Weapons of Mass Weapons of Mass DestructionDestruction

for thefor theRespiratory TherapistRespiratory Therapist

The Center forThe Center forHealth Care PreparednessHealth Care Preparedness

Established as a Established as a center of excellencecenter of excellence, , furthering education and research in the furthering education and research in the

field of health care disaster readinessfield of health care disaster readiness

Weapons of Weapons of Mass Mass

DestructionDestruction

WMD IntroductionWMD Introduction

Terrorism involving weapons of mass Terrorism involving weapons of mass destruction is an ever-present threat destruction is an ever-present threat in today’s worldin today’s world

As a hospital care provider, you may As a hospital care provider, you may be called on to deal with patients be called on to deal with patients involved in an incident involving involved in an incident involving WMD'sWMD's

Weapons of Mass Destruction:Weapons of Mass Destruction: are chiefly designed to incite terror, are chiefly designed to incite terror,

not to killnot to kill consist of a variety of different agentsconsist of a variety of different agents can be delivered through a variety of can be delivered through a variety of

different meansdifferent means can be extremely difficult to controlcan be extremely difficult to control are designed to cause are designed to cause widespreadwidespread and and

indiscriminate indiscriminate death and destructiondeath and destruction

WMD IntroductionWMD Introduction

Categorization ofCategorization ofWeapons of Mass DestructionWeapons of Mass Destruction

Useful mnemonics to categorize Useful mnemonics to categorize WMDs:WMDs:

B NICEB NICE CBRNECBRNE

B B Biological Biological CC Chemical Chemical

NN Nuclear Nuclear B B Biological Biological

I I Incendiary Incendiary RR RadiologicalRadiological

CC Chemical Chemical NN Nuclear Nuclear

EE Explosive Explosive EE Explosive Explosive

ChemicalChemicalWeapons of Mass Weapons of Mass

DestructionDestruction

Why CW are attractive to Why CW are attractive to terrorists:terrorists:

They are inexpensive to manufacture to obtainThey are inexpensive to manufacture to obtain Simple technology is needed to produce themSimple technology is needed to produce them They are difficult to detectThey are difficult to detect They are highly efficient (little quantity is They are highly efficient (little quantity is

needed)needed)

Nerve Agent LethalityNerve Agent Lethality

An amount of VX equal in size to one An amount of VX equal in size to one column of the Lincoln Memorial on column of the Lincoln Memorial on

the back of a penny would be the back of a penny would be lethallethal to you to you

Sources of CW AgentsSources of CW Agents Foreign governmentsForeign governments Internet recipesInternet recipes ““Black Market” of the former Soviet UnionBlack Market” of the former Soviet Union U.S. chemical plants (Chlorine, Phosgene, etc.)U.S. chemical plants (Chlorine, Phosgene, etc.) U.S. Military StockpileU.S. Military Stockpile

30,600 tons of nerve agents and vesicants at 8 sites 30,600 tons of nerve agents and vesicants at 8 sites across U.S.across U.S.

1985 law directed DoD destroy stockpile by 20041985 law directed DoD destroy stockpile by 2004 Outdated and recovered CW are buried at 215 sites Outdated and recovered CW are buried at 215 sites

across U.S.across U.S.

Items that don’t mix…Items that don’t mix…

Risks from Chemical Risks from Chemical AgentsAgents

Detonation of CWA-containing Detonation of CWA-containing munitionsmunitions

Atmospheric DispersalAtmospheric Dispersal Contamination of Food or Water Contamination of Food or Water

SuppliesSupplies Product TamperingProduct Tampering

Classification of Chemical Classification of Chemical WeaponsWeapons

Chemical agents are classified by Chemical agents are classified by the toxic effects they have on the the toxic effects they have on the bodybody

Chief Categories of Agents:Chief Categories of Agents: Nerve AgentsNerve Agents Vesicants or Blistering AgentsVesicants or Blistering Agents Choking or Pulmonary AgentsChoking or Pulmonary Agents Blood AgentsBlood Agents Incapacitating or Riot-Control AgentsIncapacitating or Riot-Control Agents

Nerve AgentsNerve Agents

Action:Action: Irreversibly bind to acetylcholinesterase Irreversibly bind to acetylcholinesterase (AChE), the enzyme that terminates the action of (AChE), the enzyme that terminates the action of the neurotransmitter acetylcholine (ACh)the neurotransmitter acetylcholine (ACh)

Leads to accumulation of acetylcholine, resulting Leads to accumulation of acetylcholine, resulting in:in: **Muscarinic Effects:Muscarinic Effects: small pupils, dim vision, smooth small pupils, dim vision, smooth

muscle contraction, copious hypersecretion (sweat, muscle contraction, copious hypersecretion (sweat, tears, runny nose)tears, runny nose)

Nicotinic Effects:Nicotinic Effects: skeletal muscle weakness, paralysis skeletal muscle weakness, paralysis CNS Effects:CNS Effects: changes in mood, decreased mental changes in mood, decreased mental

status, seizures, coma... respiratory failure and terminal status, seizures, coma... respiratory failure and terminal arrhythmiaarrhythmia

Ex: Sarin (GB), Soman (GD), Tabun (GA), VX GasEx: Sarin (GB), Soman (GD), Tabun (GA), VX Gas

S.L.U.D.G.E.S.L.U.D.G.E.

Muscarinic Effects of Nerve AgentsMuscarinic Effects of Nerve Agents

SSalivationalivation

LLacrimationacrimation

UUrinationrination

DDiaphoresisiaphoresis

GGI distress (diarrhea, I distress (diarrhea, vomiting)vomiting)

EEmesismesis

Nerve Agent Antidote: Nerve Agent Antidote: MARK I KitMARK I Kit Self-injectable needleSelf-injectable needle Pralidoxime Chloride Pralidoxime Chloride

(600 mg)(600 mg) Atropine (2 mg)Atropine (2 mg)

Vesicants / Blister Vesicants / Blister AgentsAgents

Produce severe blisters and chemical burns, Produce severe blisters and chemical burns, effecting epithelium of the skin and respiratory effecting epithelium of the skin and respiratory tracttract

Slow acting: causes death in 48-72 hoursSlow acting: causes death in 48-72 hours Fatality due to:Fatality due to:

Impaired gas exchange (hypoxia)Impaired gas exchange (hypoxia) Loss of body fluidsLoss of body fluids Secondary infectionSecondary infection

Skin and eyes affected first, then lungs and bone Skin and eyes affected first, then lungs and bone marrowmarrow

Once symptoms have begun, decontamination is Once symptoms have begun, decontamination is no longer effectiveno longer effective

Ex: Mustard Gas, LewisiteEx: Mustard Gas, Lewisite

Pulmonary Damaging Pulmonary Damaging AgentsAgents

Immediately irritating to the Immediately irritating to the bronchial treebronchial tree

Early effects: Early effects: rhinitis/pharyngitisrhinitis/pharyngitis tearingtearing eyelid spasmeyelid spasm upper respiratory tract irritationupper respiratory tract irritation

Later effects:Later effects: severe pulmonary toxicitysevere pulmonary toxicity respiratory failurerespiratory failure

Ex: Phosgene, ChlorineEx: Phosgene, Chlorine

Blood Agents or Blood Agents or CyanidesCyanides

Combines with a cellular enzyme Combines with a cellular enzyme inhibiting the body’s ability to inhibiting the body’s ability to transport oxygen to vital organstransport oxygen to vital organs

Quick acting: causes death in Quick acting: causes death in minutesminutes

Relatively large dose needed to be Relatively large dose needed to be effectiveeffective

Initial effects:Initial effects: rapid/deep breathing, rapid/deep breathing, anxiety, agitation, dizziness, anxiety, agitation, dizziness, weakness, nausea, muscle tremblingweakness, nausea, muscle trembling

Later effects:Later effects: loss of consciousness, loss of consciousness, decreased respirations, seizures, decreased respirations, seizures, arrhythmiasarrhythmias

Ex: Hydrogen cyanideEx: Hydrogen cyanide

Riot Control AgentsRiot Control Agents Potent lacrimators and irritantsPotent lacrimators and irritants Effects are believed to be transient, not Effects are believed to be transient, not

meant to be lethal (though some deaths meant to be lethal (though some deaths in asthmatics and the elderly have been in asthmatics and the elderly have been documented)documented)

Considered more humane than the Considered more humane than the alternativealternative

(80 countries voted to ban RCA by the (80 countries voted to ban RCA by the Geneva Convention)Geneva Convention)

Ex: CN gas, CS gasEx: CN gas, CS gas

General Treatment General Treatment GuidelinesGuidelines

for all classes of Chemical for all classes of Chemical WeaponsWeapons

Move to fresh airMove to fresh air Supplemental oxygenSupplemental oxygen Remove clothingRemove clothing Decontaminate skinDecontaminate skin Restrict physical activityRestrict physical activity Hospitalization/medical attentionHospitalization/medical attention

BiologicalBiologicalWeapons of Mass Weapons of Mass

DestructionDestruction

What is What is Bioterrorism?Bioterrorism?““Intentional or threatened use of Intentional or threatened use of viruses, bacteria, fungi or toxins viruses, bacteria, fungi or toxins from living organisms to produce from living organisms to produce

death or disease in humans, animals death or disease in humans, animals or plants”or plants”

1918 2004

Why Biologics are attractive Why Biologics are attractive to terrorists:to terrorists:

Some can be obtained from Some can be obtained from naturenature

Potential dissemination over Potential dissemination over large geographic arealarge geographic area

Creates panic and chaosCreates panic and chaos Can overwhelm medical Can overwhelm medical

servicesservices Civilian populations may be Civilian populations may be

highly susceptiblehighly susceptible High morbidity and mortalityHigh morbidity and mortality Difficult to diagnose and/or Difficult to diagnose and/or

treattreat Some are transmitted person-Some are transmitted person-

to-person via aerosolto-person via aerosol

Characteristics of Characteristics of Biological AttacksBiological Attacks

Incident may not be recognized for Incident may not be recognized for weeksweeks

Responders and health workers are at Responders and health workers are at risk of becoming casualties themselvesrisk of becoming casualties themselves

Continuing effect with re-infectionContinuing effect with re-infection Require special training and equipment Require special training and equipment

to handleto handle Large numbers of “worried well” (30:1 Large numbers of “worried well” (30:1

ratio)ratio) Fear of the unknownFear of the unknown

CDC: Critical Biological CDC: Critical Biological AgentsAgents

Category ACategory A The 9 highest priority The 9 highest priority

agents; highest risk to agents; highest risk to national securitynational security

Frequency is low; impact is Frequency is low; impact is high (speedy spread)high (speedy spread)

Easily disseminated or Easily disseminated or spread person-to-personspread person-to-person

High mortalityHigh mortality Greatest potential for Greatest potential for

widespread panic and social widespread panic and social disruptiondisruption

Category BCategory B Second highest priority agentsSecond highest priority agents Moderately easy to disseminateModerately easy to disseminate Moderate morbidity and low mortality Moderate morbidity and low mortality

(compared to Cat. A) (compared to Cat. A) Category CCategory C

Emerging pathogens that could be Emerging pathogens that could be engineered for mass disseminationengineered for mass dissemination

Readily available; easy to produce and Readily available; easy to produce and dispersedisperse

Potentially high morbidity and mortalityPotentially high morbidity and mortality

CDC: Critical Biological CDC: Critical Biological AgentsAgents

Category A Bioterrorism Category A Bioterrorism AgentsAgents

Variola majorVariola major(Smallpox)(Smallpox)

Bacillus anthracisBacillus anthracis(Anthrax)(Anthrax)

Yersinia pestisYersinia pestis(Plague)(Plague)

Clostridium Clostridium botulinumbotulinum(Botulism)(Botulism)

Francisella Francisella tularensistularensis(Tularemia)(Tularemia)

Ebola hemorrhagic Ebola hemorrhagic fever fever

Marburg Marburg hemorrhagic fever hemorrhagic fever

Lassa feverLassa fever Argentine Argentine

hemorrhagic feverhemorrhagic fever

Category B Bioterrorism Category B Bioterrorism AgentsAgents

Coxiella burnettiCoxiella burnetti

(Q fever)(Q fever) Brucella speciesBrucella species

(brucellosis)(brucellosis) Burkholderia malleiBurkholderia mallei

(glanders)(glanders) Venezuelan Venezuelan

encephalomyelitisencephalomyelitis Eastern and Western Eastern and Western

equine equine encephalomyelitis encephalomyelitis

Ricin toxin from Ricinus Ricin toxin from Ricinus communis (castor communis (castor beans)beans)

epsilon toxinepsilon toxin of of Clostridium perfringensClostridium perfringens

Staphylococcus Staphylococcus enterotoxin Benterotoxin B

Food/Water Borne AgentsFood/Water Borne Agents Salmonella speciesSalmonella species Shigella dysenteriaeShigella dysenteriae Escherichia coliEscherichia coli

O157:H7O157:H7 Vibrio choleraeVibrio cholerae Cryptosporidum parvumCryptosporidum parvum

Category C Bioterrorism Category C Bioterrorism AgentsAgents

Nipah virusNipah virus HantavirusHantavirus Tickborne Tickborne

hemorrhagic fever hemorrhagic fever virusesviruses

Tickborne Tickborne encephalitis virusesencephalitis viruses

Yellow feverYellow fever Multi-drug resistant Multi-drug resistant

tuberculosis tuberculosis (MDRTB)(MDRTB)

SmallpoxSmallpox

CDC: Electron micrograph of Variola major

Variola majorVariola major (Smallpox) (Smallpox)

Highly contagious virus (Attack rate: Highly contagious virus (Attack rate: 90%)90%)

Person-to-person spread (by Person-to-person spread (by inhalation)inhalation)

Mortality rate: 35%Mortality rate: 35% Vaccine ~95% effective, can be Vaccine ~95% effective, can be

administered up to 4 days after administered up to 4 days after exposureexposure

No effective anti-viral agentsNo effective anti-viral agents

Smallpox: Clinical Smallpox: Clinical FeaturesFeatures

ProdromeProdrome Acute onset fever, malaise, headache, Acute onset fever, malaise, headache,

backache, vomiting backache, vomiting Exanthem (Rash)Exanthem (Rash)

Begins on face, hands, forearms spreads to Begins on face, hands, forearms spreads to lower extremities then trunk over ~ 7 days lower extremities then trunk over ~ 7 days

Synchronous progression:Synchronous progression:

macules macules vesicles vesicles pustules pustules scabs scabs Lesions on palms /solesLesions on palms /soles

IncubationIncubation 7-17 days7-17 days 14-21 days14-21 days

ProdromeProdrome 2-4 days2-4 days minimal/none minimal/none

Distribution Distribution centrifugalcentrifugalcentripetalcentripetal

Scab formationScab formation 10-14 days10-14 days 4-7 days4-7 days

Scab separationScab separation 14-28 days 14-28 days <14 <14 daysdays

Smallpox vs. ChickenpoxSmallpox vs. Chickenpox

Variola Varicella

Smallpox VaccineSmallpox Vaccine

Made from live Made from live VacciniaVaccinia virusvirus

Intradermal inoculation Intradermal inoculation with bifurcated needlewith bifurcated needle

Scar (permanent) Scar (permanent) demonstrates successful demonstrates successful vaccinationvaccination

Immunity Immunity notnot life-long life-long Adequate vaccine for all of Adequate vaccine for all of

U.S. populationU.S. population

Primarily disease of herbivoresPrimarily disease of herbivores Natural transmission to Natural transmission to

humans by contact with humans by contact with infected animals or infected animals or contaminated animal productscontaminated animal products

Three clinical forms Cutaneous (least lethal) Gastrointestinal Inhalational (most lethal)

aka “Woolsorter’s Disease”aka “Woolsorter’s Disease”

Anthrax: Anthrax: OverviewOverview

CDC: Gram stain of B. anthracis

Anthrax: OverviewAnthrax: Overview

Soil reservoirSoil reservoir Forms highly stable spores Forms highly stable spores No person-to-person transmissionNo person-to-person transmission Easy to manufacture, difficult to Easy to manufacture, difficult to

aerosolizeaerosolize History:History:

1979:1979: Accidental release of spores from a Accidental release of spores from a USSR Bioweapons factory, at least 66 deadUSSR Bioweapons factory, at least 66 dead

2001:2001: Anthrax attacks in the United Anthrax attacks in the United States, 11 contract inhalational anthrax, 5 States, 11 contract inhalational anthrax, 5 dieddied

Anthrax: CutaneousAnthrax: Cutaneous

Most common form (95%)Most common form (95%) Inoculation of spores Inoculation of spores underunder

skinskin Small papule Small papule ulcer ulcer

surrounded by vesicles (24-surrounded by vesicles (24-28h)28h)

Painless eschar with edemaPainless eschar with edema Death rate: 20% if Death rate: 20% if

untreateduntreated USAMRICD: Eschar with surrounding edema

Anthrax: Anthrax: Cutaneous Vesicle Cutaneous Vesicle

DevelopmentDevelopment

Day 4

Day 6

Day 10

Day 2

Left, Forearm lesion on day 7—vesiculation and ulceration of initial macular or papular anthrax skin lesion. Right, Eschar of the neck on day 15 of illness, typical of the last stage of the lesion. From Binford CH, Connor DH, eds. Pathology of Tropical and Extraordinary Diseases. Vol 1. Washington, DC: AFIP; 1976:119. AFIP negative 71-1290–2.

Anthrax: Cutaneous

Anthrax: GastrointestinalAnthrax: Gastrointestinal

Ingestion of poorly Ingestion of poorly cooked contaminated cooked contaminated meatmeat

Fever, acute Fever, acute gastroenteritis, bloody gastroenteritis, bloody vomit, bloody diarrheavomit, bloody diarrhea

Intestinal Eschar Intestinal Eschar similar to cutaneous similar to cutaneous lesionlesion

Mortality rate ~50% Mortality rate ~50% despite treatmentdespite treatment

CDC: Intestinal lesion of GI anthrax

Anthrax: InhalationalAnthrax: Inhalational

Requires inhalation of 8,000 – 15,000 sporesRequires inhalation of 8,000 – 15,000 spores Initial symptoms “Flu-Like Illness” (2-5 days) Initial symptoms “Flu-Like Illness” (2-5 days)

fever, cough, myalgia, malaisefever, cough, myalgia, malaise

Terminal symptoms (1-2 days )Terminal symptoms (1-2 days ) High fever, dyspnea, cyanosisHigh fever, dyspnea, cyanosis hemorrhagic mediastinitis/pleural effusionhemorrhagic mediastinitis/pleural effusion Rapid progression to shock/deathRapid progression to shock/death

Mediastinal widening on CXRMediastinal widening on CXR Mortality rate: Mortality rate: ~75% with antibiotic TX~75% with antibiotic TX

~97% without antibiotic TX~97% without antibiotic TX

Mediastinal wideningJAMA 1999;281:1735–1745

Anthrax: Inhalational

Anthrax: VaccineAnthrax: Vaccine Current U.S. vaccineCurrent U.S. vaccine

For persons 18 - 65 years of ageFor persons 18 - 65 years of age Protective against cutaneous anthrax and Protective against cutaneous anthrax and

possibly inhalational anthrax (animal data)possibly inhalational anthrax (animal data) 6 dose regimen over 18 months6 dose regimen over 18 months Limited availabilityLimited availability Not currently administered to the civilian Not currently administered to the civilian

populationpopulation

Radioactive and NuclearRadioactive and NuclearWeapons of Mass Weapons of Mass

DestructionDestruction

Radiation vs. Radioactive Radiation vs. Radioactive MaterialMaterial

Radiation:Radiation: energy transported in the form of energy transported in the form of particles or waves (alpha, beta, gamma)particles or waves (alpha, beta, gamma)

Radioactive Material:Radioactive Material: material that contains material that contains atoms that spontaneously emit radiationatoms that spontaneously emit radiation Light, radio waves and microwaves are Light, radio waves and microwaves are types of radiation types of radiation (Ionizing radiation is (Ionizing radiation is

what we are concerned about)what we are concerned about) Radiation comes in four forms:Radiation comes in four forms:

Alpha particlesAlpha particles Beta particlesBeta particles Gamma raysGamma rays

Penetration Abilities of Penetration Abilities of Different Types of Different Types of

RadiationRadiationAlpha ParticlesStopped by a sheet of paper

Beta ParticlesStopped by a layer of clothingor less than an inch of a substance (e.g. plastic)

Gamma RaysStopped by inches to feet of concreteor less than an inch of lead

RadiationSource

Exposure vs. ContaminationExposure vs. Contamination

Exposure:Exposure: irradiation of the body irradiation of the body

Contamination:Contamination: radioactive material on radioactive material on patient (external) or within patient patient (external) or within patient (internal) (internal)

Internal ContaminationInternal ContaminationThe biological pathways that can introduce The biological pathways that can introduce radioactive contamination internally include:radioactive contamination internally include:

Injection

Inhalation

Ingestion

Absorption

Injuries Associated with Injuries Associated with Radiation Exposure Radiation Exposure

Acute Radiation Syndrome Acute Radiation Syndrome (ARS)(ARS)

Cutaneous Radiation Cutaneous Radiation SyndromeSyndrome

Chronic radiation exposureChronic radiation exposure Teratogenic effectsTeratogenic effects

Acute Radiation SyndromeAcute Radiation Syndrome

Also known as radiation toxicity or Also known as radiation toxicity or sicknesssickness

Requirements:Requirements: Large, acute doseLarge, acute dose PenetratingPenetrating Majority of the body is exposedMajority of the body is exposed

Three classic ARS syndromes:Three classic ARS syndromes: Bone Marrow SyndromeBone Marrow Syndrome Gastrointestinal SyndromeGastrointestinal Syndrome Cardiovascular / Central Nervous System Cardiovascular / Central Nervous System

SyndromeSyndrome

Acute Radiation Acute Radiation Syndrome Syndrome

(A Spectrum of Disease)(A Spectrum of Disease)

Acute Radiation Acute Radiation Syndrome Syndrome

(A Spectrum of Disease)(A Spectrum of Disease)

Cutaneous Radiation Cutaneous Radiation SyndromeSyndrome

Acute radiation exposure of the skinAcute radiation exposure of the skin Signs/Symptoms:Signs/Symptoms:

ItchingItching TinglingTingling ErythemaErythema EdemaEdema EpilationEpilation

Lesions may be life threateningLesions may be life threatening Lesions do not appear for days to Lesions do not appear for days to

weeksweeks Surgical treatments must be Surgical treatments must be

performed within 48 hrs to be performed within 48 hrs to be effectiveeffective

NUREG / CR-4214, p II-68NUREG / CR-4214, p II-68

Methods of protectionMethods of protection

TimeTime

DistanceDistance

ShieldingShielding

Radioactive/Nuclear Radioactive/Nuclear WMDs:WMDs:

Possible ScenariosPossible Scenarios Nuclear power plant Nuclear power plant

incidentincident Nuclear weaponNuclear weapon Improvised Nuclear Device Improvised Nuclear Device

(IND)(IND) ““Dirty bomb”Dirty bomb”

Nuclear Power Plant Nuclear Power Plant IncidentIncident

Attack by air fairly Attack by air fairly easy for terroristeasy for terrorist

Would result in little Would result in little release of radioactive release of radioactive material, if anymaterial, if any

Redundant safety Redundant safety systems make systems make catastrophic catastrophic radiation leak highly radiation leak highly unlikelyunlikely

Nuclear WeaponNuclear Weapon Manufacture requires extraordinary Manufacture requires extraordinary

degree of scientific expertisedegree of scientific expertise Requires constant maintenanceRequires constant maintenance Unlikely that a terrorist organization Unlikely that a terrorist organization

has the resources to effectively has the resources to effectively accomplish a NW attackaccomplish a NW attack

Improvised Nuclear Improvised Nuclear DeviceDevice

Weapons made from small devices Weapons made from small devices that trigger uncontrolled nuclear that trigger uncontrolled nuclear reactionsreactions

Difficult to manufactureDifficult to manufacture Require frequent maintenanceRequire frequent maintenance

Chairman Dan Burton Committee – Demonstration of example “suitcase nuke” made from US nuclear shell

““Dirty Bomb”Dirty Bomb” Radioactive/Nuclear weapon of Radioactive/Nuclear weapon of

greatest concerngreatest concern Relatively easy to manufactureRelatively easy to manufacture Consists of radioactive material Consists of radioactive material

coupled with a conventional coupled with a conventional explosiveexplosive

Immediate effect: Blast injuriesImmediate effect: Blast injuries Long term effect: chronic Long term effect: chronic

radiation exposureradiation exposure Would require massive decon Would require massive decon

effort (of people, buildings, effort (of people, buildings, environment)environment)