRENDS FAVORING BIOLOGICAL WEAPONSWEAPONS
Global transportation links facilitate the Global transportation links facilitate the
potential for biological terrorist strikes to potential for biological terrorist strikes to
inflict mass casualtiesinflict mass casualties
Urbanization provides terrorists with a wide Urbanization provides terrorists with a wide
array of lucrative targetsarray of lucrative targets
The emergence of global, real-time media The emergence of global, real-time media
coverage increases the likelihood that a coverage increases the likelihood that a
major biological incident will induce panicmajor biological incident will induce panic
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CENTERS FOR DISEASE CONTROLCENTERS FOR DISEASE CONTROLBIOTERRORIST AGENTS: CATEGORY ABIOTERRORIST AGENTS: CATEGORY A Easily disseminated or transmitted Easily disseminated or transmitted
person-to-personperson-to-person
High mortality, with potential for public High mortality, with potential for public
health impacthealth impact
Require special action for public health preparedness .Require special action for public health preparedness .
Viruses:Viruses: Variola major (smallpox), Variola major (smallpox),
Filoviruses (Ebola, Marburg), Filoviruses (Ebola, Marburg),
Arenaviruses (Lassa, Junin)Arenaviruses (Lassa, Junin)
BacteriaBacteria: : Bacillus anthracisBacillus anthracis (anthrax), (anthrax), Yersinia pestisYersinia pestis (plague), (plague),
Francisella tularensisFrancisella tularensis (tularemia) (tularemia)
ToxinsToxins: : Clostridium botulinumClostridium botulinum toxin (botulism) toxin (botulism)
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CENTERS FOR DISEASE CONTROLCENTERS FOR DISEASE CONTROLBIOTERRORIST AGENTS: CATEGORY BBIOTERRORIST AGENTS: CATEGORY B
Moderately easy to disseminateModerately easy to disseminate
Moderate morbidity and low mortalityModerate morbidity and low mortality
Require improved diagnostic capacity & enhanced surveillance .Require improved diagnostic capacity & enhanced surveillance .
VirusesViruses: Alphaviruses (VEE, EEE, WEE): Alphaviruses (VEE, EEE, WEE)
BacteriaBacteria: : Coxiella burnetiiCoxiella burnetii (Q fever), (Q fever), Brucella sppBrucella spp. (brucellosis), . (brucellosis),
Burkholderia malleiBurkholderia mallei (glanders) (glanders)
Toxins:Toxins: Rinus communisRinus communis (caster beans) ricin toxin, (caster beans) ricin toxin, Clostridium Clostridium
perfringensperfringens episolon toxin, episolon toxin, StaphylococcusStaphylococcus enterotoxin B enterotoxin B
Food/waterborne pathogensFood/waterborne pathogens: : Salmonella sppSalmonella spp., ., Vibrio choleraeVibrio cholerae, ,
Shigella dyseneriaeShigella dyseneriae, , E. coliE. coli O157:H7, O157:H7, Cryptosporidium parvumCryptosporidium parvum, ,
etc. etc.
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CENTERS FOR DISEASE CONTROLCENTERS FOR DISEASE CONTROLBIOTERRORIST AGENTS: CATEGORY CBIOTERRORIST AGENTS: CATEGORY C
AvailabilityAvailability
Ease of production and disseminationEase of production and dissemination
Potential for high morbidity and mortality and Potential for high morbidity and mortality and
major public health major public health impact impact
Viruses:Viruses: Nipah, hantaviruses, tick borne Nipah, hantaviruses, tick borne
hemorrhagic fever viruses, tick borne hemorrhagic fever viruses, tick borne
encephalitis viruses, yellow feverencephalitis viruses, yellow fever
BacteriaBacteria: Multi-drug resistant : Multi-drug resistant Mycobacterium Mycobacterium
tuberculosistuberculosis
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CHARACTERISTICS* OF PRIORITY AGENTSCHARACTERISTICS* OF PRIORITY AGENTS
Infectious via aerosolInfectious via aerosol
Organisms fairly stable in aerosolOrganisms fairly stable in aerosol
Susceptible civilian populationsSusceptible civilian populations
High morbidity and mortality High morbidity and mortality
Person-to-person transmission Person-to-person transmission
Difficult to diagnose and/or treatDifficult to diagnose and/or treat
Previous development for BWPrevious development for BW
* * * Priority agents may exhibit all or some of the above * Priority agents may exhibit all or some of the above
characteristicscharacteristics
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SOURCES OF SOURCES OF BIOTERRORISMBIOTERRORISM
Biological warfareBiological warfare
State sponsored terrorismState sponsored terrorism
International terrorist groupsInternational terrorist groups
National cultsNational cults
The deranged “loner”The deranged “loner”
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BIOTERRORISM: IMPACTBIOTERRORISM: IMPACT
Direct infection: Mortality, morbidityDirect infection: Mortality, morbidity
Indirect infection: Person-to-person transmission, Indirect infection: Person-to-person transmission,
fomite transmissionfomite transmission
Environmental impact: Environmental survival, Environmental impact: Environmental survival,
animal infectionanimal infection
Other: Social, political, economic Other: Social, political, economic
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The terrorists have an option to use exotic
organisms to spread disease in animals and plants.
Imagine somebody spread Foot and Mouth disease,
Glanders, VEE, Rinderpest, Brucellosis, Swine fever, Fowl
plague, Rabies and so on.
THREAT TO ECONOMYTHREAT TO ECONOMY
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Similarly Rice blast, Stem Rust, Late blight of
potato, Black Rust and Maize Rust and so on
would destroy all the crops and shatter the
economy of the country.
Eg:-Irish Potato Famine in 1940 due to Potato
Blast
Half a million people died of starvation and half a
million people migrated. It took one century for
the country’s economy to recover.
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BIOLOGICAL WARFARE: IMPACTBIOLOGICAL WARFARE: IMPACT[[release of 50 kg agent by aircraft along a 2 km line upwind release of 50 kg agent by aircraft along a 2 km line upwind
of a of a population center of 500,000 – Christopher et al., JAMA population center of 500,000 – Christopher et al., JAMA
278;1997:412278;1997:412
AgentAgent Downwind No. deadDownwind No. dead No. No.
reach, km reach, km incapacitatedincapacitated
Rift Valley feverRift Valley fever 11 400 400 35,00035,000
Tick-borne encephalitisTick-borne encephalitis 1 1 9,500 9,500 35,00035,000
TyphusTyphus 5 5 19,000 85,00019,000 85,000
BrucellosisBrucellosis 10 10 500 500 125,000125,000
Q feverQ fever >20>20 150 150 125,000125,000
TularemiaTularemia >20>20 30,000 30,000 125,000125,000
AnthraxAnthrax >20>20 95,00095,000 125,000125,000
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Biological Delivery Methods
• Food / Water
• Aircraft sprayers
• Vehicle sprayers
• Hand sprayers
• Air handling
systems
• Human Vector
• Animal Vector
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CHARACTERISTICS OF BIOWARFARE
Potential for massive numbers of casualties
Ability to produce lengthy illnesses requiring prolonged and intensive care
Ability of certain agents to spread via contagion
Paucity of adequate detection systems
Presence of an incubation period, enabling victims to disperse widely
Ability to produce non-specific symptoms, complicating diagnosis
Ability to mimic endemic infectious diseases, further complicating diagnosis
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FOMITE ACQUISITIONFOMITE ACQUISITION
Agents acquired from contaminated clothesAgents acquired from contaminated clothes
Variola major (smallpox)Variola major (smallpox)
• Bacillus anthracisBacillus anthracis (anthrax) (anthrax)
• Coxiella burnetiiCoxiella burnetii (Q fever) (Q fever)
• Yersinia pestisYersinia pestis (plague) (plague)ManagementManagement
•Remove clothing, have patient showerRemove clothing, have patient shower
•Place contaminated clothes in impervious bag, wear PPEPlace contaminated clothes in impervious bag, wear PPE
•Decontaminate environmental surfaces with EPA approved Decontaminate environmental surfaces with EPA approved
germicidal agent or 0.5% bleach (1:10 dilution)germicidal agent or 0.5% bleach (1:10 dilution)
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Bioterrorism agents: Laboratory riskBioterrorism agents: Laboratory risk
AgentAgent BSLBSL Laboratory RiskLaboratory Risk
B. anthracisB. anthracis 2 2 lowlow
Y. pestisY. pestis 2 2 mediummedium
F. tularensisF. tularensis 2/3 2/3 highhigh
Brucella sppBrucella spp. . 2/3 2/3 highhigh
Botulinum toxin Botulinum toxin 2 2 mediummedium
Smallpox Smallpox 4 4 highhigh
Viral Hemorrhagic feverViral Hemorrhagic fever 44 highhigh
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ANTHRAX IN THE US, 2001ANTHRAX IN THE US, 2001
Locations: FL, NY, DC, NJ, CT, VALocations: FL, NY, DC, NJ, CT, VA
Mechanism: Via the mail (4 letters positive)Mechanism: Via the mail (4 letters positive)
Infections: 22 casesInfections: 22 cases
Cutaneous anthrax: 11 (fatality rate = 0)Cutaneous anthrax: 11 (fatality rate = 0)
Inhalation anthrax: 11 (fatality rate = 45%)Inhalation anthrax: 11 (fatality rate = 45%)
Prophylaxis Prophylaxis
Initiated: ~32,000Initiated: ~32,000
60 day course recommended: ~5,00060 day course recommended: ~5,000
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UNEXPECTED FEATURES UNEXPECTED FEATURES OF ATTACKOF ATTACK
Targets (news media)Targets (news media)
Vehicle (US mail)Vehicle (US mail)
Source of strain (US, probably weaponized)Source of strain (US, probably weaponized)
Translocation of spore through envelopeTranslocation of spore through envelope
Airborne acquisition in mail facilitiesAirborne acquisition in mail facilities
Wide spread contamination in mail facilitiesWide spread contamination in mail facilities
Transmission via mail-to-mail contaminationTransmission via mail-to-mail contamination
No person or group has claimed responsibilityNo person or group has claimed responsibility
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ANTHRAX: EPIDEMIOLOGYANTHRAX: EPIDEMIOLOGY Agent: Agent: Bacillus anthracisBacillus anthracis, a Gram-, a Gram-
positive, positive,
spore forming non-motile bacillus spore forming non-motile bacillus
(straightforward lab identification)(straightforward lab identification)
ReservoirReservoir: Herbivores (cattle, goats,: Herbivores (cattle, goats,
sheep), sheep),
capable of surviving in the environment capable of surviving in the environment
for for
prolonged periodsprolonged periods
TransmissionTransmission
Contact, ingestion, or Contact, ingestion, or inhalation of inhalation of
infectiveinfective spores spores
Sources of infection: Contaminated Sources of infection: Contaminated
hides, wool, hair, bone, meat, or other hides, wool, hair, bone, meat, or other
animal productsanimal products
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SVERDLOVSK ANTHRAX OUTBREAKSVERDLOVSK ANTHRAX OUTBREAK
Site: Sverdlovsk, USSRSite: Sverdlovsk, USSR
Year: 1979Year: 1979
Cause: Accidental release Cause: Accidental release
from military microbiologic from military microbiologic
facility – Military report noted: facility – Military report noted:
“Filter clogged so I’ve removed “Filter clogged so I’ve removed
it. Replacement necessary”it. Replacement necessary”
Transmission: AirborneTransmission: Airborne
Impact: 68 human deaths, 79 Impact: 68 human deaths, 79
human cases, multiple animal human cases, multiple animal
deaths (sheep, cowsdeaths (sheep, cows))
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ANTHRAX: CLINICAL FEATURESANTHRAX: CLINICAL FEATURES
Incubation period: Incubation period: 1-7 days1-7 days (1-60 days) (1-60 days)
Clinical syndrome(s): Cutaneous ulcer, Clinical syndrome(s): Cutaneous ulcer, respiratoryrespiratory, ,
gastrointestinal, oropharyngealgastrointestinal, oropharyngeal
Inhalation anthrax = main threatInhalation anthrax = main threat
Spores may germinate up to 60 days after exposureSpores may germinate up to 60 days after exposure
LDLD5050 (human): 2,500 to 55,000 spores (human): 2,500 to 55,000 spores
Bronchopneumonia not a component (hemorrhagic Bronchopneumonia not a component (hemorrhagic
lymphadenitis and mediastinitis)lymphadenitis and mediastinitis)
Early diagnosis difficultEarly diagnosis difficult
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Anthrax: Cutaneous
Healing after treatment
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Gastrointestinal AnthraxGastrointestinal Anthrax
Hemorrhagic meningitis at autopsy. Photo courtesy of USAMRIID
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B. ANTHRACISB. ANTHRACIS MENINGITIS MENINGITIS
Lesion on chin
CSF
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INHALATION ANTHRAX: DIAGNOSISINHALATION ANTHRAX: DIAGNOSIS
Epidemiology Epidemiology
Sudden appearance of multiple cases of severe flu illness Sudden appearance of multiple cases of severe flu illness
with fulminant course and high mortalitywith fulminant course and high mortality
Clinical symptomsClinical symptoms
Non-specific prodrome of flu-like symptomsNon-specific prodrome of flu-like symptoms
Possible brief interim improvementPossible brief interim improvement
Abrupt onset of respiratory failure and hemodynamic Abrupt onset of respiratory failure and hemodynamic
collapse 2-4 days after initial symptoms, possibly collapse 2-4 days after initial symptoms, possibly
accompanied by thoracic edema and a widened accompanied by thoracic edema and a widened
mediastinum on CxRmediastinum on CxR
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INHALATION ANTHRAX: DIAGNOSISINHALATION ANTHRAX: DIAGNOSIS Diagnostic studies Diagnostic studies
Chest radiograph with widened Chest radiograph with widened
mediastinum mediastinum
Peripheral blood smear with gram Peripheral blood smear with gram
(+) bacilli on unspun smear(+) bacilli on unspun smear
Microbiology Microbiology
Blood culture growth of large gram Blood culture growth of large gram
(+) bacilli with preliminary (+) bacilli with preliminary
identification of identification of Bacillus sppBacillus spp..
PLET medium PLET medium
Pathology Pathology
Hemorrhagic mediastinitis, Hemorrhagic mediastinitis,
hemorrhagic thoracic hemorrhagic thoracic
lymphadenitis, hemorrhagic lymphadenitis, hemorrhagic
meningitismeningitis INHALATION ANTHRAX: CxRINHALATION ANTHRAX: CxR
Inhalational anthrax: CT scan
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INHALATION ANTHRAX, US
Prominent superior mediastinum,
?small left pleural effusion
B. ANTHRACISB. ANTHRACIS: PERIPHERAL : PERIPHERAL BLOOD SMEAR BLOOD SMEAR
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Cutaneous Anthrax, USCutaneous Anthrax, US7 mo male infant hospitalized with 2 day 7 mo male infant hospitalized with 2 day history of swelling left arm and weeping history of swelling left arm and weeping lesion at left elbow. Patient had been at lesion at left elbow. Patient had been at his mother’s office at a TV network. his mother’s office at a TV network. Biopsies yielded Biopsies yielded B. anthracis.B. anthracis.
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PlaguePlague
Public Health and ClinicalPublic Health and Clinical
FeaturesFeatures
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IntroductionIntroduction Due to infection with Due to infection with
the bacteriumthe bacterium
Yersinia pestisYersinia pestis
Several forms:Several forms: ––BubonicBubonic ––Primary septicemia/Primary septicemia/
secondary secondary
pneumonicpneumonic ––Primary pneumonicPrimary pneumonic
PERIPHERAL BLOOD SMEARPERIPHERAL BLOOD SMEAR
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Public Health FeaturesPublic Health Features
Most cases in U.S. occur in southwestMost cases in U.S. occur in southwest
Pneumonic plague can be transmitted Pneumonic plague can be transmitted
person to person via respiratory person to person via respiratory
dropletsdroplets
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PLAGUE: CLINICAL FEATURESPLAGUE: CLINICAL FEATURES
Incubation period: 1-4 days (pneumonia), 1-7 days Incubation period: 1-4 days (pneumonia), 1-7 days
(bubonic or septicaemic)(bubonic or septicaemic)
Clinical syndrome(s)Clinical syndrome(s)
Bubonic, septicemic, pneumonic, cutaneous, Bubonic, septicemic, pneumonic, cutaneous,
meningitismeningitis
Epidemiology and symptomsEpidemiology and symptoms
Sudden onset fever, shortness of breath, Sudden onset fever, shortness of breath,
hemoptysis, chest painhemoptysis, chest pain Gastrointestinal symptoms common (N, V, diarrhea)Gastrointestinal symptoms common (N, V, diarrhea)
Fulminant course and high mortalityFulminant course and high mortality
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Inguinal buboInguinal bubo Bubo – ruptured Bubo – ruptured inguinal lymph inguinal lymph
nodenode
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Axillary buboAxillary buboFemoral buboFemoral bubo
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PLAGUE: CLINICAL MANIFESTATIONS PLAGUE: CLINICAL MANIFESTATIONS
Cervical bubo
Ecchymosis, septicemia
Gangrene, septicemia
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PNEUMONIC PLAGUE: CxRPNEUMONIC PLAGUE: CxR
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PLAGUE: CONTROLPLAGUE: CONTROL
Laboratory precautions: BSL 2 (potentially infective Laboratory precautions: BSL 2 (potentially infective
clinical material), BSL 3 (activities with high potential clinical material), BSL 3 (activities with high potential
for droplet or aerosol production)for droplet or aerosol production)
Prophylaxis:Prophylaxis:
Post-exposure: Doxycycline (alternatives Post-exposure: Doxycycline (alternatives
ciprofloxacin or TMP-SMX)ciprofloxacin or TMP-SMX)
CDC isolation guidelinesCDC isolation guidelines
Bubonic: Standard Bubonic: Standard
Pneumonic: Droplet (until patient treated for 3 Pneumonic: Droplet (until patient treated for 3
days)days)
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SMALLPOX: HISTORYSMALLPOX: HISTORY
1754-67: Biological weapon French and Indian wars1754-67: Biological weapon French and Indian wars
1796: Edward Jenner uses vaccinia for 1796: Edward Jenner uses vaccinia for
immunizationimmunization
1967: WHO global eradication campaign1967: WHO global eradication campaign
1972: US ceases routine vaccination1972: US ceases routine vaccination
1977: Last case endemic smallpox (Somalia)1977: Last case endemic smallpox (Somalia)
1978: Last laboratory acquired case (England)1978: Last laboratory acquired case (England)
1982: Worldwide cessation of vaccination1982: Worldwide cessation of vaccination
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SMALLPOX: VIROLOGYSMALLPOX: VIROLOGY
Agent: Variola (family poxviridae)Agent: Variola (family poxviridae)
8 genera in family8 genera in family
Human infectious agentsHuman infectious agents
Orthopoxviruses: Variola, varicella Orthopoxviruses: Variola, varicella
(chickenpox)(chickenpox)
Mullucipoxvirus: Mulluscum contagiosum virusMullucipoxvirus: Mulluscum contagiosum virus
Nonhuman orthopoxviruses: Monkeypox, cowpox, Nonhuman orthopoxviruses: Monkeypox, cowpox,
canarypox, rabbitpox, etc.canarypox, rabbitpox, etc.
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VARIOLA (SMALLPOX)VARIOLA (SMALLPOX)
Large DNA VirusLarge DNA Virus
Dumb bell shaped Dumb bell shaped
virusvirus
Complex membranesComplex membranes
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SMALLPOX: EPIDEMIOLOGYSMALLPOX: EPIDEMIOLOGY
Agent: Variola virusAgent: Variola virus
Reservoir: HumansReservoir: Humans
TransmissionTransmission
Contact, droplet, and airborneContact, droplet, and airborne
Transmission does not occur until the onset rashTransmission does not occur until the onset rash
Maximum infectiousness, days 7-10 of rashMaximum infectiousness, days 7-10 of rash
Increased infectiousness if patient coughing or Increased infectiousness if patient coughing or
has a hemorrhagic form of smallpoxhas a hemorrhagic form of smallpox
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SMALLPOX: CLINICAL FEATURESSMALLPOX: CLINICAL FEATURES
Incubation period: 12 days (7-17 days)Incubation period: 12 days (7-17 days)
Clinical featuresClinical features
Non-specific prodrome (2-4 days) of fever, mylagiasNon-specific prodrome (2-4 days) of fever, mylagias
Rash most prominent on face and extremities Rash most prominent on face and extremities
(including palms and soles) in contrast to truncal (including palms and soles) in contrast to truncal
distribution of varicelladistribution of varicella
Rash scabs over in 1-2 weeksRash scabs over in 1-2 weeks
Variola rash has a synchronous onset (in contrast Variola rash has a synchronous onset (in contrast
to the rash of varicella which arises in crops)to the rash of varicella which arises in crops)
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SMALLPOX IN A CHILDSMALLPOX IN A CHILD
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Classic Centrifugal Rash of Smallpox Involving Face and Extremities. Photo courtesy of National
Archives
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Smallpox in an adultNigeria, 197027 yo female
Lesions have a peripheral distribution,Facial edema, and Uniform in terms of Stage of development
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SMALLPOX: DIAGNOSISSMALLPOX: DIAGNOSIS
Appearance of rashAppearance of rash
Hemorrhagic smallpox may be mistaken for Hemorrhagic smallpox may be mistaken for
meningococcemia or severe acute leukemiameningococcemia or severe acute leukemia
Culture of lesionsCulture of lesions
Should be obtained by immunized person; place Should be obtained by immunized person; place
specimen in vacutainer tube, tape juncture of specimen in vacutainer tube, tape juncture of
stopper and tube, place in second durable, stopper and tube, place in second durable,
watertight containerwatertight container
Alert labAlert lab
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SMALLPOX: CONTROLSMALLPOX: CONTROL
Laboratory precautions: BSL 4Laboratory precautions: BSL 4
Clothing/fomites: DecontaminateClothing/fomites: Decontaminate
ProphylaxisProphylaxis
Pre-exposure: Vaccine Pre-exposure: Vaccine
Post-exposure: Vaccine (within 4 days) or vaccine Post-exposure: Vaccine (within 4 days) or vaccine
plus VIG (>4 days); potential role for cidofovirplus VIG (>4 days); potential role for cidofovir
Isolation: Contact plus airborneIsolation: Contact plus airborne
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Vaccination With the Bifurcated NeedleVaccination With the Bifurcated Needle
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EVOLVING PRIMARY VACCINATIONEVOLVING PRIMARY VACCINATION
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Photo courtesy of CDC
Fatal case of Vaccinia necrosum at inoculation site Accidental auto-inoculation of the Accidental auto-inoculation of the
eye with eye with Vaccinia Vaccinia virusvirus
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VACCINIA VACCINE:VACCINIA VACCINE:PRECAUTONS AND CONTRAINDICATIONSPRECAUTONS AND CONTRAINDICATIONS
Severe allergic reaction to prior dose of vaccineSevere allergic reaction to prior dose of vaccine
History or presence of eczema, other skin conditionsHistory or presence of eczema, other skin conditions
Pregnancy (children in the household is not a Pregnancy (children in the household is not a
contraindication)contraindication)
Altered immocompetenceAltered immocompetence
HIV, Leukemia, lymphoma, generalized malignancyHIV, Leukemia, lymphoma, generalized malignancy
Solid organ transplant, BMTSolid organ transplant, BMT
Corticosteroids, alkylating agents, antimetabolites, Corticosteroids, alkylating agents, antimetabolites,
radiationradiation
Cardiac diseaseCardiac disease
AllergiesAllergies
Neomycin, polymyxin b, tetracyclines, streptomycinNeomycin, polymyxin b, tetracyclines, streptomycin
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VACCINIA VACCINE:VACCINIA VACCINE:PREVENTION OF CONTACT TRANSMISSIONPREVENTION OF CONTACT TRANSMISSION
Vaccinia virus can be cultured from primary vaccination Vaccinia virus can be cultured from primary vaccination
site beginning at the time of development papule (2-5d site beginning at the time of development papule (2-5d
after vaccination)after vaccination)
Transmission via direct skin contact may occurTransmission via direct skin contact may occur
Vaccination site should be covered with a porous bandage Vaccination site should be covered with a porous bandage
until scab has separated and underlying skin has healed until scab has separated and underlying skin has healed
(do not use an occlusive dressing)(do not use an occlusive dressing)
Use impermeable bandage when bathingUse impermeable bandage when bathing
Vaccinated HCWs may continue to work (vaccination site Vaccinated HCWs may continue to work (vaccination site
covered with sterile gauze and semipermeable dressing, covered with sterile gauze and semipermeable dressing,
and practice of good handwashing)and practice of good handwashing)
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Botulism ToxinBotulism Toxin A major bioweapons threat because A major bioweapons threat because
of its extreme potency and of its extreme potency and lethalitylethality
The single most poisonous substance The single most poisonous substance known.known. Easy to produce, transport and misuseEasy to produce, transport and misuse The average incubation period is 12-72 The average incubation period is 12-72
hours after ingestion.hours after ingestion.Neurotoxin produced by Clostridium botulinum
Most lethal substance known
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Modes of transmissionModes of transmission No person-to-person No person-to-person
transmissiontransmission
Exposure typesExposure types Foodborne - Ingestion of toxinFoodborne - Ingestion of toxin
Infant – Ingestion of Infant – Ingestion of C. botulinumC. botulinum
Wound – Infection with Wound – Infection with C. botulinumC. botulinum
Inhalation of aerosolized toxinInhalation of aerosolized toxin
As BT agent may be aerosolized As BT agent may be aerosolized
or added to food or wateror added to food or water
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Patients with botulism Patients with botulism typically present with typically present with difficulty speaking, seeing difficulty speaking, seeing and/or swallowing.and/or swallowing.
Prominent neurologic Prominent neurologic findings include ptsosis, findings include ptsosis, diplopia, blurred vision, diplopia, blurred vision, dysarthria and dysphagia. dysarthria and dysphagia.
Patients typically are Patients typically are afebrile and do not have an afebrile and do not have an altered level of altered level of consciousness. consciousness.
Patients may initially presentPatients may initially present with gastrointestinal distress, with gastrointestinal distress, nausea, and vomiting nausea, and vomiting preceding neurological symptoms. preceding neurological symptoms.
Six-week old infant withbotulism.
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BotulismBotulism
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BotulismBotulism
Symptoms:Symptoms: Acute, afebrile, symmetric, decending paralysis of facial Acute, afebrile, symmetric, decending paralysis of facial
musculature, multiple cranial nerve palsies musculature, multiple cranial nerve palsies Onset and severity dependent on amount of toxin Onset and severity dependent on amount of toxin
absorbed absorbed Incubation variable 2 hrs to 8 days after ingestionIncubation variable 2 hrs to 8 days after ingestion
Neurologic symptoms:Neurologic symptoms: Ptosis, diplopia, blurred vision, loss of head controlPtosis, diplopia, blurred vision, loss of head control Deep tendon reflexes diminishDeep tendon reflexes diminish Death results from airway obstruction; Death results from airway obstruction;
Respiratory and diaphragmatic muscle paralysisRespiratory and diaphragmatic muscle paralysis Diagnosis: Diagnosis:
Index of suspicion for botulism; clusters of casesIndex of suspicion for botulism; clusters of cases Treatment:Treatment:
Supportive care and administration of passive equine Supportive care and administration of passive equine antitoxinantitoxin
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Botulinum Toxin as a Botulinum Toxin as a BioweaponBioweapon
Aum Shinrikyo 1990, 1993, 1995: attempted Aum Shinrikyo 1990, 1993, 1995: attempted
aerosol dispersion in Japanaerosol dispersion in Japan
Japan WW II (Unit 731): fed cultures to Japan WW II (Unit 731): fed cultures to
prisoners in Chinaprisoners in China
US bioweapons programUS bioweapons program
Soviet Union program: gene splicingSoviet Union program: gene splicing
Iraq 19,000 liters weaponized Iraq 19,000 liters weaponized
? Iran, North Korea, Syria? Iran, North Korea, Syria
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Viral Hemorrhagic FeversViral Hemorrhagic Fevers
Arena VirusesArena Viruses Lassa feverLassa fever Argentine hemorrhagic feverArgentine hemorrhagic fever Bolivian hemorrhagic feverBolivian hemorrhagic fever FlaviviridaeFlaviviridae Yellow feverYellow fever DengueDengue BunyaviridaeBunyaviridae Crimean-Congo feverCrimean-Congo fever FilovirusesFiloviruses Marburg Ebola hemorrhagic Marburg Ebola hemorrhagic
feversfevers
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Ebola and Marburg – Ebola and Marburg – Etiologic agentsEtiologic agents
Flioviridae Flioviridae family virusesfamily viruses Among the most virulent viruses Among the most virulent viruses
(25-90% case fatality depending (25-90% case fatality depending on strain)on strain)
ZoonoticZoonotic Humans are incidental hosts Humans are incidental hosts
Marburg
Ebola
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Clinical features - VHFClinical features - VHF
Severe multisystem syndromeSevere multisystem syndrome
Overall vascular system damage Overall vascular system damage
Body’s ability to regulate itself is Body’s ability to regulate itself is
impairedimpaired
Often accompanied by hemorrhagic Often accompanied by hemorrhagic
(in itself not usually life (in itself not usually life
threatening)threatening)
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Ebola & Marburg Viruses - Ebola & Marburg Viruses - clinical courseclinical course
Sudden onset of flu-like illnessSudden onset of flu-like illness
May progress to nausea, vomiting, May progress to nausea, vomiting,
diarrhea, abdominal pain, diarrhea, abdominal pain,
photophobia, maculopapular rash, photophobia, maculopapular rash,
DIC, internal and external DIC, internal and external
hemorrhage, multiorgan failure hemorrhage, multiorgan failure
with jaundice and renal with jaundice and renal
insufficiencyinsufficiency
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Atlanta, Georgia: Electron Micrograph: Ebola virus causing African Hemorrhagic Fever. (Courtesy of the National Archives, 82-424)
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Marburg & Ebola –Marburg & Ebola –OccurrenceOccurrence
Naturally occurring sporadic outbreaks Naturally occurring sporadic outbreaks
in Africain Africa
Cases have occurred in West as a result Cases have occurred in West as a result
of exposure to animal reservoirsof exposure to animal reservoirs
BT potentialBT potential
Russian biowarfare program Russian biowarfare program
Iraq is believe to have triedIraq is believe to have tried
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Ebola and Marburg - Ebola and Marburg - transmissiontransmission
Direct contact with infected tissue Direct contact with infected tissue and body fluids or contaminated and body fluids or contaminated objectsobjects
Probably aerosol inhalationProbably aerosol inhalation
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Borio, et al JAMA consensus statement 2002
Maculopapular Rash in Marburg Disease
Ocular Manifestations in Bolivian Hemorrhagic Fever
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Psychological and Social Psychological and Social Factors during Factors during bioterrorismbioterrorism1.1. HorrorHorror
2.2. AngerAnger
3.3. PanicPanic
4.4. Magical thinking about microbesMagical thinking about microbes
5.5. Fear of invisible agents Fear of contagionFear of invisible agents Fear of contagion
6.6. Anger at Terrorist/GovernmentAnger at Terrorist/Government
7.7. ScapegoatScapegoat
8.8. ParanoiaParanoia
9.9. Social isolationSocial isolation
10. Demoralization10. Demoralization
11. Loss of faith in social institutions11. Loss of faith in social institutions
12. Attribution of arousal symptoms to infection12. Attribution of arousal symptoms to infection
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MANAGEMENT OF PEOPLE WITH MANAGEMENT OF PEOPLE WITH PSYCHOLOGICAL PROBLEMSPSYCHOLOGICAL PROBLEMS
1.1. care of health workerscare of health workers
2.2. Critical incidence stress management (CISM) for rescue Critical incidence stress management (CISM) for rescue
workersworkers
3.3. Prevention of public fleeingPrevention of public fleeing
4.4. Confidence building by the medical workersConfidence building by the medical workers
5.5. Dealing with emotional and psychological problems Dealing with emotional and psychological problems
while dealing with the dead.while dealing with the dead.
6.6. Care of emergency workers, medical and paramedical Care of emergency workers, medical and paramedical
workersworkers
7.7. Critical incidence of stress debriefing(CSID)Critical incidence of stress debriefing(CSID)
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8.Prevention of group panic 8.Prevention of group panic
9. Avoidance of emotion based responses (Knee jerk 9. Avoidance of emotion based responses (Knee jerk
quarantine)quarantine)
10. Effective risk communication10. Effective risk communication
11. Control of symptoms secondary to hyper arousal11. Control of symptoms secondary to hyper arousal
12. Reassurance12. Reassurance
13. Management of anger fear (Diazepam and other 13. Management of anger fear (Diazepam and other
anxiolytic drugs)anxiolytic drugs)
14. Provision of respite as required14. Provision of respite as required
15. Social support of the community15. Social support of the community
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Role of CliniciansRole of Clinicians
Be prepared to diagnose and Be prepared to diagnose and treat BT diseasestreat BT diseases
Keep alert to unusual disease Keep alert to unusual disease patternspatterns
Use reportable disease system to Use reportable disease system to alert public health officials of a alert public health officials of a potential problempotential problem
Get involved in disaster planning Get involved in disaster planning processprocess
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Clusters of patients with the Clusters of patients with the same disease or syndromesame disease or syndrome
Especially when:Especially when: there is more cases than would be expected there is more cases than would be expected cases are geographically or temporally cases are geographically or temporally
clusteredclustered the illness is unexplainedthe illness is unexplained there are multiple atypical presentations of there are multiple atypical presentations of
the disease the disease the mortality or morbidity is higher than the mortality or morbidity is higher than
expectedexpected
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Even a single case may be a Even a single case may be a signalsignal
Caused by an uncommon agentCaused by an uncommon agent Unusual for region, age group or Unusual for region, age group or
seasonseason Fulminant disease in otherwise Fulminant disease in otherwise
healthy patienthealthy patient Atypical presentationAtypical presentation
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Other cluesOther clues
Similar genetic type of agent from Similar genetic type of agent from distinct sourcesdistinct sources
Unusual, atypical, genetically Unusual, atypical, genetically engineered, or antiquated strainengineered, or antiquated strain
Atypical aerosol, food, or water Atypical aerosol, food, or water transmission transmission
Concurrent animal diseaseConcurrent animal disease
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DETECTION OF DETECTION OF OUTBREAKSOUTBREAKS RecognitionRecognition
• Syndrome criteriaSyndrome criteria
• Epidemiological featuresEpidemiological features
CommunicationCommunication
MedicalMedical
•Triage, psychological aspects, lab support, public Triage, psychological aspects, lab support, public
informationinformation
•Patient isolation (Follow CDC guidelines), Patient isolation (Follow CDC guidelines),
decontaminationdecontamination
•Post-exposure prophylaxis, treatment of infected Post-exposure prophylaxis, treatment of infected
personspersons
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DETECTION OF DETECTION OF OUTBREAKSOUTBREAKS
Epidemiologic featuresEpidemiologic features
A rapidly increasing disease incidenceA rapidly increasing disease incidence
An unusual increase in the number of people seeking care, esp. An unusual increase in the number of people seeking care, esp.
with with
fever, respiratory, or gastrointestinal symptomsfever, respiratory, or gastrointestinal symptoms
An endemic disease rapidly emerging at an uncharacteristic An endemic disease rapidly emerging at an uncharacteristic
time or in time or in
an usual patternan usual pattern
Lower attack rate among persons who had been indoorsLower attack rate among persons who had been indoors
Clusters of patients arriving from a single localClusters of patients arriving from a single local
Large numbers of rapidly fatal casesLarge numbers of rapidly fatal cases
Any patient presenting with a disease that is relatively Any patient presenting with a disease that is relatively
uncommon and uncommon and
has bioterrorism potentialhas bioterrorism potential
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DETECTION AND DETECTION AND IDENTIFICATION OF IDENTIFICATION OF BIOWEAPON AGENTBIOWEAPON AGENT 1.1. The conventional microbiological methods viz., The conventional microbiological methods viz.,
culture, immunodetection, serology, molecular culture, immunodetection, serology, molecular
identification take long time (hours to days) identification take long time (hours to days)
2.2. Several biodetectors (bioluminometer) based Several biodetectors (bioluminometer) based
on the principles of bioluminescence and on the principles of bioluminescence and
biofluorescence are being developed _ biofluorescence are being developed _ Fire fly Fire fly
luciferage geneluciferage gene..
3.3. There are various types of There are various types of biosensors such as biosensors such as
immunosensors, nucleic acid sensors, tissue immunosensors, nucleic acid sensors, tissue
based sensors and laser sensors based sensors and laser sensors
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EMERGINGEMERGING INFECTIONS AND INFECTIONS AND BIOTERRORISMBIOTERRORISM
New diseases have also appeared within the developed New diseases have also appeared within the developed
nations including United States. Some of these include: nations including United States. Some of these include:
Lyme diseaseLyme disease
Legionnaires’ diseaseLegionnaires’ disease
New variant of Creutzfeldt -Jakob diseaseNew variant of Creutzfeldt -Jakob disease
West-Nile virus disease West-Nile virus disease
Hantavirus pulmonary syndrome (HPS) Hantavirus pulmonary syndrome (HPS)
Multi-drug resistant TB, Multi-drug resistant TB,
Antibiotic resistant staphylococcal, enterococcal and Antibiotic resistant staphylococcal, enterococcal and
pneumococcal infections pneumococcal infections
Diarrhoeal diseases caused by the parasite Diarrhoeal diseases caused by the parasite
Cryptosporidium parvumCryptosporidium parvum and then certain strains of and then certain strains of
Escherichia coliEscherichia coli bacteria. bacteria.
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Factors contribute to the Factors contribute to the emergence and re-emergence of emergence and re-emergence of
infectious diseasesinfectious diseases 1. Unprecedented worldwide population growth draining 1. Unprecedented worldwide population growth draining the natuthe natural resourcesral resources
2. Overcrowding in cities with poor sanitation2. Overcrowding in cities with poor sanitation3. Rapid and increased international travel3. Rapid and increased international travel4. Increased international trade in animals and food 4. Increased international trade in animals and food
productsproducts5. Mass distribution of food and unhygienic food 5. Mass distribution of food and unhygienic food
preparationpreparation practicespractices6. Increased exposure of humans to disease vectors and 6. Increased exposure of humans to disease vectors and
reservoirs in naturereservoirs in nature7. Man-made changes to the environment and climatic 7. Man-made changes to the environment and climatic
changes which have a direct impact on the changes which have a direct impact on the population of insect vectors and animal reservoirs.population of insect vectors and animal reservoirs.
7. Misuse of antibiotics leading to the evolution of 7. Misuse of antibiotics leading to the evolution of resistant microbes. resistant microbes.
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Impact of biological agents on Impact of biological agents on
national economiesnational economies Highly pathogenic avian influenza, Highly pathogenic avian influenza,
Hong KongHong Kong
The outbreak of highly pathogenic avian The outbreak of highly pathogenic avian
influenza (HPAI) type A (H5N1) in live influenza (HPAI) type A (H5N1) in live
market chickens in Hong Kong resulted in market chickens in Hong Kong resulted in
6 million deaths and killing of 1.4 million 6 million deaths and killing of 1.4 million
birds.birds.
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Nipah virus, MalaysiaNipah virus, Malaysia
Nipah virus, a previously un known virus was Nipah virus, a previously un known virus was
identified in 1998, primarily in identified in 1998, primarily in pigs and in pigs and in
humanshumans in Malaysia. in Malaysia.
The virus caused over 250 human cases The virus caused over 250 human cases
resulting in 100 deaths. Approximately 1 resulting in 100 deaths. Approximately 1
million pigs were killed. Other countries in million pigs were killed. Other countries in
the region banned he importation of pork the region banned he importation of pork
products. products.
Malaysia authorities blamed the disease on a Malaysia authorities blamed the disease on a
deliberate attack by rival Asian countries deliberate attack by rival Asian countries
trying to slowdown Malaysia’s recovery from trying to slowdown Malaysia’s recovery from
the Asian Economic Crisis of the 1997.the Asian Economic Crisis of the 1997.
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Foot and Mouth disease, TaiwanFoot and Mouth disease, Taiwan
The 1997 Foot and mouth disease outbreak in The 1997 Foot and mouth disease outbreak in
Taiwan had a devasting effect on export oriented Taiwan had a devasting effect on export oriented
pork industry. pork industry.
The virus is believed to have been brought into The virus is believed to have been brought into
Taiwan through smuggled animals, meat products Taiwan through smuggled animals, meat products
or illegal immigrants from mainland China. or illegal immigrants from mainland China.
The epizootic resulted in the depopulation of 3.8 The epizootic resulted in the depopulation of 3.8
million pigs. million pigs. At one point the outbreak it was blamed as At one point the outbreak it was blamed as deliberate deliberate
introduction of FMD into Taiwan by mainland China. The introduction of FMD into Taiwan by mainland China. The
economic impact on Taiwan has been estimated in the economic impact on Taiwan has been estimated in the
billions of dollars.billions of dollars.
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ConclusionsConclusions
Less developed nations can produce biological weapons Less developed nations can produce biological weapons
that are as lethal as nuclear weapons include: Iran, Iraq, that are as lethal as nuclear weapons include: Iran, Iraq,
Israel, North Korea, China, Libya, Syria and Taiwan. Israel, North Korea, China, Libya, Syria and Taiwan.
Recent terrorist activities in India underscores it’s Recent terrorist activities in India underscores it’s
vulnerability to bioterrorism and the need for a vulnerability to bioterrorism and the need for a
comprehensive plan to defend against an attack. comprehensive plan to defend against an attack.
Currently, it does not have the infrastructure to quickly Currently, it does not have the infrastructure to quickly
detect and identify many pests and pathogens nor is the detect and identify many pests and pathogens nor is the
country able to respond to even small-scale attack. country able to respond to even small-scale attack.
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TERRORISM TODAY
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