12/9/2014 Field Treatment of the Biological Casualty PFN

12/9/2014

1

Slide 1JSOMTC, SWMG(A)

Field Treatment of the Biological CasualtyPFN: SOMEML13


Terminal Learning Objective

Action: Communicate knowledge of field treatment of the biological casualty

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


Reason

12/9/2014

2


Agenda

Identify the historical aspects of biological agents used in warfare

Identify the availability, advantages, disadvantages and delivery modes of biological agents

Identify the characteristics, clinical presentation, and treatment of bacterial biological agents


Agenda

Identify the characteristics, clinical presentation, and treatment of viral biological agents

Identify the characteristics, clinical presentation, and treatment of toxin producing biological agents

Identify the characteristics and types of biological agent vaccines


Agenda

Identify the characteristics and types of biological agent protective equipment

Identify evacuation concerns for biological agent casualties

12/9/2014

3


Historical Aspects of Biological Agents Used in Warfare


Biological Warfare

Definition

The intentional use of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals or plants

Types of agents

Bacteria

Viruses

Toxins


Biological Warfare

What makes an agent effective?

Pathogenicity and virulence

Infectious dose

Pathogen stability

• Aerosol

• Environment

Susceptibility of target object

12/9/2014

4


Biological Warfare History

184 BC

Hannibal

14th Century

Plague at Kaffa

18th Century

European conquest of the Americas

1937 to 1945

China


Biological Warfare History

1943

USA BIO program established

1953

USA Defensive program established

1969

USA Offensive program disestablished

1979

The Sverdlovsk Incident


Chemical versus Biological Agents

Chemical agents are typically man made through the use of industrial chemical processes

Biological agents are either replicating agents (bacteria or virus) or nonreplicating materials (toxin) that can be produced by living organisms

Almost none of the biological agents are dermally active and none are volatile

12/9/2014

5


Availability, Advantages, Disadvantages and Delivery Modes

of Biological Agents


Availability of Biological Agents

International Biological Warfare Agreements

1925 Geneva Protocol prohibits use, but not research

1969 President Nixon renounces U.S. program



1972 Biological Weapons Convention

103 nations agree to never to develop, produce stockpile, acquire or retain any biological agent for other than peaceful purposes

Facilitate the exchange of equipment materials and information on use of biological agents for peaceful purposes

12/9/2014

6



U.S. Biological Weapons Policy

No use under any circumstances

Research limited to defense measures

We possess no weaponized biologicals

Previous weapons stocks were destroyed


Advantages of Biological Weapons

Agents easy to produce

Inexpensive to produce

Can disseminate at great distances

Agent’s cloud invisible

Detection quite difficult

First sign is illness

Overwhelms medical capabilities

Perpetrators escape before effects

Simple threats create panic


Disadvantages of Biological Weapons

Most agents are poor tactical weapons on the modern battlefield

Agents have incubation times of several days to weeks

Countered by a rapid developing battlefield

Delayed‐onset may be the intent

• Fixed positions

12/9/2014

7


Modes of Delivery

Biological warfare agents are unconventional weapons and can be delivered by unconventional means

Conventional explosive munitions are inefficient delivery systems for agents

Heat generated

Unpredictable size of particulate matter

Approximately 1% to 2% delivered


Modes of Delivery


Modes of Delivery

Agents are most effectively delivered as an aerosol

Particles of 1 to 5 microns in diameter are most effective

Larger particles get trapped in the upper airways (filtered out)

Biological warfare agents may be used to

contaminate food or water systems/supplies

Cooking decreases contamination

Standard chlorination and filtration inactivate most pathogens

12/9/2014

8


Modes of Delivery

Agents are most effectively delivered as an aerosol

Particles of 1 to 5 microns in diameter are most effective

Larger particles get trapped in the upper airways (filtered out

Agents may also be used in food or water supplies

Limited populace affected


Modes of Delivery


Characteristics, Clinical Presentation, and Treatment of

Bacterial Biological Agents

12/9/2014

9


Bacterial Biological Agents

Anthrax

Brucellosis

Plague

Many others!


Anthrax


Anthrax

Bacillus anthracis

A large encapsulated gram‐positive bacillus

Spores are resistant to heat, cold, drying, and chemicals

When conditions are good the spores germinate to produce vegetative bacteria that are capable of producing an infection

12/9/2014

10


Anthrax


Anthrax


Anthrax

3 forms of the disease

Cutaneous

Inhalation

Gastrointestinal

Transmission

Physical contact with open lesion

Inhalation of spores

Digestion of spores

12/9/2014

11


Cutaneous Anthrax

95% of all anthrax infections

Occupational exposure to animals

Onset

1 to 7 days

Affects

Head, neck, and extremities


Cutaneous Anthrax

Signs and symptoms

Similar to influenza

• Headache, malaise, and low grade fever

Lesions

• Papule vesicle central necrosis black eschar

Complications

Malignant edema and systemic involvement


Cutaneous Anthrax

12/9/2014

12


Cutaneous Anthrax


Cutaneous Anthrax


Inhalation Anthrax

Most lethal form

LD50 ~ 2500 to 10,000 spores

Onset

1 to 7 days

Dose dependent

Signs and symptoms

Malaise, fever, fatigue, sweats, non‐productive dry cough, and chest discomfort

12/9/2014

13


Inhalation Anthrax


Inhalation Anthrax


Inhalation Anthrax

12/9/2014

14


Brucellosis

Brucella abortus(cattle), B.suis (pigs), B. canis(dogs)

Gram negative coccobacilli

Aerobic, non‐motile

Slow growing pathogen


Brucellosis

Primarily found in sheep, goats, cattle, swine, and camels

Also infects bison, elk, caribou, and some species of deer

Produced in the laboratory for biological warfare purposes using a single cell or a small amount of the organism from natural sources


Brucellosis

Transmission

Inhalation of aerosols or dust that contain organisms

Ingestion of unpasteurized dairy products and contaminated meat

Inoculation of abraded skin or mucosal surfaces

12/9/2014

15


Brucellosis

Onset

May be sudden or insidious

5 to 60 days

Signs and symptoms

Fluctuating fevers, sweating, weakness, anemia, headache, and muscular pain

Incapacitating and disabling disease in humans


Plague

Yersina pestis

Gram negative bacillus


Plague

3 forms

Bubonic

Pneumonic

Septicemic

Transmission

Man to man is through coughing (droplets)

Respiratory transmission is enhanced by humid climates

Primary reservoir is rodents, domestic cats, and wild carnivores

12/9/2014

16


Plague


Plague

Onset

2 to 5 days

Signs and symptoms

Acute onset of fever (103° to 106° F) and prostration in association with painful lymphadenitis

May have a lesion at the portal of entry

Chills

Possible necrotic tissue at the portal of entry


Plague

12/9/2014

17


Plague


Bacterial Agent Treatment

Anthrax (Inhalation)

(Cutaneous)

1‐6 days Fever/chills, malaise, fatigue, cough,

Papule, fluid filled

vesicle black eschar

Aerosol

Direct

Cipro, Doxy, then PCN

Same as Inhalation

Brucellosis 1‐2 months Fever/chills, HA, malaise, myalgia

Aerosol Doxy + Rifam

Plague (Inhalation)

2‐3 days Fever/chills, HA, hemoptysis, toximia, Resp failure

Aerosol Cipro, Doxy (IV) then PO after improvement

Agent Onset Symptoms Mode Treatment


Characteristics, Clinical Presentation, and Treatment of Viral

Biological Agents

12/9/2014

18


Viral Biological Agents

Smallpox (Variola)

Viral hemorrhagic fevers (VHF)

Lassar Fever, Congo Crimean Hemorrhagic Fever, Ebola Fever, Marburg Fever, Rift Valley Fever, and many others


Smallpox

Why the fear?

World’s population is very susceptible

Transmissible man‐to‐man

Infamous for morbidity and mortality

No specific therapy

Eradicated in 1977

• Physicians are unfamiliar with recognition and treatment

Primary threat is delivery by aerosol release


Smallpox

Transmission

Spread by respiratory droplets or by contact with scabs, draining lesions, and contaminated objects

Onset

1 to 2 weeks

12/9/2014

19


Smallpox

Signs and symptoms

Fever begins followed by a rash (exanthema)

Inflammation of respiratory mucosa

Inflammation of regional lymphatics

Minor viremia

• Spreads to liver, spleen, lung and bone marrow in approximately 7 to 14 days


Smallpox

Exanthema

Begins on face, hands, and forearms

Spreads to lower extremities

Centrifugal distribution

Macules‐papules‐vesicles‐pustules‐scabs

Infectious until scab separates


Smallpox

12/9/2014

20


Smallpox


Smallpox


Smallpox

12/9/2014

21


Smallpox


Viral Hemorrhagic Fevers

VHF agents can be transmitted by aerosol in laboratory models

Stability in aerosols must be enhanced for weaponization

Considered too dangerous to use because of the lack of protective vaccines and therapeutic measures to protect the users



Transmission

Respiratory droplets or conact with body fluids depending on type of VHF

Onset

Days to weeks depending on type of VHF

12/9/2014

22



Signs and symptoms

Fever, headache, malaise, and dizziness

Myalgias

Nausea and vomiting

Petechiae

Bleeding manifestations

Hypotension

Shock and death


Viral Agent Treatment


Smallpox 10 to 12 days Fever, chills, headache, malaise, backache, and lesions

Aerosol

Direct

Supportive care


4 to 21 days Early: headache, malaise, and myalgia

Late: bleeding, petechiae, and hypotension

Aerosol

Direct

Supportive care


Characteristics, Clinical Presentation, and Treatment of Toxin Producing Biological Agents

12/9/2014

23


Toxin Producing Biological Agents

Clostridium perfringens

Ricin

Staphylococcal Enterotoxin B

TrichotheceneMycotoxins


Toxin Producing Biological Agents

Toxins are poisonous by‐products of living organisms

They are very stable and produce severe illness when ingested, inhaled or introduced into the body by any other means

There effects on the human body range from minor illness to death


Botulism

Clostridium botulinum

Spore forming anaerobe

Botulinum toxin is the most potent neurotoxin known to man

Causes cranial nerve paralysis followed by descending skeletal muscle paralysis

• Inactivates the axon

12/9/2014

24


Botulism

Transmission

Ingestion

Contamination of open wounds

Inhalation through weaponized versions of toxin

Onset

12 to 72 hours after exposure


Botulism

Signs and symptoms

Muscle weakness and paralysis

• Double vision and drooping of both eye lids

• Difficulty chewing and swallowing• Dyspnea and respiratory failure


Botulism

12/9/2014

25


Botulism


Toxin Producing Agent Treatment


Botulinumtoxin

12 to 72 hours Ptsosis, ~bulbar, muscular and resp. weakness

Late: resp. failure

Aerosol

Ingestion

Dermal

Antitoxin Supportive

Staphylococcal enterotoxin B

3 to 12 hours Fever/chills, headache, myalgia, productive cough

Aerosol

Ingestion

Supportive

Ricin 4 to 8 hours Fever/chills, cough, malaise, dypnea

Aerosol Supportive

TricotheceneMycotoxin

2 to 4 hours Necrosis and sloughing of affected tissues

Aerosol

Ingestion

Dermal

Supportiv


Characteristics and Types of Biological Agent Vaccines

12/9/2014

26


Biological Agent Vaccines

As of January 1999, vaccines are available for the following potential BW agent threats:

Anthrax

Botulinum toxin

Rift Valley Fever

Tularemia

Yellow fever

Argentine Hemorrhagic Fever

Plague

Smallpox

Venezuela Equine Encephalitis

Q‐Fever


Anthrax Vaccine


Anthrax Vaccine

After the Gulf war

Admission by Iraq that it had indeed produced weapons containing anthrax spores confirmed fears of use of anthrax as a biological weapon

Dec 1997

In response to this threat Secretary of Defense William Cohen announced a vaccination plan to vaccinate all U.S. service members using the licensed anthrax vaccine

12/9/2014

27


Anthrax Vaccine

Side effects

Fever, malaise, and myalgia

Less common than those observed following other vaccines


Smallpox Vaccine


Smallpox Vaccine

There are no routine immunizations of US Forces for smallpox

When the threat indicates, senior leadership may direct vaccination

US adopted vaccinate in route protocol

Contraindications

Pregnancy, eczema, severe burns, psoriasis and other dermatoses

12/9/2014

28


Smallpox Vaccine


Smallpox Vaccine

Complications

Normal host

• Inadvertent inoculation (skin or eye)

• Generalized vaccinia• Erythema multiforme

• Encephalitis

Pregnancy

• Fetal vaccinia


Smallpox Vaccine

12/9/2014

29


Smallpox Vaccine


Characteristics and Types of Biological Agent Protective

Equipment


Protective Equipment

Currently fielded chemical protective equipment will provide protection against BW agents

Military Protective Mask

Battle Dress Over Garment

• JSLIST Over Garment

Protective Gloves, Over Boots, and Hood

M295 Decontamination Kit

RDIC

12/9/2014

30



M40 M42



Filters must be replaced when:

Wearer has been exposed to a suspected biological warfare agent

Elements are immersed in water

Excessive breathing resistance is encountered

Thirty days have elapsed in the combat theater of operation

Order by the commander

Supply bulletins indicate a lot number has expired



If a mask is not available:

Double layer of T‐shirt over face

• Has shown to be effective against ricin and anthrax

• Studies have shown it to be effective against several other WMD agents, but research is ongoing

Something is better than nothing!

12/9/2014

31




Battle Dress Over Garment


JSLIST Over Garment

12/9/2014

32


Protective Over Boots


M295 Decontamination Kit


RDIC

12/9/2014

33


Mission Oriented Protective Posture

Initiate

When the local alarm or command is given

When entering an area known to be or suspected of being contaminated with an NBC agent

When casualties are being received by personnel at the patient receiving/decontamination area



Initiate (cont.)

Your position is under attack by aircraft spray

Mist or smoke of an unknown source is present

Suspicious odor, liquid or solid is present



Terminate

When the all clear is given

On order from the commander or the highest ranking official with a sound knowledge of the degree of contamination

Casualties unable to continue to wear the protective clothing may be protected by using wraps to protect against further chemical‐biological agent exposure

12/9/2014

34


Evacuation Concerns for Biological Agent Casualties


Evacuation Concerns

Evacuation platforms

Difficult to decontaminate

• Especially airframes

Percentage will become contaminated

•Mark contaminated vehicles

• Protect 50% of platforms from contamination

Identify routes for contaminated vehicles

Consider effect of rotor wash


Evacuation Concerns

When preparing casualties for medical evacuation, attempts should be made to identify the agent

Decontaminate externally when at all possible

USAF will not fly any patients who are contaminated

Special wraps and containers

12/9/2014

35


Evacuation Concerns

Casualties

Apply strict quarantine measures

Isolate and evacuate all smallpox patients

Cannot be evacuated across national boundaries unless approved by major command authority

Isolate all clothing of contaminated patients to include equipment

Identifying one single case of smallpox is an world emergency


Questions?


Terminal Learning Objective

Action: Communicate knowledge of field treatment of the biological casualty

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards

12/9/2014

36


Agenda

Identify the historical aspects of biological agents used in warfare

Identify the availability, advantages, disadvantages and delivery modes of biological agents

Identify the characteristics, clinical presentation, and treatment of bacterial biological agents


Agenda

Identify the characteristics, clinical presentation, and treatment of viral biological agents

Identify the characteristics, clinical presentation, and treatment of toxin producing biological agents

Identify the characteristics and types of biological agent vaccines


Agenda

Identify the characteristics and types of biological agent protective equipment

Identify evacuation concerns for biological agent casualties

12/9/2014

37


Reason

Documents

12/9/2014 Field Treatment of the Biological Casualty PFN