# Presentation: 102544

## BIOTERRORISM

**Janice White, MPH, DR.PH (c)**
- IHS Nashville Area Epidemiologist

## Biological Terrorism

- Often _**Covert Terrorist Attacks**_
- Requires _**Strong Public Health Infrastructure**_ for early detection & control
- Coordination at _**Local, State & Federal Levels**_
_**Primary Health Care Providers**_ will probably be the first to observe & Report unusual illness or injuries.

## Biological Agents

**Category A—Critical Agents**
- Pathogens rarely seen in United States
- Pose a risk to National Security
- Easily disseminated or transmitted from person to person
- Cause high mortality
- Potential for major public health impact
- Might cause public panic or social disruption
- Require special action for public health preparedness

## Category ABiological Diseases

- Bacillus anthracis (Anthrax)
- Clostridium botulinum toxin (Botulism)
- Yersinia pestis (Plague)
- Variola major (Small Pox)
- Francisella tularensis (Tularemia)
- Viral hemorrhagic fever (Ebola, Marburg, Lassa Fever, Argentine hemorrhagic fever)

## Biological Agents

**Category B—Second highest priority agents**
- Moderately easy to disseminate
- Cause moderate morbidity & low mortality
- Require specific enhancements of CDC’s diagnostic capacity & enhanced disease surveillance
- _Examples_
- Q Fever
- Brucellosis
- Venezuelan Encephalomyelitis
- Eastern & western equine encephalomyelitis
- Epsilon toxin from Clostridium perfringens
- Staphlococcus enterotoxin B

## Biological Agents

- Category B also includes **food & waterborne pathogens**
- Salmonella species
- Shigella dysenteriae
- Escherichia coli O157-h7
- Vibrio Cholerae
- Cryptosporidium parvum

## Biological Agents

**Category C—third highest priority agents**
- Availability
- Ease of production & dissemination
- Potential for high morbidity & mortaltiy
- Major health impact
- _Examples_
- Hantavirues
- Tickborne hemorrhagic fever viruses
- Tickborne encephalitis viruses
- Yellow fever
- Multidrug-resistant TB

## ANTHRAX (Bacillus anthracis) 

- Case Definition:
_**Cutaneous:**_ skin lesion evolving during 2-6 days from papule through vesicular stage to depressed black wound
_**Inhalation:**_ resembles viral respiratory illness, followed by hypoxia, trouble breathing, & radiographic evidence of mediastinal widening; death due to hemorrhagic thoracic lymphadenitis, hemorrhagic mediastinitis, or hemorrhagic meningitis
_**Intestinal: **_Severe abdominal distress followed by fever, & signs of septicemia
_**Oropharyngeal: **_mucosal lesion in oral cavity or oropharynz, cervical adenopathy & edema, fever

## ANTHRAX

- As of 1995, 17 Nations are testing anthrax in Biologic weapons labs
- Most common in lower vertebrates: cattle, sheep, goats, camels, antelopes, other herbivores
- Transmission: Contact w/ spores; inhalation of spores; handling or eating infected meat
- # of spores that must be inhaled for infection: 8,000 but may very depending on type & strength
- Person to Person transmission is rare
- Incubation: ave. 48 hrs to 7 days (up to 6-8 weeks)

## ANTHRAX

- Case Fatality:
-  ~20% (cutaneous);
- 90+% (inhalation);
- 25-60% (intestinal)
- Release of 100 kg of aerosolized anthrax over Washington, DC estimated to cause:
- 130,000-3 million deaths
- $26.2 billion per 100,000 exposed to spores
- Lethality of Hydrogen Bomb

## ANTHRAX

_**No Quarentine necessary!**_
- Treatment: Antibiotics (Ciprofloxacin, Doxycycline, other Tetracyclines, Penicillin, erythromycin, chloraamphenicol)
- Vaccine 93% effective in protecting against anthrax
- Vaccination is 3 injections (2 wks apart); 3 boosters (6 mo apart); annual booster
- Recommendations for Vaccination:
- Lab Personnel working with organism
- Workers with imported animal hides or furs in area where standards are insufficient to prevent exposure
- Persons handling potentially infected animal products
- Military personnel deployed to areas of high risk

## SMALL POX(varioloa major)

- Considered most serious bioterroist threats to civilian population due to high mortalty rate & transmission
- Eliminated from world in 1977 (WHO)
- Russia still has labs experimenting with strains for bioterrorism
- Incubation period: 12-14 days (range 7-17)
- Initial Sx: high fever, fatigue, head & back aches.
- Severe abdominal pain & delirium possible.
- Characteristic rash on face, arms, & legs follows 2-3 days after initial sysptoms
- Lesions begin as flat red lesions, become pus filled, crust by early week 2, scabs fall off3-4 weeks.

## SMALL POX

- Transmission: Person to person by saliva droplets; also clothing & bed linen
- Can be aerosolized for use as a biologic weapon
- Most infectious in first week of illness
- Some risk until scabs fall off
- No proven treatment
- Use supportive therapy (IV, fever or pain reducers) & antibiotics for secondary infections
- Autoclave bed linen; use disinfectants such as hyperchorite & quaternary ammonia for surfaces
- Case fatality rate: 30%

## SMALL POX

- Routine vaccination ended in 1972
- National Preparedness: CDC agreement w/ OraVax to produce new smallpox vaccine containing live vaccinia virus but produced in cell cultures
- Vaccine will need to go through clinical tests & licensing
- To be held in National Stockpile until a case is confirmed
- Will be available on the International market
- Vaccine does not prevent dx in general public
- Will lessen severity or prevent illness if given w/in 4 days of exposure

## BOTULISM(Clostridium botulinum toxin)

- Muscle Paralyzing Disease
- Caused by toxin produced by bacterium
- 3 Main Types
- Foodborne (incubation period 12-36 hrs to days)
- Infant (those harboring bacterium in intestinal tract)
- Wound (wounds that are infected by bacterium)
- No person to person transmission; no waterborne cases
- Heating >=85 ̊C inactivates toxin in food

## BOTULISM

- CDC maintains a supply of antitoxin effective in reducing severity of symptoms if administered early
- Treatment should _not _be delayed for microbiology testing!
- Most patients recover in weeks to months
- US Case fatality rate: 5-10% (food) <1% (infant)

## BOTULISM

- Potential for deliberate aerosol or food-borne release as a biologic weapon
- Would be identified by large # of acute cases involving uncommon toxin type (C,D,F, G or non-aquatic food associated E)
- Common geographic distribution
- No common dietary exposure
- Diagnosis & testing though CDC & some state/local laboratories

## Pneumonic Plague(Yersinia pestis)

- Found in rodents & fleas
- Secondary Plague pneumonia can result from cats
- Plague occurs when bacterium infects lungs
- Sporadic cases in US (annual ave ~12 cases)
- Sx: fever, headache, weakness, productive cough w/ bloody or watery sputum
- Incubation period: 1-7 days (2-4 days ave; 1-2 days following an aerosol cloud exposure)
- Person to person transmission through respiratory droplets (none noted since 1925)

## Pneumonic Plague

- NO Vaccine
- Prophylactic antibiotic tx for 7 days for contacts with infected patient
- Drug (s) of choice:
- Streptomycin, gentabycin, tetracyclines, chloramphenicol
- Highly effective if used w/in 8-24 hours of onset
- Untreated, mortality approaches 100%

## Pneumonic Plague

- May be aerosolized as a biologic weapon (testing began in 1950’s & stored in microbe banks today)
- 1970 WHO Assessment found---
- Dissemination of 50kg in aerosol cloud over a
- city of 5 million might result in
- 150,000 cases
- 80,000-100,000 requiring hospitalization
- 36,000 expected to die
- Estimates depend on :
- Amount of agent dispersed
- Meteorological conditions
- Methods of aerosolization & dissemination

## Tularemia(Francisella tularensis)

- One of most infectious pathologic bacteria known
- Requires inoculation or inhalation of only _10 _organisms
- Considered very dangerous because of extreme infectivity, ease of dessemination, capacity to cause illness & death
- Studied in WWII as biologic weapon
- US destroyed stockpile in 1973; Russia destroyed stockpile in early 1990’s

## Tularemia

- Reservoirs: small mammals such as voles, mice, water rats, squirrels, rabbits & hares.
- Modes of transmission: animal bites, infected arthropods, handling infected animals, tissues or fluids; direct contact or digestion of infected water, food, soil; inhalation of infective aerosols
- Human to human transmission not documented

## Tularemia

- Believed that aerosol release would cause greatest PH consequences
- WHO reported in 1970 if 50kg dispersed as aerosol over metropolitan area w/ 5 million, estimated 250,000 incapacitating casualties; 19,000 deaths
- Signs of Aerosol attack: large number of cases of acute non-specific febrile illness 3-5 days after exposure (range 1-14 days), progression to pleuropneumonitis after days/weeks
- W/out antibiotics: shock, respiratory failure, death.
- Mortality rate: 2% (recent US rate w/ antibiotics)
- 5-15% for severe Type A strain; 30-60% for pulmonic or septicemic cases w/out antibiotics

## Tularemia

- Isolation not recommended
- Live attenuated vaccine available in US. Currently used to protect lab workers.
- Vaccination not recommended for post-exposure prophylaxis
- No reliable procedures to rapidly detect in environmental samples

## Steps to Prepare for Biological Attacks

**Enhance epidemiologic capacity to detect & respond to biological attacks**
**Establish communication programs for receiving accurate information**
**Enhance bioterrorism-related education & training for all health professionals**
**Stockpile appropriate vaccines & drugs**
**Establish relationship with labs with molecular surveillance techniques**

##  States with Bioterrorism Plans Posted on the Web

- MAINE
- RHODE ISLAND
- CONNECTICUT
- NORTH CAROLINA

- SOUTH CAROLINA
- FLORIDA
- ALABAMA
- MISSISSIPPI
- TEXAS

## Guidelines for Local Plans: What to do after a suspected attack has occurred

**Criminal Investigation**
- Alert your local police, state police & FBI Field Office
- Any suspicious letters or packages are part of criminal investigation; leave them in the room where they are found
- Police, FBI, or State Health Departments will be responsible for transporting evidence to State Labs for testing

**Clinical Investigation**
- Alert your local hazmat team, Medical response team & State Health Department
- Identify persons with potential exposures & have them wash exposed areas with soap & water
- Quarantine _only_ if suspected biologic warrants this action
- Follow appropriate disinfection methods for suspected biologic
- Provide counseling

## Current Guidelines on Nasal Swabs & Private Labs for Anthrax Threats

- CDC recommends nasal swabs _after initial threat is confirmed_ by criminal investigation
- Maryland & DC have instituted a policy to bypass nasal swabs & provide immediate antibiotic prophylaxis after the initial threat is confirmed
- Use of private labs that are not contracted by the State Health Department is not recommended by CDC
- If a private lab is used for screening, please check on 1) the method of testing* they provide and 2) the lab’s protocol for receiving results
- *Note: Some private labs provide methods of testing with lower sensitivity & specificity then state labs

## For Questions, Please Contact

- Janice White, MPH, DR.PH (C)
- 	Nashville Area Epidemiologist
- 	Cell: 240-475-2810
- 	Phone/fax: 301-231-9634
- Dr. Roy Kennon
- 	Nashville Area Chief Medical Officer
- 	Phone: 615-467-1530
- For Other IHS Areas, Please contact your area’s Epidemiologist, Epidemiology Center or Chief Medical Officer